Shared Housing

Shared housing among adult children and their older relatives has become a choice for many because of cultural preferences or need. The sharing may relieve the economic burdens of maintaining a home after widowhood or retirement on a fixed income. However, strong cultural influences predict the frequency of multigenerational residences. Among Asians, South Americans, and African Americans, it is often an expectation. A variation of multigenerational housing has long existed in what has become known as “granny flats.” These may be apartments added to existing homes or the construction of small housing units on family property with privacy as well as sharing of time and resources. Such arrangements allow families to be close enough to be of assistance if needed but to remain separate. They are practical and economical, and their production has continually expanded, particularly in Australia. In the United States, use of this model is minimal, but existing “mother-in-law” cottages and apartments have served a similar purpose for many families for years.

Another model of shared housing is that of opening one’s personal home to others. Older people often live in houses, which were purchased in their young adult years, and find that as they age, much of the space may be underused. Sharing a house can be easily implemented by locating, screening, and matching older people looking for houses to share with those who have them. The National Shared Housing Resource Center (NSHRC) (http://www.nationalsharedhousing.org/) has established subgroups nationally to assist individuals interested in home sharing. Those who have done so report feeling safer and less lonely. Studies on home sharing focus on the effects on well-being, finances, health, social life, and daily satisfaction.

Community Care

PACE (Program for All Inclusive Care for the Elderly) is an alternative to nursing home care for frail older people who want to live independently in the community with a high quality of life. It provides a comprehensive continuum of primary care, acute care, home care, nursing home care, and specialty care by an interdisciplinary team. PACE is a capitated system in which the team is provided with a monthly sum to provide all care to the enrollees, including medications, eyeglasses, and transportation to care as well as urgent and preventive care. Participants must meet the criteria for nursing home admission, prefer to remain in the community, and be eligible for Medicare and Medicaid. Adult day services are also provided.

PACE is now recognized as a permanent provider under Medicare and a state option under Medicaid. In 2009, there were 72 PACE programs operational in 30 states. PACE has been approved by the U.S. Department of Health and Human Services (USDHHS) Substance Abuse and Mental Health Services Administration (SAMHSA) as an evidence-based model of care. Models such as PACE are innovative care delivery models, and continued development of such models are important as the population ages. More information about PACE models and outcomes of care can be found at www.cms.hhs.gov/QualityInitiativesGenInfo/10_PACE.asp and at http://www.npaonline.org/website/article.asp?id=12.

Adult Day Services

Adult day services (ADS) are community-based group programs designed to provide social and some health services to adults who need supervised care in a safe setting during the day. They also offer caregivers respite from the responsibilities of caregiving, and most provide educational programs for caregivers and support groups. There are more than 4,600 adult day services centers across the United States—a 35% increase since 2002. Adult day centers are serving populations with higher levels of physical disability and chronic disease, and the number of older people receiving adult day services has increased 63% over the last eight years (National Adult Day Services Association, Ohio State University College of Social Work, MetLife Mature Market Institute, 2009).

Adult day services are an important part of the long-term care continuum and a cost-effective alternative or supplement to home care or institutional care. While further research is needed on patient and caregiver outcomes of ADS, findings suggest that they improve health-related quality of life for participants and improve caregiver well-being. ADS are increasingly being utilized to provide community-based care for conditions like Alzheimer’s disease and for transitional care and short-term rehabilitation following hospitalization.

Historically, ADS has been divided into three models of care: social (meals, recreation, some health-related services), medical-health (social activities and more intensive health and therapeutic services), and specialized (services provided only to specific care recipients such as those with dementia or developmental disabilities). However, more and more ADS are offering a range of comprehensive services. Staff ratios in ADS are one direct care worker to six clients. Almost 80% of centers have professional nursing staff, and 50% have a social worker and physical, occupational, and speech therapists. Most also offer transportation services.

