Sunday, March 17, 2019

How to Choose a Long Term Care Community

 (As I prepare a broader article for publication elsewhere,  I offer this for now. This also gives me a chance to incorporate your comments and changes.    The final will have a checklist, but for now you can make your own checklist to compare communities.)

A long-term care community can offer much to the aging adult.
The principal benefits are access to care when needed, and access to everything else, too!     

The word access needs to be foremost in your mind when choosing a community.

So let's discuss care and access individually and separately.


Starting with care, ”Lifecare” offers whatever care you need at the same ongoing price or monthly fee.     That includes assisted or personal care and nursing care, often with dementia care. This comes closest to “from each according to his ability and to each according to his needs”  (Karl Marx??).

“Continuing Care” adjusts the price upward as care needs increase.  $$

“Fee-for-service” charges a fixed basic fee for Independent Living and some amenities such as evening meals, but adds the full market cost for additional care.      Nursing, for example, could add $300 a day. $$$ Of course, you could add long-term care insurance to cover such costs.

Communities normally have an upfront cost for your particular accommodation which may or may not be refundable at some future date.

One nearby community offers both Life Care and Continuing Care contracts.


Now, turning to access to services.

Services are no good unless accessible.

For example, do I have access to a wellness program?    What is the mission? Do I have easy access to fitness equipment?   Do I have easy access to fitness classes?. How far do I need to go to get to them?    And finally, are they integrated with medical oversight?

As an illustration, one nearby community offers preventive dementia care in its fitness program which falls under medical supervision and is tightly integrated with it to ensure that all residents benefit from it.

That brings quickly to mind the subject of prevention.    Let's divert to that for a moment.  Does the community provide other programs to prevent dementia,  such as vegetarian diets and meals, along with exercise programs.


Lack of prevention can lead to financial burdens on the community, and to you!

The concept of prevention needs to extend to all aspects of life, such as exposure to loss of hearing in environments where sound is not controlled,  It also even extends to avoiding casualties in fires by designing facilities for easy exit access, and maintaining regular drills.

When the staff is up to its ears in alligators, “draining the swamp” seems like an unnecessary complication.     So the question is whether the community assigns management to deal with long-term prevention, and indeed, even with what will happen with the many changes occurring with treatment and even cure of illnesses,  including Alzheimer's. Are they up to date or still in the past?


Getting back to access, does the community maintain quiet spaces in dining rooms with easy access to food or are these dependent on staff and staff cost with resulting loss of easy access and higher labor cost.     A nearby community provides food carts so that residents may serve themselves without needing to carry trays, like Ikea does in its cafe?

For many residents the highlight of the day will be the evening meal and conversations with others.     An “eat and run” cafeteria design just doesn't work, soup kitchen style.

Is there easy access to gluten-free food, lactose-free foods, a diabetic menu?   Is it easy to view and apportion? Is the community proactive in offering a better diet?      What is it doing to raise awareness ?

Does the community provide fire exit plans prominently displayed?   Is there easy access to fire exits with a walker? Is there a compliance with the Life Safety Code?    (That's the old fire code with a new name.) Is compliance the law in your state and is that law enforced?    

And generally,  does the facility appear to be designed for the needs of seniors?     Is seating high and firm? And so on…

Then there are the questions of transportation.     What transportation capabilities are offered to residents?     How far to rail and airport? Are there services to get you where you need to go  when you cannot drive? How is traffic nearby?

There may be difficult access to shopping or there may be bus service.    Bus service may be either by the community or the public transit. There may be van services paid for largely by the state.    Some communities offer car rental on site so that you don't even need to have a car.

It is a good idea to look carefully at the surrounding community generally and see what services, and importantly, access to services are available.

Too many retirement communities require that you must go outside to get to dining.     That will catch up with you sooner or later. What may seem like a short walk now may eventually seem like a long walk.   Are there take-out meals?

Then, is there easy access to your spouse when he or she needs care separate from you.
Do you pay for that extra care?     Or does the community provide both at the same cost?    

Ideally the community provides indoor access to dining and similar services such as a pharmacy,  bank, pool, auditoriums, lunch, breakfast.

What about access to the nearest town and its services?   How near and extensive are they and how can we get to them easily?

What about the local hospital?    Is it accredited? How easy is it to get there?     What about the availability of other medical services?      Here I need to comment that my experience in Philadelphia was that the medical services were wonderful but not easy to get to.


As with any real estate that you were looking at, make sure you check location location location. Retirement communities are no different from other real estate.  Check to see how far your apartment or location is from the central core. As you get older these things get more important. If you decide on a first floor apartment check for possible mildew or mold. Does it get enough sun?     What rooms get sun and at what time of day?

Central heat and air?     Storage? Nearby storage cage?    How far to parking and bus?


When you move in, will there be privacy, or will you be in a “fishbowl” until curtains are installed?   Will there be safety grips in the bath where needed or will they need to be installed at extra cost?


Another question is access to management.      Does management have a reputation of listening?    Is there good communication between various management entities?       Or is it top-down only? iI other words, “you won't be living that long and your opinions don't count long term.”

What about access to sound financial management?     Does the community provide financial safeguards as needed?    What will protect the community from a major lawsuit and financial distress?

I worked for a nonprofit which “hedged its bets” in a careful way that some retirement communities share.     The first was that the company was actually four companies, so that if one company went down, the rest would not be pulled down with it.    

Does the community employee modern engineering methods using flowcharting and timestudy to design and run its facilities?    Are there written standard practices?


But just as important, a nonprofit needs to shield itself against loss by being accredited.      Whereas state regulations protect residents from abuses, it is desirable for a community to protect itself against legal actions by being accredited.

Accreditation simply means that someone is checking to be sure that the community is not exposing itself to financial liabilities.    That is quite a different mission from state and federal regulators.

For a time I lived in a retirement community where all of a sudden the CEO, the CFO, and the head of nursing were all fired.    Medicare compliance had been poor. Regulators were scorned. There were financial mistakes. Correction did come, as with another such community which encountered severe financial difficulties, but ultimately survived.

The “standard” Joint Commission accreditation simply looks over the organization and suggests to the management things that might do to avoid such exposures.      However the management makes a decision on any changes.

An even broader protection is certification, in which the management must conform to the recommendation of the accrediting entity.    Certification is less common.

Note that there are so-called accreditations which are simply fakes      If a retirement community is using one, avoid it. The community pays out for the accreditation and gets essentially nothing for it.


Getting back to access,  a very basic question is what access does the resident have to many types of living quarters. One nearby retirement community has suites even in its assisted care which are fully equivalent to large Independent living facilities.     

What access does the community have for entertainment and education?      My observation is that many of the best communities lack this. Is there access to such nearby?

I haven't addressed the “culture” of the community, but it is worth considering that the culture varies widely in this country.    Consider how insular the community, or management, may be.

How much access do you have to control over your own life?     How much of that will you be handing over to the retirement community?     

And as you access service, how is housekeeping?       One community I visited was wonderful except for appallingly bad cleaning of its public restrooms.   There is a culture here of cleanliness. There is also something of a culture of regimentation of staff.

So, in summary, just do not just look at the services,  but also consider how easy it is to access them. Is there a commitment to prevention?     If service is not easy to access, basically it may not be conveniently available or useful at all.   

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