Your place or theirs?: Facility-based providers are bringing the nursing home. (Cover Story).

"Home" is a standard by which today's long term care facilities are measured. As the industry moves away from the medical-institutional paradigm to a more residential model, architects and interior designers strive to create spaces that approximate the family rooms and bedrooms residents left behind. Skilled nursing facilities have incorporated pets, plants, and children into residents' daily lives, and communal "country kitchens" enable denizens of assisted living to whip up the occasional homemade treat. "Homelike" has become a marketing mantra.

But for an 85-year-old widow who has lived in the same house for half a century, "homelike" may not be enough. No assisted living facility will offer a view of that towering magnolia tree that grew from a seedling in her front yard. The local nursing home may have an excellent reputation and attractive rooms--but where would she put all of her books? The facility's dog-in-residence is friendly enough, but she prefers the company of her two cats. For as long as it is feasible, she would rather stay in her own home and have the nurses come to her.

"Our biggest competitor during the past 20 years has not been other assisted living providers," says Brian Swinton, president of Sunrise Assisted Living Ventures Division. "It has always been the same thing-and that is the client's desire to stay at home."

To meet this competitor head-on, many long term care providers, including Sunrise, have begun offering a variety of home-and communitybased programs. For some organizations, home care has become an integral part of the business plan--perhaps the first step on the continuum of care. It also helps build "brand loyalty" at an earlier stage. Many of the large skilled nursing chains have moved into home care as an additional line of business. Fort Smith, Ark.-based Beverly Enterprises now offers hospice and home-health equipment and services at some 60 locations around the U.S. Manor Care, headquartered in Toledo, Ohio, completed a merger with In Home Health Inc. in December 2000, increasing its home health and hospice operations to nearly 80 offices in 22 states.

"Home health care is going to play a central position in long term care solutions," says Tim Brown, a spokesman for the National Association for Home Care (NAHC), a Washington, D.C.-based trade organization. "And long term care will be the defining issue of the 21st century."

Nursing homes without walls

A major obstacle for those who seek home-based long term care is that most private insurance does not cover home care, and Medicare home care benefits are intended primarily for those who need short-term care following surgery or an acute phase of illness. Medicare offers limited coverage for home health visits and a Certified Home Health Agency (CHHA) must provide these services.

In the late 1970s, New York state Senator Tarky Lombardi Jr. (R-Syracuse) championed health care legislation that made possible the Long Term Home Health Care Program (LTHHCP). This program--also known as the Lombardi Program or the "Nursing Home without Walls"--enables chronically ill New Yorkers who are medically eligible for admission to a skilled nursing facility to receive long term care at home. The program offers medical and skilled nursing care and supervision, personal care, housekeeping, social day care, transportation, and homeimprovement services. Medicald reimbursement is set at 75 percent of nursing home costs for comparable patients eligible for nursing home placement.

Among the long term care providers offering services through LTHHCP are the Jewish Home and Hospital (JHH) Lifecare System and the Isabella Geriatric Center; both are not-for-profit organizations based in New York City.

Care in multiple settings

JHH operates three skilled nursing facilities--one each in Manhattan, the Bronx, and Westchester County. Its Lifecare Services Division not only offers home care, but also provides social and medical adult day services and participates in community-outreach projects such as the Naturally Occurring Retirement Communities (NORCs) that have emerged in New York City public housing.

"Home- and community-based services are really the future of caring for the elderly on a long term basis," says Jane Fields, senior vice president of the Lifecare Services Division. "We believe our mission of caring for an aging population is in multiple settings--and the home setting is one of them."

Fields adds that Lifecare Services constitutes JHH's fourth or "virtual" campus and is vertically integrated with the three nursing homes in that clients can leave subacute care and go into a home care program, or they can come into a JHH home care program through the community and eventually move into one of the skilled nursing facilities.

According to Fields, JHH began offering home care services in the mid-1980s. "At the time, the trend was very much for institutionalization and there was a long waiting list," she explains. "So it was really for two reasons: to accommodate people who were waiting and needed care, as well as for people who were searching for an alternative."