The average ADS cost/day is $66.71. Some ADS are private pay, and others are funded through Medicaid home and community-based waiver programs, state and local funding, and the Veteran’s Administration. The Patient Protection and Affordable Care Act provides additional funding to states for home and community-based care. Pilot programs have been implemented through Medicare and are being evaluated. ADS hold the potential to meet the need for cost-efficient and high-quality long-term care services, and continued expansion and funding is expected. Local area agencies on aging are good sources of information about adult day services and other community-based options (National Adult Day Services Association, Ohio State University College of Social Work, MetLife Mature Market Institute, 2009).

Foster Care

Adult foster care offers a community-based living arrangement to adults who are unable to live independently because of physical or mental impairment or disabilities and are in need of supervision or personal care.

Homes providing foster care offer 24-hour supervision, protection, and personal care in addition to room and board. They may also provide additional services. Adult foster care serves a designated, small number of individuals (generally from one to six) in a homelike and family-like environment; one of the primary caregivers often resides in the home. A growing number of foster care homes are under corporate ownership, and in these situations, the home-like atmosphere tends to be lost. However, with state-regulated, outcome-oriented quality assurance strategies focused on achieving maximal function, autonomy, and social integration, adult foster care may fill a real need.

Residential Care Facilities

Residential care facility is the broad term for a range of nonmedical, community-based residential settings that house two or more unrelated adults and provide services such as meals, medication supervision or reminders, activities, transportation, or assistance with activities of daily living (ADLs). These kinds of facilities are for elders who need more care than is available in shared housing, or for whom shared housing is not an option and nursing home care is not needed. Residential care facilities are known by more than 30 different names across the country, including adult congregate facilities, foster care homes, personal care homes, homes for the elderly, domiciliary care homes, board and care homes, rest homes, family care homes, retirement homes, and assisted living facilities.

Residential care facilities are the fastest growing housing option available for older adults in the United States. This kind of facility is viewed as more cost effective than nursing homes while providing more privacy and a homelike environment. Medicare does not cover the cost of care in these types of facilities. In some states, costs may be covered by private and long-term care insurance and some other types of assistance programs. Assisted living is primarily private pay, although 41 states currently have a Medicaid Waiver/Medicaid State Plan for a limited amount of residents (AAHSA, 2011). The rates charged and what services those rates include vary considerably, as do regulations and licensing.

Assisted Living

A popular type of residential care can be found in assisted living facilities (ALFs), also called board and care homes or adult congregate living facilities (ACLFs). Assisted living is a residential long-term care choice for older adults who need more than an independent living environment but do not need the 24 hours/day skilled nursing care and the constant monitoring of a skilled nursing facility. The typical assisted living resident is an 86-year-old woman who is mobile but needs assistance with 2 ADLs (Box 16-1).

BOX 16-1

Profile of the Resident of An Assisted Living Facility

• 86.9 years old

• Female (74%)

• 70% moved to the assisted living facility from a private home or apartment

• Needs help with at least two activities of daily living (ADLs)

• Bathing: 64%

• Dressing: 39%

• Toileting: 26%

• Transferring: 19%

• Eating: 12%

• Needs help with instrumental activities of daily living (IADLs)

• Meal preparation: 87%

• Medications: 81%

• 42% have Alzheimer’s disease or other dementia types of diagnosis

• Length of stay: 28.3 months

• 59% move to a nursing facility

• 33% die while a resident

Data from: National Center for Assisted Living: Resident Profile 2010. Available at http://www.ahcancal.org/ncal/resources/Pages/ResidentProfile.aspx

Assisted living settings may be a shared room or a single-occupancy unit with a private bath, kitchenette, and communal meals. They all provide some support services. Assisted living provides security with independence and privacy, and supports physical and social well-being with the health care supervision it provides.

Assisted living is more expensive than independent living and less costly than skilled nursing home care, but it is not inexpensive. There are 39,500 assisted living facilities in the United States. Costs vary by geographical region, size of the unit, and relative luxury. The average base rate (room and board and limited other services) in an assisted facility is $2,930 monthly, or $35,160 annually in 2010 (Prudential Life Insurance Company of America, 2011). Most ALFs offer two or three meals per day, light weekly housekeeping, and laundry services, as well as optional social activities. Each added service increases the cost of the setting but also allows for individuals with resources to remain in the setting longer, as functional abilities decline.

