Successful aging involves many aspects - health, financial security, social support among others. Some seniors choose to move to a senior community - a residential care facility for the elderly (RCFE) - where they hope to get some of their needs met.
At ChipperList, our mission is to support elders and their families in researching senior communities - we promote the high quality ones and "call out" the ones with poor track records. Most seniors however, would prefer to stay in their homes as long as possible, instead of moving to a senior community. This decision depends on whether or not their home is accessible, and if necessary services are available in their community.
Our youth-oriented culture has not done such a great job in providing "livable communities" for seniors. Many communities are a result of the suburban "sprawl" that was so prevalent over the past 50 years. We've created bedroom communities, big box stores and traffic jams. These suburbs accommodate working families, but the elderly, not so much. People tend to be isolated in their homes (often two story homes, built on smaller parcels of land) when they can no longer drive. Suburban community services tend to focus on children. Urban dwellers have similar challenges, revolving around transportation, accessibility and potential isolation.
"AARP seeks to improve older adults’ quality of life by promoting the development of safe, accessible and vibrant environments often called livable communities. Livable communities' policies address issues such as land use, housing, transportation and broadband — all of which facilitate aging in place." See more on the AARP website here.
When an elder loses their ability to drive due to physical or cognitive frailty, life becomes quite complicated. Many areas are totally dependent on cars; some have public transportation, but is it accessible and efficient? Having to walk a half mile to a bus stop for example, is not practical for most elders.
Many areas have home delivered meal programs. In San Diego, we have Meals-on-Wheels. There are also other social service agencies and some entrepreneurs who do this. Find out what is available in your community, and give it a try. When transportation becomes an issue, shopping for groceries becomes an issue too.
These are very prevalent, and can be effective for some seniors. They are widely available. As always, comparison shop, and check the features and the reviews. The best candidates for successful use of personal alarms in our view would be a physically impaired person who is not cognitively impaired. A person with dementia may not understand what the alarm is for, nor the protocol of using it. It is often said, that these alarms do more to create peace of mind for the family than they do in protecting the elder. Another sidebar, one should have a hide-a-key, with the location known to the company, or else 911 emergency personnel may need to break into the house if an elder lives alone and an alarm is activated.
A relatively new field, a geriatric case manager would most likely be a nurse or a social worker. They provide often heroic and invaluable services, but their fees are quite high, around $150 per hour. They are especially helpful in complex cases, crisis management and/or situations where the elder has no local involved family member to advocate for them. The Aging Life Care Association can help an elder find a member in their area.
Non-medical in home care is also very expensive, unless one needs just a few hours a week. Typical hourly rates range from $20-$25, often with a four hour minimum. The caregivers an agency sends are not permitted to perform medical care, nor are they housekeepers. The worker is often relatively unskilled and they are paid about 1/2 of the rate billed to the client, maybe less, so the client is often disappointed in the quality of the person sent and the services provided. An elder needing significant "coverage" from a home care agency (such as 12 or 24 hour shifts, most days a week) is looking at a very big investment in care, often exceeding the monthly cost of a senior community. Hiring privately is possible, but it is complex due to the necessity of paying payroll taxes as a household employer and protecting oneself from liability if the worker is injured in the home. These matters can be handled in a family direct hire, but it is involved. An involved and local family advocate would be necessary to manage a direct family hire.
For many seniors with chronic illnesses who are cared for at home by family members, an adult day health care (ADHC) program can be a godsend. In California, these ADHCs are licensed and regulated by the State. Staff typically includes a full time nurse and social worker, physical therapists, caregivers and activity personnel. They serve as an "activity program" for a frail elder, while giving the primary family caregiver a few hours of respite.
Senior centers abound in San Diego, due to our history as a retirement destination. They serve as information and referral services to some degree, and also host classes and various recreational activities for seniors. This link lists the senior centers in San Diego County. The services are geared for relatively healthy and active seniors. No care or supervision (such as offered in an ADHC) is provided. Although they provide informational resources for frail seniors, they themselves do not provide any support or health related services.
