A Place for Aging

An MU facility is redefining notions of elder care.

by Anita Neal Harrison

Gene Taylor and Dana Morgenthaler found themselves in a quandary. A couple of years ago, their mother, 95-year-old Marjorie Shaw, began having trouble getting around. She couldn't keep up with her housework, but she didn't like hiring strangers to help. So Taylor and Morgenthaler tried to pick up the slack.

"It became overwhelming for us," Taylor says, "trying to keep up our homes and her home." But, she adds dryly, their mother "wasn't going to make any changes until she was older."

Eventually, the sisters managed to convince Shaw to tour a few local assisted-living facilities near her Columbia home. Their mom returned from the visits adamant about not wanting to move. "She kept saying she would do it when she really needed to," recalls Taylor.

Unfortunately, the need arose quickly. Shaw fell and broke her hip, a potentially devastating injury for the elderly. She was lucky. With rehabilitation at an area nursing home, she regained her mobility. But she could no longer live on her own. For most seniors, this would mean a permanent move to a nursing home or, at best, an assisted living arrangement. Taylor and Morgenthaler's mom had another option: TigerPlace, a unique senior apartment complex with ties to the University of Missouri-Columbia.

The facility is special because its residents get the same quality of care available in skilled nursing facilities while also enjoying high levels of independence, says TigerPlace founder Marilyn Rantz, a professor of gerontological nursing at MU's Sinclair School of Nursing.

Rantz is also executive director of the University's Aging-in-Place program, the model of care being tested at TigerPlace. "Aging in place provides services that people need in the privacy of their own [apartments] while focusing on maintaining function and abilities until the end of life," Rantz says. "In most cases, with this type of care, people wouldn't need a nursing home."

Taylor, a registered nurse, was so impressed with TigerPlace and its aging-in-place philosophy that she signed on to work at the facility. Her mom signed up soon after.

"I can do as I please," says Shaw, who gets around her studio apartment with just the help of a walker. "It's different from the nursing home. Here, you can stay in your room or you can go out. There, they wanted you to stay in. I have all my own furniture here. I have my own pictures, photographs and paintings that you can't have over there. I had a good, comfortable room over there but not like here. This is more like home."

Rantz is one of the nation's most respected authorities on elder care. She became interested in the issue in 1981 when she unexpectedly landed a position at a county nursing home in Wisconsin. As the home's head administrator, she ran the 328-bed facility and managed a $12 million budget. There she met many seniors who, like Shaw, had a real dread of nursing homes.

"I never once met anybody who came there who said, 'I want to be here,' " she says. "Nobody said that. I watched families and older people struggle at home to stay there as long as possible, and [residents] always talked about how they wanted to go back."

Bernadette Wright, a policy research analyst at the AARP Public Policy Institute, cites three key problems fueling consumer dissatisfaction with nursing homes: the institutional environment, high staff turnover rates and a lack of enforcement for quality standards.

The drawbacks of the institutional environment are obvious to anyone who has spent time with a loved one in a typical nursing home. No one wants to live in a hard-surfaced, antiseptic living space where residents must endure boredom, lack of privacy, rigid schedules, unappetizing food and the depressing spectacle of their peers' downhill slide to debilitation. "The whole institutional environment is a big problem," Wright admits. "It's certainly a big area that needs improvement."

Less obvious, but no less responsible for dissatisfaction, Wright says, are the effects of high staff turnover rates. Without well-trained, caring personnel, no nursing facility, no matter how many amenities it boasts, can function properly. Yet low wages, heavy workloads, inadequate training and poor working conditions for direct care workers ensure that few highly qualified nursing home staff members remain on the job for long. "There is difficulty finding good people and retaining them," Wright says. "The worker shortage has led to a big problem with the quality of care, not only in nursing homes but in all long-term care facilities."

Wright's explanation of the third problem, enforcement of quality standards, leads her into a discussion of the 1987 Nursing Home Reform Act, part of the federal Omnibus Budget Reconciliation Act of the same year. This legislation was meant to force states to get serious about improving the sometimes deplorable living conditions found in many nursing homes. The law established quality standards and defined a survey and certification process meant to enforce the standards.

While well-intentioned, Wright says, the law has not done nearly enough. "The enforcement process is very weak and inconsistent. Often, problems are understated or overlooked, and remedies aren't imposed when they should be."

Rantz was well aware of these problems when she came to MU in 1992. She joined the faculty with two goals: improving existing nursing homes and, perhaps more important, developing alternatives to the institutionalized care status quo.

Within a year of her arrival, Rantz brought together an interdisciplinary group of faculty and challenged them to come up with ideas for improving Missouri nursing homes. What emerged was the Quality Improvement Program for Missouri, a program funded by the Missouri Department of Health and Senior Services, which uses assessment information about residents gathered from Missouri nursing homes to create detailed reports for improving care.

