When Jeanne Nutter became caregiver for her mother and uncle 20 years ago, she gained some important insights into what constitutes successful aging. Nursing homes can provide quality care when necessary, but even the best cannot replace the warmth and support of the home environment. Moreover, maintaining a loved one in a skilled-care facility is beyond the financial means of most.
Nutter saw opportunity in the challenge. She settled her relatives in an apartment with a live-in companion, allowing them to realize the benefits of aging in place. “The depression lifted and my uncle was back to eating the foods he enjoyed,” says Nutter, 63, a college professor and president of AARP Delaware.
States and communities are discovering what Nutter learned two decades ago: Aging in place is the most cost-effective and desirable method of aging. For Delaware, which is aging faster than most states, the realization cannot come too soon. Currently, about one in five Delawareans is aged 60 or over. By 2020, older persons will comprise one quarter of the state’s population. By 2025, the aged population will have doubled since the year 2000.
The numbers are even more staggering for those areas which have experienced the greatest in-migration of retirees. In Sussex County, for example, the number of persons aged 85 and over is expected to quadruple by 2030.
This “silver tsunami” will make unprecedented demands on the state’s health and social services. Is Delaware prepared to meet the challenge?
“I think we’re a little late getting started,” says Dr. Veronica Rempusheski, the Jeanne K. Buxbaum Chair of Nursing Science at the University of Delaware. “The first real emphasis I saw was in (Gov.) Markell’s ‘Delaware Facing Forward’ when he was treasurer.”
Most Delawareans want to remain in their homes as they age, according to a recent survey by AARP Delaware. Cost is one consideration. Care in a skilled-care facility costs approximately $80,000 per year compared to about $15,000 for home and community-based services. Life expectancy is another concern. A recent report by the University of California at San Francisco found that 80 percent of nursing home patients died within one year of admission.
Yet regulatory and financing requirements skew toward skilled care, confounding efforts to develop viable aging-in-place initiatives. Delaware spends 87 percent of its long-term care dollars on institutional care, more than the nation as a whole, according to a report by the Kaiser Family Foundation. But leaner budgets and a 1999 Supreme Court mandate giving capable individuals the option of living in the community are prompting the state to rejigger the balance.
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“We want to make sure we’re clearly in a system that allows people to ebb and flow into services based on their needs, that they don’t get stuck in one area if they need something other than what that area provides,” says Rita Landgraf, Secretary of the Delaware Department of Health and Social Services.
The state is ramping up efforts to assist older adults to move from institutional to community settings. Recently approved Medicaid waivers and the “Finding a Way Home” program allow eligible recipients the flexibility to match services with needs.
An important part of the state’s plan to re-balance long-term care services relies on raising public awareness about options and simplifying access to that information. The recently launched Aging and Disability Resource Center (ADRC) will play a major role in that effort. The center features a 24-hour toll-free helpline, a Web site and counselors to help individuals and their caregivers learn more about resources and decide which options best suit their needs.
“One of the improvements of having an ADRC is that previously we focused on persons who were going to be eligible for government benefits,” says Lisa Bond, deputy director of the Division of Services for Aging and Adults with Physical Disabilities and planning supervisor for the ADRC project. “With funding from the ADRC grant, we’re able to provide information and options counseling for anyone who needs it regardless of income.”
The center also assists hospitals and patients with discharge planning to help reduce the number of referrals to skilled-care facilities. “If we’re working with them earlier we can help them deliver community-based services, so they don’t feel the need to refer someone to a facility,” says DSAAPD Director Bill Love.
Information about community-based services can also be accessed through the Delaware Aging Network. Starting with just four agencies seven years ago, DAN quickly evolved into a statewide consortium of more than 50 agencies dedicated to supporting the needs of older adults.
DAN care managers work directly with adults aged 50 and over and their caregivers through lead agencies and senior centers in each county to provide information about housing, healthcare, government programs, in-home services and transportation.
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“We’ve come together as a network of providers in a way that hasn’t happened in other states,” says Susan R. Getman, executive director of the Wilmington Senior Center and chair of the Delaware Aging Network. “Last year we served about 1,200 individuals through care management across the state. Prior to the aging network coming along, those people would have had a hard time finding one-on-one support because senior centers don’t employ people with social work backgrounds.”
Still, aging in place is difficult even under the best of circumstances. Often the home itself becomes a barrier. Homes without certain modifications can greatly diminish a senior’s independence, propelling them into institutional care ahead of need. About 20 percent of the respondents in the AARP survey reported needing major modifications to their homes in order to age in place.
“Everything starts with the home,” says Dory Zatuchni, CEO of Jewish Family Services, the lead agency for DAN in New Castle County. A bill is currently working its way through the General Assembly that would require all single-family, duplex, triplex and four-plex units built with public funds to incorporate universal design features into their construction. These can include ramps, wider doorways, no-step entrances and roll-in showers.
The success of any policy designed to help seniors age in place will ultimately depend upon keeping them as healthy as possible for as long as possible. And given the complexity of their health problems, caring for them will require a multidisciplinary approach.
Last summer, the University of Delaware joined Thomas Jefferson University, Marywood University, The Commonwealth Medical College and Christiana Care in the Eastern Pennsylvania-Delaware Geriatric Education Center. The consortium works with organizations and agencies to offer interprofessional education and training programs to improve the quality of healthcare for the elderly.
“There’s an aversion across all fields to take courses in geriatrics,” says UD nursing professor Rempusheski who is also the university’s project director for the EPaD GEC. “We’re focusing on education with the assumption that if we educate more professionals about the elderly, that will trickle down into those individuals taking better care of the elderly clients they see.”
An interdisciplinary approach will also guide research at the newly created Delaware Rehabilitation Institute. Launched in February, the Delaware Rehabilitation Institute will bring together biologists, clinical scientists, engineers and policy experts from the university and its partners in the Delaware Health Sciences Alliance to help people recover from injury and disease, including stroke and osteoarthritis.
The team approach also plays an important role in the training of future healthcare professionals at the university. Physical therapists, for example, work with behavioral therapists to motivate and engage stroke and Parkinson’s patients in their rehabilitation, helping them to function better and more independently.
“I think independence is really critical in our aging population,” says Kathleen Matt, executive director of the Delaware Health Sciences Alliance and dean of the College of Health Sciences at UD. “I think the team approach really enhances the ability of individuals to function very well and enjoy their life as much as they can.”