"Make new friends, but keep the old, one is silver and the other's gold." - this rhyme from childhood rings true, but the reality is that it is harder to make new friends after retirement. And one's old friends may move or pass away. Becoming isolated is a real concern for elders. Many studies confirm the importance of social support, through family or friends and options include clubs, classes, churches, volunteering, part time employment, senior centers, adult day programs, or moving closer to family members, depending on one's health and circumstances.
Each senior will have certain healthcare providers participating in their insurance. Ideally, one should live within a reasonable proximity to participating doctors, hospitals, labs, pharmacies etc. to avoid transportation issues, both in routine and emergency care. This applies to either a senior community or living in one's own home, so know your plans' providers and give this some thought before the need arises. Larger cities offer medical transportation services, including wheelchair vans.
As with all things eldercare, there are no easy answers. Each family has a unique set of circumstances and there is no one-size-fits-all answer to "should I stay or should I go?"
Here in San Diego, we are fortunate to have so many options for both senior communities, as well as service providers in most of our areas. As always, we encourage our readers to do your homework and plan ahead - don't wait for a crisis!
There comes a time when an elder must choose to stay in their home and rely on in-home and community services in their home or move to senior housing. Both aging in place and moving to a senior community take substantial financial resources and family and/or community support.
At ChipperList, we have both personal and professional experience with this decision, and it is almost never straightforward. Every family has unique needs, and to some extent are planning for an unknown future. As always, it is better to look ahead at these needs, rather than wait for a crisis. It doesn't take much of a setback for an elder to need assistive devices such as walkers and wheelchairs and most homes (entrances, bathrooms, hallways, kitchens) are not wheelchair accessible.
AARP has much information on aging in place on their website and they state that "The vast majority of older adults want to age in place, so they can continue to live in their own homes or communities." We might add, "as long as they can manage". Therein the problem lies - there are many aspects to aging in place, we will touch on several this month and again in September.
You'll want to start with a needs assessment - both for health needs and for your home, also taking into consideration your budget for potential home remodeling. The National Aging in Place Council has a great checklist on this page.
The "gold standard" contractors skilled in home modifications for elders and the disabled are certified by the National Association of Home Builders as Aging-in-Place Specialists. There may be other local contractors who are also knowledgeable in this area, but be sure to check carefully their licenses and references for similar jobs. Also check out Yelp and Angie's List for consumer feedback.
The US Department of Housing and Urban Development (HUD) has some information on this page covering some of the aspects of accessible housing.
Our suggestions here are targeted to families who have the financial means to be making the decision whether to age in place or move to senior housing, and let's face it, both options are expensive.
We recommend researching the cost of what needs to be done to make the home accessible (ramps, door widening, etc.) using competent and knowledgable professionals. We also suggest researching and touring several senior communities for cost comparison. In some cases, remodeling a home and providing necessary in home services may be too extensive and costly, as compared to selling the home and using those funds to pay for a senior community.
Reverse mortgages are a controversial product. There are many lenders promoting these, and we are not experts in this area, but can advise our readers to do a lot of research and proceed very cautiously. "If it sounds too good to be true, it probably is." The Federal Trade Commission (FTC) website offers some information on reverse mortgages here.
This from TurboTax for tax year 2014:
"Home Modifications - If you make certain home improvements to accommodate a disability, you may be able to claim those costs as a medical expense deduction. This includes such things as adding a wheelchair ramp, chair lift or grab bars; modifying hardware, electrical fixtures or railings; or widening doorways or aisles. The improvements must be made solely to accommodate a disability and not for aesthetic reasons. If the improvements increase the value of your home, you can deduct only the portion of the cost that exceeds the increase in value. IRS Publication 502 (.pdf) provides more details and examples."
