ong term care facilities provide a community living experience, personalized care, and mobility to one of the most vulnerable age groups in the U.S. However, a lot of seniors and their families have started to look for alternatives to nursing homes due to safety concerns during the COVID pandemic. The availability of better person-centered solutions and affordable home care from PACE organizations have further complicated the matter.
Home-based care is rising in popularity because it is convenient; seniors now have the option of growing old in a familiar environment thanks to the efficiency and efficacy of programs for all-inclusive care for the elderly (PACE). “PACE is a philosophy of care that is open to a person that wants to make a choice to remain in their home and to access services through a PACE organization,” said Stephanie Button, VP at PACE CNY. “The PACE team can wrap comprehensive services around that person to deliver the best care.” She recently spoke with Peter Murphy Lewis on the LTC Heroes podcast to discuss PACE and other alternatives to long term care, their benefits, and how facilities can match these standards.
The Move Toward Nursing Home Alternatives
According to a study by the Centers for Disease Control and Prevention (CDC), Americans spent $219.9 billion on long term care services in 2012. And while a peer-reviewed article published by Johns Hopkins University demonstrates that nursing home spending accounts for the majority of long term care expenditures, it also shows that the proportion of home and community based care expenditures has increased over the past 25 years. In recent years, the trend has been towards nursing home alternatives.
Falling census numbers have been an issue that has consistently plagued nursing homes across the nation, but the National Investment Center for Seniors Housing & Care (NIC) recently reported that the census fell to 83.4% in March of 2021. This is the lowest it has fallen since the organization began tracking nursing home occupancy in 2012.
According to Skilled Nursing News, at the beginning of 2021, forty-eight states had skilled nursing facility (SNF) occupancy rates of 80% or lower, with Texas holding the lowest rate at just 56%. The biggest catalyst for such low rates was that residents’ safety could not be guaranteed during the COVID-19 pandemic. Complaints of poor conditions and a lack of social interaction were factors as well. These, though, do not tell the whole story.
It is not just dissatisfaction with the environments of nursing homes that is turning seniors away. Many elders do not want to let go of their independence and hence fear institutionalization. This, in part, stems from the stereotype that LTC facilities are where seniors go to die. Advocacy surrounding LTC was not particularly vocal until a few decades ago, and hence these stereotypes and misconceptions still exist to a certain degree. In order to be able to counter them, we must first understand them.
When seniors and their families believe false stereotypes about the long term care industry, they often end up making the wrong choice, causing them great financial losses and emotional distress.
The five common misconceptions about long term care that persist are:
- “Long-term care means the end.”
- “A nursing home is an institution.”
- “The bigger the facility, the better the care.”
- “Home care is always better than long term care or skilled nursing (nursing homes).”
- “Long term care is the same as acute care.”
Even though advocacy about senior care is helping remove these misconceptions and create a more accurate depiction of LTC, in many cases, the harm has already been done. Some of the results of choosing the wrong kind of elderly care are:
- Limited access to personalized care and the health care seniors require
- Paying more for less on account of a lack of information
- Bankruptcy due to poor saving habits in advanced age
- Restricted mobility and increased dependence
In addition to advocacy, misconceptions about long term care can be resolved through improving the quality of care provided in your facilities, painting a better picture of LTC as a whole. One way to achieve this is to study the alternatives to long term care so as to implement their best practices and gain a competitive advantage.
The National PACE Association and Other Alternatives to Nursing Homes
Alternatives to nursing homes allow seniors with various needs, ranges of mobility, illnesses, and dependency to maximize the senior healthcare system. Each, thus, appeals to different members of the senior population. It is important for those in long term care to understand how these alternatives work so that they can define their target audience better and ultimately contribute to the better distribution of quality health care. We will discuss the National PACE Association, often regarded as one of the best alternatives available, but also mention other alluring options.
Here, we will evaluate the pros, cons, and relevant regulations of the most prominent alternatives to nursing homes, which are:
- Home Care– Home care provides seniors with the assistance they need, like access to around-the-clock nursing and medical services, so that those capable of doing so can live independently. The health care workers who provide such services visit every week or month at a scheduled time, administering specialized care according to the senior’s needs.
Appropriate for: elders who prefer remaining in their homes as they age due to an emotional connection to their home and do not have a life-threatening medical condition that requires them to be in acute care.
- Seniors get to remain comfortably in their own homes, maintaining their desired independence. This option does not pose restrictions on their mobility other than those specified for their health.
- Family and friends can visit at any time without any restrictions. Giving a senior access to family members, friends, and familiar surroundings will decrease the burden of the caregiver.
- Oftentimes, home care is more affordable than nursing homes or skilled nursing facilities because it is meant for those in need of intermittent and short -term services that have been tailored to meet their specific needs.