Expanding services

JHH's Long Term Home Health Care Program currently serves 800 clients in Manhattan and the Bronx. Isabella Geriatric Center's program serves 425 long term home care patients in upper Manhattan. Tracey Sokoloff, administrator of Isabella Home Care Services, has recently applied for an additional 200 "slots" which must be approved through the state's Certificate of Need program.

Like JHH, Isabella offers care and services for the elderly in a variety of settings, including independent living apartments, adult day services, and a skilled nurisng facility Isabella is also among the first providers to open its Long Term Home Health Care Program to those with chronic mental illness. Sokoloff describes a kind of "symbiosis" between Isabella's facility-based and home care services.

"The short-term rehab cases certainly enjoy having us come upstairs and talk to them about transitioning to home care," she says. "We also have respite beds here at Isabella that complement my services. If I have an emergency on my end, we can then use a respite bed."

When a patient in Isabella's home care program can no longer live at home, he or she might be referred to Isabella's skilled nursing facility. Many residents of Isabella House, an independent living complex, also receive home care through Isabella.

"The continuum should be such that we can offer a menu of services that complement and support each other and still do what we do best, which is health care," says Sokoloff. "I think that home care provides a very strong link for that."

The two Rs

Like their facility-based counterparts, home care providers face the challenges posed by regulation and reimbursement.

"At the federal level, home health agencies operate much the same as skilled nursing facilities," says NAHC's Tim Brown. "They have to meet certification requirements to become part of the program and they have to comply with survey requirements regularly."

Unannounced home care surveys involve on-site visits with nurses and CNAs in clients' homes, and the surveyors may interview the clients themselves.

Sokoloff cites limited reimbursement for home care as a challenge for providers and consumers alike, adding that the shift to a Medicare prospective payment system for home care has prompted the closing of many freestanding and hospital-based home health agencies.

"The only payer that really pays for my total package is Medicaid," Sokoloff says. "Once we start servicing a patient for his or her chronic illness, Medicare will not pay--so I don't take patients who don't have Medicaid. That's really very limiting for the population in general. Many elderly people are faced with realization that they are not entitled to chronic home care and they begin to realistically look at spending down for Medicaid."

Geography and cultural climate may pose additional challenges to delivery of home care services. "We need escorts oftentimes because the neighborhoods are not safe for our nurses to go into alone," says Fields. "Another barrier is the multicultural aspect of Manhattan and the Bronx. Not all of our staff speak English and Spanish, so we have to rely again on our escorts as interpreters to communicate with the clients."

If they won't come to you ....

Paul and Terry Klaasen founded Sunrise Assisted Living Inc., based in McLean, Va., 20 years ago. The company now operates more than 180 communities in 25 states, the U.K., and Canada. In October 2000, Schroder Ventures Life Sciences (SYLS), a Boston-based venture capital firm, provided Sunrise with $5 million in capital funding to bring "At Home Assisted Living" to seniors in the Washington, D.C., area, where this all-private-pay program has already served more than 400 clients.

"Virtually every person we deal with would rather stay in his or her own home," says Brian Swinton, who heads the At Home program. "We firmly believe that there is a time and place when someone should leave their home but for many of the people who come to us, that time isn't quite yet."

Sunrise coordinates and schedules a variety of At Home services, including personal emergency response systems, telephonic and video monitoring, medication reminders, home health care and wellness visits, meal delivery, housekeeping, transportation, and home maintenance. Cost to the consumer ranges from about $49 a month for the Safe & Secure emergency response system to $6,000 a month for services that may include 24-hour care and a personal chef.

"At some point," says Swinton, "if you have a nurse or a CNA there too many hours a day, it's actually going to be more economical for you to make the move to a freestanding assisted living facility."

Sunrise also offers in-between solutions such as respite care and short-term stays to provide what Swinton calls "a seamless process to move from Sunrise serving you in your home to Sunrise serving you in our home."

