Changing Aging

Yoga.  Massage.  Tai Chi.  A salt-water pool.  Personal trainers.  Bike racks.  And a Wii machine.

What could be mistaken for an upscale spa or gym is actually a glimpse of the future of aging unfolding in Chisago City.    Read the Minneapolis Star Tribune article on the Vitalize! Wellness Centre at Ecumen’s Parmly LifePointes community.  Or see the Vitalize! video here.

Sometimes leadership isn’t easy.  Sometimes you get arrows shot at you.  That’s what happened to our colleagues at the Ecumen community of Lakeshore in Duluth, Minnesota (and all of us who are working on creating new and better aging services) in an ugly article on the front page of Sunday’s Duluth News-Tribune by a reporter who doesn’t hold the same crystal ball that we do . . .

What We See in Our Crystal Ball

- A U.S. health care system that is completely integrated (a real system, not a bunch of fragmented “stuff”) and provides the right care at the right time in the right place.

- A care system that doesn’t unnecessarily institutionalize people.  This happens too often, draining a person’s will and public dollars.

- Nursing homes that are specialized medical respite centers for rehablilitation and chronic care management, not under-funded, antiquated institutions where someone recovering from a hip replacement shares a wing with an Alzheimer’s patient (which also happens all too often today).

What We Did Because of What We See

- In Duluth, we tore down a 1950s-style nursing home.  Instead of selling the valuable Lake Superior shorline to a developer, we built a new neighborhood (but also a new way to deliver services) that has a short-term care and rehabilitation center, independent living, assisted living and memory care apartment homes. 

- We serve many different people there (and all incomes) but our short-term care center is exactly that, it’s for short-term stays.  It fills a service need in the community that wasn’t served previously. We want that short-term care center to be known as the place where people come to to get better and go home.  And we’re succeeding.

- If a person needs long-term intensive care, we coordinate that at an Ecumen-managed nursing home in Duluth: Bayshore.  Of the 700 people we served in short-term care last year, only 30 went to a nursing home.  The rest went home or to assisted living.  This is moving toward an integrated system that we envision.

- Because there is no federal classification for this new short-term care and rehab product, we have to license it as a “skilled nursing facility” or a nursing home.  We don’t want to create another nursing home.  Duluth has plenty.  Consequently, we’re decertifying from Medicaid, which pays for most Americans’ long-term care nursing stays.  We will continue serving all income levels at Lakeshore’s short-term care center, but we’ll do it under Medicare.  People who want to stay beyond their Medicare benefit will have the option to pay just as they would do if they wanted to stay in a hospital beyond their regular stay.  Fact is most people don’t want to stay in a hospital or at our short-term care center long-term because they want to go home.

This is the right approach to get to the vision we see in our crystal ball.  You can read the reporter’s interpretation below.  This isn’t the case where the truth lies somewhere in the middle.  He missed the story.

What the Reporter Saw

“They felt they could make it work,” Peer said. “I thought, ‘That’s not what I’m seeing, but I’m not the expert.’ ”

About 10 days later, Wick had another stroke. He’s now in a nursing home where he can’t swallow, eat or breathe on his own. He’s only 68.

“I’m hoping that the stress of the placement didn’t contribute to the stroke,” Peer said. “It’s a time when there are massive changes in a person’s life. But you trust the personnel at the home.”

While Peer wanted her brother to stay longer at Lakeshore, she said that was never presented as an option — a violation of federal law, according to Bob Daly, a manager of long-term care enforcement for the Centers for Medicare and Medicaid Services.

Though Lakeshore says it’s a short-term rehab center, it’s still licensed and registered as a skilled nursing facility. That means that Lakeshore has to provide the same type of long-term care that one would expect from a nursing home, Daly said — it has to allow people to stay there as long as they want and can afford to pay.

“They should have nursing services able to focus on people who don’t really need short-term rehab,” Daly said. “People who are older and slowly declining in their functions should be able to stay there.”

After getting a tip those services were not available, the Minnesota Department of Health investigated and found that nearly a dozen patients were discharged and sent to other nursing homes to receive care that Lakeshore should have provided. One resident was discharged from Lakeshore for being too confused, after being there for only one night. Another resident was discharged for having dementia. Another was discharged for frequently falling.

Though no actual harm came to the patients, the report noted, all those discharges violated federal law.

Officials who manage Lakeshore contend that, in the case of the violations, they did nothing wrong. In fact, they say, Lakeshore was doing what it is supposed to do: send patients who need that type of care to places better-suited to provide it.

But Daly said that as a licensed skilled nursing facility, Lakeshore has to provide services one would expect from a nursing home.