These "Show-Me Reports" provide detailed game plans outlining how individual nursing homes can improve their services. Before the program, the state gathered information but provided no feedback on how facilities could improve. "It seemed to me that if you could feed the information back to the facility, it would help them in their quality improvement," Rantz says. Studies by the Sinclair School of Nursing have proven her right. When a well-trained nurse helps a facility's staff interpret its Show-Me Report, a facility's residents fall less, have fewer behavior-related problems and are less likely to get pressure ulcers. Missouri legislators have embraced the Quality Improvement Program's success and continue to set aside funds for it.

Rantz, whose work in quality assurance was cited in the Lifetime Achievement Award she received from the National Gerontological Nursing Association last fall, says she's proud of what the Quality Improvement Program has achieved. Yet she's even more passionate about her second goal: developing alternatives to traditional nursing homes.

"My interest has always been 'How do we help people stay out of the nursing home?'" Rantz says. "My clinical experience was as a nursing home administrator, and it seemed very clear to me, looking at the aging statistics, that nursing homes are not going to be the answer."

The U.S. Census Bureau projects that the population of Americans aged 65 to 84 will more than double over the next 44 years, from today's 31 million to some 65.8 million, by 2050. Those aged 85 and above, the age group that most uses nursing homes, will nearly quintuple over the same period, from 4.2 million to nearly 21 million.

As this boom unfolds, Rantz says, our government will not have sufficient funds to support the millions of seniors who will either enter nursing homes on Medicaid or become Medicaid-eligible after spending down their life savings. "That simply, mathematically, isn't going to work as we more than triple the over-85 population," Rantz says.

Numbers aside, she continues, aging Baby Boomers are demanding alternatives to nursing homes. Most older people, like Marjorie Shaw, simply want to age in their own homes. And for good reason.

"Moving can actually precipitate an early death," Rantz says. "That's been demonstrated in care-delivery research, so you have to be very careful about moving people. It's stressful, and if you've got any kind of unstable chronic illness, that additional stress makes it more unstable. It's actually called 'relocation trauma' in some nursing diagnostic circles."

Despite the risk, many seniors find themselves moving multiple times as they age. It is not uncommon for them to move from their homes to a "senior congregate living" arrangement, then to an assisted-living facility before, finally, living out their days in a nursing home. Common problems that force resident relocation include incontinence, poor personal hygiene, inadequate nutrition, injuries such as Shaw's hip and -- perhaps the worst culprit -- mismanagement of medication. Rantz has long thought that, with early intervention and monitoring, most of the problems forcing senior relocation could be prevented or controlled. To show how, in 1996 she and several other members of the nursing faculty began developing a project to demonstrate intervention and monitoring in practice. They envisioned the project as a new model of care, one that would allow seniors to "age in place, in the home environment of their choice, with supportive health care services as needed."

In 1999, they established Senior Care (now called Sinclair Home Care), a licensed, Medicare- and Medicaid-certified home health care agency, and obtained a $2 million grant from the federal Centers for Medicare & Medicaid Services. They used the funding to investigate the effectiveness of aging in place as a community-based, long-term care program.

More than 700 seniors participated in the two-year study, which assigned participants to nurse care coordinators. The coordinators completed a comprehensive admission assessment for each participant and then put together a "care plan" that coordinated the efforts of all the participant's physicians. Such a plan is important, Rantz says, because seniors often see multiple physicians who prescribe numerous medications. Without proper coordination, the drugs can interact and cause serious problems.

"When you go to seniors' houses and go through their shoeboxes of medicine, they've got stuff left over from God-knows-when, and they still take bits and pieces of it and don't tell their physicians. That's why they need the nurse care coordinator within the home to see that and help solve it."

At the end of the study, the researchers concluded they had postponed or prevented nursing home admission for more than a third of the study's participants. They also found participants walked better, were less depressed, had better short-term memory and experienced less pain than their counterparts in nursing homes.

Rantz hopes the results will convince lawmakers to fund nurse care coordinators for Medicaid-based home health programs. Currently, reimbursement for nurse visits is low, so home health care agencies tend to provide as few as possible.

"I think if we could convince the feds to pay for nurse care coordination, we would be able to significantly reduce the need for nursing home admissions," Rantz says. "We could help people stay healthier at home longer."

After the 1999 study, Rantz and her colleagues wanted to learn how effective the aging-in-place model might be in a setting like TigerPlace and other housing complexes that would house seniors in a place with access to multiple services.

The first step was finding a private business to build the facility and manage its operation. In 2001, the Sinclair School of Nursing entered into a partnership with Americare Systems Inc., an elder-care-focused company located in Sikeston, Mo. Americare supplied the nearly $4 million needed to construct TigerPlace, a 32-apartment facility. The company, employing a staff of 22, is responsible for day-to-day operation. The University, meanwhile, is free to use TigerPlace for research.

TigerPlace is not the first elder care facility with ties to a university exploring aging-in-place concepts. Several universities, including Pennsylvania State, Kansas State and Ohio State, have ties to continuing care retirement communities, an aging-in-place model that has been around since the 1970s. Continuing care retirement communities have three different levels of facilities -- independent living, assisted living and skilled nursing care -- all on one campus. Residents move from one facility on the campus to another as their care needs increase.

