Cover Story: No Place Like Home

Subscribe | Advertise | About Us | Contact Us | Home

November 2003

By Liz Finch

The term “aging in place” refers to the ability to remain at home as we grow older, living in relative independence while still having access to needed support services. It is an attractive concept, and one gaining momentum due to several factors, including the sheer number of Baby Boomers moving into their twilight years, increasing high costs of nursing homes, and a steadily growing recognition that older persons are expressing a preference for continuity in their living arrangements.

One organization that embraces this trend, the San Francisco Institute on Aging (IOA), was the model for the Program of All-inclusive Care for the Elderly (PACE), a form of service that is now nationally used. The program began in the 1970s, when the Chinatown and North Beach communities of San Francisco saw the pressing needs of Italian, Chinese, and Filipino elders for long-term care services. The founders believed that it was better for the well-being of seniors with chronic care needs to be served within the community, and the IOA in particular takes that concept to heart.

“The IOA’s senior health centers are a home-away-from-home for frail seniors,” says David Werdegar, MD, MPH, president and CEO of the IOA. “It used to be that when frail and chronically ill seniors could not manage to care for themselves at home, or if the family had difficulty assisting them, they were most often placed in nursing homes. There, they were essentially removed from family, friends, familiar surroundings, and favorite activities. There were no other alternatives.”

Werdegar says it was the pioneering work of the IOA and kindred community-based organizations that brought about the development of home care, adult day health care, case management, transportation services, and increasingly comprehensive programs of health care and social support. This mix of programs enables seniors to continue living independently in their own homes and with their families.

“They have the daily attention of physicians, nurses, and dietitians who follow their health care. They are involved in exercise with weights and treadmills under the watchful supervision of therapists, who are their personal trainers,” he says. “And they have music, fun, laughter, and the companionship of other seniors in a warm, welcoming environment.”

IOA’s programs encompass home care, case management, community outreach, counseling, research, and support and education for families, seniors, and professionals in the field of aging. The cornerstones of the IOA, however, are its on-site adult day services: OnLok Senior Health Services and the Ruth Ann Rosenberg Adult Day Health Center.

OnLok works with 112 clients, seeing an average of 60 a day, while 121 clients are served by the Ruth Rosenberg Center, at a rate of about 40 or 50 each day. Both programs are licensed to receive Medicare and medical funding, and usually the costs are equivalent to what it would cost for those same elders to live in a nursing home. While the specifics of the programs vary, the secret to their success is the same, according to Werdegar.

“They succeed thanks to a team approach of physicians, therapists, nurses, dietitians, social workers, and other staff who create a supportive environment and provide truly comprehensive care,” he says.

OnLok Senior Health

OnLok means “peaceful, happy abode” in Cantonese, and creating such an environment is the goal of this health plan.¹ Especially designed to cover acute and long-term care for adults over age 55, the program offers full medical care, prescription drugs, home care, adult day health, and transportation. Participants typically experience ongoing medical problems, have memory loss, and/or need daily help with bathing, walking, eating, or dressing.

“For cultural reasons, most of our seniors want to stay at home, where they have support systems,” says Nicole Sorhondo, PT, who has been with OnLok for 7 years. She also spent 13 years working in the Ruth Rosenberg Center. “For every one person in a nursing home, there are three equally impaired people in the community, relying on their own support system to get by. We focus on helping them do that.”

“Most people are out in the community and we want to keep them there. So our package of services is aimed to keep them out of nursing homes,” says Richard Bookwalter, OT, who has been with OnLok for 4 years. He also spent 2 years at the Ruth Rosenberg Center.

OnLok is not for healthy elders; rather, it targets those at risk of otherwise landing in a nursing home without the proper support network. The staff is responsible for everything from getting its clients up and dressed in the morning, to transporting them to and from the center, to keeping them active while they are on site. Regular audiology, podiatry, and optometry check-ups, as well as some mental health care services, are available on site. More intensive medical care is contracted with off-site providers, and OnLok provides transportation to some appointments. There is no overnight care at OnLok, though a hot meal is provided. Bookwalter jokes that it is literally the “center of the day” for most clients—and some clients have personal care such as toilet training or showering.

