Living Environments

Chapter 10

1. Concept of Home

Most people have a social connection to home. Home signifies independence, family connection, familiar routine, and comfort, because it is a territory we have each  built. Where one lives also defines, to some extent, who we are. For example, it might reveal :

• if we are a city or country person 
• our love for gardening or music
• our hobbies or special talents and skills
• our educational level (books, art, or collectables)
• family composition (family pictures, furniture, sports equipment, or if 
  you're an an active young adult or grandparent)
• what you collect and value often points to who you are and much more

 

1. Did you know that 75-80% of elders own their own home, and live alone?
   
   1. It's true. Most older adults own their own homes. Many would like for someone to come and live with them, but most are not willing to give up their dwelling. In fact, the ownership rate is higher for older adults than it is for other age groups. However, the cost of maintaining that home is higher (Can you guess why? read on).
      
      In surveys of older adults, they overwhelming note that they want to age in place. This means to live where they have always lived. When caring for older adults who want to age in place, the goal should be to assist them with staying in their own home for as long as possible. 
      
      What might keep elders from being able to live in their own homes until they die? Well, lack of adequate assistance with ADL's, inability to navigate safely in the home, and costly repairs are a few examples. Because the houses of older adults are usually older too, roofs, plumbing, fences, etc., need more frequent repairs . However, the most common reason elders must leave their own homes is inability to get up unassisted at night to use the bathroom. One can often find daytime caretakers, but reliable and adequate nighttime help is both costly and difficult to  find. 

Did You Know?

Many elderly take diuretic pills (commonly known as water pills) to help control blood pressure and other heart conditions? The effect of this medication is frequent trips to the bathroom to urinate. That's what the drug is supposed to do-- pull excess fluid out of the body. 

This pill can mistakenly be given in the evening resulting in multiple trips to the bathroom all night long. It exhausts both the elderly person and the caretaker. So, be sure to ask the doctor if diuretics or water pills can be given in the morning, and check to see if you can delay a dose for a special outing or special occasion day.

back to top

 

2. Problems With Aging in Place:
   
   1. As you have seen when we studied finances, when a spouse dies, the surviving spouse may have financial problems. Loss of pensions and reductions in Social Security and other forms of income can place a hardship on maintaining independent living.
      
   2. This financial burden can especially affect older adults with older homes in need of costly repairs to maintain. Trying to find reliable and professional house repair also becomes an issue. Too often, unscrupulous contractors cheat unsuspecting older adults out of cash and leave repairs undone. 
      
   3. Family homes can suddenly become too large to take care of. Many elderly close up entire top floors or rooms of their homes because they are no longer accessible and too costly to heat and maintain. In Nevada City, where I was a public health nurse for many years, I often found frail elderly living in their kitchens and dinning rooms. The entire house had become to large to navigate, heat, and maintain.  
      
   4. Aging in place can also become an issue with failing health and increased needs for assistance. Live-in helpers are almost impossible to find in most communities, and the cost of 24-hour custodial care (help with ADL's) can run $10-$25 per hour. Do the math! At $10.00 per hour that's $240 per day, or more than $7,000 per month. 
      
   5. Homes where the elderly raised their families often are in older neighborhoods that have deteriorated. The fear of crime keeps many elderly indoors. These neighborhoods also lack activities in which the elderly can be involved. These factors often create a sense of isolation for elders in their own homes and feelings of loneliness. In most instances elders looking for a live-in helper out number helpers available for hire. 
      
   6. Because deteriorating neighborhoods can also increase the chance of crime it may not be safe for some elders to age in place. 

       

II. Environmental Needs When Aging in Place:

1. Service

Elders may need help with everyday livings skills (ADL's) to remain at home. There are a variety of programs to assist. These include Older American Act programs (remember the aging network and the Area Agencies from week one's handouts?). Services might include: home delivered meals, lifeline (the "help I've fallen" buttons), chore workers, homemakers (for meal prep and housecleaning), utility bill and weatherization programs.

To find a specific service, call the local Area Agency on Aging or the California 800 elder care locator number: 800-677-1116. You can also use an internet search engine using the key words "elder care locator" and the city where you want services.

