Get ready for community-based long-term care

I guess I had best admit to my bias at the start: I am-and am proud to be-a Howard County resident. I have been for as long as I've lived in Maryland, now more than 30 years. Beyond that, I'm an appointee to Howard County's Commission on Aging. So when, five years ago, my county was named by the National Civic League as an All-America City, my excitement was understandable. But that wasn't the sole reason for my enthusiasm. According to the sponsoring organization, "the fifty-two year-old award is given in recognition of communities that triumph over partisan politics to improve the quality of life for their citizens by finding solutions that achieve uncommon results." And among the programs highlighted by the league was Howard County's "Aging in Place" initiative.

Now there's something worth discussing. We all talk about aging in place. Some of us even write about it, perhaps even skeptically (as per my own article, "'Aging in Place' Conveys the Wrong Idea," in the November 2005 issue). But to actually see a community take this on as a key priority-that's noteworthy.

Especially in Howard County. The county is perhaps best known as the location of Columbia, Maryland, a planned community developed by urban planning pioneer (and shopping center mogul) James Rouse. He was going to create an environment that learned from (and thereby avoided) all the mistakes that characterized similar developments in the past. Columbia certainly didn't achieve all of Rouse's goals. But it was successful enough to attract well over 100,000 highly enthusiastic residents, most of them young. A 1999 survey by the Columbia Association, the entity that governs the "new town," pointed out that "the planned community of Columbia began with virtually no seniors."

Well, times have changed. Seniors in Howard County (defined by the county as those over 60 years of age) now constitute 10% of the population and have made it the second most rapidly aging county in the state. While still below the figure for Maryland (15%) and the country as a whole (16%), it clearly reflects the degree to which residents of the county (with Columbia at its center) chose to make it their home for life.

At the outset, I need to admit that Howard County is a very well-to-do community-among the ten most affluent in the nation, with a median annual household income of nearly $80,000. In that respect, it certainly doesn't mirror most U.S. counties. But the increasing frailty that comes with age is no respecter of affluence. Howard Countians face the same obstacles as most Americans do when it comes to exercising a preference to productively age in their own homes as they get older. Surveys by AARP in 1989, 1992, and 1996 all reflected a consistent desire on the part of seniors (more than 80% of them) to "stay in my own home and never move."

But the desire to stay at home runs afoul, in most communities, of an inherent bias toward facility-based care for the elderly. That bias is reflected not just in the tendency of financing systems to focus on it, but in the absence of both infrastructure and referral mechanisms designed to support alternatives. This is a status quo that readers of this magazine may want to cheer for-but read on.

Howard County chose to confront this issue head-on. With seed money from the Horizon Foundation (one of Maryland's largest philanthropies), the county's Office on Aging became one of only a limited number of American communities with truly seamless, comprehensive programs designed to facilitate aging in place. (Others that come to mind are the Philadelphia Corporation for Aging and Multnomah County's Aging and Disability Services programs in Oregon.)

The particular needs of seniors require services totally unlike those provided to other populations in our society. Most healthcare, for example, is typified by acute interventions designed largely to address singular episodes of ill health. Seniors, however, pre-sent a preponderance of chronic conditions, increasing frailty, multiple comorbidities, and decreasing cognitive capacity. Additionally, social concerns are often more of an issue for seniors because of decreasing physical and cognitive capacities, compounded by limited financial and social resources. And mental illness-especially depression and mental illness associated with dementia-is widespread among the elderly. Indeed, a survey conducted among Howard County seniors as part of its aging in place initiative showed a large proportion (63%) admitted to having experienced some depression over the 30 days preceding the survey.

These are not people for whom a compartmentalized single episode, a single practitioner, a single focus for service delivery is appropriate. Their need is not for discrete and individual interventions, but for long-term and coordinated management of multiple services. And that means management, focused as it must be on the myriad factors attendant to the individual, must itself bring to bear the various specialties and functions appropriate to those concerns. Anything short of that is a disservice to the client.

A team approach, therefore, is key. It is critical at every stage of the process-from needs assessment through service planning, delivery, and follow-up. It is as relevant to the overall management of the service and care program itself as it is to the specific needs of the client. And managing productive aging is no exception-particularly any effort designed to allow productive aging in one's own home.

This has to take into account the changes in physical as well as mental health that contribute to reduced independence. Such changes result in predictable occurrences, including increased needs for affordable home care, homes that offer the physical environment conducive to the needs of increasingly frail seniors, and the identification and treatment of depression and other mental health problems.

