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.

Develop (and refine) budgets, particularly with respect to staffing, based on resident mix. If the product (or service) is being determined proactively, so too must the budget be designed proactively to support it. In assisted living, this means staffing. The characteristics (and consequent needs) of the residents must be reflected in the numbers and skills of the staff hired to care for them. A reasonably vigorous resident population with only limited ADL dependencies will require fewer staff than a frailer population. Too many facilities, however, experience a disconnect between actual resident characteristics and their staffing (and, ultimately, budgets). Indeed, this might well be the most telling of the allegations leveled against assisted living.

I’ve often referred to the assisted living community as an “ICF (intermediate care facility) with a chandelier.” ICFs were the predominant form of nursing facility prior to nursing home reform legislation in 1987-and they were thought to be understaffed. Assisted living facilities, although providing care to an equally frail population, appear to have fewer staff than did the typical ICF. I would suggest that phenomenon is a result of failing to anticipate that the character of a facility, as determined in the pro forma, is often at variance with its character following the admission of actual residents. Thus, the estimated staffing needs, as determined in the development budget, were likely a result of operators focusing on “making the budget work,” not on the anticipated (and changing) characteristics of the customers. And once the customer is admitted to the community, it is unlikely that budgetary pressures-already extreme-will lessen.

Assess residents prior to, not following, admission. Unfortunately (and somewhat incredibly), it is not universal practice for facilities to assess their residents prior to admission. Even when done prior to move-in, assessments are too often a function of marketing rather than wellness (a sadly predictable recipe for creating disgruntled customers). A comprehensive resident assessment is the indispensable first step in the provision of long-term care services at any level. And, just as the assessment determines the care needs of the customer, so too will it determine the price of the service package. Any price established absent a comprehensive resident assessment is only fortuitously reflective of customer need and just might bear within it seeds of trouble.

There are just too many examples of customers made painfully aware of their financial liability only after their loved ones have been admitted to a facility. The short-term advantages of the artificially low-price approach are clearly outweighed by its long-term disadvantages. Certainly, prior to execution of a contract, the community owes the customer its best assessment of the customer’s needs and the financial consequences thereof.

Fully disclose policies and prices to residents and families. Beyond discussing the assessment and likely financial consequences, there needs to be a discussion of the community’s genuine service obligations. If the base price includes only two meals per day, make it clear that the third, if desired, is the responsibility of the resident. If the base price includes only 45 minutes of care per day, make sure that (and what level of service 45 minutes actually entails) is clear to the customer. Better a lost admission than an unhappy client once the community’s pricing policies go into effect.

This might be the most difficult of my five recommendations to follow. There is, for providers, an inevitable inclination to convince the prospective client that the community is suitable to his or her needs-even if there is some doubt this is true. Absent total honesty in final negotiations with the customer, the result will surely not be pleasant. Remember, one of the primary methods of marketing assisted living communities is word of mouth. Satisfied customers help a project succeed. Unsatisfied customers will torpedo your plans before you know it.

Work with families at discharge, and include appropriate lead time. For many a resident, the time will likely come when a new care setting must be recommended. When the first signs of care needs going beyond the provider’s call of duty become manifest, that is the time for the provider to remind the family of the discussions that accompanied the admissions process. Don’t wait for this discussion until time is at a premium-the time needed not only to search for a more appropriate facility, but also to prepare both resident and family for the transition. (Transfer trauma is, after all, a reality in long-term care.) Although even good facilities will try to postpone a transfer as long as possible, good facilities will not postpone these discussions with residents and families beyond the point at which the transfer becomes a rushed, stressful event.

Will the above recommendations eliminate family concerns that Mom might not, after all, be able to age in place indeterminately in your facility? Probably not. But those concerns might just be directed not at the community, which tried its best to inform and involve the family, but at the inevitable consequences of aging itself. And those concerns, natural as they are, are less likely to result in litigation. Most customers are reasonable; they will not expect the impossible. They have seen their loved ones become increasingly frail. And, I suspect, they are well aware of the inability of any single facility to handle all eventualities possibly occasioned by that frailty.

What customers may be less willing to accept is something other than complete candor. As one reads an increasingly critical press, most reporting seems to reflect unfulfilled customer expectations-expectations the customers felt were prompted by a facility’s words and actions. Yes, people sometimes hear what they want to hear, perhaps especially when confronted with the often traumatic decisions surrounding long-term care. But doesn’t that in itself speak to the need for complete and candid discussions?

Assisted living, provided appropriately, has the market attractiveness that will resonate with potential customers. We need to make sure that we are not the parties responsible for losing that appeal and, eventually, losing our private market freedom and maybe a lawsuit or two.

To comment on Dr. Willging’s views, as expressed here, send e-mail to
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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