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I recall having a conversation 5 or more years ago with a colleague who was an Admissions director of a highend assisted living community.   It was around the time when I observed assisted living communities were going beyond providing “stand-by” assistance with activities of daily living (ADLs = bathing, dressing, toileting, transferring, walking and eating) and providing “hands on” care to residents in need.  Hands on care typically had been handled at the intermediate nursing care level, when a resident needed 24-hour supervision and “hands on” care with ADLs.  My colleague looked across the desk at me and said, “Andrea, the days of skilled nursing as you and I know it are dead.”  I remember that my immediate, gut reaction was, “You are crazy. Nursing homes will never disappear.”

A recent article published in Crain’s Chicago Business (August 21, 2017), titled “Out with nursing homes, in with home health care,” showcased the fact that Northwestern-owned Lake Forest Hospital, located in the affluent suburb of Lake Forest, Illinois, has plans to replace its hospital but will not include plans for building a new long-term care unit.  The reasons cited were that the “Northwestern Medicine may have found the one market where investment in longterm care has not paid off.” A spokesperson from Northwestern’s partner law firm said that “Only the sickest patients end up in nursing homes.  People 65 and up tend to find home health care and assisted living more comfortable.”

Given such trends, nursing homes may start to diminish in a community as wealthy as Lake Forest.  But nursing homes will probably always exist in one form or another.  I have to admit that among the many senior housing placements that I have completed in the past few years, the number of assisted living placements is way up, and the number of nursing home placements has decreased.   I recently reviewed some pricing for assisted living in a northwest suburb that featured help with ostomy or catheter care (a service the assisted living communities wouldn’t touch a few years ago because it was considered a skilled nursing service), hands on service with ADLs, a 2 person assist in transferring, medication assistance including help related to diabetes, chemo or radiation therapy or dialysis, and assistance with a feeding tube.  The price for this kind of care in a studio assisted living apartment is under $6,500 a month.  That pricing is well under the price of nursing home care, which on the lowest end can start at $7,000-$8,000 per month in the Chicago metro area.  So why wouldn’t someone opt for assisted living in the comfort of a private apartment vs. a semi-private room in a nursing home setting?

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My father suffered a stroke at the age of 86. He had received diagnoses of Parkinson’s and Alzheimer’s at the age of 84. As the diseases can have similar symptoms, it was very difficult to pinpoint which disease was causing his behaviors. At times he was depressed, moody, lethargic, and verbally abusive.

After the stroke, he required skilled nursing home care.  That prevented my mother from bringing him home. My mother felt an obligation to place him at a nursing home that was owned by the hospital where he had practiced as a physician for many years. That was our first mistake. We assumed that since he practiced at the hospital well into his 80’s that he would have decent care. Much to our family’s dismay, it was quite the opposite.

My story is no different than anyone else’s nursing home nightmare. But at the time, I was not yet in the eldercare industry and didn’t know any better. I didn’t know that checking the ratio of the staff to residents, observing the staff’s attitude, and watching for possible language barriers were critical components in the selection of a community.

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An article posted in National Real Estate Investor has predicated that active senior living communities and Continuing Care Retirement Communities will be the most profitable in the future senior housing market.

I was trained in a faith-based, Continuing Care Retirement Community (CCRC) that offered independent living, assisted living, and a nursing home all on one campus.  A CCRC will allow the senior to move between the various levels of care without having to move out of the building or complex, thus saving the senior and his/her family the stress and heartache of having to move a second time.  In the case of a couple, if a husband or wife requires a different level of care, placement at a CCRC will allow them to remain together in the same home.  If a resident needs short term rehabilitation, most of the skilled nursing areas of CCRCs are certified by Medicare.  The necessary rehabilitation programs are offered right there without having to temporarily move to another community.  Therefore, I wasn’t surprised to see the posted article’s author predicating that CCRCs will be one of the most profitable options for senior housing.