“There was no reason for this facility to discharge these residents to other facilities,” he said.

CHANGES TO BUSINESS MODEL

This was the first time Daly had heard of a case like this.

“I know that the nursing home industry in many instances is focusing on the short-term rehab patient,” he said. “But we’ve never had a case that I know of where a facility was actually discharging people because they didn’t meet that business model.”

Lakeshore is managed by the nonprofit Ecumen, one of the country’s largest nonprofit senior housing companies. Ecumen leadership stresses that Lakeshore is not set up to provide long-term care anymore. Instead, they describe their facility as a new model of care designed to get recovering patients back to their homes as soon as possible.

The services they provide are unique in the Duluth area and were developed in response to local demand, they say.

“The nursing home that used to be called Lakeshore is gone,” said Eric Schubert, Ecumen’s vice president of communications. “We don’t have a nursing home there anymore. We built a new product. It’s a short-term-care rehab center. It’s not a long-term-care center.”

Patients who aren’t making progress in rehab belong in traditional nursing home facilities, said Mick Finn, Ecumen’s vice president and chief of operations. Finn said Ecumen essentially has been forced to be licensed as a nursing home because there’s no licensure for a short-term-care center or any facility that fits their business model. In essence, they say, federal policies haven’t caught up to their product.

“We were hoping we could be accommodated in the current licensure system and it turns out that we cannot be,” Finn said. “So, you know, our bad.”

But Darcy Miner, who manages compliance monitoring for the Minnesota Department of Health, said that though Lakeshore may say it’s a short-term care facility, “it’s still certified as a skilled nursing facility.”

“As such, they need to accommodate residents who develop long-term-care needs,” Miner said. “This raises a lot of very interesting questions, to say the least.”

Lakeshore, or any other adult care center, must be certified as a skilled nursing facility if it wants to get Medicare reimbursement. Medicare will cover the cost of rehabilitation, room and board for up to 100 days. After that, patients must pay for services through private insurance, private dollars or Medicaid, which covers long-term care for those not able to afford it but doesn’t reimburse providers at as high a rate as Medicare does.

That Lakeshore is still licensed as a nursing home and has to provide long-term care is a surprise to some in the medical community who refer patients there.

“They made a public showing that they were getting rid of their long-term beds,” said Dr. Paul Sanford, an internist and chief of medicine at St. Luke’s.

Sanford said he believes Lakeshore has provided exemplary care, but he doesn’t understand why patients who need long-term care are being admitted. For them, he said, he worries they might be discharged too soon.

“It’s a real ethical issue,” he said.

Peer wonders if that’s what happened to her brother.

“If they were anxious to get rid of him — if they weren’t 100 percent sure or at least weren’t very certain that he could succeed somewhere else — and they encouraged it because they wanted wealthier people,” she said, “then I’m very distressed by that.”

CHANGING TO ADAPT

It is no secret that most traditional nursing homes across the state and the country are struggling financially. Since 2000, 50 homes have closed in the state, according to the Minnesota Health and Housing Alliance. About a third of all the state’s nursing homes are in danger of closing, according to the Long-Term Care Imperative, an advocacy group for nursing homes.

Daly, of the Centers for Medicare and Medicaid Services, said that’s why more homes have turned to short-term care models to improve revenues.

But some health-care experts speculate there might be financial incentive for Lakeshore to continue to be registered as a nursing home.

Jennifer Schultz, a health-care economist at the University of Minnesota Duluth’s Labovitz School of Business and Economics, reviewed Lakeshore’s deficiency report from the state as well as the tip letter sent to the state, which the News Tribune obtained, and felt that Lakeshore could be targeting patients in need of care that is reimbursed at higher rates.

“What I think they’re doing is they’re keeping patients as long as they need expensive rehab services that can be reimbursed at a higher rate, and then it looks like they’re transferring them to other nursing homes when they don’t need that level of skilled services and don’t get that level of reimbursement,” Schultz said. “I would say this looks suspicious and needs to be investigated.”

Still, she said, Lakeshore is doing what would be expected of a business trying to stay profitable.

“It’s an incentive setup to conduct that type of behavior,” she said. “And if it’s operating like a business, it’s maximizing revenues. You would expect them to game the system that way.”

Jill Klingner, an assistant professor of health care and operations management at the Labovitz School of Business, also reviewed the report and tipster letter and concurred with Schultz.

“They just want to keep the people that don’t need help with daily living,” she said. “They want to keep the people they can provide rehab to that they can bill additional charges for.”

