Friday, November 22, 2013
A fascinating article in The Gerontologist analyzes Naturally Occurring Retirement Communities (NORCs) and a similar community-based model for aging in place, known as the Village. Frankly, it was only recently that I realized these labels may be used for developments with different identities.
Researchers in social work, welfare and public health programs at Rutgers, Berkeley, Michigan, and Maryland surveyed program leaders representing 69 Villages and 62 NORCS in early 2012, gathering data on services, activities, beneficiaries and funding sources.
Their analysis, presented in "A Tale of Two Community Initiatives for Promoting Aging in Place: Similarities and Differences in the National Implementation of NORC Programs and Villages," suggests that while both programs "aim to promote aging in place by offering a diverse range of supports and services to older adults within a locally defined geographic area," the means by which they achieve their aims differ. For example, "NORC programs reported offering more traditional health and social services, had more paid staff, and relied more on government funding than Villages."
The article also identified topics for further study, including the potential for longitudinal studies. Regional differences may also exist. "For example, NORC programs in New York likely differ in some ways from NORC programs nationally, given different organizations overseeing their development, . . . as well as distinct public policies defining the programs and eligibility criteria."
As a bit of history, Beacon Hill Village in Boston was begun in 2001 by a group of seniors who wanted to remain at home as long as possible in their neighborhood. An early model for NORCs is widely attributed to a co-op in New York City, begun in 1986 with support from private philanthropy and local government funding.
Thursday, November 21, 2013
Via the Center for Medicare Advocacy:
Late November is often a time for gatherings with family and friends – Thanksgiving and Hanukkah, soon followed by Christmas and the New Year. Nursing home residents often want to participate in these gatherings but may worry that they will lose Medicare coverage if they leave the facility to do so. Residents and their families can put their minds at ease. According to Medicare law, nursing home residents may leave the facility for holidays without losing their Medicare coverage. However, depending on the length of their absence, beneficiaries may be charged a "bed hold" fee.
The Medicare Benefit Policy Manual recognizes that although most beneficiaries are unable to leave their facility, "an outside pass or short leave of absence for the purpose of attending a special religious service, holiday meal, family occasion, going on a car ride, or for a trial visit home, is not, by itself evidence that the individual no longer needs to be in a SNF for the receipt of required skilled care."
A facility should NOT notify patients that leaving the facility will lead to loss of Medicare coverage. The Medicare Benefit Policy Manual says that such a notice is "not appropriate."
Tuesday, November 12, 2013
A new report highlighting the need for urgent action to improve residential aged care includes case studies of people being shackled, assaulted, sedated against their wishes and turned into "zombies". Australian of the Year and Alzheimer's Australia national president, Ita Buttrose, today launched the report calling for good quality residential aged care to be the norm. Quality of Residential Care: the Consumer Perspective acknowledges there are dedicated, compassionate people who work hard to provide quality care but notes there are instances of poor quality care. In 2012 there were more than 220,000 people in Australia in residential aged care in more than 2700 facilities across the nation.
"What worries me is that a minority of facilities are not providing good care, and that residents are not being respected and, in some cases, are subjected to physical or psychological abuse," Buttrose said. "Since becoming president of Alzheimer's Australia many consumers have shared disturbing stories with me of physical, psychological and sexual abuse, inappropriate use of restraint, unreported assaults and people in extreme pain at end of life not having access to palliative care. "The objective of the report developed by Alzheimer's Australia is to articulate the concerns of consumers, set out for discussion possible strategies to address them and to seek a higher priority for tackling them.
"It proposes strategies to bring providers, staff and consumers together to address the systemic issues in the aged care system that have led to breakdowns in quality care. Funding issues are important but equally so are the leadership and culture that respects the rights and dignity of older people. Common decency and respect costs nothing."
Source: Brisbane Courier Mail
Irving Levin Associates hosts commercial webcasts on industry perspectives in M & A and finance in health care and senior housing. On Thursday, November 14, they are offering a webcast (1:00-2:30 p.m. Eastern) on "Assisted Living Facilities: Buying, Selling and Valuing."