There will probably come a time when elders need to turn to family members to help oversee their care (hiring and supervising in-home caregivers, making arrangements, providing transportation etc.) whether in a private home or in a residential care senior community. Be realistic when evaluating if family members are going to be able to step up to this role, when needed. And consider that this need can occur with little or no warning, if an elder is in a healthcare crisis. It is possible but not easy to provide long distance support. If family support is not available, to successfully age in place, one must factor in the cost of hiring professionals, such as geriatric care managers, fiduciaries and attorneys. Elders also may need help with daily money management and home repairs and maintenance.
The title of this post is a quote by Benjamin Franklin - it may be old school, but like many words of wisdom, it still holds true.
We recently attended a small expo - emergency preparedness for seniors. One of the best "takeaways" was to break the preparation into small weekly tasks, since it is so overwhelming. It is hard to plan for the unknown, and no amount of planning can prevent natural disasters. Preparedness can lessen the impact on our lives. Here we will cover a few of the main points and include links we obtained from the material we received at the expo.
Zone 1 - (from structure out to 50 ft. ) - should contain low growing plants with low fuel volume.
Zone 2 - (minimum of 50-100 ft. from structure) - Low growing ground covers that are resistant to fire and low in fuel volume. Thin natural vegetation - remove dead woody debris.
What is a "hardened home"? Download Ready, Set, Go on this page.
For earthquake safety tips (strapping your hot water heater, natural gas safety, fastening shelves securely, bracing overhead light fixtures, etc.) can be found in this FEMA Earthquake Safety Guide for Homeowners download.
Emergency evacuation plans will vary depending on circumstances. State licensed senior communities are required to have emergency disaster plans, in writing and readily available. Ask for a copy and be sure you are familiar with it. Relocation sites and supervision for medically or memory impaired residents can be complex. Be sure family members are also familiar with the protocol and the communication channels.
Nomatter what your living arrangement, when you make an emergency kit, think about what you would need if you had to evacuate your home without much notice. Set aside (in suitcases or storage containers) some bottled water, non-perishable food, medication, medical supplies, toiletries, extra glasses, clothing, shoes, gloves, flashlights, batteries, portable radios, pet supplies, cash and copies of valuable personal paperwork. Make a list of your personal valuables such as computer external hard drives, digital devices and powercords, jewelry, photos or mementos that can't be packed in advance. Don't let your gas tank get below half a tank. The following checklists will help "jog your memory" about what is important in various situations.
The USAA Educational Foundation has some excellent information on how to prepare those with special needs here.
More detailed information on disaster preparedness for the elderly and disabled is provided by FEMA here and here. FEMA also publishes a booklet on preparing our beloved pets.
The San Diego County Office of Emergency Services has a detailed Caregiver Disaster Plan on this page.
If sheltering-in-place is your best option, SDG&E offers emergency preparedness information on their website. We were told at the workshop by SDG&E not to shut off the gas unless there was a gas leak. Click through to this page on gas leaks and download "What you and your family should know" under Emergency Checklists.
The San Diego County Office of Emergency Services publication Family Disaster Plan and Personal Survival Guide includes some good information on sheltering-in-place during an earthquake and after a disaster.
The Red Cross Food and Water in an Emergency (Google it for the link to the .pdf) publication offers some tips for sheltering-in-place including how to cook if the power goes out, and how to purify water. They also offer information on recovering after a disaster.
We are all about helping the senior housing consumer find and evaluate options for their loved ones. This recent article in Senior Housing News threw us for a loop! Apparently, around 30% of Baby Boomers searching online for senior housing for loved ones use the search term "nursing home". Clearly, they are not dialed into industry lingo and probably not aware of the various levels of care available in senior housing.
ChipperList was founded by Chip Allen, a software engineer. Chip founded the company after his father had difficulty finding suitable senior housing for his grandfather. Senior housing is not easy to research online as with other industries such as travel, real estate and electronics for example. In days gone by, people used paper booklets featuring ads for senior communities, drove around and met with sales people onsite. Today's marginal "Internet presence" could be due to the lack of computer literacy among the Greatest Generation, who are now the majority of residents in senior communities. As the Baby Boomers age, tools for searching and researching senior housing must be ramped up to meet the growing demand. Other statistics show that something like 80% of senior housing consumers start their search online. We would like to help people get it right!
