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Home-Grown Innovations In Senior Care AGING SERVICES OF CALIFORNIA ANNUAL MEETING May 4, 2010 Long Beach, CA PowerPoint Presentation
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Home-Grown Innovations In Senior Care AGING SERVICES OF CALIFORNIA ANNUAL MEETING May 4, 2010 Long Beach, CA. Presented by Pamela S. Kaufmann, Partner Hanson Bridgett LLP (415) 995 5043 pkaufmann@hansonbridgett.com. Presented by Scott E. Townsley, Principal

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Home-Grown Innovations In Senior CareAGING SERVICES OF CALIFORNIA ANNUAL MEETINGMay 4, 2010Long Beach, CA

Presented byPamela S. Kaufmann, Partner

Hanson Bridgett LLP

(415) 995 5043

pkaufmann@hansonbridgett.com

Presented by

Scott E. Townsley, Principal

ThirdAge, a division of LarsonAllen, LLP

(610) 594-8100

Stownsley@larsonallen.com

presentation from 5 000 feet
Presentation From 5,000 Feet
  • Current senior care options
  • Challenges in meeting seniors’ needs
    • classically
    • in current economy
  • Home-grown innovations
  • Challenges for providers
current senior care and living options
Current Senior Care and Living Options
  • Facility-based
    • Nursing facility
    • Assisted living facility / RCFE
    • Continuing care retirement community
    • Multi-level retirement community
    • Program-rich senior housing
current senior care and living options4
Current Senior Care and Living Options
  • Community-based
    • Adult day care
    • Home health care
    • Home care
    • Hospice care
    • PACE – comprehensive services/public funding
  • Focus of our presentation is facility-based models
seniors needs
Seniors’ Needs
  • Physical
    • care and access to care
    • specially designed housing
    • transportation
  • Financial
    • affordability
    • financial security
seniors needs cont
Seniors’ Needs (cont.)
  • Spiritual/Personal
    • Companionship
    • Dignity
    • Autonomy
    • Mental stimulation
    • Spiritual expression
    • Individuality
challenges of existing facility based models
Challenges of Existing Facility-Based Models
  • Classic Challenges
    • Affordability/limited market
    • Concerns about long-term financial commitment (especially in CCRCs)
    • Impulse to remain at home
challenges of existing facility based models8
Challenges of Existing Facility-Based Models
  • Classic Challenges (cont.)
    • Inability to relate to “older” residents aging in place in an established care facility
    • Failure to value service program
    • Concerns about provider’s ability to meet senior’s spiritual and psychosocial needs
challenges in current economy
Challenges in Current Economy
  • Same as above, plus:
    • Anxiety about personal finances
    • Concerns about provider’s financial stability
    • Doubts about future of public reimbursement programs (Medicare, Medicaid) and impact of health care reform
    • Reluctance to sell home in depressed market
    • Continuing frugality in face of recession
evolution of home grown innovations
Evolution of Home-Grown Innovations
  • Started with informal efforts to create less expensive, more tailored alternatives
    • remain at home; access doctors, hospitals as needed; lean on family, friends
  • Evolved into independent movement among seniors to create their own care models and exploration by providers of “care without walls”
    • mission- and business-driven
a survey of home grown innovations
A Survey of Home-Grown Innovations
  • Cooperative arrangements
  • Care at home / continuing care at home
  • Town squares
  • Intergenerational programs
  • De-licensing, down-licensing & supplemented affordable housing
  • Café Plus & virtual neighborhood models
cooperative arrangements
Cooperative Arrangements
  • E.g., Beacon Hill Village (locally, Avenidas, Ashby Village)
  • Membership org enables senior to remain at home by organizing and delivering programs & services
  • Membership fee entitles members to:
    • information and referrals
    • grocery shopping
    • walking groups and exercise classes
    • members-only events
cooperative arrangements cont
Cooperative Arrangements (cont.)
  • Membership fee covers (cont.):
    • service provider discounts
    • rides home from MD-prescribed procedures
  • Other services include:
    • meals
    • care referrals and management
    • social, cultural, educational events
cooperative arrangements cont14
Cooperative Arrangements (cont.)
  • Advantages:
    • low cost
    • promotes access to care, autonomy, mobility
  • Limitations:
    • may not meet financial security or housing needs
    • designed for seniors living independently
    • dependent on charitable giving
care at home continuing care at home
Care at Home / Continuing Care at Home
  • Models have sprung up in several states in past decade or so
  • Models vary from care coordination to services; may include an insurance/ prepayment feature
  • Can be sponsored by facility or be freestanding
  • Key is to allow senior to remain at home and to receive supportive care/assisted living at home or in care facility
california s care at home bill
California’s Care at Home Bill
  • Vetoed by Governor during budget battle
  • Defined “care at home” and “continuing care at home” and exempted home from RCFE Law
  • Set forth minimal standards for care agreement
  • DSS supports variations on theme even w/out law
  • Need for bill persists
    • Safe harbor; protection if new regulators are hostile to concept
care at home out of state
Care at Home – Out of State:
  • CCRC Without Walls – life care program regulated as a CCRC
  • Includes Entrance and Monthly Fees
  • Full continuum of LTC services provided in home and at facility, including home care, assisted living and nursing care at a fixed price
  • Access to wellness center, social events at facility
  • Little financial support needed from parent org
slide18
(cont.)
  • Services:
    • Care coordination
    • Home inspection
    • Transportation
    • Home nursing care
    • Home health aide
    • Companion/homemaker services
slide19
(cont.)
  • Services (cont.):
    • Live-in assistance
    • Emergency response system
    • Adult day care
    • Assisted living
    • Nursing care
    • Social and wellness programs
slide20
(cont.)

