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I recently had a very interesting conversation with an Admissions Director of a well-respected Chicago skilled nursing home. We made the observation that due to the poor economy, many Chicago assisted living homes* are accepting residents whose medical needs cannot be met. In other words, the resident belongs in a skilled nursing home.** Being a former Admissions Director and with my current position as a Chicago Senior Living Advisor, I thoroughly understand the current market conditions.

The Admissions Director is the most important contact at a long-term care community. He or she is responsible for attracting and residents, while maintaining a high census. Many Admissions Directors also act as marketing liaisons. They provide your first impression of a long-term care community, and often are a direct reflection of the care your loved one is going to receive. They are also responsible for the initial assessment of the type of care that is appropriate for the senior. It is important to bear in mind that Admissions Directors are often commissioned salespeople. They are accountable to, “the powers that be,” for maintaining a high census. I can remember the terrible pressure that was exerted upon me by the management in order to keep filled the continuing care retirement community where I was working. Scarcely was a bed emptied before pressure came to fill it. The passing consolation that the seniors, “were called home by God,” just didn’t cut it in terms of lightening the pressure for quick turnarounds. I know that with a bad economy, the pressure is even worse.

My point is this. Don’t let someone “sweet talk” you into thinking they can take care

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Prospects will often call me and open the conversation by saying something like, “My mother needs some assistance.” A statement such as this one can mean anything. Assisted living actually means the next level of care that is necessary when the senior is no longer completely independent. Specifically, he/she needs some help with activities of daily living: eating, bathing, dressing, walking, transferring, and toileting. This is not hands-on care. It is stand-by assistance. For instance, the aide will not give a loved one a full bath or shower. The aide will stand by and watch the senior take their shower. The aide will hand the senior the soap and towel. The assistant will not scrub the person down. People have a lot of misconceptions as to what “assisted” really means.

According to the Assisted Living and Shared Housing Establishment Code in Illinois, the personnel requirements to qualify for assisted living are:

  1. There must be someone age 18 on the premises for 24 hours
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I attended a networking breakfast that was organized for professionals involved in different areas of the senior industry. I was asked by the leader to share the greatest challenge that I was currently experiencing with my business. I didn’t have to think too long to respond.

Over the past year or so, I have witnessed my nursing homes engage in the process of converting entire floors to short-term rehabilitation units. Short-term rehabilitation costs are covered by Medicare. Without going into great detail, Medicare covers the first 100 days of short-term rehabilitation after a three night qualifying stay in the hospital. It doesn’t cover long-term custodial care, which many people don’t understand. Short-term rehab is where nursing homes are currently making their money. The tendency is to admit the senior and rehabilitate him or her until a plateau on the therapy is reached. The senior is then discharged and it’s on to the next person.

So what is the impact of facilities converting entire floors to short-term rehab? Many of the nursing homes making this change are not currently accepting any long-term residents. The long-term residents who currently live in the community are slowly being transitioned from their current floors and moved to another floor. So now there is a shortage of long-term beds at selected communities. The certification change to short-term beds results in not only a smaller number of long-term beds, but fewer beds that are certified for Medicaid (public aid).

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As a former Admissions Director of a continuing care retirement community (CCRC),* it was my responsibility (along with the community nurse) to assess prospective residents for placement in the appropriate level of care. During many consultations with my clients, I’ve found that people often don’t understand the different definitions of the levels of care that are offered by long-term care communities. Here are some very basic, broad definitions:

Independent living – The senior can perform all of the activities of daily living** on his or her own. S/he may want/need some assistance with meal preparation and housekeeping.

Assisted living – The senior needs help with some of the activities of daily living. It isn’t “hands on” care. It is normally stand by assistance. For example, a senior may need some assistance with a bath or a shower. However, the aide will hand the senior the wash cloth and soap and perhaps help wash any part of the body the senior cannot reach. It isn’t a full scrub down shower like those provided in the nursing homes. However, I will place a caveat on this definition. There are some assisted living communities that are based on a medical model where more “hands on” help is offered; e.g., the person needs total assistance getting in and out of bed. The presence of a nurse and his/her functions will vary according to each assisted living community.

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A Real Life Story

I am currently advising an elderly couple who recently chose a beautiful apartment in a continuing care retirement community. The items on their retirement community “wish list” included the following:

  1. The apartment had to be no less than 1000 square feet.
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During the latter stages of Alzheimer’s disease, it is common for individuals who are bilingual to revert to speaking and understanding only their original, native language. An event such as this can present challenges as described in the following Real Life Story.

Real Life Story

My clients are the daughters of a seventy-two year old woman with the latter stages of Alzheimer’s disease. The daughters live in Chicago, another U.S. city, and a city overseas. Their mother is a native Spaniard who is totally ambulatory and incontinent.

