Managing risk: handicap with care: facilities gear up to meet challenge.

When staff at Chestnut Lane want to plan a surprise birthday party, they do it behind closed doors or in one of the assisted living facility's private alcoves.

If they don't, there's a chance one of the residents will see what they're talking about.

That's just one of the adjustments people at the Gresham, Ore., apartment complex have to make when all of the residents and most of the staff are deaf.

But Jackie Blair, Chestnut Lane's director and one of its few hearing individuals, doesn't mind being in the minority. "About 95 percent of my staff is deaf, including the cooks, the hairdresser and the maintenance staff," she said. "My assistant director is deaf. All the nurses (use sign language) fluently. It's a very deaf-friendly environment."

That doesn't mean the 70-unit facility is without its share of challenges. Everything is slower paced because the communication process is more drawn out, according to Blair. There's no such thing as a quick bath or shower. Multi-tasking doesn't exist when cleaning a resident's room. Visual thinking is a necessity by nature, except for the deaf-blind residents, who require a tactile method for all communications.

Although Chestnut Lane is one of the nation's only long term care facilities that caters to an exclusively deaf population, it's not the only one faced with the challenge of caring for physically challenged residents. Any facility that cares for this demographic must make numerous operational changes to ensure the safety and welfare of everyone involved.

"There are so many things you have to take into consideration with a population like this," Blair said. "You really need to get to know your residents well and understand what their needs are."

Number crunching 

At first glance, it's easy for long term care facilities to gloss over the matter of care for physically disabled people. "In the broadest sense of 'handicapped,' almost all of our patients have some sort of disability or handicap," said Claudia Murray, director of nursing at Sentara Nursing Center in Norfolk, Va. "They're wheelchair-bound, bed-bound or have a disease that prevents them from functioning completely. If not, they wouldn't be here."

The physically impaired represent a lion's share of the nation's disabled seniors. According to the U.S. Census Bureau, almost 40 percent of persons age 65 or older--13.5 million people--are disabled. Nearly 12.8 million of these seniors have a physical or sensory disability.

The disabled are an expensive group, costing Medicare more than $203 billion in 2001, according to a June 2005 report by the Henry J. Kaiser Family Foundation. More than a third--$70 billion--went for services to disabled seniors.

Disabilities are also a growing problem for seniors. According to a 2004 study from Scripps University Gerontology Center in Oxford, Ohio, nearly four in five nursing home residents have four or more Activity of Daily Living limitations (ADLs), up from three in four a decade earlier.

"Mobility issues have a tendency to occur more and more as people hit age 50 and older," said Walt Kolt, president of Access Solutions, a Buffalo, N.Y.-based supplier of mobility aids for the handicapped. "And with the baby boomers approaching old age, people are running into more physical difficulties. It makes for a growing market." Kolt should know: his six-year-old company's sales have increased from $18,000 in 2000 to more than $2 million this year.

As the disabled population grows, so does the liability risk, experts note. That's not happy news in an industry that saw the annual patient care liability cost grow from $430 per occupied bed in 2004 to $2,310 in 2005, according to a recent study by Columbia, Md.-based Aon Risk Consultants and the American Health Care Association in Washington, D.C.

"The acuity level of people in nursing homes--how ill or incapacitated they are--has definitely gone up in the last decade or two," said Theresa Bourdon, managing director at Aon Risk Consultants. "A nursing home used to be a place where fairly mobile seniors went to hang out with other seniors. Now we're finding it's a much more acute patient, further along in dementia and other ailments, as well as the physically handicapped, who end up there. And the more frail and elderly you are, the more bad things happen."

The physically limited are also getting younger. The Scripps study reported that persons under age 65 made up 14 percent of the average nursing home's resident base in 2004, up from 7 percent in 1994.

David Abraham, administrator at Sentara Nursing Center in Norfolk, Va., said most younger persons in long term care--those under age 55--are there due to major injuries. Hospitals also aren't keeping patients as long because of reimbursement pressures. His own facility has two dozen such residents, which is "a fairly high" population. "I think what you're going to be seeing across the nation is more facilities that will have--and should have--this type of environment as well," Abraham said.

The changing, growing populations also place employees at greater risk of injury, according to Kolt. "The health care field has the second-highest percentage of back injuries in the United States," he said. "A standard back injury costs more than $100,000 in worker's compensation rates over the lifetime of the injury. $100,000 will buy an awful lot of equipment."

Accommodation via modification

While many facilities accommodate their physically handicapped residents in the best manner possible with existing services, more frequently others are making modifications as needed.

Roger Borgenicht, director of Assist Inc., a nonprofit community design center in Salt Lake City, said his firm regularly works on 25 to 30 projects a month involving homes, hospitals, nursing homes, independent living facilities and rehab centers. "People want to figure out what they can do to make their homes safer or what can be done to allow them to be more independent," he said.

There are many things people don't think about when preparing to care for a handicapped person, according to Borgenicht. For example, in a long term care facility, a typical refinement would be to replace a step-up shower entry with one that allows roll-in access for wheelchairs. This often requires lowering the drain. It might also entail replacing shower tile with a larger, 2-by-2 swimming pool tile due to its higher friction coefficient. "That's an important detail," Borgenicht said.

Several years ago, Sentara Nursing Center-Norfolk rebuilt its facility entrances to accommodate the growing number of electric wheelchairs among its residents. "We had to take a lot of the sharp turns out of the sidewalks and make them more curved so that people could be more ambulatory--so to speak--in their wheelchairs," Murray said.

Sentara also installed electric sliding doors at the entrances and has extra-wide doorways throughout the facility for all wheelchair access, Murray added.

Access Solutions offers a ceiling track that enables transport of a physically disabled resident on a lift throughout the facility. "With it, I can actually lift you out of bed, take you to the bathroom, put you in the shower, place you in your wheelchair--wherever you need to go," Kolt said. "You actually have a caregiver who can provide care for a longer period of time."

Other important needs of people with disabilities might not be as obvious. To accommodate a paraplegic who enjoyed gardening, Sentara built a garden that was chest-high. "He plants flowers and vegetables by using a fork in his good hand," Murray said. "He still has the pleasure of doing his favorite hobby despite his disability."

Borgenicht's company gives people suggestions on how to make "practical" improvements that are within code without spending hundreds or thousands of dollars. For example, replace thick shag carpet with a thinner, tighter-looped variety for use with power wheelchairs; replace standard door hinges with a swing-clear variety that can add two inches to the doorway opening, meaning the owner probably won't have to rip out the entire door frame to make it wider; make sure toilets have right- and left-side transfer bars. "The weak side in people can vary from right to left," Borgenicht said.

Probably the most difficult element of the long term care provider's job is psychological--helping residents cope with recent disabilities. This is increasing as more people lose limbs due to complications from diabetes, or deal with spinal injuries and others requiring surgical reconstruction, according to Murray.

"You have to address the entire patient--the psychological and the physical handicap of being paraplegic, and the alteration in body image," Murray said. "You need to keep them feeling as normal as they possibly can."