Many seniors and their families prefer ALFs to nursing homes because they cost less, are more homelike, and offer more opportunities for control, independence, and privacy. However, many residents of ALFs have chronic care needs and over time may require more care than the facility is able to provide. Services (e.g., home health, hospice, homemakers) can be brought into the facility, but some question whether this adequately substitutes for 24-hour supervision by registered nurses (RNs). Not every ALF has an RN or licensed practical–vocational nurse (LPN/LVN), and, in most states, any skilled nursing provided by the staff other than nurse-delegated assistance with self-administered medication is prohibited. In the ALF, there is no organized team of providers such as that found in nursing homes (i.e., nurses, social workers, rehabilitation therapists, pharmacists).

With the growing numbers of older adults with dementia residing in ALFs, many are establishing dementia-specific units. It is important to investigate services available as well as staff training when making decisions as to the most appropriate placement for older adults with dementia. Continued research is needed on best care practices as well as outcomes of care for people with dementia in both ALFs and nursing homes. The Alzheimer’s Association has issued a set of dementia care practices for ALFs and nursing homes (Alzheimer’s Association, 2009) (http://www.alz.org/national/documents/brochure_DCPRphases1n2.pdf) and an evidence-based guideline, Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes (Tilly & Reed, 2006) (www.guideline.gov) is also avaliable.

The Joint Commission and the Commission for Accreditation of Rehabilitation Facilities have published standards for accreditation of ALFs, but many are advocating for more comprehensive federal and state standards and regulations. The nonmedical nature of ALFs is a primary factor in keeping costs more reasonable than those in nursing facilities, but costs are still high for those without adequate funds. Appropriate standards of care must be developed and care outcomes monitored to ensure that residents are receiving quality care in this setting, which is almost devoid of professional nursing. Further research is needed on care outcomes of residents in ALFs and the role of unlicensed assistive personnel, as well as RNs, in these facilities.

The American Assisted Living Nurses Association has established a certification mechanism for nurses working in these facilities and has also developed a Scope and Standards of Assisted Living Nursing Practice for Registered Nurses (www.alnursing.org). Advanced practice gerontological nurses are well suited to the role of primary care provider in ALFs, and many have assumed this role. Consumers are advised to inquire as to exactly what services will be provided and by whom if an ALF resident becomes more frail and needs more intensive care. The Assisted Living Federation of America (2010) provides a consumer guide for choosing an assisted living residence (http://www.alfa.org/images/alfa/PDFs/getfile.cfm_product_id=94&file=ALFAchecklist.pdf ).

Continuing Care Retirement Communities

Life care communities, also known as continuing care retirement communities (CCRCs), provide the full range of residential options, from single-family homes to skilled nursing facilities all in one location. Most of these communities provide access to these levels of care for a community member’s entire remaining lifetime, and for the right price, the range of services may be guaranteed. Having all levels of care in one location allows community members to make the transition between levels without life-disrupting moves. For married couples in which one spouse needs more care than the other, life care communities allow them to live nearby in a different part of the same community. This industry is maturing, and there are 1900 CCRCs in the United States, housing more than 745,000 older adults (AAHSA, 2011).

Most CCRCs are managed by not-for-profit organizations. They usually charge an entry fee ranging from $60,000 to $120,000 that covers and reflects the cost of the residence in which the member will live, the possible future care needed, and the quality and quantity of the community services. The average monthly cost of living in a not-for-profit CCRC is $2,672. Important to remember about these types of communities is that the residence purchased usually belongs to the community after the death of the owner.

Population-Specific Communities

As the number of senior communities expands, older adults will have more options of moving somewhere that they find especially welcoming. These options include communities that emphasize a particular sport, like tennis or golf. Groups of people can also come together to form intentional communities, buying a cluster of home tracts and building in such a way to support their particular lifestyles or needs or personalities. Still others provide unique additional services, such as those in communities that specialize in providing residences for persons with, for example, a mental illness, alcoholism, or developmental disabilities.