As always, we want to remind our readers that many of the "hits" a user will get (even using the proper search terms) are commercial enterprises who are profit driven (such as the senior communities' websites themselves and "free to the client" placement agencies). They are not advocating for the best interest of the consumer, as we do at ChipperList. Search Engine Optimization (SEO) and search engine algorithms are complex, and the buyer must always be aware that he or she is being sold something by very smart marketers.
First, we are not addressing "senior communities" where people own their homes or condos in a 55+ age restricted development. We are focusing on "senior communities" that are State licensed residential care facilities for the elderly (RCFEs). We will discuss Continuing Care Retirement Communities (CCRCs) in a future post.
The senior housing industry does not make it easy for consumers to sort through the various options. In fact, in our view, their marketers (and highly paid Search Engine Optimization SEO consultants) probably make matters worse for the consumer through euphemisms. Considering the prevailing discrimination toward age and disability in our American culture, this is not surprising. Even the term "senior community" is really a softer word for "facility".
Eu·phe·mism - noun - a mild or indirect word or expression substituted for one considered to be too harsh or blunt when referring to something unpleasant or embarrassing.
- Typically, an IL resident lives in a small studio, 1 or 2 BR apartment in a large building or campus of smaller buildings. They are typically rentals, and may be furnished or unfurnished. Basic support services may be offered, such as 2-3 meals per day served in a common dining room, scheduled transportation, housekeeping, group activities, some utilities. There is no personal care offered, outside of perhaps periodic "wellness checks" such as blood pressure.
- All of the services provided in IL would be included, plus the facility provides caregivers to help the resident with the Activities of Daily Living (ADLs) such as bathing, dressing, ambulation, assistance with eating and toileting. Costs for the assisted care are over and above the basic charges for the apartment, meals, activities, utilities and transportation. Assisted living fees are often convoluted and based on individual care plan assessments (on admission and ongoing) to determine the amount of assistance the resident requires. There is usually a nurse (typically an LVN) on staff at least part of the time, not usually 24 hours.
- All of the services provided in AL would be included in a dementia care facility, plus more caregiver and nursing oversight and building security in terms of alarmed entrances and exits, secured outdoor spaces and specialized activities. Dementia care facilities usually have awake staff overnight. They should be offering specialized staff training, due to the difficult behaviors staff will encounter with dementia patients.
- Licensed in California as RCFEs, they are typically large single story homes, or a group of homes modified to care for the frail elderly. They offer similar services to larger AL facilities, but typically they don't offer transportation or activities. They are more "homey" and less institutional, and often at a lower rate than the large national senior housing chains. The quality can vary tremendously, there are hundreds of them all over San Diego and with the State of California CCLD in perpetual budget cutting mode, oversight is inadequate. The better ones have two caregivers for six residents, one awake overnight. That is a good caregiver ratio compared to the larger AL facilities, but other aspects of a quality life can be lacking in the smaller homes. The caregivers typically do the cooking and the housekeeping in addition to providing resident care. Many residents are very impaired. Some homes are suitable for dementia patients, some are not.
- The highest level of care is offered in skilled nursing facilities. SNFs typically have RNs on duty 24/7 and one must need daily skilled nursing services to be admitted. Medicare pays for "rehab" (such as after a stroke or a hip fracture) in a SNF on a very limited basis. Longer term "custodial care" is private pay, VA or Medicaid (Medi-Cal). Most SNFs resemble acute care hospitals - shared rooms, call bells, nursing stations, dining and activity areas and a lobby. They are not fancy or "homey". SNFs, since they take Federal money, are also regulated by the Federal government as well as the State. There are many instances of inadequate staffing and poor care in SNFs. Many residents have some dementia, but not all SNFs are suitable, especially if a resident with dementia is ambulatory.