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I had to chuckle because a national advice columnist was asked the following question about a senior who was in apparent need of assisted living services: “My mother-in-law was diagnosed with dementia over a year ago. She can no longer do anything for herself. She can no longer climb the stairs, get to her bed, shower or do laundry. She does nothing all day but watch TV and eat sweets. What can be done for an elderly person who obviously can’t take care of herself but “fakes” it so her kids won’t put her in a home?” The columnist’s answer was basically, “You have my sympathy. Convene a family meeting, and call the Alzheimer’s Association.” Frankly, I found the response to be an oversimplification and glib. While the associations for specific diseases will provide you with excellent sources to begin your research, they will not help you analyze and identify the appropriate option for your loved one. You will still have to complete all the legwork that comes with identifying the appropriate option for your loved one.

Since I’ve already completed the research, why not let me streamline this time-consuming and emotionally draining task for you?

My father had Alzheimer’s disease and was a master at “faking otherwise” when his baby daughter was there to visit, in order to keep her from worrying about him. He was so good at acting that at times I was in denial that anything was wrong with him. However, sometimes the person who has Alzheimer’s becomes so good at “faking it” that the results are detrimental. .

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As you can imagine, I’m often asked how to convince a loved one who has dementia to move out of a home when she or he has refused. The issue is further complicated when someone is ambulatory, somewhat functional, but safety is a concern. If your loved one refuses to move, it is unlikely that you’ll be able to talk him or her into moving anywhere. It isn’t worth bringing up the subject. The person may become upset and dig his/her heels in deeper. The disease prevents the individual from rationally understanding the situation. While each case is different, here are some basic ideas I have seen work for my clients.

  1. Once a community has been selected on behalf of your loved one’s best interests, have his/her physician write orders saying that the person should be admitted for general care and management of a medical condition. The move should be presented as a temporary situation that has nothing to do with your loved one’s mental capacity. Remind your loved one that life for all of us is best lived One Day at a Time, and that nothing is ever written in stone. The move is a step, taken with his/her safety in mind. It is not an “end.” Hopefully once the person is settled, s/he will adjust well and forget prior objections.
  2. Convince the person that the home or apartment is unfit for habitation due to physical problems and have them “temporarily” relocate to the chosen community.
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When I opened my doors in 2006, I began touring and evaluating communities under wrap; meaning, I didn’t volunteer to the admissions director at a community that I was a consultant. I did this because I wanted to see how an outsider would be treated during an unexpected “walk-in”, if the community was a mess from a housekeeping standpoint, and how long I would have to wait for someone to take care of me. All my findings have been duly noted, documented, and shared with my clients.

The practice of “walk-in” tours is a great strategy when you’re conducting your senior living search. In my opinion, your first tour should always be a confirmed appointment with the admissions director. The second tour (you’ll always want to take a second one to confirm your first impressions) should be unannounced. That way, you’ll receive an initial tour from the person who has expertise in the care, features, and amenities that a community has to offer. Many times, the admissions director will have marketing responsibilities that will cause him/her to be out of the building. If you choose to tour at a time when the admissions director isn’t available, you will be handed off to the activity, maintenance, or dietary director. At times, the “manager of the day” is responsible for conducting the tours on the weekends, another time when the admissions director may not be available. Unless that person has been thoroughly trained on how to conduct a good tour, you’ll be on the receiving end of a presentation that’s unsatisfactory. In the end, you may pass on a community that is totally acceptable as exemplified in the following “real life story.”

real-life-story200Real-Life Story

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I often have seniors and their families hire me to find the right community because the senior is lonely and wants to socialize with people his/her own age. The feeling of being isolated and depressed while eating alone is often a major cause for concern. While I empathize with such concerns, I always encourage the senior to sample the food and the “communal dining experience” before signing on the dotted line at a new home. The senior could be eating one to three meals a day at the community depending on the level of care and type of dining program offered. If a senior could be spending up to 30% of his or her time eating, the food better be good. Couple that with table mates who have personality clashes and you could be headed into a situation that spoils the whole retirement experience.

Most of the time, admissions directors are more than happy to have a prospective resident and his or her family members sample the food. However, I recommend that the sampling be conducted during an ordinary meal, rather than during a special event. The food at an event won’t be reflective of a meal that is typically served. I also recommend that the senior be seated with some of the residents during the sample meal. That way, s/he will always get truthful opinions of what the food is really like on a daily basis. It also allows the senior to sample the social setting and resident personalities. Some communities have unassigned seating. Others will purposely mix the residents to prevent cliques from forming at meal time.

Please be advised that independent living and assisted communities may not have a dietician on staff. Many of them note “heart healthy” and sugar free foods on their menus. Then, it’s up to the senior to behave. If your loved one needs a special diet like pureed or mechanical, ask if that can be accommodated. I have even arranged for my nursing home clients who are lucid and contemplating a change in nursing homes to travel to the proposed new home via Medicar to take a tour and sample the food.

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