Ken Skoonberg, 97, likes the PACE program and says he doesn't miss a day.

Ken Skoonberg, 97, likes the PACE program and says he doesn’t miss a day.

Choices, Choices

Health care makes adjustments for the boom

Back Longreads Jul 1, 2009 By Christine Calvin

Boomers are booming, and skilled-nursing and long-term care facilities are struggling to keep up. But the focus isn’t on beds and population numbers alone. Baby boomers are a picky bunch, and they’re not likely to rest easy with the status quo, say caretakers, many of whom are seniors themselves. That’s part of the reason rehab care has taken on a new face in the past few years, one that’s focused on a philosophy change about senior care.

The future of health care for older Californians is all about options: the ability to choose a doctor, a care plan, a lunchtime and perks — high-tech waiting rooms, anyone?

These options are taking all forms, but the most substantial movement as of late was the January passage of the Physician Orders for Life-Sustaining Treatment paradigm in California. The program, which was moved by the Legislature, allows for written medical orders that enhance the congruence between desired medical care in the event of a serious injury or terminal condition and actual care.

POLST is not a legal document like an advance directive, which is completed far in advance of injury or illness in the event that the individual is incapable of decision making. Instead, POLST is tailored for an individual who already has a chronic or terminal illness with a life expectancy of one to two years. It specifically addresses the medical condition and the patient’s desired course of care. For example, would the patient want to be hospitalized? If so, would he or she want a life-sustaining feeding tube? After an injury, does the patient want to participate in rehabilitative therapies? If so, how aggressively?

Of the roughly 300,000 nursing facility patients cared for in California annually, nearly 40 percent have Alzheimer’s disease or a related dementia, 27 percent have behavioral symptoms and approximately 38 percent experience depression.

federal Online Survey, Certification and Reporting data.

The POLST form is signed by a physician and moves with the patient’s medical file through all future exams and surgeries.

“I have a 97-year-old patient who broke his knee, and he doesn’t want to go through rehabilitation. He says, ‘I don’t care if I walk again; I’m just tired.’ And before, he might not have had that choice,” says Deborah Kania, administrative director of Sutter Oaks Midtown. “We are finding that patients don’t realize they have a choice in how much care and what kind of care they want to get, and now we are seeing a cultural change in our industry.”

That change is going to mean big adjustments in the way facilities manage patient care.

Take medication delivery, for example. Traditionally, in a hospital or other such care institution, a medical worker will make his or her rounds with the medicine cart at breakfast, lunch and dinner. Dozens of patients receive their medications at the same time.

“You’ve got an institution and a system of delivering care that allows us to manage care efficiently for the most number of people, and that’s what we’re funded to do,” says Joesslyn Montgomery, registered nurse and director of clinical affairs for the California Association of Health Facilities.

But at home, not everyone takes meals at the same time. Maybe a certain medication gives a patient heartburn if taken after dinner. Maybe the patient would rather take everything at once. Or maybe the patient gets annoyed when he or she is awoken by the nurse at 6 a.m. to take a multivitamin. The bottom line: Different patients have different needs.

“But if 15 people want their medications at separate times, you have a need for a creative management structure,” Montgomery says. “It’s not that people can’t get their medical wishes honored, but making this happen in an individualized way can be difficult. The cultural change is important because the boomers are demanding it. This new wave of individuals are getting to have dialog with their caregivers that is very two-way. It’s customer service [through] individualized care.”

In many respects, this cultural shift has been happening over the course of the past decade, says Carol Burger of Burger Rehabilitation Systems Inc., which has 12 physical therapy and rehab centers in the greater Sacramento area.

58 percent of patients admitted to nursing facilities are discharged within 30 days.

California Association of Health Facilities

“I can recall administrators saying, ‘Don’t work with them too long because they’re old, and they can’t handle much,’” she says. “If you are 80 years old, so what? We’re not looking at your age; we’re looking at your condition and what you need in order to recover. If you need three hours of therapy a day, you’re going to get it.”

The approach to patient care has changed, and with that, so have the facilities. Gone are the days of dark hallways, drawn curtains and mustard linoleum. Capital Region facilities have spruced up with brighter lights, bay windows, softer fabrics, landscaped gardens and cheery décor.

But, as is the catalyst of most institutional changes, much of the alteration came as a result of a mid-1990s amendment to the Medi-Cal and Medicare fee structures. Rather than reimbursing hospitals for the length of a patient’s hospital stay, the providers began reimbursing by diagnosis. Hospitals, therefore, had little incentive to keep patients any longer than necessary, so patients went to skilled-nursing and rehab facilities.

“Now you see more independent people coming to nursing homes,” Montgomery says. “They have become more known for their rehab services, managing higher acuity and helping patients to get better. We can provide those services at a much more reasonable rate than hospitals can, and Medicare doesn’t want to pay hospitals for that sort of post-acute care. Many, if not most, of our facilities have pretty dynamic rehabilitation programs, and they are used to as many as 80 admissions a month.”