The county's Office on Aging, therefore, brought together three additional partners in creating its "team." Family and Children's Services of Central Maryland assumed responsibility for the provision of home care. Older Adult Consultation Services addressed the mental health of seniors. And Our House youth home offered home modifications designed to enhance the ability of the client to function safely in his or her own residence.

A steering committee (on which I was privileged to serve), consisting of representatives from all of the component organizations, provided ongoing oversight and coordination. The committee was also responsible for providing joint training for the agencies involved, determining the best way to track and monitor the project and the progress of clients being served, developing community awareness and outreach, and making necessary changes to increase the initiative's effectiveness.

Because of the multiple needs of seniors, a key element in the initiative was the coordination of intake and referrals though the Office on Aging. A client who came to the attention of one component-say, for example, home modification services-might also be referred to Family and Children's Services for home care, or Older Adult Consultation Services for a mental health evaluation. The Office on Aging was responsible for ensuring that information about all clients was entered into a county tracking system used by all agencies providing services to them.

This coordination and collaboration across all components of the initiative "expands our ability to help older people stay in their homes," says Sallie Hedenstad, MA, director of elder services at Family and Children's Services. For example, if one of her staff made a home care visit and found that the client had a fall, or was depressed, one could easily tap the initiative's other components-mental health services and home repair-to provide necessary assistance. Howard County's initiative was one of the few in the nation that functioned in concert with multiple critical components, all working together to provide a seamless web of appropriate services.

Interestingly enough, it was the home modification component of the program that brought about the initiative's most cost-effective results. The success stories were both touching and instructive. They suggested that, in many cases, it takes little more than appropriate (and inexpensive) changes in the physical environment to forestall more expensive facility placement. Mrs. W., for example, continued to live in the home where her husband had died from a fall down the stairs. Despite severe arthritis, hypertension, osteoporosis, nerve damage, a history of falls, and macular degeneration to the point of legal blindness, she was still able to handle most of her activities of daily living. The initiative provided her with assistive devices to help sort out her many medications, use the telephone, do her laundry, and generally navigate throughout her home. It prescribed behavioral and environmental modifications and installed new handrails, lighting fixtures, grab bars, and stairway modifications. Mrs. W.'s enthusiastic acceptance of the initiative's help and the resulting success became the subject of a feature article in the Washington Post, and Our House, the organization providing the home modifications, was prominently featured on Oprah Winfrey's TV talk show.

But Howard County wasn't through. While the aging in place initiative was a demonstration, a demonstration that worked and for the most part continues to work, it pointed to the need for even greater attention to more overarching issues that prevent seniors from continuing to age in place. Perhaps the most critical of these was the absence of information and referral sources for those eager to productively age, regardless of the setting. So Howard County applied for and received a grant from the federal government enabling it to become one of only 12 "aging resource centers" across the country. These centers are designed to serve as single points of reference for seniors and others looking for information they might need in planning for a productive retirement. Maryland Access Point offers information regarding an entire array of support services and information, from financial planning to housing, from healthcare to transportation.

So, there you have it-a small success story, perhaps, but one that reflects a growing need for similar initiatives. Aging in place is not, after all, a denial of the critical need for facility-based long-term care services. Congregate care, assisted living, nursing facilities-all are important to the continuum of long-term care. But all of them share one characteristic: a perception by most potential residents that they reflect an option less desirable than remaining in one's own home. That is not an indictment of facility-based long-term care. It is simply a reflection of customer preferences.

You, readers of Nursing Homes/Long Term Care Management, can look at Howard County as a precursor of trends that will become ever more prevalent across the entire country. You can look at those trends as having serious implications for market share-and you would be right. As such, you might be inclined to oppose them-and you would be wrong.

Better to understand them, accommodate them, and attempt to profit from your involvement in them. That is precisely what the nursing home association in my state has decided to do in addressing a waiver request submitted by the state Medicaid agency to revamp Maryland's long-term care system. That response by organized long-term care will be the topic of my next column.

Paul R. Willging, PhD, was involved in long-term care policy development at the highest levels for more than 20 years. For 16 years as president/CEO of the American Health Care Association, Dr. Willging went on to cofound the successful Johns Hopkins Seniors Housing and Care postgraduate program (cosponsored by the National Investment Center for the Seniors Housing & Care Industries), and later served as president/CEO of the Assisted Living Federation of America. He has enjoyed an equally long-lived reputation for offering outspoken, often provocative views on long-term care.

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