Illustration of cost$38,000 Ent. fee$15,000 Ent. feefor 75 year old $500 Monthly fee $250 Monthly fee

care at home cont
Care at Home (cont.)
  • Advantages:
    • lower cost than facility care (no bricks & mortar)
    • satisfies senior’s desire to remain at home
    • may provide access to licensed facility
    • may allow senior to test facility without large fee commitment (but different market?)
    • may afford companionship (if facility-based)
    • may increase socialization through technology
care at home cont22
Care at Home (cont.)
  • Limitations:
    • lack of constant provider presence – greater possibility of undetected injury
        • but remote monitoring can address issue
    • service model is not as suited to higher levels of care (e.g., nursing), but coordination and insurance models may be
    • senior may still feel isolated when at home
care at home cont23
Care at Home (cont.)

Risk:

  • DSS has been open to model in recent years, but risk remains that future regulators may:
        • treat model as traditional insurance and impose large reserve requirement
          • real risk if CCRCs are regulated by DOI?
        • resist regulating additional care settings
        • hyper-regulate model
town square
Town Square
  • “Mini”- city center is designed to meet seniors’ needs on a usable, walkable scale
  • Includes many nearby services, amenities
  • Advantages:
    • may meet transportation needs
    • promotes feeling of autonomy
    • may meet spiritual and personal needs
town square cont
Town Square (cont.)
  • Limitations:
    • still a facility-based model with challenges identified above:
      • affordability / limited market
      • desire to remain at home
      • failure to value service program
    • not truly “home-grown”
intergenerational programs
Intergenerational Programs
  • Deliberate programs to bring school-age children, adults & seniors together in housing, programming
  • Advantages: stimulation, companionship, benefits of intergenerational contact and activities
  • Limitations:
    • typically a facility-based model with same challenges
    • not all seniors enjoy the company of children
de licensing down licensing supplemented affordable housing
De-Licensing, Down-Licensing, & Supplemented Affordable Housing
  • De-licensing and down-licensing designed to:
    • reduce operating expense;
    • eliminate regulatory burden;
    • increase flexibility of operations; and/or
    • provide care in least institutional environment
  • Often motivated by economic necessity; might also reflect desire to change product to meet demand
de licensing down licensing etc cont
De-licensing, Down-licensing, etc. (cont.)
  • Can involve conversion of
    • Skilled nursing to assisted living
    • Assisted living to unlicensed housing
  • Might involve elimination of a level of care in multi-level facility
  • Might also involve placing housing and services in separate legal entities
    • beware control issues; will not be approved if deemed an evasion of regulation
de licensing down licensing etc cont29
De-licensing, Down-licensing, etc. (cont.)
  • Housing plus services (e.g., meals on wheels, IHSS, PACE) paid by charities or government
  • AB 123 (Portantino) promotes affordable model
    • Exempts from RCFE/CCF licensure affordable housing for elderly or disabled persons that makes available optional supportive services
    • Housing must qualify under HUD or federal tax credit program
