Quality of life and peace of mind worth the cost, some say

By Jim DeBrosse and Margo Rutledge Kissell

Dayton Daily News (OH) – Monday, December 6, 1999

(C) 1999 Dayton Daily News 

When 78-year-old Lowell Whiddon began wandering from home, his 69-year-old wife Lois decided he needed more supervision than she could provide. 

So she chose to place him at Marriott’s Brighton Gardens in Centerville, one of the newest and glitziest assisted living facilities in the Miami Valley. 

Lowell, in an early stage of Alzheimer’s disease, lives there in a secure environment but is able to enjoy a bit of gardening, take field trips to parks and pizza parlors and eat his meals family-style in an intimate dining room for 12. 

For the Whiddons, it’s worth the $2,500 a month for the Marriott’s home -like elegance and its staffing ratio of one aide to every four patients. 

“It’s expensive, but I would rather have him here than any place else I looked at,” Lois said during a recent visit with her husband. “It allows him a degree of dignity and a lot more activities than I could give him.” 

Ohioans increasingly want alternatives to nursing home care – choices that allow their loved ones to maintain their independence as long as possible. 

Among the fastest growing of these alternatives is assisted living, where residents not yet ready for nursing homes can live in private apartments and arrange for the services they need. 

But in Ohio, most alternatives to nursing homes are available only to those who can afford them. 

About 92 percent of the state’s Medicaid funds for the elderly go to nursing homes , and not a penny goes to assisted living. 

Ohio does provide home health care for some 15,000 Medicaid-eligible patients through its PASSPORT program, but strict entry requirements bar thousands of others. 

Candidates must have depleted their assets well below the federal poverty level and qualify for nursing home care. 

Veda Thompson can’t afford to place Goldie Archer, her 87-year-old mother, in an assisted living facility, although she feels her outgoing mother would be an ideal candidate. 

Ironically, Archer’s care in a Xenia nursing home costs the state $122 a day in Medicaid funds. 

The assisted living facilities Thompson looked at for her mother would have charged $75 to $85 a day, or about a third less. 

`It’s a good thing nursing homes are there for people who need them,’ Thompson said. `But there is no quality of life there – the days just melt into each other. The high point of my mother’s day now is walking to the dining room for lunch and dinner.’ 

Many nursing homes do offer a wide variety of activities, but people like Archer can end up there simply because they have no other alternative. 

Ohio is one of 11 states that don’t pay for assisted living facilities. Most of the others pay at least for the service portion of the bill through Medicaid funds, while some kick in additional state funding for room and board. 

Public funding is a mixed blessing, however, say officials in the assisted living industry. The expansion of the market through Medicaid and other public assistance programs “is a tremendous opportunity to serve more than just those folks who can afford to pay their own way,” said Whitney Redding, a spokeswoman for the Assisted Living Federation of America. 

“But wherever government money is involved, the state wants to control how it’s being spent . . . Our industry started with a tradition of real flexibility in responding to consumer demand rather than having government as our largest customer.” 

Redding and others say Medicaid may not be the best mechanism for expanding assisted living into the middle-income market. 

That’s because it currently pays only for the service portion of assisted living and is limited to the poor. 

In recent months, the industry has been lobbying Congress to approve a voucher plan that would put money in the hands of both low- and moderate-income elderly to help pay for the assisted living facility of their choice. 

“It would be just as if you were 45 years old and looking for a house,” Redding said. “It would create a lot more options out there to choose from.” Critics say the lack of public funding for assisted living is one reason the industry here has targeted primarily an upscale private-pay market, leaving few choices for those of more modest means. 

The average cost of an assisted living facility in the Miami Valley exceeds $2,500 a month. Nationally, more than half of assisted living facilities charge less than $2,000 a month, according to the industry’s trade group, the Assisted Living Federation of America. 

Sparkling new facilities in the Miami Valley feature lobbies with chandeliers and sweeping Fred and Ginger staircases, cozy sitting rooms with libraries and fireplaces and private dining rooms with linens and table service. 

There are in-house clinics, beauty salons, ice cream parlors, drugstores, even banks. Most offer free transportation and activities nearly around the clock. 

“It’s as nice as any catered living environment you can get and it has nurses,” said Kenn Daily, former director of the long-term care ombudsman program in Dayton from 1988 to 1995. 