The bulk of each day for OnLok’s clients is spent participating in one-on-one rehabilitation, exercise programs, and other activities designed to retain their level of function.

“That means addressing issues of pain management, dealing with the population that has dementia, as well as helping those who are no longer able to function physically in their environment,” Sorhondo says. “That said, we have a range of activities available, including art therapy, music, and other group activities such as a book group, poetry group, jazz group, gardening group, and a Praise religious group.”

“Our clientele at the Fillmore site is 40% African-American, and the Praise group is very important for them when they can’t get to church regularly,” says Frances Hornback, a rehab aide who has been at OnLok for 5 years after spending a year at the Ruth Rosenberg Center. “They gather to read from the Bible, then they do a little bit of roof-raising. That has an impact on their faith as well as their mental health.”

Every 3 months, the staff members do an evaluation to determine their clients’ needs and decide if something should be added, such as more medical services or more rehabilitation.

“Part of that process involves looking at the daily services we are offering to see if they match our patients’ needs,” Sorhondo says.

The Ruth Ann Rosenberg Center

The needs of the clientele at the Ruth Rosenberg Center differ slightly from those in the OnLok population, because although the center caters to “frail older adults,” that generally means the population is healthier than those who utilize OnLok’s services.

“We have two different groups of folks here, the ‘frail elderly,’ which for our purposes are really anyone over age 85, and those suffering from Alzheimer’s disease,” says Rivkah Cohen, OT, who has been working at the center for 2 years. “In addition, about a fourth of our clients have had strokes, and those patients receive specialized rehabilitation.”

Even if specialized rehab is not in order, everyone has access to a lot of occupational and physical therapy. “Their bodies are changing, because as we age, we lose strength and get stiffer,” Cohen says. “So we do general exercises to increase their strength, which increases their balance, reduces their chance of falling, and improves their fine finger dexterity.

“If they are trying to live at home, it’s safer when they are transferring because they are less likely to injure themselves in a fall or end up in a skilled nursing facility,” she adds. “That really makes a difference with aging in place.”

Clients come 2 to 5 days a week to participate in activities and social programs; check in with the nursing staff on issues of health and medication; take part in occupational, physical, and speech therapy; and have a hot noon meal. As with OnLok, the activities include music, art projects, and crafts. Among the Alzheimer’s participants, however, the staff is involved in more intensive therapeutic work.

“At some point these people tend to lose motivation for movement, or the memory links that make movement make sense start to deteriorate,” Cohen says. “Their strength level may not be as changed as in other elders, but the toothbrush and tube of toothpaste don’t look familiar, so there is no reason to use them.

“We have to work with them on those tasks, and many times it helps to combine therapy with something else, such as movement or music,” she continues. “They get exercise in a way that’s fun, that holds their attention, and that engages more of their brain because of the sound of music and the physical stimulation.”

The Therapist Perspective

The therapists who work at OnLok and the Rosenberg Center are testaments to the impact of such programs. “These programs are more cost-effective than nursing homes, and more effective—period,” Cohen says. “If we looked at how many of our clients would otherwise be in a nursing home within 6 weeks, I think about 10% would be if not coming here. That’s pretty fast. Within 6 months, that number goes up to about 50%.”

Part of the client benefit comes from the more intimate relationship that occurs with the therapists, who may have an unusual level of access to their personal lives and homes.