- The recreational activities available at nursing homes are not going to be possible in home care.
- The home might need refitting to accommodate the resident (ramps, railings, etc.)
- Not all home healthcare services are covered by Medicare or private insurance. This cost can add up over time and prove to be a huge financial burden.
- Home care is temporary. Home health care agencies are not meant to serve long-term needs or chronic illness. Most home health care services last from a few weeks to six months, meaning caregivers may rotate frequently, which could be unsettling from some seniors.
- One of the best options, PACE, is not currently available nationwide, as only 30 states have registered programs. You can find out if your state has a PACE program by clicking here. PACE programs provide all-inclusive care, or, preventive, primary, acute, and long term care, in the context of a community. The National PACE Association (NPA) works in coalition with political organizations in advocating for better care and support for older Americans. You can read more about the NPA here.
More information on home care: The four federal home care regulations to keep your eyes on are caregiver payment regulation, employee payment regulations and safety regulations
- Holistic Care– This is a form of palliative care that improves the emotional, psychological, and spiritual health of seniors by treating them holistically and not just physically. That means paying attention to their minds, bodies, and social and spiritual needs.
Appropriate for: seniors who, as they age, would like to be viewed as people rather than patients and do not need constant medical care.
- Cognitive development and maintenance
- Healthy relationships with caregivers
- Increased sense of self-worth and self-respect
- Cost efficiency
- No side effects.
- No professional medical intervention necessary
- A lack of medical supervision can prove to be dangerous in cases in which a senior has a serious illness.
- The majority of laws in care are centered around biomedical – and not holistic – care.
- It can be time-consuming for caregivers, as holistic care involves more tasks. This can decrease their productivity due to exhaustion.
Other relevant information about holistic care:
The current state of holistic care is based on five core values as determined by the American Holistic Nurses Association (AHNA):
- Holistic philosophy and education
- Holistic ethics, theories, and research
- Holistic nurse self-care
- Holistic communication, therapeutic environment, and cultural competence
- Holistic caring process
The American Holistic Nurses’ Certification Corporation (AHNCC) provides certification in holistic nursing. They use a combination of portfolio review and standardized testing to evaluate candidates before awarding them the title of “Holistic Nurse – Certified (HNC).”
- Senior Apartments– Available to adults aged 55 and older, these apartments include numerous senior-friendly facilities that allow residents to remain social while still providing them with a sense of independence. Senior apartments are a viable alternative to nursing homes for those who have trouble with mobility but can still live on their own. The housing facility will provide seniors with everything they need to live independently in a space that is tailored to their needs, whether they are physical or mental. These prove to be a great compromise between SNFs and home care.
Appropriate for: seniors who want more social interaction while also looking to downsize their living situation.
- Low maintenance costs – Senior apartments have crews that can handle any maintenance issues that may arise.
- Smaller living space – This makes their homes more manageable to maintain.
- Higher standard of life – Seniors in these spaces maintain their independence but also have the social interaction available in nursing homes.
- Support – Staff members are always at hand to provide care if necessary and to help with daily chores, such as laundry and grocery shopping.
- Limited space – Many seniors will find that going from a 1,500 square foot home to a 500 square foot apartment is more difficult than they imagined.
- Lower level of service and attention than nursing homes – The resources for physical and psychological support at nursing homes far exceed those of senior apartments.
- Higher rates than assisted living facilities or board and care homes – The overall cost depends on the services offered, like housekeeping, food preparation, and transportation to doctor’s appointments.
- A lack of at-home assistance – This can create dangerous situations for everything from taking a shower to preparing tea.
More on senior apartments: The Department of Housing and Urban Development (HUD) regulates senior communities to ensure that they are in compliance with the Housing for Older Persons Act (HOPA). These regulations pertain to age qualifications, marketing, and community design.
- Assisted Living Facilities – Seniors who do not need constant medical attention, but could use help with daily tasks, will find these facilities appealing, as they provide great flexibility to those who may not be particularly mobile but still want to participate in social engagement. Seniors in ALFs receive minimum help for activities of daily living (ADLs) whereas in SNFs, the help offered is much greater.
- A variety of great activities for residents
- Rooms are often catered to the resident’s desire and thus feel more like home.
- Greater social support for seniors
- Some facilities might have residents sharing a room, which could create problems related to limited space and privacy.
- Assisted living does not usually offer the extensive care provided in nursing homes.
- Board and Care Homes – These facilities are for adults who do not require medical assistance but still need help with more basic daily tasks, such as walking or bathing. Typically these are residential care communities for senior adults located within a particular neighborhood.
- Relaxed, home-like environment
- Smaller number of residents, allowing for better personalization of care
- Suitable for seniors who wish to maintain their independence while also being able to participate in activities.
