Talk to any senior care or geriatric doctor today and they’ll all say the same thing: Nobody wants to go to a retirement home. But for many of us, it’s too expensive or inefficient to age gracefully in the comforts of home. Or is it? Here’s what aging NoVinians have to look forward to in their golden years.
By Tim Regan / Photography by Erick Gibson
Everyone knows it takes a village to raise a child. But can you apply the same adage to senior care? Here in Northern Virginia, some people say you can. And experts say we’ll need at least a village’s worth of extra help—this area is full of aging people.
According to 2010 U.S. Census data, nearly 14 percent of Fairfax City’s residents were ages 65 and older. Compare that to the entire state of Virginia, where that number hovered around 12 percent of the general population, a 23 percent increase from the previous decade’s census. And with more and more baby boomers reaching retirement age each year, that number should grow steadily over the next decade. We know the wave is coming, but how do we deal with it?
While experts may not agree on best practices just yet, one thing is for certain, it will be expensive, but NoVA can pay for it. Last December, the Census Bureau reported that five counties in Northern Virginia enjoyed some of the highest median household incomes and some of the lowest poverty rates in the country. But it’ll take more than money—10,000 baby boomers reach retirement age every day according to Census data. What we need is an army. Whether or not we’ll get it remains the million dollar question. In the meantime, here’s how NoVA plans to lead the fight on aging, from specialized centers to wearable microchips.
Aging at your own PACE
A chorus of voices joins in a song to the tune of “London Bridge is Falling Down.” It’s a few hours past lunchtime, and the senior attendees of Northern Virginia’s only PACE program are winding down after a long day of exercise and recreation. PACE—which stands for Program for All-inclusive Care of the Elderly—is a Medicare and Medicaid sponsored alternative for people who might otherwise qualify to live in a nursing home. The program began in San Francisco the 1970s amidst dismal senior care and widespread fear of “being put in a home.” The idea is simple: to keep people living comfortably as long as physically possible, but above all else, to keep people happy.
“One PACE site replaces a nursing home,” says Dr. Terence McCormally, the InovaCares for Seniors’ PACE medical director. He explains that, decades ago, when the program was created, people would be admitted to nursing homes for a wide range of problems, not all of them serious ailments. Someone with Alzheimer’s or dementia might end up sharing space with another patient who has trouble bathing themselves or going to the bathroom alone. Because they have vastly different needs, this pairing can be stressful for both patients, leading to undue stress and low morale. And it’s expensive. Instead of Medicaid or Medicare money being spent on what a patient might need, it’s being spent on expensive medical care they may or may not ever use. “There’s a lot of money being spent, but we spend it on the wrong stuff … nobody thinks it’s a great idea to live in a nursing home,” says McCormally.
But the way we care for seniors is changing. More and more assisted living homes—specialized senior citizen communities that blend support with independence—have opened across the country. There, seniors can benefit from the exact kind of live-in care they need with all the privacy of living in their own space.
“Twenty-five years ago, what was in the nursing home is now in the assisted living home … there’s been this sort of shift that puts people in an area with the appropriate level of service, but no more service than they need,” says McCormally.
But they’re incredibly expensive, often billing residents thousands of dollars each month for rent and medical services. McCormally says that, in other states, the government might pick up some of the bill for poorer residents, but not here—NoVA tends to have wealthier residents who can afford the high price of care at full value. And that means a price hike for everyone, regardless of income.
“In Northern Virginia, the price of an assisted living home is so high that it exceeds the county’s budget,” says McCormally. And with seniors living longer than ever these days, the cost of care becomes too heavy a burden, and they fall right back into a Medicaid- or Medicare-funded nursing home, even when they don’t need it.“What do you do if you don’t need skilled nursing care … but you can’t afford to go to an assisted living home?” McCormally says. That’s where PACE comes in. Instead of using an all-or-nothing, nursing-home-or-assisted-living approach, PACE provides the bare minimum services needed to keep a patient happy and healthy, but does it on Medicare or Medicaid’s dime the way a nursing home might.
Here’s how it works: Each day, buses bring about 50 residents in to the PACE center in Fairfax from their homes. Throughout the day, they engage in activities, eat meals and snacks, meet with doctors and undergo physical therapy if needed. At the end of the day, instead of spending the night, they load back onto the buses and return home. It’s a win-win—seniors get to stay home and receive whatever help they may need, and staff members can funnel their patients into one place without making too many house calls. It’s not only doctors, either. PACE employs a team of specialists and practitioners to ensure every need is met to custom standards.