It's an improvement over the elder care status quo, but less than perfect. "Every time you move on a CCRC -- from senior housing to residential care to a nursing home -- every one of those moves is traumatic, physically and mentally," Rantz says.

At TigerPlace, residents face no moves. Thanks to two Missouri statute changes made specifically to accommodate aging-in-place research, TigerPlace residents stay put, even when they need skilled nursing care. This is in spite of the fact that TigerPlace does not meet all the state regulations governing traditional nursing homes. TigerPlace, for example, has a smaller staff than is mandated. Even frail residents get to stay in their own apartments, all of which feature an exterior entrance and interior hall entrance, kitchenette, private bathroom and a patio or screened-in porch. Most also feature a roomy walk-in closet and a washer and dryer. Residents even have the option of renting a garage.

Sinclair Home Care, the school of nursing's home health care agency, provides for TigerPlace residents' health care through a program called TigerCare. TigerCare's key feature is a wellness center where residents receive ongoing assessments of their health care needs and where they participate in health-promotion activities, including exercise and health classes. Sinclair Home Care also helps residents with care-coordination between their primary physicians and other health care providers.

Rantz and her colleagues expect all the preventive care to help TigerPlace residents stay healthier and active longer, and they have begun studies to test this theory. They do not, however, expect all residents to stay in perfect health. In fact, some already need help for such tasks as getting up in the morning or filling their pillboxes. Residents who need this extra care must opt for a "personal service package" that provides extra attention from the Sinclair Home Care staff.

The cost for this additional care is added to TigerPlace's already hefty fees. Depending on size, apartments for singles range from $2,209 to $3,409 per month, a rate that includes two meals each day, housekeeping and a number of other services. Rantz says those rates actually compare favorably to those of other assisted living and skilled nursing facilities. It's common, she says, for individuals to pay $2,000 a month or more at a traditional assisted-living arrangement and twice that much for a skilled nursing facility.

At TigerPlace, few residents and their families are complaining.

"It's a lot cheaper than a nursing home," says Gene Taylor, who is not only the daughter of a resident but also the nurse care coordinator at TigerPlace. Her mother contracts with Sinclair Home Care for an hour of extra help in the morning and a half hour at night. With that care, she spends about $3,500 a month. In a nursing home, she would spend at least $5,000, Taylor says.

Shaw can pay for her care out of pocket, but most seniors could not. Nationwide, roughly two-thirds of nursing home residents receive Medicaid assistance, says Barbara Manard, vice president of the American Association of Homes and Services for the Aging, an association of nonprofit organizations that range from Meals On Wheels to nonprofit nursing homes. None of these seniors could live at TigerPlace, because it is a 100 percent private-pay facility.

"We serve the few, the proud and the wealthy," says Charles Servey, Americare's executive director of TigerPlace. "We have an excellent high-end, hotel-like setting for a group of seniors who have planned well and have the means to afford this level of service."

Regardless, well-to-do seniors will not be the only ones benefiting from TigerPlace. That's because the research conducted there will eventually make life easier and safer for all seniors who want to age in their homes.

Some of the most promising investigations have focused on technology, among them a project using data from electronic sensors to enhance patient monitoring capabilities. The collaborative project, involving faculty and students from MU's College of Engineering and researchers from the University of Virginia, entails developing an improved means of alerting TigerPlace staff when residents fall, sleep fitfully or spend too much time just sitting.

"The students and faculty are developing algorithms that allow a computer to sort out what's normal and what's not normal for every individual and then, when necessary, to send out an alert," Rantz says.

The researchers say such sensors could benefit stay-at-home seniors by alerting remote caregivers to problems before they get too serious. "A good example of that is bed restlessness," says Marjorie Skubic, an associate professor of electrical and computer engineering who is working on the project. "Restlessness in sleep can be an early symptom that there's a problem. It could be a sign of infection or pain." People often don't realize they're not sleeping well, Skubic continues, but a bed sensor would catch changes in sleep patterns and allow caregivers to intervene before the underlying problem resulted in loss of function.

Testing the sensors and other new technologies out in the community would be extremely difficult, if not impossible, Rantz says. TigerPlace provides the University with the perfect place to conduct research safely and easily. It also provides numerous willing subjects.

"The people who live here are movers and shakers," Rantz says. "They're educated folks, many of whom are connected to MU, and they recognize the value of research. They like to help us as researchers develop things that can help other people in their homes. They see this as a contribution they can make to help other people."

These contributions have already attracted international attention. Researchers from across the globe have invited members of MU's senior tech team to give lectures. Public policymakers are also paying attention.

"The state is interested because they see this as something that consumers want and that will, in the long run, help them reduce the use of nursing homes, one of the largest state budget demands," Rantz says.

Meanwhile, hundreds of elderly Columbia residents have already benefited from the research. "They are so appreciative," Rantz says. "What people want is to be able to stay in their own homes. What we are learning will hopefully keep people longer in their homes, safer in their homes and more independent in their homes."