“It’s not that people can’t get their medical wishes honored, but making this happen in an individualized way can be difficult.”

Joesslyn Montgomery, director of clinical affairs, California Association of Health Facilities

Nearly 90 percent of patients entering a nursing facility come from the acute hospital. They’re dealing with massive trauma, neurological issues and post-operative recovery, for example. Still, in today’s nursing homes, patients aren’t waiting around to die.

“When we first began, I would say it was a very small percentage of patients who returned home — 10 percent maybe, though that’s just a guess,” Burger says.

Today, 58 percent of patients admitted to nursing facilities are discharged within 30 days, according to the California Association of Health Facilities. Just 8 percent remain for more than a year.

“People are looking pretty holistically at the patient and what they are going to need when they get home,” Burger says.

California currently has 3.5 million people over age 65 — the largest population of this demographic in the nation — and that number is expected to increase to nearly 6 million by 2020, according to the California Association of Health Facilities. The greatest growth will be among those who are most reliant on the state’s nursing services: the elderly aged 85 and older; by 2040, the state will be home to more than 1.7 million of them.

To cope with those demands, long-term facilities must be made more available and accessible. Not only that, they will need to support the demands of a different breed of elders — boomers who hold a wider variety of needs and desires.

Few programs in the area implement the holistic approach more fully than PACE. PACE, an acronym for “program of all-inclusive care for the elderly,” provides everything under the sun for its outpatient participants. Funded by Medicare and Medicaid, Sacramento’s PACE programs (two of just 70 such programs in the country) offer area residents access to health care, rehabilitation, dental care, optometry, social workers, mental health providers, laundry assistance, meals, transportation, legal assistance, in-home care and entertainment all under one roof.

The program was developed more than 25 years ago in San Francisco’s Chinatown but has failed to blossom into a robust answer to the needs of the elderly nationwide. The reasons are unclear, however, because PACE participants, while generally more frail than the average Medicare recipient, cost tax payers far less in government-funded assistance, are hospitalized less and report wildly high satisfaction rates — close to 100 percent according to some estimates.

“We make friends here … and I enjoy the people I work with,” says 83-year-old PACE participant Margaret Pipolo-Weinbaum. “They’re just wonderful to me, and they just bend over backward to make sure your health is in optimum condition. They also see to it that we have fine doctors on the outside. I just can’t say enough about what they’ve done for me.”

Weinbaum comes to the PACE center on 12th and U streets about three times a week for socializing, medical checkups, outings and impromptu drama performances. She says she’s able to live alone because her social worker makes sure all her needs are met — in and out of the home. She even calls her groceries in for delivery.

Ken Skoonberg, 97, says the same thing. A former war spy, Skoonberg describes himself as “a little independent soul” but likes the PACE program because, “You can come, or you don’t have to.” 

He says he doesn’t miss a day. Mostly he plays cards with the other gentlemen, but he also takes regular advantage of the medical and legal assistance and activities that “make these declining years a little more tolerable.”

California currently has 3.5 million people over age 65, the largest population of this demographic in the nation.

California Association of Health Facilities

While he plays cards, other residents eat lunch, meet with their social workers, visit the dentist and play Nintendo Wii. Yes, Wii. Apparently, it’s the next big thing in rehabilitation for senior citizens.

“We are always thinking of the next thing we can add,” says Candace Kuhl, facility rehab director at Emerald Gardens Nursing Center. “We want to make things fun and inviting for all types of people. We introduced the Wii first with our group therapy because it adds a lot to the atmosphere. They’re in there cheering people on; it brings out that competitive nature in people. We use it for endurance training, eye-hand coordination and balance; there are even some strength programs with Wii Fit.”

The game system, which offers such interactive selections as bowling, baseball and golf, is a fun alternative for residents who can no longer enjoy their favorite physical activities, and it also offers a fitness option for participants who are chair- or bed-bound.

“Patients seem much more motivated in the therapy process,” Kuhl says. “They enjoy coming and being a part of the activity. We have seen how it has increased their endurance and ability to complete functional tasks.”

Emerald Gardens also implemented an Internet café about four months ago. It’s accessible to all residents, and Kuhl says usually someone is in there. Such amenities will likely be the norm in the future, say caretakers and residents. Boomers will be looking for more such options, but for now the perks are great even for old-timers such as Skoonberg, who shows up to PACE four days a week, cell phone in hand.


Brie Bazinet (not verified)December 5, 2016 - 8:28am

7 years later, and the boom is still hitting hard. The best rehab facilities, hospitals, and health care professionals can't seem to keep up. Still no U.S. single payer system, and medicare and medicaid are being gutted. Things are only going to get worse.

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