“That’s critical to how PACE functions. It’s the team,” says McCormally. For example, a normal PACE team meeting might involve a clinic nurse, a physical therapist, an occupational therapist, a social worker, dietician and even the bus driver, all on the same page. If a diet needs tweaking, staffers tweak it. If a wheelchair ramp needs installing, they install it. Geriatric physicians are just one piece of the puzzle—in fact, McCormally hypothesizes that too much solitary doctor care might be counter-intuitive to what a patient needs. “[Doctors] don’t get the pill to the person. It doesn’t get the person to take the pill. And the pill isn’t the most important thing anyway. It’s the other kind of services that keep them functional,” he says. But when the PACE doctors do take over, they’re getting to know patients on a more personal level. “A family doctor might take care of 2,000 patients. [At PACE], one geriatrician takes care of 140 patients.
“You get a lot more attention,” says McCormally. And more attention means better care.
So why don’t we have more PACE centers? McCormally says it’s a complex issue, but like anything, the main obstacle is money. “It costs, literally, a couple million dollars to bankroll,” he explains. And even though the program pays for itself once it reaches full capacity, it’s hard to get local governments to spend that kind of money up front. Still, McCormally remains optimistic about the program’s future. “In five or six years, I’d like to have four PACE centers and 500 participants. I think that’s where we’re going with this idea,” he says.
Training the next generation of nurses
But the team approach that PACE emphasizes is nothing new. In fact, George Washington University in the District plans to churn out class after class of nurses trained in team-based senior care with a three-year, $790,000 grant from the U.S. Department of Health and Human Resources.
“A team needs to include the person that’s got the illness and their families. That’s the shift we’re trying to get right now in health care,” says Assistant Professor of Nursing Beverly Lunsford, adding that the grant exists to “build the workforce in geriatrics and gerontology.” Awarded in 2012, the money has already paid for geriatric care education as well as tuition aid for 17 students. Among other skills, nurses will have a newfound appreciation for the competency of aging adults after graduating from the program. “How do we recognize that the older adults really can and need to be providing for their own self-care,” says Lunsford. Oftentimes, just because.
GWU’s School of Nursing Dean Jean Johnson says we need some innovation, and fast. “Everybody knew that the baby boomer wave would be rolling through. … It’s crashing now.” says Johnson. Part of the challenge has been students’ awareness of the issues. She says it’s hard to make senior care seem interesting, and nursing students don’t always jump at the chance to learn about it.
“We keep trying to get our students excited about care for the elderly,” she says. But Johnson says she’s confident she can help change the stereotype. “Students initially think it is the intensive-care environment that is the most challenging and exciting, but … care of the elderly, you run into so many issues that you honestly don’t know what to do with,” she says. And GWU is doing everything they can to break the mold, including running an actual simulation lab of an elderly person’s home for valuable experience. Johnson, who’s worked with this population her whole life, says hands-on experience is essential to her students’ training due to the nature of their patients’ care.
“Taking care of elderly patients is very complicated,” she says. “You’re working with people who may be mentally compromised. You’re working with people who might have a problem list of 21 unrelated health problems … they may have 12 or more medications,” she says. And unlike a hospital’s intensive care unit, the goal is not curative; it’s about quality of life. “You’re trying to keep people more functional,” says Johnson. And functionality, happiness depends on what a patient and their families want.
At Inova Mount Vernon, some of these newer practices are already affecting senior patients. They’ve adopted the national NICHE (Nurses Improving the Care of Healthsystem Elders) model. Laura Shanks, a clinical nurse specialist at Inova Mount Vernon, says the effort aims to get more nurses specialized in gerontology and its nuances.
“The goal is to work with the older adult population, age 70 and older, who have risk factors for developing delirium during their hospital stay,” she says. The center’s new emergency center will also be adaptable for seniors, and they’ll focus resources on new geriatric resource nurses, clinical technicians and an entirely new job role, geriatric physical therapists. Though this won’t completely scratch the itch, it’ll be a good first step. “I think we still have a ways to go. I think we’re heading in the right direction,” she says.
The daunting future of senior care
But what in direction are we headed? George Mason University Professor and Executive in Residence Andrew Carle says he has a pretty good idea, and contrary to what others say, he’s not painting the most optimistic picture of in-home care. “Staying in your home may be more of a luxury than a given right,” says Carle.