REAL LIFE STORY

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A client who heard me speak a number of years ago decided to hire me for an interesting project. He and his wife live in a large beautiful older home (estimated over 5,000 square feet with three floors). The couple was wondering what the potential future costs of staying in the home would be if one or both of them became ill. I generated a report for them based upon three case examples. Although I didn’t know what the current costs of maintaining their home are, I included places in the report to “fill in the blanks.” I gave the couple some general ideas of what they might need to consider in the future. Many of the future costs would vary by the dimensions of their home and the models of safety equipment chosen (e.g., stair lifts, as they had three floors). The report was meant only to give them ideas of what the costs might be, and what they might need to think about for future safety. I ended the report with a ball park comparison of what it might cost to move to one of the higher end senior living communities. Here are the results:

Case Examples

Client M had been healthy until recently when s/he was diagnosed with a serious heart condition. The client was ambulatory, but now needs a walker. Because the disease has left the client very weak, s/he needs help with meal preparation, bathing, dressing, and standby assistance with toileting. In addition, the caregiver must run errands, provide medication reminders, do laundry, and light housekeeping. All of the necessary help can be obtained through a private caregiver from a licensed non-medical home care agency. The current cost for care of the individual would be $22 per hour. The non-medical home care agency estimated that the client would need at least 8 hours of care per day, 7 days a week so as not to exhaust the spouse. Therefore, the cost of the care would be $176 per day, and $1,232 per week. The total annual cost for the caregivers would be $64,064. In addition, the bedroom was on the second floor, so the stairs would need to be modified in order to accommodate a lift, the cost of which would start at $1,600. The bathroom needed to be outfitted with grab bars, and the shower needed to be modified to a walk-in model, with the addition of a raised toilet seat. A ramp needed to be fitted to the back door, with access to the driveway. Additional support had to be hired to keep the ramp and other areas free from snow and ice. The house needed to be canvassed for tripping hazards and slippery floors.

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Elder abuse is a crime. It can occur whether your loved one is at home, attending adult day care, or living in a senior living community. And like any other crime, you have an obligation to report it. This month, I have asked one of my trusted partners, Mike and Mary Doepke of Home Helpers Home Care of Hinsdale, to share some information on Elder Abuse:

From all outside appearances, 80-year-old Shirley seemed well cared for by the niece who had moved in with her a few months earlier. She even told her friends how she was enjoying the company and the help around the house.

Shirley had always been frugal with her credit cards, using them only when needed. So when the bank called to ask her about some recent, unusual charges on her account, she was alarmed. She was even more surprised to find out that the purchases were made by the niece she had welcomed into her home.

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There are approximately 44 million Americans who are caring for an elderly loved one.   Between one and two million people over the age of 65 have been abused by someone who cares for them.  During the eleven years that I have owned my senior living consulting business, I have one story involving elder abuse that really stands out in my mind.  Here it is:

A respected colleague called me and said that a couple in their 80’s were in a very tenuous position, and asked if I would assess their situation with regard to recommending some senior living communities.  When I called and spoke to one member of the couple, I was told that he and his wife were not interested in senior living communities, but would rather speak to someone who could help them integrate back into society via participation in activities at a senior center.  He also expressed interest in having a personal trainer come into the home and exercise with them.    I told him I would get back to him in several days.

When I contacted him a few days days later with potential resources, his conversation with me went in several drastically different directions.  I felt that an onsite visit was in order, so I made an appointment with him for  visit.

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This month, I am celebrating the 11-year anniversary of the opening of Andrea Donovan Senior Living Advisors. I am hoping that I have at least another 11 years of rewarding work ahead of me. I have to chuckle because I have had so many unusual requests over the past decade, not to mention finding that special apartment for the senior who has the 90 pound Labrador that must continue to attend its current doggie day care, requests for caregivers who speak a special dialect of Indian or Farsi, accommodations for religious preferences, transportation to senior symphony practice for a senior cellist, and finding a nursing home that would allow my senior loved one with dementia to store and play her piano in her room. I figure that I have evaluated more than 450 senior communities in the Chicago metro area over the past decade and completed over 6,000 hours of research. I know that sounds like an insanely large number of hours, but how else would I be able to get the answers for my clients? Admittedly, in some cases there may only be one right answer, as I share in this month’s REAL LIFE STORY.

