Arcadia is a continuing care retirement community (CCRC) for adults age 62 and older. It provides independent living, assisted living and a nursing facility which offers skilled nursing, intermediate care, special care for those with Alzheimer’s and dementia and hospice. The “Continuum” at Arcadia refers to the range of services that will enable a resident to be accommodated at Arcadia as his or her health and physical condition changes.
Through the many laws and regulations applicable to every aspect of the operation of a CCRC, Arcadia continues to refine and develop programs and services for successful aging.
Laws and regulations governing senior living and long term care directly impact the cost of operating Arcadia. These rules require well-defined criteria, parameters and documentation within each area of Arcadia’s Continuum.
In this regard, regulations promulgated by the State Department of Health for Assisted Living require that Arcadia license every independent apartment at Arcadia in order to provide Assisted Living services to any resident in his/her apartment.
A mandatory “functional assessment” performed by Arcadia’s Geriatric Nurse Practitioner indicates the assistance, if any, which a resident may require to function in an independent living unit in order to maintain an independent lifestyle or an independent assisted living lifestyle. The assessment will also indicate if a resident meets the criteria for transfer to Arcadia’s Health Care Center.
As we age at Arcadia, there needs to be a realistic recognition that eventually everyone of us in varying degrees, will probably need the services available in Assisted Living or available in Arcadia’s Health Care Center, and that the cost for these services is substantially greater than the monthly service charge for independent living.
We cannot allow the age-old battle against encroaching frailties and infirmities to deter us from achieving the best quality of life each of us is capable of having.
Successful Aging at Arcadia
Nothing can be more disconcerting for seniors than a cold, hard look at a “functional assessment” of one’s activities of daily living and instrumental activities of daily living which activities we have taken for granted over a lifetime. The “assessment” can bring a sense of dread, embarrassment and, at times, an awful feeling of helplessness. And, of course, our tendency as we age is to dismiss any “assessment” which shows a decline in our “functional abilities”. We simply believe that it cannot and will not happen to us, or that given time, we can correct it.
As we know, there is no all encompassing balm that will assuage one’s innate fear of losing ground on one’s ADLs and IADLs, bit by painful bit. Yet, everyone of us must confront this eventuality, since one in two seniors 85 years and older can expect to spend an average of 1½ to 3 years in long-term care.
Nevertheless, I think that Reverend Dr. Dale Turner, a wise and wonderful minister, offers some sage advice to us as we grow older. He acknowledges that growing old imposes a constant demand for practical and emotional adjustment as physical disability advances against each of us. Although we are not always free to choose what will happen to us, Dr. Turner reminds us that we are indeed free to choose what our response will be, and that we have at least two alternatives: We can respond angrily with resentment, “Why did this have to happen?”, or, we can sift through what has happened and say, “What can we find here to be thankful for?” Our attitude determines whether we are victim or victor. In this regard, Dr. Turner refers us to an old gospel song that encourages us to “Count your many blessings; Name them one by one; And it will surprise you what the Lord has done.”
I know we are all thankful for living at Arcadia and for the services available should the need arise for assisted living in one’s apartment or for nursing care and long-term care in our Health Care Center. But, I also know that each of us has a deep-seated and, at times, stubborn belief that the personal need for, and cost of, assisted living or long-term care will never arise. This thinking is unrealistic in light of national and local statistics which tell us that assisted living mostly serves frail elderly residents with an average age of nearly 84 who require help with bathing, dressing and eating, and that slightly over 50 percent have some level of Alzheimer’s or dementia impairment.
Today, the nuances of Assisted Living Programs both at Arcadia and in the larger community are evolving. Arcadia’s continuum of care and services continue to be refined and adjusted. The purpose of this article is fourfold: (A) review several general definitions regarding retirement living; (B) look at the impact of federal and state regulation on Arcadia’s continuum of care and services; (C) review the general parameters for independent living, assisted living and nursing/long-term care at Arcadia; and, (D) examine several questions and answers about the impact and implementation of the Assisted Living regulation at Arcadia, including a specific look at the assessment procedure used to determine when an independent assisted living lifestyle is appropriate for you.
As you may be aware, in January, 2001 Arcadia was the first facility in the State to receive a license for 13 Assisted Living units. By embracing the new state regulation for assisted living, Arcadia recognized that it was also providing assisted living services in several of its independent apartments to residents who require help with a number of the activities of daily living. In order to continue to provide these services to independent apartments under the new assisted living regulation, Arcadia licensed every apartment at Arcadia for assisted living should the need arise in any given apartment for assisted living services.