A business model of this type isn’t illegal, Daly said, but patients can’t be discharged if they want to stay and can pay for it.

Lakeshore administrator Paul Libbon flatly denied that the facility is only seeking higher-reimbursing patients. The only patients they’re seeking, he said, are those seeking short-term care.

NO LONGER WILL TAKE MEDICAID

Both the state health department and Ecumen leaders said steps have been taken to ensure that similar violations don’t happen again. Ecumen now provides information to new patients that they can stay and receive extended care at the home.

But administrators still insist that Lakeshore will only provide short-term treatment. To avoid getting patients seeking long-term care, Finn said, Lakeshore will no longer accept patients on Medicaid, or patients with low incomes.

For those patients, under general reimbursement rules, that means they likely can only stay at Lakeshore for 100 days — or the amount of time Medicare will cover 100 percent of costs before Medicaid payments kick in.

To some, that poses another line of questions. Ecumen is affiliated with the Evangelical Lutheran Church in America and raised money for the center’s renovation by saying it would help provide charity care.

“Given that the community made contributions to this charitable organization, what was the community’s idea about the facility?” Klinger asked. “Did the community know this would be a high-end facility that, if you couldn’t make improvements, you’d have to go somewhere else, and they wouldn’t allow just anybody in?

“It looks ugly. It sounds ugly. It is ugly.”

The ELCA referred questions to Lutheran Services in America, which declined comment.

But Schubert said Lakeshore provides thousands of dollars in charity care.

“We’ve served a ton of low-income people that come through here for short-term rehab,” he said. “When short-term rehab is done, they can move on to places that provide people with long-term care.”

Libbon agreed, noting that Lakeshore provides home-delivered meals to 100 seniors in Duluth, provides computer training to seniors and accepts Medicaid clients at the campus’s Assisted Living facility.

“It’s about what do people want,” he said. “We are fortunate to have this in the city of Duluth.”

Christian Scientists might soon bring one of the country’s smallest nursing homes to Minnesota and continue the “Not So Big House” Movement in long-term care and aging services.

The city of New Brighton, Minn., has approved the nonprofit’s preliminary plan to build a small, six-bed care center next to the First Church of Christ, Scientist.  It would be 10,000 square feet.  The faith’s form of nursing care doesn’t include medications but covers personal and bedside care, cleaning and dressing wounds, and spiritual support. 

Approval of the final plan is expected within the next couple of months.

For our readers who are nursing home professionals: 

Mary Leber, who heads Ecumen’s consulting division, which works with many long-term care and senior housing providers, has provided key tips for nursing homes preparing for the Quality Indicator Survey (QIS).  You can download the QIS tips and other articles here.  If you have suggestions on other articles , please let us know here.  Thanks.

FYI for our readers in the long-term care profession . . . In March and April, Ecumen is providing two courses at several sites in Minnesota and Wisconsin.  One focuses on a huge topic in the news lately: psychoactive medications and the other on optimizing reimbursement, which is always a big topic in long-term care. 

 You can learn more about the upcoming courses and sign up here.

If you get a second, read the large article that was in this Sunday’s New York Times, about the surge in private equity firms taking over nursing homes. 

Beneath the text is an underlying question for America:  Should older Americans be cared for as commodities or as people? 

Interested to hear your thoughts on this article and what it says about the state of long-term care in America.

Michael Graves, the renowned designer who has created many cool wares for Target, was in Minneapolis this weekend to receive the National Courage Award from the amazing  Courage Center, which empowers people with disabilities.  

When he received his award, he commented on the people in the audience with wheelchairs and walkers, saying “I love it, welcome to what will soon be the new normal.”  He, of course, is talking about the age wave.  Michael Graves became paralyzed three years ago when he contracted a viral infection.  It changed his life and, undoubtedly, because of that, he’s going to change the lives of many others.

In a great article in Metropolis Mag, journalist John Hockenberry describes Michael Graves’ personal transformation . . . .After a lifetime of seeking beauty in everything he designed and obsessively making sure every detail in his physical space was selected to be purposeful and beautiful, he was suddenly trapped in a world of ­mundane medical objects. “Everything was ugly,” he says. “Nothing was designed. It seemed as though the makers of these objects never had to use them. There was no color, no style; nothing about any of the objects said that a human had made them. It was outrageous.” Graves said he once had his doctor come into his hospital bathroom, where he was trying to shave from his wheelchair: “ ‘Who designed these bathrooms?’ I asked him. He said, ‘Experts.’ I said, ‘Oh, really,’ and I had him sit down and look at himself in the mirror, which was too high, and then turn on the water, which was out of reach. It took him two seconds to get it.”

