Nursing Homes, Assisted Living or…some alternative?

Multi-generational alternatives benefit everyone.
Multi-generational alternatives benefit everyone.

I’ve written a lot about the process of choosing an Assisted Living or a Nursing Facility or other alternatives. Actually what I’ve typically written about is the lack of choice we have in such matters and that most of us arrive at that weigh station through a medical crisis with a parent or loved one and our choices have become quite limited.

I’m sure many people don’t even realize there are alternatives to these options. I’m going to talk about several. These options exist or are in the works here in the Charlottesville, Virginia area or nearby. Many of these also exist in other communities or are being planned, so it is worth checking out even if you are living somewhere else.

Many of us are graced with the presence of an aging parent or other relative living in our homes.  Or, if they are able, perhaps still in their own homes. Some of them are able to care for themselves and others need constant supervision  and assistance 24/7.   The first and sometimes only option considered by most, especially if they must work outside the home, is home health or home companion care.  If you can afford it, that’s a great solution. However, agency personnel can be quite expensive with costs ranging anywhere from $ 18-30 or more depending on the type of service you need (or combination of services). The types of services are typically: Companion Care, someone to cook, do light housework, watch over someone to ensure they safety, give reminders for medications, perhaps do errands or drive for you:Certified Nursing Assistants (CNAs) can assist with bathing, dressing, shaving, feeding, toileting and the like, in other words, “personal care”  and then there are fully trained, professional nursing care, such as LPN’s or RNS and therapists such as physical, occupational or speech therapy.  Different agencies provide different levels of care and some may overlap. For example, the national company (generally locally owned and managed franchises), Interim Healthcare provides all sorts of medical personnel from therapists to CNA but no companion care.  Another nationally franchised company with locally owned offices is Home Instead which provides home care including CNAs plus companion care but no other medical professionals. Also worth noting is that most agencies have a minimum hourly assignment, typically 3 hours. As you can see this can add up very quickly.

You can also hire non-agency, non-certified, non-regulated assistance.  While this tends to be cheaper, it is also a much riskier proposition. Agencies are required to do background checks (including criminal background and sex offenders). This is not easy information for most private citizens to acquire.   If non-agency caregivers are licensed – for example a CNA or LPN – they should be able to present you with their credentials and hopefully, references. You can also check their license against online databases (in Virginia and most states) to make sure they are genuine and you should verify all references. On the flip side, freelance caregivers, because they are unregulated, are able to do more without worrying about the credentials. So a single caregiver could do both the companion work and the personal care piece for a single lower hourly rate. Private rates can run anywhere (in the Charlottesville area) from $14 upwards.

How does one pay for all this? If you’re lucky, your elder invested in a long term care (LTC) insurance policy that covers home care.  Barring that, most will expect you to pay privately. In some cases – for example after a hospital stay and with a doctor’s order – Medicare may pay for care and even therapy in your home. This is a great way to avoid “Rehab” – a nice word for a nursing facility stay though typically not permanent.  In other cases, particularly low income cases, you may be eligible for an Elderly or Disabled with Consumer Direction waiver orECDC Waiverfrom Medicaid. One advantage to working with an agency if that they typically have staff that will work with you to help figure out the financing of care.  If your elder is a Veteran who served during a “time of war” (not necessarily in “combat”) they may be eligible for cash assistance from the Department of Veterans’ Affairs (VA) known as Veterans Pension and “Aid & Attendance.”

As you may have concluded by now, home care can be a pretty daunting and expense challenge both to manage and for which to pay. What other alternatives are there?

Another reasonable alternative for many working adults with elderly parents or others needing care is Adult Day Care.  The most prominent agency providing daycare programs in Charlottesville is JABA.  JABA offers a caring and safe environment for any adult (18 years +) who needs assistance with daily health or personal care activities and would like to engage in activities with other adults. JABA specializes in the care of adults with dementia.

Temporary or short term Home Care and Adult Day Care are also excellent opportunities for family caregivers to simply take a break and tend to their own needs for rest, recreation and relaxation.

There are two recent, very exciting developments that have come to Charlottesville!

The first, all ready up and running and signing up participants even as I write, is the brand spanking new Blue Ridge PACE which stands for Program of All-Inclusive Care for Elderly.  PACE is a collaborative effort between UVaMedicalCenter, Riverside Medical and JABA – our local Area Agency on Aging. PACE programs are operating all over the country and proving a very successful alternative model (they’ve had one in Lynchburg for a couple of years. Its associated with the Centra Health group).

PACE programs literally provide all the services the elderly need under one roof – or under your roof. Doctors, nurses, social workers, activities, day programs including breakfast, lunch and snacks, pharmacy, transportation, physical/occupation and speech therapy and more – all in one place. You must be a “dual eligible” (Medicare/caid) and over 55 to participate. You may also “join” and pay privately for membership (e.g. not Medicaid eligible) paying a flat fee for membership and using all services.  They deliver services both in their new facility at 1335 Carlton   Ave and in your home. Even if you need to have an in-patient stay at a rehab facility following an illness or surgery, your stay there is covered by your PACE participation.  Sounds too good to be true doesn’t it? Well, time will tell. but I am very excited about the prospect for Charlottesville seniors.  I hope you’ll take the time to stop and visit them and ask for a tour.

There’s another interesting project underway, this one a little further out in terms of its availability. It is called CharlottesvilleVillage.  This concept allows seniors with varying levels of need for assistance to stay in their own home and to – collaboratively – design the kinds of services they need to remain independent. Whereever possible, these services are provided by volunteers from within the community. For a good look at how a “Village” works, take a look at the recent PBS documentary on the subject, titled “There’s No Place Like Home: Seniors Hold on to Urban Independence into Old Age”  If you’d like to find out more about the Charlottesville Village project, you can visit their facebook page here.

