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Careful Choices

Author: Bonnie Durrance
June, 2011 Issue

Deciding where—and how—to spend the Golden Years can be a difficult and often confusing choice.

Almost everyone knows someone it’s happening to. Maybe it’s an aged neighbor, who, tending the spouse with dementia, is suffering physical collapse. Maybe it’s an elder parent, who has a stroke and needs hospitalization and then long-term care. Maybe it’s an in-law, who’s sound of body, but not of mind, and can’t manage safely alone. Maybe it’s a friend, or even oneself, whose care for a parent or loved one has become an overwhelming emotional, physical or financial burden.

Then, one day, something happens: Maybe someone has left the stove on and there’s been a fire, they’ve not been taking their meds and have become disoriented, or they’ve had a fall. It could be a husband and wife have been taking care of each other and one has passed away. Suddenly, the need for help, for solutions, for the right care—at the right price—is urgent. And the parties involved, usually with little warning and no experience, must figure out the options and make the best decisions. Everyone’s at a loss.

“Usually, when someone is confronted with this,” says Frank Samson, founder of Sonoma-based Senior Care Authority, “they’ve never been through it before. They’re panicked, stressed. They have to find something quick.”

The tiers and costs of senior care

Samson’s business is to help his clients find a safe and affordable living situation within an often-urgent timeframe. “We’re a case management company specializing in senior living for the elderly,” he says, describing his company’s range as from San Francisco through the East Bay, Napa, Sonoma, Marin, Solano and Sacramento counties. Much like a real estate agent, his commission is paid not by the client, but by the facility in which the client is placed. He’s able to understand the needs and abilities of his clients, he knows the options available and is able to match the client with the right situation. He says his background in the travel business prepared him well. “I was in the leisure side of the business for many years,” he says, “dealing with high-end villas and resorts—places that cost many thousands per night. Those clients expect more hand-holding and red carpet treatment. So when we work with family members and other loved ones, that’s what we do.” He has four staff members, plus a radio show, “The Aging Boomers,” on KSVY in Sonoma, and says, “I live and breathe this now.”

To find the right place for the right client, Samson spends a lot of time assessing the senior, which also includes talking to the adult children and to the doctor. To determine the best options, he needs to know if the elder has been diagnosed with dementia, a heart condition, diabetes, if they’ve had any falls and other ailments. He needs to know whether they want to be in a larger place with more activities, or a smaller place with a higher ratio of caregivers. His goal is to find the right place, for the right client, at the right price.

While he works with a wide range of options, the locations to which he most often guides his clients are generally referred to as “assisted living,” which he describes as somewhere between living independently—either at home or in a retirement community designed exclusively for seniors—and the dreaded nursing home. “A lot of people get assisted living confused with nursing homes,” he says. “But our goal is to keep people out of nursing homes.” This is a theme echoed by some of his associates in the senior care business who, rather than place people in care settings, prefer to bring the care to them.

Home is where the heart is

“Many of our clients say they don’t want to end up in assisted living,” says Todd Vaughan, owner, with his wife, Catherine, of the Marin County office of Home Instead Senior Care, a worldwide company, based in Omaha, Nebraska, that provides nonmedical, in-home care to those who need help with activities of daily living, but want to stay in their homes.

Vaughan says his clients, who range in age from 50 to 105, often call for their own service, and all opt, even insist, to stay in their own homes. “Here in Marin County,” says Vaughan, “people are independent. They don’t want to go to assisted living. ‘Home Instead’ means being at home instead of in a home.

“Our overall objective is to let Marin County seniors stay in their homes,” says Vaughan. “So many of our clients have lived in their homes for 40 to 50 years, and they want to be there to the end. We’re able to help them do that. Home Instead provides trained caregivers who perform nonmedical services, including light housekeeping, meal preparation, errands, medication reminders, basic transportation and even companionship. They also provide personal care, which means care for incontinence, bathing, dressing and grooming.
“It’s an HR industry,” says Vaughan. “It’s comprehensive human care.”

