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Paul Willging Says...

May 1, 2004
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With "Aging in Place," Honesty Pays
PAUL WILLGING says...

With 'aging in place,' honesty pays Seven months ago I wrote in this space about "aging in place," a concept that both defines and threatens assisted living. In the 1990s, aging in place had become the marketing mantra for a new approach to meeting the needs of long-term care recipients. It appealed to the indisputable desire of most Americans to remain in their own homes and to do so as long as practically possible. The assisted living facility offered itself to the customer as the epitome of this concept. It was not only "homelike" but offered the equally compelling promise of meeting the customer's healthcare needs without further need to change residences.

I also pointed out the concept's potential for real harm. "Aging in place," I suggested, "can become a quality-of-care problem; it can become a truth-in-marketing issue; it can occasion operational difficulties; and it can, ultimately, raise legal concerns." Events since have only confirmed my fears. Articles have proliferated in the national press pointing to the downside of promising too much to the assisted living customer.

So why are such promises still being made? The answer, of course, lies in the changing economic realities of the industry itself. Once upon a time, the competition for assisted living was the nursing home. The principal competition today is neighboring assisted living communities. In today's market, according to surveys by the National Investment Center for the Seniors Housing and Care Industries, the typical assisted living community competes with eight similar and closely situated facilities.

Little wonder, therefore, that communities might be looking to attract customers who might, in fact, stretch the facility's capacity to provide care. To keep units occupied, some assisted living companies have sought to retain their most frail and dependent residents longer than might be deemed appropriate. Indeed, Wall Street analysts say success on this score-the score, that is, of occupancy rates-has become crucial for providers, as more and more facilities are built.

The reality of aging in place, though, is just that: People will age. And there is a direct correlation between increasing age and increasing frailty. The average age at admission to an assisted living facility is 84 for women and 82 for men. Even if relatively healthy upon arrival, their conditions will eventually deteriorate, and ADL dependencies numbering one or two can quickly approach three or four.

The politics of aging have only exacer-bated the trend. In Michigan, for example, the state has been legislatively denied the authority to require the transfer of a resident out of a facility even when the facility is no longer capable of caring for that resident's needs. Rather, the ultimate decision rests with the family, in concert with the provider. The assisted living industry has greeted that legislation favorably, and it has comparable legislation in states such as Texas.

I did so, myself, as president of the Assisted Living Federation of America. In retrospect, I'm not so sure that was wise. I now see such legislation as more mischievous than beneficial, absent elemental safeguards underpinning a facility's continuing responsibility for care. When continued frailty and comorbidities lead to the inevitable mishap, will the family remember that it was a part of their decision to ignore the community's ability to provide adequate care? Or will the unfortunate result, as is so often the case, be left to the courts to determine culpability? History suggests the latter.

So what are the solutions available to us? In last October's column, I pointed to providers, such as CCRCs and the PACE (Program of All-inclusive Care for the Elderly) organizations that offer a full continuum of care, as potential remedies. But only about three dozen PACE sites are completely operational today, and CCRCs are vastly outnumbered by freestanding assisted living and nursing facilities. So what's a provider to do? I would recommend at least five fundamental approaches:

Establish community policies in advance, including desired resident mix. Too many communities let events dictate their resident mix rather than establishing such policies by design. The character of an assisted living facility should be determined proactively by management, not by the circumstances of an increasingly frail resident population. The provider should decide up front: How much mild and intermediate dementia will fit within our program? What level of ADL dependency is appropriate to our service package? What, if any, medical interventions do we anticipate handling? What approach to medication management fits within our philosophy of care?

It's better that issues like these be resolved systematically by management as a part of the development process, rather than by ad hoc decision making based on the exigencies of the moment. Exceptions can (and inevitably will) be made. But at least management will know it is making exceptions and will, consequently, be better prepared to handle the repercussions.

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