As part of the marketing, Levin reports that in 2012, commercial transactions for "assisted living communities set a new pricing record at an average price of $164,000 per unit, which topped the previous record set in 2007." Further, Levin reports:
"Many factors enabled this to happen such as a drop in cap rates, an increase in lenders in the market, higher quality properties and portfolios in the market and many more aggressive buyers, including the smaller REITs and private equity firms. . . . There is a fear that with so much new development in certain markets, and with new developers entering the market, the assisted living sector may be faced with another round of overbuilding."
Sounds like an interest set of issues for discussion by the panel, as investors continue to look to retiring boomers for market inspiration.
Monday, November 4, 2013
In a lengthy article, Pro Publica (in collaboration with Frontline) discusses quality of care problems along with the history of assisted living regulation. As an additional resource, Pro Publica also has developed a state-specific summary of key assisted living regulations.
In addition, California Advocates for Nursing Home Reform released a report on problems in California's assisted living facilities. The report's recommendations for reform include adoption of a tiered level of care system, annual inspections, and an on-line consumer information system.
The Assisted Living Consumer Alliance played a role in each of these examinations. ALCA board members Eric Carlson, Toby Edelman, Richard Mollot and Lori Smetanka each were quoted in the Pro Publica quality of care article. ALCA board member Jody Spiegel was part of the CANHR team that produced the report on California assisted living.
Albuquerque Real Estate Appraiser David Pearson shared a recent issue of Seniors Housing Research Report from Marcus & Millichap, focusing on commercial real estate development trends in the second half of 2013. The report observes that overall "demand for seniors housing units is intensifying thanks to a rapidly improving housing market. . . . In fact, occupancy in both independent living and CCRCs is anticipated to rise this year, spurring rent growth in both product types."
In certain areas of the country, including the southeast and Texas, new development may be slowed by the still soft market for recently constructed facilities. Interestingly, the report predicts growth in dementia care units, while at the same time predicting occupancy rates for traditional "skilled nursing" facilities will continue to decline. As Shakespeare might observe if he were writing today, "would a nursing home by any other name smell as sweet?"
Thursday, October 31, 2013
Part of my recent legal research and writing focuses on state regulation, accountability, and resident rights at Continuing Care Retirement Communities or CCRCs. In one of my early articles I wrote about what I thought might be a niche for elder law attorneys who could advise prospective CCRC residents about the ins and outs of CCRCs, particularly on contracting issues.
Turns out a Financial Planner and CPA have decided to make a business out of offering advice to consumers on CCRCs. Recently I had the chance to talk to Brad Breeding (the financial planner) and Ken Taylor (the accountant). The idea started when they were getting questions from clients about CCRCs near their base in North Carolina and realized there was a wider consumer market for critical information. In 2009 they started working on a web-based consulting tool for prospective CCRC residents and others who are thinking about retirement options.
The resulting company is LifeSite Logics, offering "a central database of objective data" about CCRCs across the country. Sounds like Brad and Ken have the start on a strong data set, and are already offering comparable data on several hundred CCRCs. The search price is about $40. Most important, the two seem determined to stay objective about their data points; they report they aren't backed by any CCRC operators or developers.
In addition, their LifeSite Logics website offers some free background and educational documents on CCRCS, including some information on contract (A, B, C or "other") types.
I have to say I've often thought "A, B & C" labels are potentially confusing to the public. This is especially true for the financial risks assoicated with "refundable fee" contracts which may look to the average consumer like "life-care" contracts that are usually associated with the "A" label, but are closer to "Type C" fee-for-service contracts when carefully analyzed. Further, these letters are not "grades" for the facilities or contract types, another point of potential confusion.
Good luck, Ken and Brad, on a promising start for what looks to be a very consumer-friendly product.
Wednesday, October 30, 2013
At their annual meeting this week in Dallas, LeadingAge celebrated the good works of another nonprofit, the Hearth program in Boston, Massachusetts, awarding Hearth one of their top awards for "Excellence in Leadership."
Hearth is dedicated to "the elimination of homelessness among the elderly through housing, outreach and advocacy." They identify strategic goals, including increasing the supply of permanent, affordable and supportive housing in Greater Boston, as well as support for national initiatives directed to end elder homelessness. Hearth also facilitates elders' access to specific services, including legal services. Hearing about their projects, going back to 1991, was definitely a feel good moment at the conference.