Personal, intimate care requires reliability, competence and trust (see “Taking Care,” June 2008). Key to the reputation and reliability of such a service organization is the quality of the personnel. Vaughan says he and Catherine spend a great amount of time interviewing and doing background checks on prospective caregivers, including county criminal searches, DMV checks, drug tests and multiple reference checks. “We go back seven years,” he says. “We train, bond, insure and supervise our caregivers.”

Home Instead has been serving Marin since 1998, providing care to individuals and to clients in their homes and in assisted living centers, helping their clients with the basic tasks of independent living. The business model suits the Vaughans. He previously worked in the corporate world and managed large staffs, and she was an investment banker, where she helped companies finance the development of skilled nursing centers, senior housing and assisted living projects—a growing industry. He expresses pride in the services his office provides, and in the reach of the parent company.

“We have more than 900 offices globally,” says Vaughan. “We’re the oldest home care provider, with offices in North America and 13 other countries, including Japan.” He’s particularly enthusiastic about its expansion into Japan. “We have more than 200 offices in Japan. And that’s a culture where they really don’t like outsiders to come into their homes. It’s such a family-oriented society. But they’re one of our fastest growing territories.” He says he thinks the reason is that, because of the economy, the members in the Japanese households have all had to go to work, so they’re bringing in outside companies to care for their elders.
All the offices are independently owned and operated, he says, and the company’s resources and training makes it possible for Vaughan to offer the quality professional services he speaks about with zeal.

But how do you judge reliable home care companies? Right now, in California, there are no license requirements for nonmedical home care. (Note: Medical home care is a completely different service, prescribed by doctors, often after surgery, and provided by licensed health care workers. They may offer references for ADL [activities of daily living] care, but don’t provide such care themselves.) “We’re pushing for statewide licensure,” says Vaughan. “We’d like to have that, as it would help us differentiate our business.”

As far as the price goes, Vaughan says it’s reasonable. Home Instead offers an hourly rate of $25, with a minimum of $100 per month, which means that, depending on the level of coverage—which tends to ramp up, he says, as the senior’s needs increase—typical coverage averages from a baseline of $2,000 per month and up, with a 24-hour coverage typically running “around $9,000 to $10,000 a month.” This, he says, favorably compares with assisted living, which runs from $5,000 to $12,000 per month in Marin.

Assuming you can afford it, the lack of disruption sounds nice—but is it really safe to keep failing elders at home? Vaughan says it is, if you have the right amount of help. “And, remember, the client is in his or her own home.”

Speaking of affording it, who pays for this extensive, in-home care? The short answer is, unless you have long-term care insurance, or some veterans benefits, you do. “Somewhere between 30 and 50 percent of our client base use their long-term disability,” says Vaughan. “The rest use private pay. No Medicare.”

“Board and care” or assisted living

Not necessarily less expensive, but offering care with companionship in a group house setting, is an option called “board and care.” These are individual, licensed, private homes, in neighborhoods, which offer elders a domestic setting with other elder housemates and a full-time caregiver. “I helped find a place for a lady whose daughter had lived in Sonoma her entire life,” says Samson, “and we ended up putting the mom in a home near the daughter’s house.”

This type of situation can be perfect for some, but not for everyone. “Though most seniors do want to live at home as they age, it’s not necessarily the safest or most mind-stimulating thing,” Samson says. “They may be home sitting in front of the TV all day with nobody around and no place to go. I’ve seen people thrive after being placed in an environment where there’s more activities.” In a recent study that appeared in The American Journal of Geriatric Psychiatry, he continues, it was concluded that, “a constricted life space is associated with increased risk of Alzheimer’s disease, mild cognitive impairment and cognitive decline among older persons.” He suggests that some people do better in an environment where there are more activities and opportunities to socialize, such as the option generally known as “assisted living.”