"Senior friendly" technology

According to Sunrise, its Safe & Secure emergency response system is the most popular At Home service-second only to home health care. The system consists of a "senior friendly" telephone with large, backlit buttons and a pendant that turns it into a speakerphone providing 24-hour access to emergency assistance. Four auto matic reminders can be programmed as medication prompts or wake-up calls. By pressing a button each morning, the client can send a signal to head quarters that all is well.

"We also have devices that we can put in someone's home to automatically signal with a light, buzzer, or voice that it's time to take their medication," says Swinton. "If they haven't taken the medication within 45 minutes, then we're alerted and can contact them to find out what's happened."

Sunrise can combine this service with visits from a nurse who comes every two weeks to check on the client, set up his or her medications, and have the meds dispensed auto matically every day for the next two weeks.

Due to the initial success of its home-based services, Sunrise recently obtained a second round of financing from SVLS to expand the At Home program into the Philadelphia, Boston, Long Island, and northern New Jersey markets.

"We have set out to do this as simply another product line for Sunrise," says Swinton. "It's a matter of saying we're willing to provide whatever assistance you need where, when, and how you need it."

Bringing it all together

Will other assisted living providers start looking homeward? Paul R. Willging, PhD, director of the NIC Seniors Housing & Care Program at Johns Hopkins University, feels that it is too early to tell.

"To some extent, people are going to wait and see what happens with Sunrise," he says. "But I think Sunrise has made a fairly smart move. Perhaps as much as any assisted living company, Sunrise not only talks about aging in place, it actually tries to fulfill that vision. And the only way that can really be done is to bring services to people in the original place where they've decided to reside."

Whether a home care venture succeeds may depend largely on its level of integration with a company's facility-based operations. Otherwise, says Willging, home care will be far more expensive than facility-based care for a very simple reason: Sending a nurse out to 100 different clients is more expensive than having 100 different clients in one place for the nurse.

"It's best to tie it all together," Willging adds. "Because ultimately, people do age. You can strive to maintain an individual in his or her own home as long as possible. But there will come a time for some when their level of debility is such that they can't easily be cared for at home."

This may necessitate a move to facility-based long term care. The provider who has developed a degree of brand loyalty with the client and family members through homebased services may then be the most likely choice. The "continuum of care" can begin at home.

RELATED ARTICLE: Handheld health care

For many home care nurses, the PDA (personal data assistant) has become an essential piece of equipment to be packed alongside the stethoscope and sterile dressings. These palmtop devices enable nurses to cut down on paperwork and facilitate various clinical and patient-monitoring tasks.

The Visiting Nurse Association of Brooklyn (VNAB) has begun using Pocket Point of Care, a handheld application designed for the home care industry by Farmingdale, N.Y.-based NovaSync. VNAB helped develop the application, which runs on both Palm and Windows CE handheld devices. According to NovaSync, Pocket Point of Care incorporates OASIS data elements, captures the patient's signature, and offers biometric fingerprint security features in anticipation of changing HIPAA standards. It also enables caregivers to capture vital clinical data and transmit it from the patient's home to the back-office billing system. Thomas Gilmartin, vice president of VNAB, comments that "Improving our ability to validate and submit claims within tight, lockdown time constraints, reducing clerical errors, and improving our cash flow are just a few of the benefits we anticipate."

PDAs are also standard issue for clinicians at the Visiting Nurses Association Home Health Systems (VNAHHS) in Santa Ana, Calif. VNAHHS now uses a pocket-sized EKG to identify post-operative cardiac patients who need additional monitoring. Approved by the FDA in May 2001, the PDA-based EKG--called ActiveECG--was developed by emergency medical technicians Jeff and Karen Siegel. The device, which weighs 6 ounces, performs the same basic functions as a full-size EKG. Three wires are attached to the patient's chest, and results are recorded through a PDA for transmittal to the cardiac surgeon. According to VNAHHS, its clinicians also use PDAs for field access to schedules, patient records, and a drug-compatibility database. On-site recording of patient visits on PDAs has cut down on paperwork, and the entire care team synchronizes information into a central database so that all clinicians have access to the most current data.