Monday, October 28, 2013
The fall meeting of the National Continuing Care Residents' Association (NaCCRA) in Dallas on October 27 was attended by CCRC residents from at least a dozen states, including Arizona, California, Connecticut, Florida, New Jersey, North Carolina, Oregon, Pennsylvania, Texas, Virginia, Washington, and D.C.
The morning workshop focused on "Imagining CCRCs of the Future," starting with round table discussions that identified 25 topics deemed important to the future of the industry, including planning for consumers who may have less financial resources while also seeking greater services; interest in building more diverse communities; and the importance of training for emerging leaders. From the broad list, the group identified 7 priorities for NaCCRA in the coming year and beyond, accompanied by specific action recommendations. Stay tuned!
In the afternoon, members of NaCCRA were part of a panel discussion on "Resident Engagement" led by Ron Herring, the President-Elect of NaCCRA. The panelists were Ellen Handler, President of ORANJ, the residents' organization in New Jersey; Marilyn Kennedy, Chief Operating Officer for Episcopalian Senior Communities in the San Francisco area, and Mary Ann Colwell, a resident at St. Paul's Towers, one of Episcopalian Senior Communities' CCRCs.
Handler presented highlights from successful advocacy on the part of the New Jersey group in achieving state legislation requiring resident membership on governing boards of CCRCs, and, most recently, mandating threshold rights for residents in "independent living." Kennedy and Colwell talked about the 10 year history of progress in their communities, building multiple pathways for residents to participate in the life of their communities, including working with provider representatives to plan for the future. Kennedy discussed the role of California state law that helped to frame the provider/resident discussions.
The audience included provider representatives. During the Q & A that followed the panelist presentations, the interaction generated observations about effective roles for residents on governing boards and key board committees (such as finance and quality), including success stories from communities. Several people remarked on the "process" of resident engagement, as it takes time for true engagement to become engrained as the culture of the community.
The NaCCRA meeting was part of the opening day action at the national meeting of LeadingAge, the national trade group for nonprofit senior living providers, which runs through October 29.
Friday, October 25, 2013
This weekend I'm heading off to Dallas for a quick visit, to help with a Sunday workshop for the good folks at NACCRA, the National Continuing Care Residents' Association. Then I get to attend part of the LeadingAge Annual Meeting & Expo that runs from October 27-30.
I have to say I've been a bit overwhelmed with the email traffic from participants at the LeadingAge Expo (next time I'll be more careful about what boxes I check on the registration forms). But, it is always good to see an industry from different perspectives and to get outside the "academic" world for a broader view. I'm also looking forward to catching up with friends, including Trisha Cowart, who will be presenting on "Surviving the Medicaid Maze," on Tuesday, October 29, speaking from her experiences the last few years as an attorney representing long-term care providers. Trisha and I co-authored a book on Financial Abuse and Exploitation (Bisel 2011) and she's a cherished former partner from the Penn State Elder Protection Clinic.
I'm also looking forward to seeing some of the high-tech developments in long-term care I've been reading about. More after I return.
Monday, October 21, 2013
On October 16, New Jersey Governor Chris Christie signed into law a detailed "Bill of Rights" for residents of New Jersey's Continuing Care Retirement Communities (CCRCs).
Key features of the law (S2052/A3132) include:
- clarification of the circumstances under which residents can be transferred from independent living to skilled care,
- the right for prospective residents to have at least 30 days to review mandatory disclosure statements before signing the admission agreement, and
- further specification of the state's right to enforce the law, including sanctions or fines.
The new legislation serves to amend New Jersey's Continuing Care Retirement Community Regulation and Financial Disclosure Act, N.J. Stat. Ann. Sections 52:27D-330 through 360. The law was first enacted in 1986, becoming effective in March 1987.
My first reading of the final legislation suggests it covers rights about which even the most paternalistic provider would agree.
ORANJ, the Organization of Residents Associations in New Jersey, was very active in raising resident concerns during the several year process that led to the bill's passage.
Hat tip to David Hibberson for keeping us up-to-date on New Jersey developments. Congratulations to New Jersey CCRC residents on their hard work.