2. Safety

Older homes may need adaptations to prevent accidents and to prolong independence.

1. Physical Needs: Aging bodies often can adapt to an environment and remain independent with assistive devices and someone to assist coordination of their use. These include:

• eyeglasses
• hearing aids
• dentures
• canes, walkers, grab bars, high rise toilet seats, and shower chairs
• telephone and doorbell amplification, brighter lighting
• clothes that open in front (especially bras and tops for women)

Please refer to your handout

1. Home safety checklist

back to top

3. Relocation Patterns

   Younger people simply think of skilled nursing as the only option for  elders leaving their homes but over the last 20 years there has been an increase in the options that bridge the gap between home and a nursing home (nursing homes are also referred to as a skilled nursing facility or SNF, because the facility offers nursing care and not just custodial or ADL care).

    

A. Typical Relocation Patterns While Active:

 

1. First Move - (age 60 or more)
   The first move is usually to a rural area or vacation spot to be closer to recreational amenities or retirement communities, or to be closer to preferred climates. When these elderly relocate, they often leave long-time neighbors and support systems.
   
   This population may also engage in seasonal moves. Elders who go south for the winter to escape the cold are referred to as snowbirds. When they move north in the summer to escape the heat, we refer to them as sunbirds. 

    

2. Second Move - As functional ability declines, elders typically move to the suburbs or city to be closer to family or children, and to be closer to hospitals and services. Ties to familiar neighborhoods and dependence on children are often motivating factors. If an elder has been even lightly confused, the confusion may increase when relocated. For this reason, consider all possibilities before relocating a confused older adult. 

    

3. Third Move -This move is typically to a higher level of care or Long-Term Care (LTC) as health deteriorates and frailty increases. Types of long-term care are discussed below. 
   

2. Long-Term Care Defined

Traditionally LTC was defined as skilled nursing care and meant that one was institutionalized. Today it includes all the services and care an elderly person may need during the end stages of life. These services can be provided in a facility (institutionalized care) or in the community (non-institutionalized care).

back to top

1. Non-institutional or community-based care can include a host of supportive services designed to help the elder age in place. 
   
   These services include:

• custodial care ( ADL assistance) also called supportive care (described below)
• home delivered meals
• a chore-worker
• transportation
• home care; This includes skilled nursing care, requiring nursing or medical intervention, provided in the elder's home.  

Custodial and Supportive Care means hands-on assistance, such as: bathing, shampooing, dressing, light housekeeping, meal preparation, non-medical supervision (help up to the bathroom or to bed), monitoring health status, (calling the doctor or seeking care when needed) self-administered medications, and companionship.  

• It might also include Instrumental  Activities of Daily Living or IADL's which can 
  include non-hands-on help, such as reading to the elder, or help in paying bills, providing 
  transportation to the doctor, market, bank or post office.
  
• Normally, Medicare will not pay for these services on a long-term basis. Instead, these expenses 
  are paid by the elderly themselves (called out-of-pocket expense) or by 
  Long-Term-Care Insurance.  The Long Term Care Insurance  option however, 
  is used by less than 2% of the population. The need for Long Term Care Insurance 
  is just beginning to come to the public's attention. 

 

2. Skilled Nursing and Medical - skilled services usually are medically necessary care that is prescribed by a doctor and implemented by a hospital's or private agency's home care divisions. 

Sometimes, home care can fill in between moves and keep an elder in his/her home longer. After an illness that requires a hospitalization, Medicare will pay for home care with a physician's orders.

They will not pay for custodial care (long-term-care with ADL's), but short-term rehabilitation needs only. Many elders assign their Medicare benefits to an HMO. They often gain prescription coverage, but lose the extended home care options provided by Medicare.

Home care can include a nurse, physical therapist, occupational therapist, social worker and homemaker (they cook and serve meals and do light housekeeping and help with ADL's). IADL's typically are covered, too.

3. There is a wide range of non-medical services designed to assist those who find it difficult to function independently due to illness or injury or just gradual diminishing capabilities.