“People who become disabled have to radically redesign their outlook about the physical world,” Graves says, remembering the first days after he was out of danger and learning to live with paralysis. “They redesign their sense of privacy and their sense of independence. Yet in the products they have to use, design has abandoned them.”

Out of personal experience and vision, Graves has founded a new venture called Michael Graves Solutions, which brings smart design, style and elegance to products that help people live fully.    Here’s a sampling of what is coming out of Michael Graves Solutions:

Tub Rail
This height-adjustable tub rail is part of the first batch of medical devices by Michael Graves Design Group that debuted last year. The rail clamps onto the tub with a metal bracket, which the orange knob adjusts. “When-ever we can in the products we try to use the orange color to signify ad-justment,” director of design David Peschel told Metropolitan Mag. The orange rings on the handle pop off to allow it to be raised or lowered (there are four height settings). A soft rubber grip is overmolded onto the blue plastic, and a flexible white TPE rubber cover is available—it conceals the metal base and has two recessed surfaces for soap or other items. 

Bath Seat
“The bathtub is a pretty scary environment for a lot of people,” Peschel says. This white plastic bath chair is designed to have a soft rounded look—harmonious with common bathroom elements—but also be extremely sturdy. “We wanted it to give off a character that it’s very strong and can support a lot of weight,” Peschel says. The design team achieved this by making the chair wider across the seat and back, and by attaching nonslip rubber end cups to the feet that have a patterned bottom surface to allow water to flow underneath, preventing suction to the tub surface. The seat also has a molded nonslip wave pattern (Graves’s sketch, above right) and built-in handles on the sides. 

 Shower Heads
Graves Design developed two handheld shower-spray products, both in white injection-molded plastic with blue overmolded rubber grips. The smaller one was designed to fit in the palm of the hand; people with arthritis or dexterity problems can comfortably use it without a tight grip. A swivel connector at the base allows the unit to spin without twisting the attached hose (it also fits into standard shower holders). —

Some policymakers are starting to feel the ripples of the age wave and how it will impact America.  Whether that impact is good or bad, will depend on the actions we take today.

When you look at the Ecumen Age Wave Study, you can see how aging is a great opportunity for policymakers to have a hugely positive impact.  Successful aging is an American issue, not a Republican or Democrat issue.

According to Kristine Gerencher at cbsmarketwatch.com between January and June Congress introduced 14 bills that would positively impact family caregivers or those they care for.

Last week we talked about legislation introduced by Minnesota Sen. Amy Klobuchar.   Today she had an op-ed appear in the St. Cloud Times addressing senior care.   The text of which is below.  

Minnesota Senator Norm Coleman also is taking a look ahead, seeing the substantial role that technology can play in successful aging and senior care, he introduced in February legislation that would create a consortium to foster development of technologies that would enhance independence, health and lower costs.  The age wave is coming . . .

Minnesota and the nation will soon experience major changes as the baby boomer generation reaches retirement age and as more Americans live into their 80s and beyond.

We know seniors want to be able to live independently and stay in their own homes as long as possible. Families, especially adult children, are essential in helping to make this happen.

It is already a big issue for many families, and it will only get bigger.

The number of Minnesotans older than age 65 is expected to double from 2000-30, approaching a quarter of the state’s total population.

At the same time, the number of Minnesotans available to care for them will shrink. Although suburban communities will experience the most dramatic changes in the future, the impact is currently most serious in rural Minnesota.

Most senior care comes from informal caregivers. Adult daughters and sons are increasingly responsible for helping their parents with tasks ranging from the mundane (like shopping for groceries and helping with chores around the house) to the more intensive (like managing personal finances and helping to make major health care decisions).

Many caregivers belong to the “sandwich generation.” They support their aging parents while also struggling to raise their own children, sandwiched by competing demands for caregiving.

Caregiving can be an overwhelming responsibility for many families. It can be an exhausting and endless job. It does not get easier over time. As a result, many caregivers develop physical and mental health problems.

Caregiving also comes with serious financial costs.

Most caregivers report taking time out of the work force, cutting back on hours and turning down promotion opportunities.

One recent study found women who provide care to an aging parent suffer about $8,600 per year in lost wages and benefits.

Family caregiving also has a significant impact on our economy, costing businesses an estimated $33 billion annually in lost productivity.

For all of these reasons, I am introducing federal legislation to assist our family caregivers.

First, I want to provide financial relief by expanding the existing federal Dependent Care Tax Credit so families can claim tax credits for expenses incurred caring for their aging relatives who do not live with them.