When asked about PACE, he compares the day program to a slapping a Band-Aid on a gaping wound. He believes it can’t treat enough people at one time to make a difference. And he isn’t far off: A typical PACE center treats about 140 seniors, and so far, this area has just one such center. Another problem, according to Carle, is that the services offered are too limited to meet all the needs of an aging senior. “It doesn’t address all the other problems that happen to people when they return home. They’re still alone for 16 of the 24 hours of the day. They can still fall down. They can still mess up their medications,” says Carle.
But above all else, he says the biggest obstacle to in-home care will be money. According to a 2012 JD Ameritrade Survey, 71 percent of baby boomers believe they are financially prepared for retirement. But the costs are monumental. The Employee Benefit Research Institute estimates that the average retirement-age couple will require $387,000 in savings to cover health costs, not including long-term care. Compare that to the 2012 Ameritrade survey, which says the average Baby Boomer has only saved $275,000 for retirement.
“The numbers are the numbers; everybody knows this is a tsunami waiting to happen,” says Carle. And despite the public perception that the government will be able to front the costs, unless something changes, the government won’t be able to care for everybody. “It may not mean you get to stay in your home unless you figure out a way … to pay privately for it. The government is not going to be able to afford to do that.”
Still, an AARP survey of public perceptions on long-term care says that nearly 6 out of 10 Americans age 45 and over think Medicare will pay for a long-term nursing home stay. And although the government might one day enact programs to pay for more care, Carle says it won’t happen until we’re deep in the midst of the impending problem. “As a matter of policy, Capitol Hill tends to not think more than a few years ahead of time. They love to kick things down the road on both sides of the aisle. … Hell, they’re still arguing over Obamacare.”
Dr. McCormally agrees that money and legislation will be a big hurdle. He argues the amount of money seniors spend on health care is too high for the return, and that we’re not spending it on worthwhile programs. “There’s a lot of money being spent,” he says. “We just spend it on the wrong stuff.” At PACE, part of his job is directing patients toward more cost-effective methods without sacrificing their quality of life. Instead of spending $30,000 on a drug with limited effectiveness, or prescribing dialysis for a 90-year-old, he argues, why not try other methods that directly affect quality of life? “We spend money on things that don’t help very much, and not enough on things that do help, like someone to give you a bath.” And it’s clear families will have to face some tough decisions ahead regarding care. “Is the most important thing to get out every last possible breath?” says McCormally.
And who’s going to care for seniors? Even with new nurses and PACE centers, Carle says there may be a huge shortage in home-care labor. “By 2030 when the last of the baby boomers retires, there will be 35 million more jobs of any kind in this country than people to fill them. … We are going to need to triple the number of long-term care workers between now and then,” he says. One answer might lie in new technology that does away with the need for as many humans.
Over the past decade, Carle has worked on and studied what he calls, “nana technology,” a technological innovation effort aimed at improving the lives of older Americans. While we’re still far from automated medical robots, Carle says the future of geriatric health is taking shape as we speak. “We’re looking at things that can help you with your medications like robotic medication managers … devices that can monitor if you’ve fallen. Systems that can detect a fall and automatically call for help … the ability to take your own blood pressure and heart rate and weight and just send it over the internet automatically.” Instead of meeting with a doctor every week, you might only need to Skype with them, meaning seniors will be able to more easily live at home. “Some of these technologies will allow you to stay home by yourself longer,” says Carle.
Another advancement of seniors could benefit from lies in new urban development. “The stuff they’re talking about doing at Tyson’s in terms of making this community walkable is just astonishing,” says McCormally. Instead of driving everywhere, the seniors of the future might simply walk to whatever services they need, provided they can still walk. But as overall health care improves, the number of active seniors is growing, and the willingness to stay mobile is as strong as ever with boomers. “When [baby boomers] retire, and we’ve got studies to back this up, [they’re] not interested in sitting on a rocking chair on the porch. [They] want to stay active and involved,” says Carle.
But what can a boomer do now aside from saving money and hoping for the best? Carle argues it’s about education—and research. He says it might be inevitable to stay out of an affordable assisted living home, and that might just be OK. Carle says that quality of care at these facilities is improving, and as more seniors move into assisted living homes, the process should get easier and easier to manage.
And Dr. McCormally says, if boomers want to age gracefully, they need to start now—right now—but stick to the basics. “They’ve got to eat their fruits and vegetables, and they’ve got to exercise. Those are the two most important things to preserving your health.”
(February 2014)
