The acuity creep challenge

by Jeff Shaw

As the population of residents grows older and frailer, the industry grapples with new ways to provide care and services.

By Jane Adler

A popular expression about aging says 50 is the new 40. Other versions say 60 is the new 50, and 70 is the new 60. You get the point. Everyone is healthier and living longer, and feeling better at older and older ages. 

But it’s a dilemma for seniors housing and care providers. The 80-year-olds who feel like they’re 70 probably won’t even think about moving into a retirement community until they’re quite advanced in age and often suffering with multiple chronic conditions. 

A majority of assisted living residents are 85 or older, and need help with at least one activity of daily living (ADL), according to the Centers for Disease Control & Prevention 2010 National Survey of Residential Care Facilities. Nearly 40 percent need help with three or more ADLs. 

The average age of assisted living residents has risen noticeably over the last decade, building operators say. One property manager observes that the typical assisted living resident of today is more like the nursing home resident of the past, while the current independent living resident resembles the previous assisted living resident. 

The growing prevalence of older and frailer residents is often referred to in the industry as acuity creep (see sidebar, page 51). In other words, a gradual shift is taking place that is changing the nature of the population of seniors in retirement settings. They need more services, more supervision and often more medical attention. Even seniors who enter a community at a relatively young age will age in place and naturally suffer decline, requiring extra help. 

Rising acuity, or frailness, among residents is a huge issue for the industry. Providers face liability questions and they struggle to meet the needs of residents while operating within a regulatory system that varies widely from state to state. Operators of independent living properties often have residents who need help with ADLs, though the building is not licensed to provide assistance. 

As a result, housing and care providers are implementing new programs and policies to manage acuity creep. Outside vendors often fill the gap by providing home health and other services. New technologies offer possible solutions, too. 

“A building has to have the right infrastructure in place to care for this new type of resident,” says Stephanie Handelson, president and COO at Benchmark Senior Living, a Wellesley, Mass.-based operator of 50 seniors housing properties.


Learning how to manage acuity creep

In 2009, Benchmark changed its business model to manage rising resident acuity. The company invested $6 million over a two-year period to hire additional nurses and certified nursing assistants. Benchmark also partnered with home health, rehabilitation and hospice providers to bring those services into the buildings as needed for residents. “We became our own coordinator of care,” says Handelson. “At that time, we chose not to do it ourselves, and developed preferred partners.”

Brookdale Senior Living offers “personalized living” — a program meant to let residents age in place instead of moving to a higher level of care. A staffer can help with medication reminders, offer several hours a day of companionship, or take a resident to the doctor. Brookdale’s personalized living program is available at more than 145 of its communities. “We plan to grow the program in 2015,” says Kim Estes, senior vice president of clinical services at Brookdale in Brentwood, Tenn.       

At Benchmark, the management of acuity creep includes modifications to resident rooms, including specialty towel bars and toilet paper holders that also act as grab bars. New residents considered at risk for a fall — a big danger for the elderly — are asked to participate in a fall program that includes a “high-low” bed, which is an adjustable bed that can be easily lowered close to the floor, and a specialty floor mat next to the bedside to cushion falls. “We’re doing things to stay ahead of the curve,” says Handelson. 

Spectrum Retirement Communities LLC owns and manages 23 buildings with a variety of unit types. Combination buildings — those with both independent and assisted living — have similarly sized units.  Residents who move from independent living to assisted living don’t have to downsize and suffer another loss, according to Jim Parker, senior vice president of development and capital markets at Denver-based Spectrum. Residents who must move to assisted living can still use the same common areas, wellness center and dining venues, he adds.

Spectrum recently developed and opened new buildings in Eugene, Ore., and in Creve Coeur, Mo., near St. Louis. Monthly rents in independent living units average about $2,500. 

Spectrum offers a program to help those seniors with failing memories to stay in assisted living as long as possible instead of moving to a secure dementia unit. A life enrichment staffer with special training in memory care supervises about eight residents, making sure they attend activities and stay safe. “It adds to the resident’s quality of life and costs less than full-blown memory care,” says Parker. 


Assisted living redefined

Assisted living was originally conceived as a social model in contrast to nursing homes that provide medical care. In the 1990s, when assisted living first appeared in many suburbs, consumers welcomed the idea of a place to age that was not a nursing home — the only alternative at the time to home care. 

As assisted living grew in popularity, states stepped in to regulate the facilities. But not all states have kept up with the new reality of aging residents, building operators say. Many states still regulate facilities under a social model instead of a medical model. 