Daily, now president of a local nursing home management consulting firm, said the nursing home industry in Ohio has watched anxiously as its assisted living competition has skimmed the cream from the private-pay market. 

Nursing home occupancy in the Miami Valley is about 83 percent and declining, he said. Meanwhile, since 1993, the number of assisted living facilities in Montgomery, Greene, Miami, Preble, Darke, Warren and Shelby counties has grown from 25 to 49, according to the Ohio Department of Health. 

“You build it and they will come. It sounds corny, but that is how it is here. We opened our doors and they came in droves,” said Holly Wheeler, director of Sterling House of Piqua, which filled to capacity soon after it opened in October 1997. 

So why has Ohio given such a large share of its public money for the elderly to nursing homes ? 

`Ohio has a nursing home industry that remains very powerful (politically),’ said Robert Applebaum, director of the Scripps Gerontology Center at Miami University. 

`We have a system here that is heavily biased toward giving long-term care in an institutional setting, even though that’s where people don’t want to get it.’ 

Between 1996 and 1998, the nursing home industry contributed $1 million to candidates for public office in Ohio, ranking in the top 10 percent among industry groups, according to data from Ohio Citizen Action, a government watchdog group. 

Ohio not only won’t pay for assisted living, it has no working definition or standards for what assisted living should be. Any facility in Ohio can claim to offer assisted living services. 

And while operators of assisted living facilities often are licensed by the state as residential care facilities, the staffing requirements for RCFs are minimal: State law mandates only that the facility provide an “adequate level of care” for its residents and have at least one caretaker on the premises at all times. 

Penalties for substandard care in assisted living are likewise scant. State authorities can’t fine RCFs or deny them Medicaid or Medicare admissions. 

Their only recourse is to revoke a facility’s license for the most egregious offenses. 

Health care experts fear that as assisted living residents age, many will become too frail to be cared for safely in an unregulated environment. 

At what point should a responsible facility transfer such patients to a nursing home ? 

In recent years, one confused resident of a local assisted living facility drowned in a nearby pond and another fell to her death from a second-story window. In both cases, the operators of the facilities escaped state censure. 

Applebaum said that with no clear state guidelines for discharging patients, assisted living facilities are damned if they do, damned if they don’t. 

They can be accused of being greedy if they hold onto patients too long. On the other hand, they can be accused of ignoring consumer choice if they transfer a resident to a nursing homewhen care becomes expensive. 

`There’s a very fine line between preserving a patient’s autonomy and neglecting their needs,’ Applebaum said. `If somebody is getting along well, they’re of sound mind and they’re willing to be a little less safe in order to stay there rather than go to a nursing home , is that good or bad?’ 

Sherry Stanley wants to keep her 78-year-old mother, Mildred Gearheart, in the Singing Woods assisted living facility in Harrison Twp., but in Gearhart’s case, it’s state health department officials who are insisting she be moved to a nursing home . 

Gearhart, who suffers from Alzheimer’s disease, has fallen 10 times in six months, with four trips to the emergency room, and yet remarkably has broken no bones. 

Before the last fall, Stanley had agreed with a doctor’s order to place her mother in a “merry walker” – a strap-on device designed much like a child’s walker to keep her from falling. 

But state health officials say the device qualifies as a restraint, and only nursing homes in Ohio are licensed to use restraints of any kind. 

More often, assisted living facilities are criticized for holding on to patients they are ill-equipped to handle. 

A recent General Accounting Office survey of assisted living, which included Ohio, found that 25 percent of facilities had problems delivering adequate care to their residents. 

Frequently identified problems included insufficient, unqualified and untrained staff and failure to provide residents with appropriate medications. 

The GAO study also found that nearly half of assisted living facilities provide misleading information to potential customers about their costs and services and the circumstances under which they will discharge patients. 

`Ninety-eight percent (of the assisted living residents) believed they would be able to stay as long as they wanted – but half of them were wrong,’ said Catherine Hawes, a senior researcher with the Myers Research Institute in Beachwood, Ohio, who headed the GAO study. 

At the same time, she said, 70 percent of the residents said `that no one had discussed with them or provided them with written material about the conditions under which they would be asked to leave the assisted living facility.’ 

* Staff writer David Gulliver contributed to this report.