Real-Life Story

My clients were the child (and her husband) of a 94 year old gentleman. He had been a white collar professional, an avid musician (stringed instruments) and recently lost his spouse. He underwent some very serious cancer surgery several years ago and had recovered very well. He and his late wife had been living in a luxury condo owned by the child. Since it was located in the middle of the downtown area, it allowed them easy access to their doctors, the symphony, and shows they deeply loved. After the death of his wife, he remained in the condo with several caregivers who came in at 2 different intervals during the day. He remained in the condo alone in the evening. However, the child told me he had recently been hospitalized with pneumonia, wasn’t drinking enough fluids or eating 3 meals a day, and had fallen. The child no longer wanted him to live in the condo alone. I was also told that the senior was “putting on a good act,” and that his need for more help was being well hidden. I was told that I would need to duplicate his environment in order for a move to occur. The environment could not have an “assisted living or nursing home feel.”

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This week, I was overjoyed when a former client called me to tell me about her mother’s progress. Her mother was a young 70 when they became my clients less than a year ago. When I first met the elder during an assessment, she was at a short-term rehabilitation community and was covered under Medicare. She had been living in an independent living community with a 24-hour caregiver. A stroke had left her unable to use her left side. Then, the caregiver dropped her while she was transferring her in the bathroom and broke my client’s leg. That is how she ended up in a nursing home receiving short-term rehabilitation.

My client’s 100-day allotment under Medicare rehab was coming to an end, and she soon would have to begin paying privately. Although the care was satisfactory at the current community, she wanted a private room. This nursing home didn’t offer any private rooms. She did have the personal funds to pay privately for quite a while, even though the rate for a private room was over $300 per day. I knew, however, that since she was a young 70, and the cost of nursing home can run $9,000 and above for a private room, she would need the safety net of Medicaid if her money ran out. Because the stroke and the broken leg had left her totally disabled, she had to be transferred in and out of bed, bathroom and shower with the use of a Hoyer lift. I sent the senior’s adult children to tour a half dozen selected communities with the needed equipment, but nothing seemed to pass muster in their eyes. Either the rate for a private room was way too high, they didn’t like the Admissions Director, or the aesthetics were not what they wanted. They were being very specific about their location preference. Finally, I identified a community that was half-way in between for both daughters and had several Hoyer lifts available for the residents’ use. I was also very selective about the physical therapy that would be available to my senior client, as the daughters stated that she may want to pay privately for additional therapy. The therapists at the community were actually employees of the nursing home, not a separate agency. As a result, I knew she would have a better chance at receiving therapy from the same therapists.

When I recently spoke to the daughter, she said, “I have been meaning to call you. My mother has been moved from the nursing home (needing full assistance with bathing, transferring, toileting, dressing, walking and eating) to the assisted living area (some hands-on assistance with the aforementioned activities) of the nursing home. She can transfer in and out of bed and bathroom without the assistance of the Hoyer lift. The cost of her care was also reduced! And it is all because the therapists at this community worked so closely with her to improve her condition. Thank you!”

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When I started serving in the senior living industry over 15 years ago, all communities included three meals in the rent. Three meals were just part of the senior’s care package, whether the level of care be independent living, assisted living, or skilled nursing home.

While that still holds true today for assisted living or nursing home care, the meals/food picture has changed in the independent living landscape. Most independent living communities are offering one main meal per day, with the choice of paying for 2 extra meals on an ala carte basis. Other independent living organizations are offering “flex dollar” arrangements, where the senior is given a fixed dollar stipend on a monthly basis. The flex dollars can be used to purchase meals, haircuts in the salon, or other amenities the community has to offer.

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About one-half of the clients who engage me for my services do so after they have already selected a community for a loved one. Then, when a problem arises, they call me to help fix the problem. Unfortunately, no one has a crystal ball and can anticipate some of the unusual circumstances that can arise. Most of the time, clients are so pre-occupied with fixing the senior living problem that exists now, they do not consider what can happen in the future. Clearly no one is to blame, as it is always what we do not anticipate that causes a problem.

Real-Life Story

My clients were the children of a senior aged 78. She had been placed at a Continuing Care Retirement Community (CCRC) that offered Independent Living, Assisted living, Assisted living with a memory care unit, and Skilled Nursing care. She had a lovely apartment in the independent living area that required an entrance fee of more than $200,000 when she moved in.