Assisted living locations have caregivers onsite 24 hours a day to help with ADLs (such as grooming, toileting, washing, meal preparation, transportation and socializing). A good example is Vintage Sonoma, located at the gateway to the city of Sonoma, which offers the full spectrum of care from independent living through assisted living, memory care and hospice.

Like many such communities, Vintage Sonoma features a pleasant setting, beautiful lobby, attractive art and nice lighting. Generally, there’s an upscale but not imposing atmosphere differing from a nice hotel in that everyone in the restaurant looks to be in their eighties, and the people moving along the halls may be riding motorized chairs, or using walkers or canes. But they tend to be smiling, and as Activities Director Shane Clarkson tours a visitor around, the residents greet him warmly and the atmosphere is upbeat and friendly. Large windows in the various rooms offer views of well-kept gardens and courtyards. Here, people enjoy social activities, trips to town, games and entertainment in attractive surroundings with residents ages 50 through 105.

Here, too, says Clarkson, they can enjoy the continuum of senior living from independent living to assisted living and, if it becomes necessary, on to memory care—an oxymoronic phrase that means care for those lacking memory, who are moving into dementia—or hospice. The advantage of the full-spectrum assisted facility, such as Vintage Sonoma, is that residents, once they move in, are “home.” They don’t have to be resettled in another facility as they move through the natural decline of the aging process. Clarkson, kindly and cheerful, clearly loves his job. “I come here for the smiles,” he grins.

Also grinning, you may imagine, will be those residents, or adult children of residents, who’ve previously arranged for long-term care (LTC) insurance policies. Those people—if their policies have been written favorably by trustworthy agents with trustworthy companies—will have their expenses, ranging from $3,000 to $6,800 per month, completely covered. Executive Life Coach Chris Lynch, who once was an agent for long-term care insurance, compares LTC to car insurance—it’s that necessary. “It protects your assets incredibly well. When Dad had a stroke, I had a sense of relief that it would all be taken care of. We didn’t have to worry about which asset to liquidate, we knew he’d be covered and it was a lifetime policy.”

Some warn that such policies are often fluky and companies can refuse to pay, and so, assuming you can afford it, how can one judge which policy or company to go with? “Look for a company that’s been in the business for a long time, that has a history of not raising rates,” he says. “I think there’s only one or two left, by the way. Then I’d look for an agent who you feel would be an advocate for you. It helps to have an agent who really knows the product.” This is one case, Lynch says, where price should not be the object. “When something like stroke, heart problems or dementia happens to one of your family members, you’re in no position to deal with voicemail trees and unknown insurance companies somewhere on this planet. You want an agent to come and take charge for you. And that’s assumed to be included in the price.” (For more information about LTC insurance, see “Who Will Take Care of You?” November 2010.)

Those without such insurance may, as with the other options, get some help from veterans benefits, but otherwise, again, they’re on their own. If they have assets, it’s up to the adult children to liquidate them. If they don’t have assets—well, that’s another story.

Denial is not just a river

David Hahklotubbe, gerontologist and executive director of Vintage Sonoma, sees the mounting problem of elder care, both in the increasing numbers of seniors who will be needing care (simply Google “Baby Boomers” for pages of scary websites with threatening headlines and eye-popping statistics), and the consequences to individuals who cannot get care in time, as a catastrophe waiting to happen. He attributes part of the problem to our culture: “Americans are reactive to health care rather than proactive,” he says. “We tend to run from aging, not embrace it. So that sets us up for major failure. And by ‘us,’ I mean the elders, the spousal caregivers, the adult children and even the third generation, the grandchildren.”

Like Samson, Hahklotubbe, who describes himself as a Native American of the Choctaw tribe, also talks about the precipitating event, where, because of a fall, an accidental fire or a wandering off, “suddenly” the family members realize the elder needs help—and that the need, and the problem, is immediate. The solutions are usually complex, always expensive and, without proper research, can even be dangerous. “As of December 2010, I’ve performed more than 1,000 geriatric assessments,” he says, “and I’ve seen my share of tragedy.” People will present their situations, listen to his recommendations and then, he shakes his head, “They’ll say, ‘You know, that all makes sense, but we think we’ll just wait and see.’”

