CCRC shopping: One couple’s view
[Editor’s note: This article is the first part of an ongoing conversation on how CCRCs can better serve the incoming census and how LTC facilities can learn what matters to incoming consumers.]
Sandi and I are both in our mid-70s—We are not old by today’s standards. Both of us have been involved with aging issues, not only through our personal explorations but also through our professional involvement during our work years with various programs designed to support older adults.
For several years, we have looked into privately run communities offering independent living to people aged 55+. Mostly self-sufficient and self-contained, these communities offer opportunities for personal growth, recreation, friendship and independence. In many instances, these communities can be quite large, approaching 10,000 individual units, with multiple clubhouses and pools, golf courses and extensive opportunities for residents develop artistically and intellectually. Many other, smaller retirement villages control their size to provide more intimate communities for retirees. We knew that other options for an independent lifestyle existed that we had not yet examined, so we searched further for our future retirement site.
Recently, we toured several continuing care retirement communities (CCRCs) and independent living complexes designed for the 55+ audience. Our trip took us through six states: Alabama, Florida, Georgia, Kentucky, North Carolina and South Carolina. All of our site visits, seven in total, were to "for-profit" retirement communities. Our visits ranged from one-night/one-day visits to four-night/five-days, with the majority being two-night/three-day stays—long enough to see how a community really operates around the clock.
CCRCs are designed to include a continuum of care, offering independent living, assisted living, skilled nursing and, in many cases, memory and Alzheimer’s care. Although private, individually run homes exist in many areas, most are corporate-run with multiple units in many states, some with nationwide coverage and as many as 350+ locations. Almost all CCRCs and independent living-only communities allow prospective clients to visit and stay for little or no cost—a "try before you buy" arrangement well worth taking advantage of by prospective residents.
Conditions at the facilities we visited varied greatly, with the best of those we encountered being extraordinary in their quality, and with the worst of our visited sites being absolutely horrid. We were both gratified and shocked by what we encountered.
WHAT WE LIKED
Across all six states, the high points of our CCRC visits were the extraordinary residents we encountered—many of whom were in their 80s and above, each and every resident possessive of life experiences and skills worth sharing. Most were friendly and outgoing, whereas others were withdrawn and fighting to survive illnesses, some of them fatal. There were younger residents as well, living by choice and for various reasons as an integrated aspect of each community. We expected to see high percentages of single female residents but were surprised to find large populations of single males as well. The average age of residents reported to us by staff varied from 82 to 84, meaning that each facility had portions of its population above and/or below the average estimated national age for CCRC demographics.
We have always sought to find and live in communities with diverse populations. Diversity adds vibrancy, and the intermixing of a variety of international and ethnic populations adds interest to conversation, lifestyle and programming. We exulted when we observed residential communities with a variety of races, ethnic origins and religions, with different skills, occupations, education and beliefs. Thankfully, most communities we visited on our trip met our criteria for diversity and presented an interesting mix of residents.
FROM GOURMET TO BASIC, PERSONAL TO IMPERSONAL
In some cases, our CCRC visits revealed that residents' attitudes toward their own aging (coupled with corporate and staff attitudes) had a direct effect on facility policies, the scope of activities and the living conditions. Yet in many of the facilities we visited, older adults continued to be "treated as children," leading to limitations in activity choices, food selection/delivery and personal interaction. Where healthier attitudes prevailed, usually at the higher-end facilities, there was a noticeable difference in self-determination, personal interaction, level of conversation, activities, food preparation and delivery, facility management and cleanliness.
Let’s face it, no independent living situation (with the possible exception of buying a home within a retirement community) will approach or become an adequate substitute for living in one's own home. In CCRCs and some stand-alone independent living facilities, the nature of the situation automatically changes a person's independence to dependence. The transition in some facilities is almost immediate, but in most situations, the transition is subtle and takes place over a longer period of time.
For example, the fostering of dependence occurs simply and quickly by changing the rhythm of resident daily activity. The offering of three meals at specific times—let’s say 8:30 a.m. breakfast, lunch at noon and an evening meal at 5:30 p.m.—fosters dependence by altering daily activity to meet institutional requirements. Apartments or cottages may have kitchen facilities, but many are rudimentary, causing residents to prepare microwave meals or reheat food prepared by the institution and delivered (usually in takeout containers) under special circumstances. At some higher-end facilities, apartments come with full kitchens, including full-sized appliances—allowing a modicum of increased independence for residents.
Residents automatically become more dependent on the institution as they develop a daily pattern for living. For example, eating meals at specific times, partaking of activities at scheduled times or taking shopping trips on specified days are standard offerings at most facilities. In many instances, this may not be a negative aspect of independent living, but it certainly alters the definition of "independent" as understood by both prospective and current residents, simply by cutting down the options a person possessed before moving to an independent residence.