Lesbian, gay, bisexual, and transgender (LGBT) seniors face several problems in housing in their older years. They may have little family support and may face discrimination in housing options. Many LGBT seniors say they do not feel welcome at traditional residential options. Those who wish to live together are discouraged from doing so by some organizations. Residential facilities and communities designed specifically for LGBT seniors are increasing in number across the country. Nurses should be aware of this heretofore invisible group of older adults who need access to welcoming resources. Chapters 21 and 22 discusses issues specific to LGBT seniors in more depth.

Senior Retirement Communities

Communities designed for elders are proliferating. Numerous combinations of single-family homes, apartments, activities, optional services, meals in the home, cafeterias, restaurants, housekeeping, golf, tennis, and security are available. In some cases, emergency services and health clinics are adjacent. These are all designed to make independent living feasible with the least effort on the part of the elder. Some senior communities are luxurious and have a wide range of physical and cultural amenities; others are simpler, providing only the basic necessities. Prices are consistent with the level of luxury provided and the range of services available.

Although the costs of the majority of senior communities are borne by the consumers, for elders with limited incomes, federally subsidized rental options are available in some areas of the country. Older adults benefiting from this option are assisted through rental housing subsidized by the U.S. Department of Housing and Urban Development (HUD). Although not all HUD housing is designated for senior living, Section 202 of the Housing Act, U.S. Department of Housing and Urban Development, approved the construction of low-rent units especially for elders. These units may also have provisions for health care, recreation, and transportation. Under Section 8 of the Housing Act of 1983, tenants locate their own unit. Usually the tenant pays 30% of his or her adjusted gross income toward the rent, and HUD assists with supplementary vouchers to meet the fair market value of the rental (American Association of Homes and Services for the Aging [AAHSA], 2011).

Nursing Roles and Models of Care

Nurses caring for older adults in hospitals may function in the direct care provider role, as well as in leadership and management positions. Most nurses who work in hospitals are caring for older patients, and many have not had gerontological nursing content in their basic nursing education programs. In a survey of hospital nurses, only 37% reported participating in a hospital in-service training program on care of older adults (Mezey et al., 2007). “Few of the country’s 6,000 hospitals have institutional practice guidelines, educational resources, and administrative practices that support best practices care of older adults” (Boltz et al., 2008, p. 176). As part of the Nurse Competence in Aging project, the American Association of Nurse Executives (AONE) has developed guiding principles for the elder-friendly hospital/facility (Box 16-2).

Recognizing the need for models of nursing practice to prevent iatrogenesis and improve outcomes for older hospitalized patients, the Hartford Geriatric Nursing Institute developed, in 1992, the Nurses Improving Care for Health System Elders (NICHE) program. “NICHE is built on the premise that the bedside nurse plays a pivotal role in influencing the older adult’s hospital experience and outcomes, through direct nursing care, as well as coordination of interdisciplinary activities” (Resnick, 2009, p. 81). More than 300 hospitals in more than 40 states, as well as parts of Canada, are involved in NICHE projects. NICHE units of various types have been developed including the geriatric resource nurse (GRN) model and the acute care of the elderly (ACE) unit (www.nicheprogram.org).

The GRN model is the most frequently implemented NICHE model. In this model, staff nurses receive competency-based training and are mentored by advanced practice nurses in care of hospitalized older adults. GRNs then function as clinical resource experts on geriatric issues to staff on their unit. Evidence-based interdisciplinary protocols, geriatric-specific resources, management strategies, policies to meet the specialized needs of older adults, as well as an online knowledge center providing educational support, are features of the NICHE model (Resnick, 2009). This is an innovative role for a hospital staff nurse interested in care of older adults. Outcomes in hospitals using NICHE models include enhanced nursing knowledge and skills related to treatment of common geriatric syndromes, patient and nurse satisfaction, decreased length of stay, reductions in admission rates, and reductions in hospital costs (Fulmer et al., 2002; Mezey et al., 2004b; Boltz et al., 2008; Steele, 2010). Further research on patient outcomes, patient and staff satisfaction, and cost of implementation of NICHE models is needed.