Regulations vary from state to state, presenting a challenge to building owners with properties located in multiple states. Take, for example, the administration of insulin via a dial-a-dose pen, notes Benchmark’s Handelson. In New Jersey, insulin doesn’t have to be given by a registered or licensed practical nurse. Conversely, in New Hampshire, a licensed practical nurse or registered nurse must handle the job. But in Massachusetts, even under newly passed regulations, a registered nurse employed by the assisted living facility cannot give insulin, thus resulting in more cost for the family as a result of having to hire home care and pay privately since the service is not covered by Medicare. 

“These antiquated regulations are making it difficult for providers to offer high-quality care in a more cost-effective setting,” says Handelson. “The whole (regulatory) situation perplexes me.”

Belmont Village Senior Living licenses all of its units for assisted living, including those meant for independent living residents. “We run all our buildings the same,” says Patricia Will, president and CEO of Houston-based Belmont. The average age of a new Belmont resident is 85, though the average age of current residents is 87 across the company’s portfolio of 24 buildings. 

“We license all our units, so we can deliver assisted living care,” explains Will. “It’s turned out to be a valuable approach.” 

All units are constructed to assisted living standards. Licensed nurses are available at every building around the clock. This practice by Belmont occurs even in California, where regulations do not require that level of staffing. The approach does result in higher construction and staffing costs, acknowledges Will, but it allows residents to age in place. The approach also helps Belmont accommodate couples who age at different rates. Belmont can provide extra care in the unit for the needier spouse, thereby forgoing a move to a different section of the building that would separate the couple.

“We are in a need-driven business,” says Will. “The socialization and hospitality aspect of our industry is important, but we have to be prepared to provide a therapeutic benefit to our residents.” 


Advances in technology

Technology plays an increasing role in the management of acuity creep. Wi-Fi is available in many buildings to connect caregivers, families and supervisors. Medication management systems and other automated care practices are being introduced in seniors housing settings.

A number of software companies offer solutions for buildings. Toronto-based PointClickCare, for example, provides a cloud-based software platform that includes a number of modules for medication management, nurse’s notes, intake and referral, risk management and rehospitalizations. 

To address acuity issues, one module enables building management to capture the actual amount of time caregivers spend with each resident. Caregivers log their time on a kiosk in the hall or on a mobile device. 

Time spent caregiving tends to lengthen as residents age, a fact that often isn’t captured, according to Jayne Warwick, solutions specialist at PointClickCare. The time-tracking module records services rendered that can then be billed to the resident.  

To avoid the possibility that families could be blindsided by big unexpected bills, Warwick says the extra time is not automatically billed and must be authorized. But having the data available regarding the amount of caregiving time provided gives the building manager an opportunity to start a discussion with the family about the resident’s real needs. 

“Building managers can have more intelligent conversations with families about the cost,” she says.

Open communication with the family is key to managing acuity creep, building operators say. Families should receive progress reports to forestall problems when the elderly person needs additional care or must be moved. 


Litigation worries

Liability remains a nagging fear. The operator of an independent living building was sued after a resident, who had her own privately contracted aide, regularly wandered unattended to a nearby store. Since she was renting an independent living apartment, the building had no obligation to provide supervision. However, that didn’t prevent the filing of a lawsuit. 

Other building operators have been sued on the basis of disability discrimination after evicting residents whom the building could no longer handle within the bounds of state regulations. 

Gray areas exist. Many independent living buildings have emergency call systems. Does that imply that the building is responsible for the elder who calls for help? 

A notorious California case in which a staffer refused to administer CPR to a resident because of building policies resulted in a new law that requires assisted living facilities to have someone on staff 24/7 trained to provide CPR. The law also prohibits a building from having a policy that might keep a staffer from giving CPR.

“You can’t prevent the possibility of a lawsuit,” says attorney Paul Gordon, partner at Hanson Bridgett, a San Francisco law firm that works with seniors housing providers. But contracts should be carefully drafted, he notes. Independent living agreements should include a provision stating that the building does not provide any care, and if care
is needed that the resident or family is responsible to provide that care.  

Providers must carefully explain to residents and families the limits of care — what the facility can and can’t do based on how the facility is licensed. 

Buildings should develop a comprehensive set of policies and procedures to mitigate high-risk situations, says Gordon. These high-risk situations include falls, a wandering resident who leaves the premises, cognitive decline and how to respond to emergencies. Policies should also be communicated to any third-party providers working in the building. 

“The facility needs to manage the high-acuity residents,” says Gordon who sounds this warning: “If you’re not diligent, your residents will conspire with you to stay longer than they should because they don’t want to move either.”

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