Elder care is a family affair

Hahklotubbe sees four barriers that keep families from getting the right care for their elders. First, reluctance to understand and accept that they need care. “People will go through psychological trauma just addressing the fact of their loved one’s mortality,” he says. Naturally, if the parent is suddenly seen as mortal, the implication for the adult child, who may not be inclined to embrace his or her own mortality, can be uncomfortable.

The second barrier is pain, and there are two kinds. First, the pain of due diligence, which is from facing their traumas head-on before eventually coming to a reasonable solution: “Mortality is a huge deal,” he says. The second is regret due to inaction that leads to something catastrophic; this pain is irreconcilable and is often precipitated by the “wait and see” mentality. (“Dad’s wandered out a couple of times, but he’s always found his way back…”) Along with that, some expectations also have to bite the dust. “The first expectation is that the government is going to foot the bill for this quality of care. That’s not the case.” So who is? He’ll get to that.

The third barrier is family dynamics: “So now, you’ve gotten over the psychological traumas, and you think now is the time to present [the idea of assisted care] to your family. What then? Surprise! Elder care costs money!” He describes a common reluctance on the part of adult children to liquidate the parents’ assets to provide for their care. “It’s a shameful thing, but it’s routinely said: ‘We’re not going to make a move, because the downturn in the economy has driven down the equity in Mom’s house, so we don’t want do anything quite yet.” This, he says, is because the adult children don’t want to “lose” the equity she’s built in the house she bought in 1952, for $15,000, and would sell for $750,000 today, instead of the million of a few years ago. “They don’t want to ‘waste Mom’s money taking care of her.’ We hear this every day in this industry. The adult children are saying, ‘We can’t sell your house because the market is so bad, or we’ve lost our job and can’t pay for your care.’”

Epic family quarrels don’t limit themselves to soap operas and murder mysteries. “I’ve seen it all,” says Hahklotubbe “I’ve seen where the elder has more money than they’ll ever be able to spend in their lifetime, others who’ll need to liquidate some assets to survive, and those who may need to liquidate some but also have some veterans benefits or some long-term care insurance. Then there are those who have neither. Which all leads to barrier number four: money. What resources do you have? Here is where, in most conversations about proper elder care options, there comes a long, uncomfortable silence.”

Some may say the issue of quality of care isn’t about money, but Hahklotubbe, after a long sigh says, “All I’ve seen, in my 12 years as a gerontologist, running long-term care homes, is that money does dictate and influence quality in older life.”

Marylin Barnes, regional director for Senior Helpers, a nationwide provider of nonmedical in-home care, echoes his concerns. “The bulk of the baby boomers aren’t going to have any real resources, because we make a little too much to really qualify for any [financial help], but we don’t make enough to pay for the kind of service we’ll need. This is a problem that’s only getting bigger as the boomers age and with the rise in the number of those diagnosed with Alzheimer’s. It’s going to be overwhelming for our communities and medical facilities, and all the resources currently out there will be overtaxed. We need to be quickly finding solutions for this problem.”

Final thoughts

Carl Gerlach, former CEO of Sonoma Valley Hospital and member of the board of directors of Eskaton, a nonprofit provider of visionary community living and home-based support for seniors, offered his own experience as a caution. His mother, when she reached her eighties, had more than sufficient assets and a large family of willing caregivers, all of whom lived relatively close by. All conditions on the rare side. Her final years were horrific, he says, not just for her, but for her adult children and also her live-in caregivers. She had, over the years, become obese and developed diabetes, which made life for her and her caregivers more difficult. Her extended life was one of discomfort and frustration. “The last three years, she didn’t want to live,” he says, “but it just dragged on.”

For Gerlach, given his experience, money alone, however awful it would be without it, isn’t the only answer. “It’s really a culture change we’re needing to look at.” He advises two basic things. First, communication: “Connect with your families, talk about the issues—you have to talk about it.” Second, getting healthy: “Eat better, stay out of the hospital! You can attack this thing on all kinds of levels.”

