Report questions state’s ability to provide assisted living to aging population

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By Brian Goslow

BOSTON —The bad economy has dealt a double whammy to another segment of the housing market in Massachusetts. Aging boomers who will someday need supportive housing to remain living independently, may find their access limited. Not only is there less supply, but those contemplating a move may find themselves without the resources to pay for it.

A recent Harvard Medical School (HMS) study found Massachusetts has less than half the supply of assisted living units available to its elderly population than the national average.

According to the findings of “Sizing Up the Market for Assisted Living,” as of 2007, there were 163 assisted living facilities with a total of 11,364 units in Massachusetts. The report, by assistant professors of health policy at Harvard David G. Stevenson and David C. Grabowski, found that 13 out of every 1,000 state residents 65 or older live in an assisted living facility.

Massachusetts Assisted Living Facilities Association (MassALFA) president and executive director Emily Meyer said there are more than enough spaces to meet current demand, with seven new buildings having opened in 2009. “I don’t think that many will be opening in the next year,” Meyer said. “It’s hard to predict five to 10 years from now, but they certainly are opening.”

New facilities won’t be coming online in dramatic numbers soon. The economic downturn, which has affected all segments of the construction business, is one reason. Another is Massachusetts was late to the table in building assisted living complexes.

“We didn’t begin regulating them till 1994 when a bill (I wrote) was passed in the legislature,” said Massachusetts Senior Care Association Vice President Scott Plumb. “Up until that time, no one knew how they would be regulated so they didn’t build them here. They didn’t know what model would be the standard here, medical or social.”

Chapter 19D of the Mass. governs assisted living residences. The Executive Office of Elder Affairs (EOEA) certifies and regulates the facilities, utilizing the assisted living statute and related regulations to provide a process for certification for assisted living units and services, as well as issuing minimum standards and guidelines. The EOEA also offers the Assisted Living Ombudsman Program to provide advocacy, information and complaint resolution to consumers.

Plumb said unlike other states that aren’t as heavily regulated, Massachusetts has 40 to 50 pages of regulations and requirements that must be met to operate an assisted living facility. “Ours is not a medical model but it’s not the Wild Wild West either,” he said.

Assisted Living Residences (ALRs) offer a combination of housing, meals and personal care services to adults on a rental basis. Unlike licensed nursing facilities, ALRs do not provide medical or nursing services — those must be secured privately, if needed. Nor are they designed for people who need extensive medical care.
Rather, assisted living is intended for adults who need some help with activities such as housecleaning, meals, bathing, dressing and/or medication reminders and who would like the security of having assistance available on a 24-hour basis in a non-institutional environment.

“You’re renting an apartment and getting your own personal care services,” Meyer said. “It’s a residential model with services.” The average age of assisted living residents here is 84, 85 years old.

Assistant living offers qualitatively different facilities than nursing homes, Stevenson said. “They (residents) can have their own rooms, locking doors and a greater level of privacy. It’s more home-like in construction. It can feel less institutional but it varies a lot from facility to facility.”

These varying services are the result of its owners shaping their services to market demands. “The challenge is there’s no one definition of assisted living,” Stevenson said. “There can be a wider range of what assisted living facilities are across the state.”

But when it comes to requiring a more uniform format, Stevenson noted, “Increased oversight and the standardization of what you see in assisted living facilities could cause the loss of flexibilities and new innovations going into place that the consumer would like to see.”

The Harvard study found that Massachusetts assisted living facilities tend to be located in wealthier areas with high home values and lower minority numbers. Developers, who already have to deal with the high cost of land here, only build where they expect to operate at a profit.

The first facilities, Plumb said, were built in affluent communities, including Swansea, Wellesley, Needham and Lexington, where clients had the resources for the private model. They were followed by a second generation of facilities further outside greater Boston in Peabody, Shrewsbury and Quincy. The latter had lower entrance deposits. With a lower number of high-income residents, Western Massachusetts has few assisted living facilities.

Assisted living facilities are not cheap alternatives to nursing homes. “It’s unaffordable to the majority of elders,” said Plumb. Some have entrance fees of as much as a half-million dollars. Prior to the housing market crash, potential residents could sell their homes to cover the cost. With so many having trouble selling their homes, many assisted living facilities have moved to an “à la carte model” with a basic monthly charge. “The other services you need as you get frail, are add-ons,” Plumb said.

According to MassALFA’s Assisted Living in Massachusetts Resource and Consumer Guide, monthly assisted living fees range from about $2,000 to more than $7,000; the high-end fee usually covers the cost of special care units and programs for people with memory loss and/or dementia that require additional staffing and services.
While most assisted living is privately paid (in Massachusetts, the numbers are 85 to 90 percent), some long-term care insurance policies now offer coverage for some of the costs. Coverage provisions vary widely, so anyone considering this option, should carefully review different policies. Some assisted living residences have financial assistance programs.

As boomers begin seeking assisted living, they probably will have different expectations of what they want from those facilities. “Boomers will have more resources and be more demanding,” Plumb said. “They’ll want choices: privacy, their own apartment and a kitchen. They’ll demand to age-in-place. If they demand skilled care, that demand will be forced to become more medical.”

This is where the line between assisted living and nursing homes becomes clearer. “If you have daily care needs, you’re not supposed to be accepted into assisted living,” Plumb said.

Executive Office of Elder Affairs Secretary Ann Hartstein said assisted living facilities try their best to inform people on what they do offer but people don’t always hear what they’re telling them.

This can include thinking they’ll receive long-term care there, covered by Medicare. That’s not the case. “They can’t be the primary provider of helping people with their medication,” she said. “They can cue them but they can not give them their meds. They (the residents) think they’ll be monitored but it’s not their (the facility’s) responsibility. Many assisted living facilities have outside services coming in that look like they’re from inside the house (facility) but it’s an outside provider hired to come in. It’s why there’s some confusion.”

Hartstein didn’t feel the huge difference in assisted living units available here in comparison to other states noted in the Harvard study was relevant to Massachusetts’ ability to provide the services its residents will require as they age. “The number of assisted living that exists in the state is based on private market conditions and what the needs are,” she said. “The developers define what they’ll build based on population, market and because they see a demand for them.”

Massachusetts, she said, is certainly working to keep people in their homes through a series of initiatives directly addressing the shortage of assisted living options for low-income residents. “We’re trying to make assisted-living type services available to lower income residents through group adult foster care programs,” Hartstein said. “SSIG (Supplemental Security Income, a joint federal and state program administered by the Massachusetts Department of Transitional Assistance) is available to help people of low income go into assisted living but it’s up to the facilities to accept program participants and let lower-income people into their facility.”

The Supportive House Initiative, developed by the EOEA and Department of Housing and Community Development, provides residents at 22 state-funded elderly and disabled housing facilities with the services they would get in an assisted living facility, including case management; 24-hour personal care, as needed, onsite; an on-call person for emergencies; and at least one meal per day. “These are ways to provide services to people in their own homes that they’re getting in facilities so they can age-in-place in their own homes,” Hartstein said.

For more information: www.massalfa.org; www.mass.gov/elder.