These options can include:

• Adult Day Health Care or ADHC  - a center where elders who live in the community spend the day for socialization and meals. ADHC  includes rehabilitation services in physical therapy, occupational therapy, speech, and nutritional services. These services are typically covered by Medicaid (not Medicare) for low income elders
   
•  Meals may be delivered to their homes
  
•  Lifeline may be used to keep in contact in emergencies
  
• Paratransit can help with door-to-door transportation (for disabled elders) 
  and In-Home Supportive Services, or IHSS, assists low income elders with homemaking duties.  
  
• Check the electronic handouts in week one, Area Agencies on Aging and click on services for a complete listing of programs offered. 

 

3. Hiring Help
   back to top

 

1. When Medicare (not Medicaid) benefits for skilled care run out, seniors often turn to hiring in-home help. If they are low income, most communities provide IHSS services. This is a means-tested service that offers assistance during the day with ADL's and IADL's. One usually applies for these through the local Social Services Department.
   
2. If an elder does not qualify for IHSS, then paying someone to assist them is another option. If a family member or close friend is not available, it is preferable to hire from an agency rather than a newspaper. Workers from agencies are bonded and insured. Here are some guidelines for hiring agency personnel for the families of the elderly:
   • Get references, phone numbers, address, driver license, and Social Security numbers.
     
   • Have friends drop in for unscheduled visits.
     
   • Don't get overly dependent on the worker. You might find yourself in a bind needing help and not being comfortable with the current care giver. Have a back up plan.
     
   • If the person hired is not measuring up, notify the agency.

    

• Supervise their work personally when possible.
  
• Protect valuables and banking accounts. Although most home-care workers are hardworking
   and honest people, some strangers have been known to carry off the assets in an elder's 
  home one spoon at a time. It is often too late by the time someone notices that the house 
  is becoming sparse. 

 

3. If you hire help not from an agency:

    

   • Recruit through a public agency such as a college, church, senior center, or community center.
     
   • Ads in newspapers are risky! One can be open to unscrupulous thieves and elder abusers. 
     
   • Tap into local community-based long-term-care services for referrals such as: 
     the Area Agency services,  Friendly Visitor Program, Telephone Reassurance, or public health agencies.
     

4. Relocation Patterns, Level 2 Options
   

Most of us assume that when our parents get old, they will either go to a nursing home or move in with us.

This can bring up many issues for a family. If the relationship between parent and an adult child has never been close, moving them into the family home can create an escalation of these issues.  

Privacy problems might develop for the younger family members as well as for the elder, and relationship strains with family members not living in the home may develop; especially if they are being counted on for respite, physical, and financial support. 

If relationships were never close, the pressure of care giving can increase the chance of elder abuse. If possible, a granny unit can be a better option.  A granny unit can be attached or not attached to the main house and can increase independence and privacy.

1. Step Down Housing
   back to top
   

1. Mobile Homes - Mobil homes are usually less maintenance because they are newer and park maintenance cares for the grounds and services. Although less maintenance, elders often lose control over their housing costs because of rising rents. Elders also increase their chances of an unwanted second relocation when parks close or require limits on residents' activity levels. Some require that residents are  mobile and active to remain in the park.
   
   
2. Continuum of Care Retirement Community - These centers take care of elderly people from the time they move into an independent living apartment through their death . A CCRC provides step-down units that increase the levels of care as needed. 

 

Did you know
In other levels of housing options, such as a senior housing units (independent living), the senior must remain ambulatory to qualify for residence. They must again relocate when the need for more help with activities of daily living arises.

Can you imagine what this looks like for some elderly. They must remain independent to remain in their home. If not, they have to move. As a public health nurse in a small rural town I visited many elderly who were in independent living apartments who really needed assisted living. Because their facility did not provide a higher level of care they would hide out in their apartments for fear someone would see them and force them to move to a higher level of care.

Check the electronic handout "Questions to Ask When Choosing A CCRC".

There are typically three different levels of care:

• Independent living; usually an apartment with a small kitchen.  Meals are  provided either 
  in a community dinning room, or the elder may cook simple menus in his/her room. 
  
• Assisted Living Centers where meals, medications, and ADL assistance is provided 
  usually in a single private or semi-private room.
  