The right to self-determination is a key factor for individual freedom in any democracy and should remain intact as much as possible in senior living spaces. Yet during our visits to independent living facilities, we noticed increasingly limited opportunities for self-determination. Is it necessary to limit opportunities to individually programming ones’ own remaining years as a sacrifice to care? We believe not. Yet, as the definition of independent living evolves, the self-determination factor decreases. Limits on choices and opportunities to perform creative thinking, inadvertently placed on residents by standardization of services and poor programming, have removed much of the meaning of "independent living" from the former definition of the term.
Institutions advertising independent living must rethink their priorities: The alteration of policies designed to increase profit margins (but which, in turn, alter the rhythm of daily living) will limit independence and opportunities for residents’ self-determination. Which should be more important to corporations: The increased profit margins or the opportunities for psychological and creative growth through programs and increased individualization for residents as an aspect of care?
Lifestyle changes caused by corporate policies such as these give rise to many stressful situations, complaints, depression (in some) and insecurities (in others). Many complaints seem trivial to observers, but over time they become important issues to residents. In some communities, the cumulative effect of resident dissatisfaction negatively governs the atmosphere within and can become a leading factor for why some independent living situations appear worse than others.
By far, the most negative factor we observed (and a factor present in more than 95 percent of the residential units we visited) was the changing nature of independent living. To us, independent living means that you are able to take care of yourself, you are ambulatory, fully sentient, active and able to partake in activities of your own choosing both on and offsite, can pay your own bills, handle your financial and legal affairs and successfully provide for your own general well-being. Yet in the locations we visited, independent living had been broadened to include those in wheelchairs, those with full-time aides and sometimes those seemingly in the early stages of dementia.
Most of the facilities we visited had separate wings for independent living, assisted living and nursing home residents, with each area having its own dining room, activity areas and staffing. In theory, a person (or a couple, like us) would begin residency in independent living quarters, progress to assisted living when help is needed to perform the activities of daily living, and finally progress to the nursing home for full 24/7 care.
Yet in most of the locations we visited, many residents in independent living appeared far from able to fully take care of themselves. When we asked administrators about this, we were told that it was so difficult to make residents move to assisted living from their independent living apartments that they just left them in place.
We wonder whether the hidden rationale is caused by economic concerns. Administrative costs and food costs have risen, and residents’ nest eggs have shrunk during the economic collapse of the past five years, forcing many older adults to stay in place while using home healthcare services. It seems many older residents living independently but in need of assisted living cannot afford the increased cost associated with moving from one wing to another.
Changing the definition of "independent living" helps fill a possible occupancy problem caused by rising costs. Recruitment of additional assisted living clients from the outside increases total occupancy into the 90th percentile, a perfect example of profiteering off the backs of a captive older audience. So, in a CCRC, the limited number of assisted living units makes it almost impossible for corporations to keep their promise of continuity of care for all residents. The wait for space can span several months or longer, robbing residents of the care they desperately need. As a stopgap, residents must employ their own aides and rely on family and friends during the long wait for assisted living space.
Often, we observed, an independent wing can suddenly become an assisted living wing, changing the definition of independent living. Those residents who are fully independent may face the alteration of positive attitudes about independent living, possibly leading to a more negative mindset, dependency and depression, and certainly increased dissatisfaction.
Similar changes have taken place in fully independent living facilities. Frankly, these facilities no longer can be considered independent. In the four facilities we observed (we stayed in each for three days and two nights) many residents were using wheelchairs, and several them had full-time attendants. Obviously, the bottom line takes precedence over the promises inherent by marketing these situations as independent. Unfortunately, the solution may not be easy to find and may require alteration of marketing strategies for both CCRCs and independent living facilities.
EXAMPLES OF DAILY ACTIVITIES
At the seven CCRCs we visited, we observed a variety of food service models. In one Georgia facility, part of an independent living chain, food was distributed within a large dining room setting, yet from stainless steel carts more commonly seen in hospitals.
Carts were filled with multiple plates of food at lunch and dinner, sometimes covered to keep them warm, but mostly uncovered. At breakfast, staff would first roll out carts with juice and fruit, then a second cart would follow with hot and cold cereal, then a third cart offering the main course, usually eggs. Coffee and tea were served to each resident by the administrator as a way of staying in contact with residents and checking on their well-being. Desserts during lunch and dinner, usually with two choices, were served the same way. Service alternated, beginning in the front on one day, in the rear another, so that each area would have a chance to be served first. Those being served first had the full menu choice. But if one choice was very popular that day, those served last often had to settle for what was left.