The ACE model was originally developed at University Hospitals in Cleveland in conjunction with the Frances Payne Bolton School of Nursing at Case Western Reserve University. A 29 bed medical surgical specialty unit was renovated and dedicated as an ACE unit to prevent functional decline of targeted older adult patients. The NICHE ACE model designates a specific unit or section of a unit to deliver interventions known to improve the clinical outcomes of older adult patients. Key elements include environmental modifications for older patients and interdisciplinary staff with expertise in geriatrics and prevention of geriatric syndromes (www.nicheprogram.org/niche_models).

Characteristics of Nursing Homes

The settings called nursing homes or nursing facilities most often include up to two levels of care: a skilled nursing care (also called subacute care) facility is required to have licensed professionals with a focus on the management of complex medical needs; and a chronic care (also called long-term or custodial) facility is required to have 24-hour personal assistance that is supervised and augmented by professional and licensed nurses. Often, both kinds of services are provided in one facility. Most nursing homes offer subacute units that function much like the general medical-surgical hospital units of the past.

Subacute care is more intensive than traditional nursing home care and several times more costly, but far less costly than care in an acute-care hospital. Skilled nursing facilities are the most frequent site of postacute care in the United States, and they treat 50% of all Medicare beneficiaries requiring postacute care following hospitalization (Alliance for Quality Nursing Home Care and the American Health Care Association, 2010). The expectation is that the patient will be discharged home or to a less intensive setting. In addition to skilled nursing care, rehabilitation services are an essential component of subacute units. Length of stay is usually less than one month and is largely reimbursed by Medicare. Patients in subacute units are usually younger and less likely to be cognitively impaired than those in traditional nursing home care. Generally, higher levels of professional staffing are found in the subacute setting than those in the traditional nursing home setting because of the acuity of the patient’s condition.

Nursing homes also care for patients who may not need the intense care provided in subacute units but still need ongoing 24-hour care. This may include individuals with severe strokes, dementia, or Parkinson’s disease, and those receiving hospice care. More than 50% of residents in nursing homes are cognitively impaired, and nursing homes are increasingly caring for people at the end of life. Twenty-three percent of Americans die in nursing homes, and this figure is expected to increase 40% by 2040 (Carlson, 2007). Nursing home residents represent the most frail of all older adults. Their needs for 24-hour care could not be met in the home or residential care setting, or may have exceeded what the family was able to provide.

There are approximately 16,100 certified nursing homes in the United States, and more than 1.4 million older adults reside in nursing homes. The majority of nursing homes are for-profit organizations (67%), with 31% managed by not-for-profit organizations (AAHSA, 2011). Nursing home chains own 54% of all nursing homes (Harrington et al., 2010). The number of nursing home beds is decreasing in the United States and the number of Medicaid-only beds has decreased by half since 1995 (Gleckman, 2010). This is most likely a result of the increased use of residential care facilities and more reimbursement by Medicaid programs for community-based care alternatives.

Residents of long-term facilities are predominantly women, 80 years or older, widowed, and dependent in ADLs and instrumental activities of daily living (IADLs). While the percentage of older people living in nursing homes at any given time is low (4% to 5%), those who live to age 85 will have a 1 in 2 chance of spending some time in a nursing home. This could be for subacute care, ongoing long-term care, or end-of-life care.

With the increasing number of older people, projections are that there will be a threefold increase in the number of older people needing nursing home care by 2030. People who reach age 65 will likely have a 40% chance of entering a nursing home, and about 10% who enter a nursing home will stay there 5 years or more (Medicare.gov, 2010a). Continued attention to the development of a range of appropriate, high-quality alternatives and different models of long-term care and services is needed.