“Through OnLok, I am able to do home visits with each client to modify their environment. In the real world, the way Medicare works, those same clients would have 2 weeks of care and that’s it,” Bookwalter says. “They would not necessarily get another referral a month later when their wheelchair is no longer adequate. We, on the other hand, are able to intervene during episodes that are bound to happen in the natural rhythm of the way people experience illness. Then we can bridge the gap between outpatient care, adult day health care, and home care.” “We are able to see the whole picture, not just the hip fracture or the stroke injuries,” Sorhondo says. “We see how the patient manages in their community, which has a tremendous impact on how a person responds to treatment. In many rehab settings, the therapists don’t have to worry about their patients after a limited time. Here, we see what small adjustments need to be made to their program as they progress.

“Of course, that also means we often have to ask ourselves whether they are going to progress or decide whether they are no longer able to stay at home,” she adds.

Indeed, from the therapist’s perspective, working in an environment that supports aging in place can be difficult. As Sorhondo says, the therapists see clients for years. Many of those who start out in the program are now moving toward the ends of their lives, and that puts a different bent on rehabilitation.

“This represents a very different market for therapists,” Cohen says. “We see 35 to 40 clients a day, instead of six to 12. Most therapy settings for adults are for various physical disabilities, and the therapist establishes a relationship with patients that is fairly short-lived, ie, a week to 2 months. Our relationships last for years, so we really get to see people change, and learn how we can help someone. It’s a demanding job emotionally, though, and in that sense it’s sometimes harder than more traditional therapy jobs.”

Bookwalter and Sorhondo agree and stress that if therapists really want to specialize in a certain area only, this is not the place.

“We really have only 15 minutes for most people, with the acute cases being a bit longer,” Bookwalter says. “For new graduates coming in, they must have a certain amount of experience in various settings,” Sorhondo says. “We have to be prepared to make lots of clinical decisions in tandem with the clinic, so we have a consulting role in addition to physical skills.”

But for one therapist who is a new graduate, this aging-in-place model has been a challenging experience in the best sense of the word.

“I’ve trained inpatients, also done outpatient, some skilled nursing, but this seems like the missing piece,” says Helen Lhim, PT, who came to the Rosenberg Center in January as a recent graduate. “Many times, clients in other facilities are discharged before they are functionally ready to go home because they can stay at a rehab facility for only so long. I think a lot of people fall through the cracks when they really need more training and assistance.

“Facilities like the Rosenberg Center enable geriatric patients to get to their previous level of activity and be monitored the whole time,” she says. “Our clients are able to do as much exercise as they believe they need and continue on a regular basis for maintenance or improving function. We see people in their 60s, 70s, and 80s who want to maintain their independence. The rehab they get at the center backs up that principle and allows them to have a higher quality of life.”

Cohen notes that other factors in the center that may be harder to quantify, such as access to friends, are likewise crucial to the ability to age gracefully.

“Our clients maintain a level of socialization that is not available to them in a nursing home,” she says. “When you are lying in bed knowing you can’t get up under your own steam, it’s hard to hang onto humanity. Here they are in a room with their friends for 4 to 5 hours a day, and that provides a level of independence and self-esteem that simply [helps them feel] human longer.”

Liz Finch is a contributing writer for Rehab Management.

Reference

VanderMeer JL, Savage GT, Davis JA. Restructuring rural health care—expanding the PACE for rural elders. Online Journal of Rural Nursing and Health Care. 2002;2:1. Available at: www.rno.org Accessed September 16, 2003.

LOOKING FOR EXPERT ADVICE?

Experts here are available to answer all your questions!

Please contact us for more information about this feature, or to become an expert.

MEDIA CENTER

Interactive Media

Resources

	Calendar
	Consumer Resources
	Media Kit
	Advertiser Index EAB Reprints Submit an Article

ADDITIONAL ONLINE RESOURCES

Allied Media
24X7mag Clinical Lab Products (CLP) Orthodontic Products The Hearing Review Hearing Review Products Rehab Management		Physical Therapy Products Plastic Surgery Practice Imaging Economics RT Magazine Sleep Review

Subscribe | Advertise | About Us | Contact Us | Home

November 2003