Finally, for those seniors for whom living in their own home (or yours) is truly no longer an option and some sort of institutional care is the only route left, there is one more chance to avoid the traditional “medical model” we all hate.   It is called the Greenhouse Model and it has nothing to do with ecology or saving the earth. Except in a psychic sense!  The Greenhouse Model is also sometimes referred to as the “Eden Alternative” and was first conceived and brought to life by a doctor, William H. Thompson, in 2003. He decided to redesign long term care from the ground up.  Since that time, Dr. Thomas created The Green House Project a national non-profit organization dedicated to creating alternatives to traditional nursing home care. The project creates “caring homes for meaningful lives” for elders where each has a private room and bath, can move freely throughout the home, build deep relationships with each other and participate in preparing their own meals. It is based on a philosophy designed to reverse “enforced dependency” in a traditional nursing home by creating small intentional communities of 7-10 residents created to foster late-life quality of life and continued intellectual, emotional and physical stimulation and health.

Unfortunately, Charlottesville does not yet have a Greenhouse Model project (yet! Its my dream to bring one here!) However, they do have one just over the mountain in Harrisonburg. The Virginia Mennonite Retirement Community (VMRC), a 750 bed “Continuing Care Retirement Community” nestled in the Shenandoah Valley recently opened a Greenhouse community. While I’ve not had a chance to go see it myself, I’ve heard – from very reliable sources – that it is indeed a dream come true.

I’ll continue to explore the possibility of opening a Greenhouse Project in Charlottesville (the initial barrier is a licensing issue, but that’s another blog post and too boring). In the meantime, I just wanted to let people know that there are already several viable alternatives to traditional Assisted Living and Nursing Care facilities and that you should look into them before making any decisions.


Senior Citizens and — Sex?

seniors sex
No dysfunction here!

Yep. Old people gettin’ it on.

For all the ads for Viagra or Cyalis or other drugs to help men with “Sexual Dysfunction” there seems to be no shortage of older folks have no trouble whatsoever doin’ it.

For folks that work in nursing and assisted living facilities one of the most unsettling issues they have to deal with is intimate relations between residents.

It’s true that in some older folks, either desire or function has diminished. In some cases its a health issue. In others the side effect of some drug.  But for many older folks – even VERY old folks – sexual function is still alive and well.

While some are actively engaged in sexual relations, others are just looking for a intimate connection and that often includes close physical contact.

One major problem in long term care facilities is a lack of privacy. Most nursing facilities only offer “semi-private” rooms as their standard accomodation; that means two perfect strangers of the same gender sharing a very small space and a bathroom. Its hard enough to agree when lights are on or off, how the TV volume is managed, who has how much storage space. Imagine having to hang a sock on the doorknob to advertise you’re needing some privacy with your loved one when you’re in your 70’s?

Under such conditions its impossible to have a close, personal relationship with someone which may or may not include sex.  But residents and their family’s should know that thanks to the 1987 Nursing Home Reform Act, they DO have rights, explicit rights to privacy for instance, and they should be respected.  You can read more about “Residents Rights” here

Another problem is the moral or religious values of caregivers — nurses, social workers or aides who frown on consensual sex relations between adults and actively work to prevent it.  The imposition of one’s cultural, moral or social beliefs on another is also wrong. The  freedoms and rights surrounding beliefs and mores of senior citizens are to be as respected INSIDE a nursing facility as they are in the halls of the Supreme Court.

More recently, a seemingly new social problem has arisen. In 1969 the “Stonewall Generation” kicked off the creation of a new, “out and proud” gay and lesbian community. These folks built community in our cities and countryside, they created community centers and health centers catering to the gay communities unique needs; they won protections against discrimination in housing, employment and public accomodation in many states, and more recently won battles over gaysserving legally  in the military and in some states, equal marriage rights. They came “out of the closet” in force – suddenly appearing in television programs, plays and movies, on the streets, in the bars, in your YMCA – and in your church, your schools and everywhere straight people were.  But notice that if you were a gay activist or just coming out at say, age 25 in 1969, that means today you are 68 years old today.  You may be in good health, but many others are not and “grey gays” are thinking about and talking about Long Term Care options  in greater numbers than ever before.

If you are husband and wife, you can share a room in a nursing or assisted living facility. As a same-sex couple, you are treated as perfect strangers and have no right to demand a shared room with someone who may have been your lifelong partner.

If you are a husband and wife, you also have options with regard to Social Security, Medicare and Medicaid and other retirement benefits that may help preserve assets for the couple. As a gay couple, none of this applies and both halves of a gay couple are subject to the likelihood of being completely impoverished by the high cost of Long Term Care.

Its a little uncomfortable thinking about sex among seniors in nursing homes. Imagine how uncomfortable it is for some seniors – greying gay seniors – whose relationships are completely and officially unrecognized and often unofficialyl go unremarked. The issue is not really about the sex — although just as for younger people, sex is certainly a part of our lives and finding ways to meet the needs of seniors in this regard is important as it is for younger people. More importantly, its about preserving the longtime, intimate relationships that keep us healthy, vital and happy.

Denying that older people have intimacy needs and sex lives is silly. Forcing them to deny their sexuality is unhealthy. Forcing gay seniors back into the closet in order to live in our typical Long Term Care facility seems unconscionable.