    • Owner/operator cannot contract for or provide supportive services; however, it can coordinate services or help residents access them
de licensing down licensing etc cont30
De-licensing, Down-licensing, etc. (cont.)
  • Advantages:
    • cost (& fee) savings
    • saving an otherwise troubled project
    • potentially less institutional environment
    • service for a less acute population
de licensing down licensing etc cont31
De-licensing, Down-licensing, etc. (cont.)
  • Limitations:
    • potential loss of a level of care
    • marketing challenges without license in place
    • legal exposure without license in place
    • dependence on public/private safety net
    • still a facility-based model
caf plus model
Café Plus Model
  • Model to increase providers’ outreach, visibility
  • Might be facility-based or senior center-based
  • Services include:
    • restaurant/cafe w/Internet
    • social connections, learning center, lectures, continuing education
    • health and fitness facilities
    • network of community resources
caf plus model cont
Café Plus Model (cont.)
  • Advantages:
    • reduced isolation; enhanced wellness
    • spiritual and educational enrichment
    • resources, referrals, discounts
  • Limitations:
    • may not address more acute care needs
    • not necessarily designed to provide care delivery or funding
virtual neighborhoods
Virtual Neighborhoods
  • Two types of consumer: planners and users
  • Model coordinates services – few of which may be provided by sponsor
    • Key staff: marketing; service/care coordination
    • Services may be “brokered” with other credentialed orgs providing service
  • Social & service connections are key: value derives from ability to receive quality service w/o effort & maintain enhanced social network
virtual neighborhoods cont
Virtual Neighborhoods (cont.)
  • Financial models are evolving
  • Offer similar advantages to Café Plus
  • Contain fewer limitations than Café Plus
    • Geographic scope can be broader
    • Design anticipates delivery of service
challenges for facility based providers
Challenges for Facility-Based Providers
  • Need to anticipate future demand and funding
  • How to introduce new model if all resources (human resources, hard assets, funds, borrowing capacity) are dedicated to current model?
  • How to get residents to embrace new programs?
    • opening up their home to strangers who may be in a different socio-economic class
    • sharing limited resources
challenges for providers cont
Challenges for Providers (cont.)
  • How to overcome lack of track record?
    • Potential resistance of lenders/donors to untested models -- but foundations may be open to community-based care
    • Board’s potential lack of familiarity with model
    • Lack of training of staff
    • Risk of financial failure – need for involvement of savvy businessperson
recommendations if interested
Recommendations If Interested
  • Study and visit alternative models; review financial viability
  • Compare notes with other providers
  • Explore the need (if any) for more flexible legal models
  • Educate your board regarding alternative care options and future trends
  • Be creative!
recommendations if interested cont
Recommendations If Interested (cont.)
  • Take “baby steps” – E.g.
    • Offer a limited care at home program
    • Consider down-licensing a wing or floor (only if circumstances warrant)
    • Create an intergenerational activity program
    • Form a (resident-led?) task force to study residents’ spiritual and personal needs & housing and care preferences