Friday, October 18, 2013
Another consequence of tough financial times is the unaffordability of professional long-term care. But in Greece, that phenomenon has an additional component, as families apparently need the elder's pension to make ends meet in the family home. Pennsylvania Elder Law attorney Dionysios C. Pappas (great name, right? Although we all call him "Dennis"), shared an article from Greece, "Care Homes See Mass Exodus," and suggested these key excerpts:
“…Grandma and grandpa’s pension has become the main source of income for thousands of Greek families struggling with unemployment, along with rising living costs and taxes. This shift has been accompanied by a mass evacuation of retirement homes across the country as elderly family members move in with their children and grandchildren in order to make ends meet…”
“…Greece has around 200 nursing homes for the elderly, half of which are private facilities while the other half are run by nongovernmental organizations and the Orthodox Church. Their total capacity is estimated at 15,000 people…before the crisis, these facilities were operating at 100 percent capacity. Today, however, this has dropped to 80 percent as one-fifth of their patients have
“…Taking elderly relatives out of retirement homes has become something of a 'solution’ to the unemployment problem…Most of the unemployed people in this country are surviving on the pensions of their parents or grandparents anyway rather than on their unemployment benefits. If unemployment continues to rise, then so will the evacuation of nursing homes…”
Thanks, Dennis, for providing this comparative information on caregiving.
Wednesday, October 16, 2013
community-based services, better balance services from institutional to non-institutional settings, and promote affordable, accessible housing.”
Earlier this year, Congress passed the Reverse Mortgage Stabilization Act of 2013, and under this legislation the Federal Housing Administration (FHA) was directed to make key changes in the reverse mortgage program, also known as the "Home Equity Conversion Mortages for Seniors" program. FHA has issued several advisories to Lenders, Financial Counselors and Borrowers (links to recent "Reverse Mortgage Cautions" available here).
During my years in Penn State Law's Elder Protection Clinic, we often were frustrated by reverse mortgages. We saw clients who had taken out the mortgages without guidance on whether there was enough money to keep the home afloat, especially when equity was stripped to pay for daily living expenses, but there still wasn't enough money to pay real estate taxes. The mortgages sometimes delayed the client's departure from the home -- but not by much. Sometimes clients came to the Clinic in time for a discussion about whether selling the home would be a more effective solution to serious money problems, combined with moving into a more affordable rental. But, of course, pride and affection for the homestead, combined with the illusion of easy money, could be strong motivation, stronger than practical advice.
Will the FHA changes be effective to promote sound use of reverse mortgages?
Monday, October 14, 2013
When I first began writing about modern enforcement of filial support laws, I was examining what I would now call a "little" Pennsylvania case, Savoy v. Savoy, 641 A.2d 596 (Pa. Super. 1994) where a mother was asking for financial support from her adult son because she was unable to work after a hospital stay. Citing Pennsylvania's filial support law, requiring children "to care for, maintain, or financially assist" an indigent parent, the court ordered the son to pay $125 per month, but the court did not order him to pay her; rather, the court ordered the son to pay his mother's health care providers. The relief granted in that case was probably of little practical value to the plaintiff. Most likely, the mother could have discharged those bills in a no-asset bankruptcy. What she really needed was help in the future. She needed help with daily expenses because she was unable to work and was sliding into poverty. I learned that even a few years after the court case was over, the family relations were still pretty much destroyed. Money had been paid, but that was about all.
I was worried about the implications of the Savoy decision for future cases involving reluctant adult children. What if the reluctant child chose to provide direct care to the ailing parent only because the law imposes such a duty, or because the child is avoiding a court order requiring him or her to pay real dollars for future support? It is great when family members voluntarily provide care, and it is often heroic when they do so even at huge emotional and fiscal cost to themselves. But, doesn't court-ordered "filial support," imposed upon a reluctant family member, pose a real danger to the elder, especially a frail elder?
So, let's look to China. Earlier this year, some were talking about news of China's decision to enforce its filial support laws, and there was speculation that such enforcement could be a better alternative to the rising cost of publically supported long-term care, such as the costs of Medicaid in the U.S.
This is where journalist Kristen Gelineau's latest work is important. Kristen is in Australia, where she writes for The Associated Press. Several months ago she contacted me, asking about Pennsylvania's law, as well as the law of other states and countries. We talked about China. It turns out Kristen went to China to track down exactly what happened in a key case of enforcement, where a Chinese elder was granted relief under China's version of a filial support law. Kristen travelled to a village with a photographer and translators (used to translate the local Chinese dialect to Mandarin, then Mandarin to English).