Rehabilitation and Restorative Care Services

Rehabilitation is a philosophy, not a place of care, or a set of specific services. In all settings, rehabilitation and restorative care is focused on maximizing the individual’s strengths and supporting limitations to assist the patient to achieve the highest practicable level of function. Rehabilitation and restorative care “seeks to improve the individual’s quality of life in any way, no matter how small, in relation to physical, emotional, or spiritual well-being; and ultimately return that individual to a residence of his choice and at minimal personal risk. This implies integration into society plus support in and by the community” (Williams, 1993, p. 361).

People who are cared for in subacute units, as well as long-term units of nursing facilities, require access to rehabilitation and restorative care services that maintain or improve their function and prevent excess disability. These services are required under federal and state regulations and are integral to quality indicators in nursing facilities. Barbara Resnick, a noted gerontological nursing researcher, has published extensively on restorative care in both nursing facilities and residential care facilities (Chapters 2 and 12). Restorative nursing programs for ADLs, toileting, range of motion, ambulation, and feeding contribute to restoration and maintenance of function for nursing facility residents who may have been discharged or who are not eligible for reimbursement for rehabilitation services by physical, occupational, or speech therapists. Both rehabilitation and restorative programs require comprehensive multidisciplinary assessment and involvement of the patient and family in development of a plan of care with short and long-term goals (Box 16-3). Rehabilitation and restorative care is increasingly important in light of shortened hospital stays that may occur before conditions are stabilized and the older adult is not ready to function independently.

Costs of Care

Costs for nursing homes vary by geographical location, ownership, and amenities, but the average annual cost for a semiprivate room is $215 per day or $78,475 annually. Nursing home rates have increased more than 10% since 2008 and nearly 50% since 2004 (Prudential Insurance Company of America, 2010). The majority of the cost of care in nursing homes is borne by Medicaid (42%), followed by Medicare (25%), out of pocket (22%), and private insurance and other sources (11%) (AAHSA, 2011). Medicare covers 100% of the costs for the first 20 days. Beginning on day 21 of the nursing home stay, there is a significant co-payment. This co-payment may be covered by a Medigap policy. After 100 days the individual is responsible for all costs. In order for a nursing home stay to be covered by Medicare, you must enter a Medicare-approved “skilled nursing facility” or nursing home within 30 days of a hospital stay that lasted at least 3 days (Medicare.gov,2010). Complex medical treatments (e.g., feeding tube, tracheostomy, intravenous [IV] therapy) and rehabilitation services such as occupational therapy (OT), physical therapy (PT), or speech therapy (ST), are considered skilled care. Medicare does not cover the costs of care in chronic, custodial, and long-term units. If the older person was admitted to the nursing home because of a dementia diagnosis and the need for assistance with ADLs and maintenance of safety, Medicare would not cover the cost of care unless there was some skilled need (Chapter 20).

Concern is growing nationwide about the financing of long-term care and the ability of the states and the federal government to continue to support costs through the Medicaid programs. The reimbursement levels of both Medicare and Medicaid do not cover actual costs, and there is fear that if further cuts are made, quality of care will be more drastically compromised. The increasing burden on Medicaid is unsustainable, and assuming present growth, Medicaid costs for long-term care will double by 2025 and increase fivefold by 2045 (AAHSA, 2008).

The purchase of long-term care insurance is an option, but it is expensive and pays for less than 5% of long-term care costs (AAHSA, 2011). The Community Living Assistance Services and Support (CLASS), approved as part of the Patient Population and Affordable Care Act, is a voluntary, federally administered, consumer-directed, long-term insurance plan. The CLASS plan provides those who participate with cash to help pay for needed assistance if they become functionally limited, in a place they call home, from independent living to a nursing facility.

Health care coverage for people with long-term care needs is a major national issue that demands attention along with the growing numbers of uninsured individuals of all ages and the rising costs of care in the United States. In response to the nation’s need for a long-term care financing solution, the AAHSA has made recommendations for a model for future financing for long-term care (www.thelongtermcareresolution.org/problem.aspx).