• Skilled Nursing - 24hr institutionalized care that involves the skills of a registered nurse. 

Upon admission to the CCRC, the elder must be able to live independently. For that reason careful planning is required to know when to move into a CCRC, before fragility becomes an issue. As a person becomes less independent, services are added and the level of care increases.

1. There is usually an entrance fee plus monthly rent. Most require an elder to have long-term care insurance or other means of paying for custodial care. 
   
   A very nice CCRC near American River College is Eskaton Village on Walnut Avenue or Gramercy Court at Cottage and Fulton. Stop by and ask if you may visit or go for a tour.  Because of licensing issues, there are not many CCRS's left in Sacramento.
   
2. Residential Care Facility For The Elderly (RCFE)
   

Often a residential care facility is a private home or a home purchased for the intended use of providing care for the elderly. A license to run a residential care facility is rather easy to obtain ( a few weeks of training and an examination).

RCFE's  have become a popular alternative to institutional care for people who can afford to pay for the care. As of this date, there are no Medi-Cal or Medicare funds to pay for these facilities. However, there is a demonstration project in California for a Medical waver and there may more in the future, because they are a less costly alternative for elderly in nursing homes who do not need nursing care. 

Many long-term-care insurance policies cover the costs of assisted living. Costs range from just under $1000.00 to several thousand dollars per month depending on the standard of care provided. Some are elaborate homes with pools and hot tubs while others are simple living quarters. 

 

1. RCFE's usually have a live-in staff person. These facilities are designed for adults who:

• don't need constant medical care, but who can not live alone
  
• are semi-independent physically and mentally
  
• are frail and need frequent assistance with ADL and IADL's
  
• need some health care monitoring or assistance with medications
  
• can not maintain their own homes and need transportation

Many think that RCFE's are a good middle ground between living in one's own home and skilled nursing.

This may be an important concept to control the high cost of institutionalization in the future.

3. Low Income Options
   back to top

    

   1. There are a few options for low income elders:

       

      1. Housing and Urban Development Projects or HUD is a subsidized senior housing program that charges 30% of the elder's income for rent. It is administered through the Federal Housing and Urban Development Department. As you can imagine, there are many more applicants than funds to provide housing. Often long waiting lists are hard for seniors who need immediate housing. 
         
      2. Section 202 - Also a U.S. Dept. of Housing and Urban Development program. Section 202 housing can be a residential hotel, apartment building or specially-built facility . This is specifically senior housing (where HUD is not ) and a type of Section 8 (see below)
         
      3. Section 8 - is managed by the local housing authority and is for low income clients. They are given certificates and choose their own place to live. There are also long waiting lists - sometimes there are lotteries to apply for.
         
      4. Public Housing - Open to all ages who are low income. It is also run by the public housing authority who receive government funds. The housing is owned and operated by the authority.
         
      5. Shared Housing - arranged by the elderly themselves or by agency-sponsored referrals. Unrelated individuals share a home. If three or more are in a home, it is considered a group shared residence. Management and maintenance of the household are decided mutually. There is a problem however. The elderly can lose means-tested income. Up to 1/3 of their Supplemental Security Income or SSI and any food stamps they may be entitled to are at risk because the whole household's income is considered when means testing for programs. 
         
4. Nursing Homes

    

   1. Perhaps the most dreaded thought, for many seniors, is living in a  nursing home. There is an image of uncaring family members dumping unhappy parents so they don't have to care for them. This is not true.
      
   2. Most elderly stay only briefly, until they recover and go home. Forty-three percent (43%) will use a SNF at some point in their lives, yet just five percent (5%) live there permanently.
      
   3. Some are hospital based, but these are not permanent residences and provide medical rehabilitative care only. Remember, Medicare is limited to restorative care for a maximum of 100 days. Cost for full-time residence can be more than $200 per day.
      
   4. Not all nursing homes are alike. It takes footwork to find the right facility and person match. The California Medicare web site now includes results of complaint investigations of nursing homes. You can log on at http://www.medicare.gov and then go to the Nursing Home Compare section.  
      
      Also check out your handout "If You Think You Need A Nursing Home"  and this site for more information. http://www.canhr.org      
      CANHR has good information on nursing home reform, elder abuse, reporting abuse and much more. 
      