In one instance, the dessert to be served was ice cream. It was fresh and frozen at the beginning of service, but at the end it was completely melted and was served anyway. Other deserts were prepared, placed on the cart and sometimes displayed on the side of the dining hall, where they stayed for an hour or more uncovered.
At breakfast, when we ordered cereal, the server would fill the bowl and add the milk, usually to the rim, and then serve. Residents were not allowed to serve themselves or add the quantity of milk they desired. Similar limits were observed with other foods. In one facility, when we asked for a second bread roll, we were told we could have one if there were any left after all had been served. A second roll never arrived. Another time, a resident requested a second hot dog at lunch and was told, "only if there are some left after everyone is served."
When asked for special diabetic food choices, none were available and residents were forced to pick and choose from available choices. No diabetic desserts were ever available during our stay, with one exception. Sugar-free ice cream was available at lunch and dinner by request.
We also were told by more than one resident that food quality and amounts seemed to vary with the percentage of occupancy. Food was better when occupancy was high, worse when low. It seems that this particular chain has allotted a food budget based on numbers without regard to the effect budget cuts might have on total bulk purchasing power or food quality and choice, and more importantly, the effect cuts would have on menus carefully designed by dietitians.
The consequences of open food delivery and uncovered food carry the danger of contamination by all manner of airborne diseases. At one site in Alabama, a facility lockdown was necessary to control a stomach illness from spreading throughout the entire facility. A lockdown means that residents are confined to their rooms until the disease has run its course, all activities are cancelled, the dining room is closed (to be completely decontaminated), food is delivered to rooms and health professionals are brought in to check on resident health. Luckily for us, the first lockdown day fell on the day we were to depart for our next stop.
Food service plans such as these are demeaning to seniors who expect more from independent living. Taking away choices make residents more and more dependent and rebellious, providing them with many things to complain about and thus negatively affecting the atmosphere (happiness factor) of the facility. Open food delivery endangers resident health at every meal and is another instance of a profit-over-care initiative.
The aforementioned situation is not an isolated case. We stayed in several facilities run by the same corporation, and the service, attitudes and food quality were similar at each site. For a corporation with 300+ locations to foster such antiquated policies is unbelievable in this day and age. Unfortunately, little governmental control exists over such situations, and this corporation is free to continue its unhealthy practices on a national scale, simply to enhance its financial bottom line. Unfortunately, the practices we observed at just one of this chain’s sites will keep us from further considering any of this chain’s localities as a possible retirement home.
Restaurant-style food service delivery was the second model we encountered. It proved to be more satisfying. Both food service and quality, as well as the number of food choices and table service, were greatly enhanced. Although the wait for food seemed longer, the opportunity to converse with table mates was increased, which in turn fostered friendships and positive relationships.
We observed a few issues with dining rooms that used open seating, however. In most cases, we noted that residents would sit at the same table, same seat, same seat mates for every meal, becoming quite possessive of their locations. Mixing with others at meals became quite impossible because each table seemed "walled off" from others, thus forming exclusive groups or cliques. To us, this inadvertently "permanent" seating plan seemed detrimental to the formation of additional friendships and akin to a high school cafeteria situation.
In one independent residence, the restaurant manager controlled seating. He would seat individuals and couples with different seat mates at every meal, automatically increasing resident knowledge of others and providing more of a feeling of family and mutual respect. The enhanced level of conversation proved lively and beneficial. We could sense that such mealtime contact carried on throughout the day, fostering idea exchange and a sense of individual self-worth.
So, although we now know what to look for and what will be important to us if and when we decide to move to independent living, we continue to be undecided. We hope we will find a CCRC that has the aspects of cleanliness, food service, activity and resident self-determination we seek. One, we hope, that also treat senior adults with the respect they so richly deserve.
Donald H. Hoffman, EdD, is a professor emeritus of art at the University of Kentucky, where he directed the Council on Aging/Donovan Scholars Program, served as associate dean of the College of Fine Arts and taught art education and art therapy. He is the author of Rural Aging, Arts for Older Adults, An Enhancement of Life, and Arts Activities for Older Adults. He has testified before Congress on various aspects of aging, has attended White House conferences on aging, worked closely with the National Council on Aging and has been a leadership development specialist with the NRTA/AARP.
Sandra M. Hoffman, RN, worked prior to retirement as a psychiatric nurse, a visiting nurse and an industrial nurse. She also spent many years as an antiques dealer, where she assisted numerous older adults with downsizing. The authors can be reached for questions or comments at firstname.lastname@example.org.
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