Kristen's story, In Aging China, Older Woman Sues Children for Care, is powerful and it deserves careful attention. She tracks the misery associated with desperate financial conditions for an entire family, and how such misery can be intensified when "by the book" enforcement of filial support laws takes place. As Kristen told me over the weekend, everyone in Zhang's story is struggling to get by and "no one is happier now than they were before they want to court."
Kristen's story is a vivid reminder that there are reasons why Elizabethan-era Poor Laws were replaced with social insurance and public welfare programs, a reminder that is even more relevant to our aging planet in the 21st Century.
And there is more to come from Kristen Gelineau. Her next piece, to be released later this month, looks at elder neglect in Australia and the wider problem of elder abuse globally.
Thursday, October 10, 2013
I have been seeing and hearing a fair number of inquiries about the effect of reverse mortgages on an individual's eligibility for Medicaid, with suggestions the answers differ both by type of reverse mortgage contract and by state. That sparked my curiosity about whether there is emerging scholarship about reverse mortgages as a tool for financing long-term care. Here are some of the articles I found, with a few notes about the substance:
Bradley Schwab, "The Birth of a Real Right: An Overview and Analysis of the Recent Revision of Book III, Title X of the Civil Code," 73 Louisiana Law Review 821 (2013):
The title of this article probably means a lot in Louisiana, but I have to say I would not have realized it was an entire article about annuity contracts, until my research discovered the author's conclusion for why annuity contracts are often "more appropriate than a reverse mortgage for those who eventually need long-term nursing home care." An impressive analysis -- from a recent graduate. Perhaps another example of an Elder Law student who "rocks?"
Paul Black, "Reverse Mortgages and the Current Financial Crisis," 8 NAELA Journal 87 (2012):
Starts with a detailed outline of the mechanics of reverse mortgages, before moving into analysis of the potential risks to borrowers, including predatory lending tactics, the recent prohibition on "bundling" of reverse mortgages with deferred annuities, and the potential for unintended consequences for Medicaid eligibility. Turns out the author, a 2010-11 Borchard Foundation Fellow, is a fairly recent graduate and this article is actually an expanded version of a paper he first wrote as a law student. Another Elder Law student who "rocks?"
Andrew Hyer et al., "Paying for Long-Term Care in the Gem State," 48 Idaho Law Review 351 (2012):
While surveying financing alternatives for long-term care in Idaho, the co-authors who are academics at Boise State, caution that studies suggesting use of reverse mortgages "saves" the state money on Medicaid. while interesting, could be based on out-of-date information.
It strikes me that I might be missing more recent analyses of reverse mortgages impacting Medicaid. Please don't hesitate to send me links to thoughtful pieces.
Tuesday, October 8, 2013
The alphabet soup for deciphering housing and long term care options can be daunting. ALs, CCRCs, NHs (or my old favorite, SNFs), NORCs. Are the differences real or just part of marketing?
Those bright, hard-working folks at the National Senior Citizens Law Center (NSCLC) know the differences, including what is or isn't eligible for Medicaid coverage from state to state. Even better, they're willing to share their expertise, offering a webinar on the "Pluses and Minuses of Assisted Living, for Policy-Makers and Consumers." I would add "students" to that list of important participants.
Date: Tuesday, October 15 (Yikes -- that is soon!)
Time: 2:00 to 3:00 p.m. (Eastern time)
Details and on-line registration are here. And even though there's no cost for this session, I suspect that if you find yourself appreciating this kind of programming, and want to see more offerings, someone at NSCLC just might accept your (tax deductible) donation!
Friday, October 4, 2013
Across the US, there are some 1,800 Continuing Care Retirement Communities (CCRCs). These are typically upscale settings that offer a range of housing options, services, activities and health care. Residents of CCRCs often have common interests, not just within their individual community's setting, but in the "larger" community of residents throughout the nation, and thus the idea of a National Continuing Care Resident's Association (NaCCRA) was born.
NaCCRA has two annual gatherings, as well as regular meetings at the chapter level in individual states. NaCCRA's Fall 2013 Meeting will be in Dallas, in conjunction with the LeadingAge Annual Meeting. Here are some of the planned NaCCRA sessions and related LeadingAge sessions:
Saturday, October 26: NaCCRA Board Meeting (starting at 5:30 p.m.)