   5. This site provides consumers with comprehensive, consumer-friendly comparative information about the quality of California nursing homes  http://www.calnhs.org/

3 extra credit points-- Read about the new trends in nursing homes in your text then design a model yourself. What would the home look like physically? Then explain at least 5 things that would make it unique. Make sure the subject of your post is 'EXTRA CREDIT'.

3. Long-Term-Care  Insurance - Still Being Assessed if Worth the Cost

   Long-term-care insurance can cover expenses for community or institutional based long-term-care. Some  policies pay for home care, homemaker services, respite care and community-based programs. Premiums vary according to age, services covered, waiting periods before benefits kick in and inflation protection ( if the cost of living goes up, so does the coverage of the policy). 

   The rule of thumb for insurance cost is  5% of your annual income for premiums. Long-term-care insurance is not for everyone. If income and assets are low, it may be wiser to spend extra income so one can qualify for MediCal. This process is called divestment planning . Usually elder care attorneys help with this process. You can check this process at this web site. http://www.coverageglossary.com/pages/asset.htm Age 50 is suggested as the best time to purchase this insurance considering the balance between premiums and life expectancy. 

   Did You Know

   Professor Renee Chevraux currently works as a Social Worker in a rural area and has many years experience working with older adults in their homes. Here is what she sees in the field about LTC insurance.
    

   "I personally do not think LTC insurance is a good buy for most people. The insurance is generally expensive, it is difficult to get the claims going and the companies tend to delay the claim process as long as possible so the don't have to pay. There is a waiting period (usually 30 to 90 days) and the patients have to pay for care for the waiting period.  Many people will not put out that amount of money for care just to get their policy stared.  Most people also never use their policy and some of the companies have gone out of business.

    

   There are some exceptions that I feel you should buy insurance............if you are single and probably do not have any children who would help you at all.  Also, if one spouse is much older than the other or if you really want to protect your estate and CAN afford the costs of LTC .

    

   Another way to think about it--  consider a reverse mortgage to supplement your LTC costs later in life.  If your home is paid off, you can always borrow against it (the values will vary).  The only LTC insurance that I believe is currently worth looking at is the Cal Partnership Plan."

    

   
   
    

   Here is another reference book on the subject: Thinking about a Nursing Home: A Consumers Guide to Long Term Care.  American Health Care Association, 120 L St., NW, Washington DC 20005.

    

4. Inappropriate Placement

    

   1. Approximately 10-40% of elders in nursing homes could be maintained at a lower level of care if funding and services were available. Currently, if low income elders can not get up to go to the bathroom by themselves at night and have no one to help them, a skilled nursing facility is their only option.  
      
      MediCal will pay for this level of care if the elder is low income,  but not for lower levels of care (such as residential care (RCFE) or continual care (CCRC). For this reason, skilled nursing  is often used for elderly who are low income and  need custodial care because there is no financial help for home-based care.
      
      1. This is changing:
         • On-Loc and the  Pace Model  have been  pilot projects of Medicare for many years.  
           Clients assign their Medicare payment to the program in exchange for on going, managed care. 
           If you would like to learn more about this alternative check out their overview at this web site. It is highly
           praised and a model program.   http://www.onlok.org/
           
           
5. OBRA -Omnibus Reconciliation Act of 1987

    

   1. OBRA helped clean up the image of nursing homes. Some still question if the law was adequate. The nursing home industry is one of the most tightly regulated industries and yet, society still is not satisfied with their services.  OBRA provided for :

       

      1. tighter licensing requirements. Nursing homes now must have a licensed long-term-care administrator who oversees the operation. This license requires either a Master's degree or several years of hands-on experience in the field. 
         
      2. increased patients rights: Patients have the right to visitors, knowledge about their care, resident council, and other controls. 
         
      3. each patient must have a care plan that is followed by every staff member and Certified Nursing Aides are required to be certified and trained.
         
      4.  unscheduled on-site audits.
         
      5.  restrained with orders from a physician only.
         
         Check this site for more on OBRA http://www.nursinghomeabuse.com/brgi2.html

back to top