The underlying message of each one of these spokespersons for the world of elder care is this: think ahead. Think way ahead on all fronts. Then life after the middle years can actually start looking like a positive experience, to be pleasurably shared with families and communities participating and benefiting from the elder members. As Hahklotubbe says of his native culture, aging is a process, to be respected and even cherished. For our culture, we have a long way to go toward that, but organizations such as these, and many others like them, are working toward it.

Aging in Place

By Chris D. Craiker, AIA/NCARB

The changing demographics of baby boomers desiring retirement has been served a double whammy of falling real estate prices and 401Ks. The so-called “move-up” market has been stalled, while move down and move out has become a reality. At the same time, the huge number of baby boomers reaching retirement age without the resources they anticipated has transformed the housing market and our state economy.

I’ve always had an extra apartment in my home, for my daughter, for extra income or as an office. I expect to see this trend pick up steam as more as boomers decide where they’re going to live or if they can adapt their present home to the changing lifecycles of our times.

What will the baby boomer home of the future look like? For a moment, let’s picture the sensible, 21st-century baby boomer pad: One story with no floor changes and steps; a two- or three-car garage with ample storage or a workspace of 100 square feet; a master bedroom with plenty of closet and storage; a den and a guest room; no family room, only a great room that encompasses the kitchen, dining and living areas. Attached and accessed from the main house is a one-bedroom auxiliary unit (apartment or studio) with a private entrance. This could be on the second floor, but most likely on the first, especially if it might accommodate an aging parent. The unit would be able to act as an extension of the house should a larger family desire that in the future. This can be accomplished within 2,600 to 2,700 square feet on one level.

The baby boomer home of the future will be exceptionally energy-efficient by today’s standards, with close to net-zero energy consumption, using solar panels and geothermal heat exchangers. The construction will be of the highest sustainability—its waste will fill a single trashcan. Bathrooms are large and easy to navigate for universal accessibility. The kitchen counters are adjustable to varying heights and the upper cabinets can be lowered for easier reach. Floors are easy to clean and throw rugs are machine washable. Plenty of windows flood the house with light and have drapes or shades that open and close automatically as the daylight or mood changes. As the inhabitants grow older, they may move into the auxiliary unit and rent out the larger quarters, or perhaps their family members can take residence there.

The state of California has passed a law to let each city regulate auxiliary units. They can’t overtly refuse a unit, but any proposed second unit must respect good neighborly practice, such as adequate off-street parking and noise suppression. Generally, it boils down to whether the municipality has a specific requirement for a second unit having a separate kitchen. Even that issue is defined as whether there’s a stovetop included. A small apartment for your grandma or son with a kitchenette consisting of a sink, under-counter refrigerator and a microwave usually doesn’t qualify as a kitchen. But check with your own building and planning department before you put up a for-rent sign or stop your son’s dorm payments.

The cost of creating an extra unit, either new or within an existing home, isn’t cheap in most metropolitan areas. Most cities consider it a second unit using extra utilities, thus requiring extra utility connection fees. Even though such a unit cann’t be subdivided and sold separately, the city considers it a separate residence and can require a sanitation connection fee of almost $6,000. PG&E requires separate meters costing $2,000 to $4,000, and a separate municipal water meter costing $5,000 may be required (among many other expenses) before a single pipe is laid. Additional requirements will consider the height of structures and property placement.

Baby boomers maybe an oxymoron, as they’re neither babies nor boomers. But this flower child generation has no intention of going out with a whimper. They sense they’ll live longer and better than their parents, but now they may have to plan for care of multiple generations: both their elders and their children. Aging in place may be one more instrument in their toolkit.

Chris Craiker AIA/NCARB is a nationally renowned architect, founder of the Napa Valley Architects Exchange, with more than 35 years of experience as a babyish boomer. His website is



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