- Ample companionship and family bonding time since there is always a loved one around.
- Fewer opportunities for socializing
- Fewer amenities and recreational activities
- An emphasis on social activities, not a holistic approach to health care
- Limited accommodations for seniors with mobility issues
More about board and care homes: The regulations for Board and Care homes differ from state to state since they are licensed by the state. Medicare does not usually pay for board and care homes.
- Continuing Care Retirement Communities (CCRCs) – CCRCs consist of independent living, assisted living, and nursing home care all under one campus. Although the living spaces can change from community to community, they usually include houses, cottages, clusters, townhouses, duplexes and apartments.
- Flexibility for spouses that may have differing needs
- Oftentimes these are all-inclusive, giving residents full access to recreation, transportation, and meals.
- The highest ratio of staff – composed of DSPDs (direct support professionals) – to residents to ensure that each client is looked after appropriately
- These facilities are not just purpose-built retirement homes; they also offer social activities for residents.
- High cost
- High financial risk – Residents of CCRCs risk losing their entire investment if the CCRC goes bankrupt.
- Limited privacy and isolation due to the high number of residents per facility
As made clear above, most of these alternatives offer a certain level of independence. Seniors are generally hesitant to give up the independence they have had most of their lives, and, as they age and control less and less in their lives, they want to at least be able to decide how they receive care.
Now that we have outlined the pros and cons of each of these alternatives, let us look at how nursing homes can incorporate the positive aspects of each into their organizations.
How Nursing Homes Can Win Seniors Back
Nursing homes must work with senior care advocates to both learn how they can improve the quality of care at their facilities and to convey the nature of care they provide. This means that effort must be exerted to challenge dangerous stereotypes but also to borrow the best elements of nursing home alternatives and adopt them as their own.
Challenging Stereotypes about Nursing Homes
Most of the stereotypes surrounding nursing homes exist because of outdated information or a lack of familiarity with the actual environments of long term care facilities. That means that you must work in tandem with advocates to better represent the services and care you provide. Thus, you will want to:
- Show that nursing homes have changed – Nursing homes nowadays are well-lit places filled with life and vibrancy. Many hold daily activities, offer great dining, and invite young volunteers to interact with residents and brighten their days. Think about how your own facility has kept residents active and uplifted. Highlight these positive aspects when promoting your facility to prospective residents. And help keep your facility jovial by borrowing ideas that work for others.
Of course, putting forward a positive front will require advocacy and external support. You can read our blog talking in detail about how LTCs can partner with advocacy groups to improve the image of the LTC industry.
- Broadcast positive experiences – Long term care facilities are capable of considering resident preferences and contributing to greater quality of life and experiences for their residents. If your facility is not doing that right now, you can consult experts and come up with a plan. And if your facility is already consistently providing great care, make it known, record testimonials, talk about yourself. Making your facility a happy place is great, but your target audience also needs to know about it.
- Highlight the sense of community – Many new residents are afraid of becoming isolated in their new homes. But there are actions that you can take to prevent this. These strategies will not only help acclimate residents but also provide them assurance that aging is natural and can be a wonderful process if handled carefully and sensitively. Focus on the efforts of your staff to provide emotional support, give seniors a sense of purpose and meaning, and organize religious services when publicizing your services.
What Nursing Homes Can Learn From the Competition
The pros of the alternatives to long term care are many, and not all of them translate to nursing homes. The primary lesson to learn, then, is that, even though the needs of residents may vary, basic human needs must be respected and met at every single facility. Here we will present a few ideas taken from home care and PACE organizations that can elevate the quality of care you provide.
What home care has that LTC does not:
Home care offers flexibility. That means seniors can choose to have their care delivered from a private doctor or through an agency. If they decide upon the latter, they can avoid a lot of hassle. According to Jeff Hoyt, the editor in chief of Seniorliving.org, agencies will handle the jobs of: finding qualified candidates; running background checks; confirming their credentials; handling the financial aspects, which include caregiver payments; and calculating withholdings for taxes.
As opposed to the staff at a nursing home, in-home caregivers are able to provide quality care while residents remain within the familiar surroundings of their homes. Home care is often more affordable than long term care as well. Lastly, one of the biggest advantages of home care is that friends and families can come around at any time, whereas in most nursing homes, visiting times are restricted.
Where long term care is better than home care:
The amenities that nursing homes provide are often looked upon more favorably than those of home care. Hoyt notes that residents do enjoy the regular activities in homes that include crafts, games, and fitness as well as group outings to malls and places of entertainment. Moreover, nursing homes are staffed with full-time professionals who work around the clock to ensure that residents receive adequate care.
