Long-Term Care

San Francisco District Attorney’s Office launched its Senior Pedestrian Safety Campaign by posting these “Drive Slow” and “Seniors Crossing” banners on streetlight poles near senior communities, in honor of Elder Abuse Awareness Month in June.   

Beware of seniors … especially if loaded guns are in the home! While checking my email account on July 4, I was distracted by this Yahoo! News headline: “'You Took My Life, So I'm Taking Yours.' Woman, 92, Allegedly Kills Son Who Tried to Put Her in Assisted Living.”  I wanted to go beyond the sensational headlines to understand what happened.  Was 92-year-old Anna Mae Blessing a victim of elder abuse? Did she shoot her 72-year-old son in self-defense because he threatened to put her in assisted living? Was her desperate act to avoid assisted living preventable? 

As I read reports from other sources, I noticed the media often confused assisted living with nursing home:

·       Biz Pac Review: “Anna Mae Blessing, 92, charged with murdering son because he was going to put her in a nursing home” 

·       CBS News: “13 guns found in home of woman, 92, who allegedly killed son over nursing home dispute”   

·       Patch: “Arizona Mom, 92, Kills Son Over Nursing Home Plans” 

·       Slate: “92-Year-Old Woman Allegedly Killed Son Who Wanted to Send Her to Nursing Home” 

Then I read readers’ comments that ran along the lines of:

·       If she did all this without assistance (after shooting her son, “she bent down to check his pulse,” and “before police arrived, Blessing walked back to her room and sat in her recliner, intending to kill herself”), she definitely is not a candidate for assisted living.

·       She’ll get the shortest life sentence in history.

·       Now she’s really in assisted living supported by the state.

·       Assisted living is luxury prison.

·       Caveat – “note to self: don’t send mom to assisted living,” or “I forwarded this story to my son, and said remember this in the years to come.”

While the investigation of Anna Mae Blessing’s case continues, the related issue of long-term care (LTC) planning affects us all.  More than half of Americans age 65+ will develop a disability serious enough to require LTC.  Like Anna Mae Blessing, most people want to age in their homes and communities, and avoid institutional care. 

LTC is labor-intensive, consisting of informal care by family/friends (often unpaid) and formal care through paid caregivers, adult day care centers, home healthcare, assisted living, memory care, or (often spending down resources to qualify for Medicaid payments which pay for) nursing home.  
Effective July 1, 2018, San Francisco’s hourly minimum wage increased to $15, the highest in the nation.  This pay rate boost is expected to benefit minimum-wage workers such as domestic workers, janitors and food preparation help – typical positions in LTC work – and lead to reduced employment (giving employers incentives to produce what they can with fewer unskilled workers, through slower hiring).    

“…underpaid women who clean our homes…, prepare and serve our meals, and care for our elderly—earning wages that do not provide enough to live on—are the true philanthropists of our society.”

—Barbara Ehrenreich, “It is Expensive to be Poor,” The Atlantic (Jan. 13, 2014) 

According to AARP, private nursing home costs in 2012 averaged 252% of the median household income for those ages 65+, while the cost of home health services (30 hours per week) averaged 88% of median income.  The Aging Services Network has developed home- and community-based services (HCBS) as less expensive alternatives to reduce dependency on nursing home care and to address quality of life issues for older adults who wish to remain as integrated within their communities.  

Gray Panthers’ meeting, Looking at the Many Forms of Long-Term Care, featured panelists: Teresa Palmer, MD, geriatrician; Katie Owens, Advanced Approach to Senior Care Director who connects clients to LTC providers; Benson Nadell, LTC Ombudsman; and Michael Lyon, Gray Panther advocate of universal LTC who shared Health Affairs article, “Long-Term Care: Who Gets It, Who Provides It, Who Pays, and How Much?” 

Dr. Palmer, who practiced geriatrics for over 35 years, including 15 years at Laguna Honda and 10 years at On Lok, presented on Basics of LTC with data provided by San Francisco Department of Public Health:

·       LTC provides services to meet medical and non-medical needs of people with a chronic illness or disability who cannot care for themselves.  Medical services include skilled nursing (e.g., wound care, IV injections), rehabilitation (speech, occupational, and physical therapy), medication management, durable medical equipment, health promotion/disease prevention, hospice care.  Non-medical services include assistance with activities of daily living (ADLs, such as dressing, bathing, toileting, eating, transferring), home-delivered meals, transportation, home repairs and modifications, financial and/or legal services.

·       Optimally, post-acute care (medical services that support recovery from illness after a hospitalization) is provided in home- and community-based settings whenever possible, and the majority (64% + 15% with home health) of patients are discharged home after a hospital stay. 

·       Some (9%) patients who cannot be safely discharged home rely on skilled nursing facilities (SNFs) to receive post-acute care, 24/7 medical care, which can be paid from Medi-Cal or Medicare (short-term only); average cost is $11,700 to $14,200 per month.

·       Residential Care Facilities for the Elderly (RCFEs, such as “assisted living” and “board and care”) provide 24/7 supervision and are paid out-of-pocket.  Since RCFEs are non-medical, no insurance covers this level of care; average cost is $4,300 per month, and few to no facilities accept Social Security.