Families will be eligible for up to $1,200 in tax relief per year. While this will by no means cover all elder care expenses, it is a start.

Second, I want to enhance support for family caregivers by promoting best practices in quality, coordinated care and by providing more direct support for family caregivers.

The legislation will establish a National Caregiving Resource Center where families, public agencies and private organizations can learn about best practices and promising innovations.

This legislation will also bolster support for the National Family Caregiver Support Program, which helps fund direct services to family caregivers.

Third, I want to protect consumers and make it easier for families to prepare for their needs by requiring more accountability from the long-term care insurance industry.

About 8 million Americans have bought long-term care insurance to protect themselves and their families.

But one of the biggest complaints is the denial of benefits.

The only recourse for consumers right now is to go to court, which is expensive and time consuming when people are most vulnerable and in need.

My legislation will provide consumers with the right to have their claims reviewed by an independent board.

These proposals represent small steps in addressing the needs of our nation’s caregivers. But they are important steps, and I hope more will follow. …

This approach is good for our seniors, our families and our businesses.

And, because providing care to seniors at home is far less expensive than in a nursing home, it is also good for all of us as taxpayers.

Two-thirds of baby boomers told us in our Age Wave study us that their ideal situation if they need care as seniors is to have it at home with a mix of family caregivers and professional caregivers. 

Look below at the “language” HouseWorks uses.  It is all customer-focused.  HouseWorks is a Massachusetts-based home care company that has set out to completely differentiate itself from others in their marketplace.  They highlight that they provide the best home care services, whereever “home” is, including one’s condo, single-family home, assisted living community, or nursing home.  I’ve highlighted a few areas below from the “about us” section in their website where they use language differently than most home care organizations and further differentiate HouseWorks for their customers. 

From the beginning, HouseWorks was meant to be a different kind of private-pay home care company — more flexible, more reliable, and more responsive than any of its predecessors.

A better home care solution for seniors and their families

Founded in 1998, HouseWorks is a local company dedicated to helping seniors live independently, no matter how challenging their circumstances. Today, HouseWorks is fulfilling its mission by providing the most responsive and reliable home care services in Eastern Massachusetts.

HouseWorks’ fundamental innovation has been its entrepreneurial approach to service delivery, a customer-driven approach that returns a sense of control to adult children and their elderly parents. Rather than telling customers what they can or should have, HouseWorks listens to what they want and bends over backward to meet their needs. HouseWorks’ professional staff makes a direct connection with adult children of aging parents, speaking to them as peers and respecting their point of view.

HouseWorks’ dedication to helping seniors live independently goes beyond providing great home care services: it also means giving back to the community and forming active affiliations with organizations that share our commitments. Through the company’s remarkable growth and community involvement, HouseWorks is realizing its vision.

Two different approaches to Alzheimers:

A.  If you get a moment, please visit Kathy Hatfield’s blog at www.KnowItAlz.com.  Kathy is a caregiver in North Carolina.  She is the primary caregiver for her 79-year-old father who has Alzheimers. Earlier in his life, he was a stockbroker in New York City.   Her daily accounts are insightful, warm, compassionate and bring a genuine light-heartedness that only a caregiver could bring.  What you take away is that “yes” her father has lost much of his memory, but he is still very much her father, a human being, and someone who is still very much alive. 

Aging is all about living  . . . . even at the very end of life.  Thanks for sharing your blog with us Kathy.

B.  The New York Post, a tabloid newspaper recently broke a story that New York Yankees owner George Steinbrenner reportedly has Alzheimers.  The Headline:  Tragic Madness of King George.  Peter Himler writes about it at his blog The Flack.  Other blogs also hopped on this, using terms of senility, maddness, etc.

Last month, Post sports columnist Phil Mushnick wrote that, “All reasonable signs indicate that [Steinbrenner's] dementia . . . is now so profound that he is being carefully hidden from public view.”

Getting Rid of the Stigma

George Steinbrenner is a public figure (and one that a lot of people don’t like) but let’s get rid of the potshots and embarrasment that seem to be attached to losing one’s memory. Kathy hits it head on and doesn’t “put her father in the closet.” 

Unless a cure is found, many of us reading this today are going to have dementia or Ahlzheimers.  Consider these stats from the Alzheimer’s Association:

- 26.6 million people worldwide were living with the disease in 2006.
- Researchers predict that global prevalence of Alzheimer’s will quadruple by 2050 to more than 100 million, at which time 1 in 85 persons worldwide will be living with the disease.
- More than 40 percent of those cases will be in late stage Alzheimer’s requiring a high level of attention equivalent to nursing home care.