Sunday, October 27:
9:00 - 9:15: General Business Meeting
9:15 - 11:45: "Imagining CCRCs of the Future," a moderated discussion, involving residents and other guests. (Moderators: Ron Herring, resident of The Glebe, Daleville, VA & Katherine Pearson, Professor of Law, Penn State Dickinson School of Law)
1:00 - 3:00: Opening General Session for LeadingAge
3:50-5:00: LeadingAge Concurrent Educational Sessions (24 sessions!), including:
- Progress toward Resident Engagement: One Year Later: Moderator Ron Herring (NaCCRA), Speakers: Ellen Handler, President of New Jersey's resident association (ORANJ); Marilyn Kennedy (COO for Episcopal Senior Communities); May Anna Colwell (CCRC resident and board member)
- Financial Ratios for CCRCs
- Urban Design Concepts to Reinvent Aging Communities Anywhere
- Governance Roundtables: Practical Solutions for a Better Board
The LeadingAge programming, with concurrent educational sessions throughout, continues on Monday through Wednesday, October 27-30. CCRC residents can register for the combined NaCCRA/LeadingAge meetings on line. Registration for the combined Meetings is without cost for CCRC residents!
For additional thoughts on CCRCs, from informed, resident perpsectives, visit NaCCRAU, a Learning Center for current and future residents.
LeadingAge is holding its annual meeting in Dallas this year, October 27-30, with a very busy and interesting schedule of events, including educational workshops. The workshops and associated meetings offer a deep well of cutting edge information about aging services, relevant to both the industry and the public.
So what is LeadingAge? To use their words, it is an association of "6,000 nor-for-profit organizations" that provide services to seniors, persons with special needs, and their families. The history of the organization as advocates for aging service providers traces to 1961. For a number of years it was known as the American Association of Homes and Services for the Aging (AAHSA), recognized as a leading trade group for non-profit providers, especially on the housing side, including Continuing Care Retirement Communities, Assisted Living facilities, and Nursing Homes. AAHSA initiated a self study in 2008, and in 2011 announced its change of name to LeadingAge. As with any strong trade group, LeadingAge keeps a close eye on legislation, public finance, and policy developments, both at the national and state levels.
My experience is that with the name change came a broadening of the association's identity, including greater involvement by older persons as individuals, volunteers, consumers, and users of aging services.
Larry Minnix is the long-time head of LeadingAge, with deep experience in the industry of aging services.
Monday, September 30, 2013
"Perdue tried to get help from Meals on Wheels Atlanta. In mid-April of 2012, she was twenty-seventh on a waiting list of 120. In November, she was still on the list, which had grown to 198. Her daughter finally found another program.
Such is the world of food rationing for the elderly—the hidden hunger few ever see. Tenille Johnson, one of two case managers at Meals on Wheels Atlanta, said there were others on the list who were even more in need than Perdue. In 2012, the program served 106,000 meals—up from 84,000 three years before—and it will serve about 114,000 this year. “We’ve been able to up our game and reduce the waiting list to between 145 and 160 seniors, but the need has outpaced us,” says executive director Jeffrey Smythe. “The numbers are going up more quickly than we projected. We have waiting lists all over the metro Atlanta area, even in suburban counties.”
The Nation writer first reported on underfunding for programs assisting home-bound elderly in 1998. "Little has changed in the last fifteen years," she reports. Except, as her article demonstrates in detail, the need is greater, on a nation-wide basis.
"The National Association of Area Agencies on Aging says nearly 60 percent of all Older Americans Act programs had waiting lists in 2010, but the ones for home-delivered meals are particularly urgent, since food is so basic to good health."
Remember the Older Americans Act (OAA), first enacted in 1965? Meals on Wheels was once a core component of OAA's programming, and administered to the states through Area Agencies on Aging. Charities, churches and other nonprofits have not been able to cover the gap in funding. As discussed earlier on this Blog, Congress still has not reauthorized the OAA,and as Lieberman's article demonstrates, there are very real consequences to Congressional gridlock and Congress's failure to address even uncontroversial programs while rehashing party-politics on the Affordable Care Act.
Hat tip to Kevin Schock, Penn State Law, for spotting this timely article.