·       While our aging population with LTC needs continues to grow, the supply of beds in SNFs (especially closure of CPMC’s 79 SNF beds at St. Luke’s , plus shutdown of 25-bed Swindell’s Alzheimer’s Residential Care Program) and RCFEs continues to decline. 

Benson, who has been San Francisco’s LTC Ombudsman since 1986 (or 32 years), presented, “What does a Gray Panther need to know?” 

·       LTC Ombudsman investigates complaints or allegations of abuse/neglect in LTC facilities, and often refers to licensing agency for enforcement (California Department of Public Health for SNF, California Department of Social Services for RCFE). 

·       Common complaints for RCFEs include poor coordination of care with professionals in the community; yelling and verbal abuse of residents; failure to take persons to appointments; sub-standard food choices; evictions for running out of money (e.g., Benson mentioned 98-year-old resident with $2,500 monthly income paying $7,000 monthly to Assisted Living); taking person back from hospital without screening; labeling complainers as difficult rather than looking at content of complaint; and staffing numbers not adequate, poorly supervised and trained.

·       LTC Ombudsman also monitors closure/ownership transfer of LTC facilities.

Panelists discussed the sad state of memory care, which are mostly locked facilities to “redirect” “wandering” or “elopement,” often lacking true person-centered care for residents with different stages of memory loss.  Some families pay over $10,000 per month for Memory Care, and their visits are needed to monitor proper care of residents by staff.  For example (true incident from my very brief stint in Memory Care), after a resident’s daughter asked why her father was served water and deprived of juice, it was discovered that the Food Restrictions Cheat Sheet which identified residents by their room numbers (instead of personal names) mixed up her father’s diet of NO NUTS with another resident’s diet of DIABETIC/NO SUGAR … and the diabetic resident who was served juice and other sweets later died of a stroke!

During the Aging in America conference in San Francisco, Benson asked why call a place Memory Care when it includes residents without memory problems? While I don’t agree with this practice, Assisted Living residents who have higher care needs (such as recovering from a stroke or adhering to strict diet, yet no memory issues) are transferred to Memory Care, which has higher cost due to staffing levels to assist with ADLs and locked facility to prevent residents from accessing forbidden foods; this practice then frees up space to accommodate wait list for Assisted Living.

This state of formal LTC—bed shortages, high costs, inappropriate care, etc.—sounds like doom and gloom.  But each time I see someone looking refreshed from a stay at Jewish Home & Rehab Center, I think I need to check myself in there to look and feel so good!  No one mentioned the expansion of Jewish Home to San Francisco Campus for Jewish Living, based on proposed Robin Hood model to use new high-end independent and assisted living units to subsidize SNF which has been dependent on dwindling Medicare/Medicaid.  Competition that offers more choices is a partial response to the wait lists.  Age and Disability Friendly San Francisco included this recommendation:  Identify the challenges faced by residential care facilities and develop recommendations that will support and expand their capacity. 

Assisted living residents tell me they're not living at home because they are at the mercy of staff to get through ADL and must adjust to community living, including waiting turns to get on elevators and avoiding potential injuries as others using wheelchairs and walkers navigate common areas.  Unlike home care, where one can replace hired help, assisted living residents tolerate their situation because where else can they go when there are wait lists?

Enforcement of existing regulations at SNF and RCFE may not improve care because regulators do not want to discourage business of LTC facilities with penalties.  

Flower Piano at San Francisco Botanical Garden.  For myself, home should include easy access to nature: fresh outdoor air and plants.  I wonder whether Anna Mae Blessing had an opportunity to tour assisted living facilities? The internet offers many evaluation checklists from 

·       Aging Parents and Elder Care 

·       CANHR  

In Journal of Aging Research article, “The Factors Influencing the Sense of Home in Nursing Homes: A Systematic Review from the Perspective of Residents,” a study of 17 articles identified three main factors:  

·       Psychological (behavioral, cognitive and emotional): sense of acknowledgement, preservation of one’s habits and values (personal routines, moments of privacy), autonomy and control (perceptions of freedom and mobility, voluntary move to LTC, shared decision-making), coping (emphasizing advantages of living in nursing home, such as safety and receiving prompt emergency help)

·       Social (home as place of connection and socialization): interaction and relationship with staff (attentive, individualized care; available, reliable, flexible, physically and emotionally accessible, reciprocity), residents, family and friends, and pets; activities (engage with community to preserve continuity with past and society)

·       Built environment (layout, interior design, surroundings): private space and (quasi-)public space (smaller residential density increase perceptions of belonging, place to walk), personal belongings (help create attachment to place in nesting and being in charge), technology (improve ease of life and being in charge, TV link to outside world and distraction), look and feel (architecture, interior design, maintenance), and outdoors and location (connection with nature, balconies and views from room)

One researcher identified two situations that support the process of feeling at home: “haven” (place that is secure, comfortable and predictable) and “heaven” (place where you can be who you are and feel connected with like-minded people).