What to take from home care:
Since the major pros of homecare revolve around independence, mobility, and familiarity, here are our suggestions to improve care at your facility:
- Increase self-sustenance and allow residents more independence. This can be done through a variety of activities, like allowing residents to wash, dry, and fold their own laundry, participate in gardening activities around the facility, and step up to assist other residents with daily activities.
- Establish a culture of community. This can be done by providing both more privacy and greater opportunities for socialization by improving staff-to-resident and resident-to-resident interaction ratios during activities.
- Increase visiting times for family members by a few hours, or, on some days keep it flexible to cater to the schedules of seniors’ family members. This can help residents stay connected and avoid feeling isolated or lonely.
What assisted living facilities have that LTC does not:
Assisted living facilities are different from nursing homes in that they are only equipped to handle the needs of seniors who still have some level of independence. This means that they do not offer medical assistance and hence have no nurses on site. Assisted living facilities provide a lifestyle for independent seniors, giving them a helping hand when needed with activities like meal prep, housekeeping, medication, and grooming.
This lifestyle is appealing to seniors who want to maintain their independence and dignity by living at home for as long as possible. The advantage of assisted living facilities is that, while they are not equipped with all the tools needed to care for a senior, they are located near skilled nursing facilities. So, when needed, full medical intervention is provided at an appropriate LTC facility.
What to take from ALFs:
It would not be possible for a nursing home to provide the same level of autonomy that an ALF does, but some modifications can be made to how you provide LTC. In ALFs, the rooms are designed according to the resident’s choices, requirements, and preferences. The same can be done in an LTCF to make it feel more like home. Seniors in long term care facilities most miss the feeling of familiarity, which can be overcome through active resident participation in decision making.
ALFs also have a number of unplanned fun activities that residents can engage in during their free time. In an LTCF, things tend to run on schedule. It could be a good idea to allow your residents a good two to three hours of free time each day where they are allowed to move around the facility, explore, and speak to fellow residents. The nurses can choose to accompany them during this time or just oversee the situation. This ensures that seniors do not feel institutionalized. A study in BMC Geriatrics demonstrates that seniors that have a sense of control and autonomy over their own lives in ALFs and SNFs tend to be happier and more content with their lives.
What holistic care and the PACE Program have that LTC does not:
As previously mentioned, holistic care is centered around the whole individual, taking into account mind, body, spirit, and social demands. The most prominent example of a holistic care program is PACE. Elders who are typically eligible for skilled nursing services are also eligible for PACE services. This means that any senior that is considering making the switch to a nursing facility, either due to age or disability, would have the option of enrolling in a PACE. With PACE, seniors live at home, but then travel during the day to a day center run by program leaders. There, they receive any care they need and can participate in activities and eat meals. When they are done, they travel back to their homes.
PACE, like home care and ALFs, emphasizes the independent choices of seniors and their ability to choose how they wish to receive care. As mentioned previously, nursing homes must do more to show that residents who enter their homes are not totally giving up their independence.
While PACE CNY is a non-profit organization, they still manage to garner a profit through a per member per month payment structure in which the program charges participants a monthly fee and is then reimbursed through either Medicare, Medicaid, or Medicare Part D. Participants may also privately pay for the services, but overall, Button says, “We are 93% dually eligible, so most of our participants have both Medicare and Medicaid.”
Ultimately, the appeal of PACE can be reduced to comfort and convenience. When Lewis asked Button why residents may choose PACE over a traditional nursing home, she responded, “I think of PACE as a philosophy. It’s a philosophy of care that is open to a person making a choice to remain in their home if they think that is what’s best for them.”
Nursing homes can adopt this philosophy and take a resident-centered approach by trying to recreate a home-like ambiance at their facilities. Joe Mason, the administrator of Prairie Manor, told us how he was able to accomplish this by giving his residents more autonomy.
The transition from PACE to a nursing home:
Many PACE organizations have contracted with nursing homes in preparation for future moves to long term care, thus facilitating this difficult transition. This is beneficial to seniors who may have otherwise been overwhelmed by moving from their homes and being cared for by unfamiliar faces. The PACE organization will continue to monitor the health and wellness of those who were previously under their care alongside the staff at their new nursing homes, ensuring that specialized, quality care is still being provided. Thus, a partnership with PACE organizations may be the answer for nursing home facilities looking to bolster their census numbers.
Census numbers in nursing homes have fallen dramatically across the nation for reasons ranging from COVID-19 to a preconceived idea that long term care means the end of life. Regardless of the cause, it is clear that more people are opting for alternatives. Thus, whether nursing homes like it or not, it is evident that adaptation is necessary. Changes can be as simple as offering residents the option to select the color of paint of their room or partnering with a PACE organization to ease residents into nursing home care. The decision you reach should be made with the residents’ best interests in mind.
To hear the full interview with Stephanie Button, click here.