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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 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

Presented by

Scott E. Townsley, Principal

ThirdAge, a division of LarsonAllen, LLP

(610) 594-8100

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
  • Services:
    • Care coordination
    • Home inspection
    • Transportation
    • Home nursing care
    • Home health aide
    • Companion/homemaker services
  • Services (cont.):
    • Live-in assistance
    • Emergency response system
    • Adult day care
    • Assisted living
    • Nursing care
    • Social and wellness programs

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.)


  • 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