The state regulation for Assisted Living and the licensing of Arcadia for Assisted Living required Arcadia to review the manner in which the personal services and care associated with Assisted Living are administered.
Allow me to share with you Arcadia’s direction in our continuum from independent living through assisted living and skilled nursing, intermediate, long-term and special care for those with Alzheimer’s and dementia, as well as those needing hospice.
First, let’s review some general definitions involved with retirement living that I think you will find helpful as we chart our continuum at Arcadia:
Arcadia’s Independent Living refers to a program designed for adults 62 years of age or older who can live without the daily intervention of others. Within our Arcadia community, one has dining, housekeeping, maintenance, group outings, transportation availability, a wellness program, security and emergency health care and medical response 24-hours a day, as well as access to an Assisted Living program and a long term care facility offering skilled nursing, intermediate, long-term and special care and hospice.
Under Arcadia’s Assisted Living program one receives assistance in one’s apartment with personal care which may include help with bathing, taking medications, meals, housekeeping, laundry, dressing and grooming, reassurance checks and escort services. Intervention by trained staff occurs over the course of a day. An Arcadia resident in assisted living in one’s apartment can still participate in decisions about his or her care, but needs a helping hand to stay in an independent type of environment.
In Arcadia’s Skilled Nursing/Intermediate Care Facility one receives care for a medical and/or physical condition that requires the supervision of licensed nurses to monitor symptoms and treatments twenty four hours per day whether one is at a skilled nursing level of care or an intermediate level of care. Assistance is provided by trained, licensed and certified staff to residents who can no longer live on their own. The individualized safety net of services provided to each resident enables each resident to maintain an optimal quality of life.
Arcadia’s Continuum refers to a range of services that allows an individual to be accommodated within the community as his or her health and physical condition changes.
In a nutshell, the State of Hawaii does not regulate senior independent living. It does, however, regulate Assisted Living Facilities and Skilled Nursing/Intermediate Care Facilities. The Federal Government regulates, in consonance with the State of Hawaii, Nursing Facilities under the Federal Government’s Medicare and Medicaid programs.
As you know, Arcadia’s marketing focus has always been, and will continue to be, on independent retirement living in a vibrant and active senior community.
Entering a Residence Agreement with Arcadia entitles one to reside at Arcadia for the remainder of one’s life. Under the Residence Agreement “aging” in place in one’s apartment, supported by a viable continuum of care and services, is the general path one follows from his or her first day of occupancy.
The State’s entry in 1999 into the regulation of Assisted Living has further formalized and defined the characteristics, expectations and documentation required for assisted living. As you are aware, at Arcadia and in the community, there are three specifically defined levels that pertain to senior living: (i) independent living; (ii) assisted living; and, (iii) skilled nursing and long-term care. At Arcadia, after one enters Arcadia under a Residence Agreement, all three levels are available in Arcadia’s continuum.
During the past few years we have been reviewing, refining and developing the programs of care and criteria for each living level. At Arcadia, we subscribe to the premise that each resident is special as he or she “ages in place” in his or her own way. But, there are guidelines, definitions and studies which enable each resident to develop a personal understanding of what he or she may face in Arcadia’s continuum. It is in this vein that Arcadia plans and adjusts the services it provides at each of the three aforementioned levels of living.
Let’s briefly review the general parameters for independent living, assisted living and nursing/long-term care at Arcadia:
To be admitted to Arcadia, in addition to the financial requirements, one must be able to:
These criteria for independent living in a senior (age 62 years or more) residence, like Arcadia, are governed in great measure by the Fair Housing Act.
Equally important and necessary in the admission process are obtaining one’s medical history and receiving a physical exam and tuberculin skin test, all of which are performed by Arcadia’s Medical Director for each applicant prior to admission. Arcadia’s Geriatric Nurse Practitioner (GNP) also performs a functional assessment. The purpose of these evaluations is to document that an applicant fulfills, in pertinent part, the criteria for admission and what assistance, if any, a new resident may require to function in an independent living unit.
As previously noted, the State of Hawaii does not specifically regulate senior independent living, as it does for Assisted Living and Skilled Nursing and Long-Term Care. State Law does, however, require the formation of an Advisory Board of Residents in a senior living facility. The Advisory Board’s responsibility is to submit recommendations concerning operations and management of the senior living facility to the governing board. Arcadia has an advisory board comprised of 8 individuals elected by the residents.
The absence of specific regulation relating to senior independent living does not mean that Arcadia’s operations are without the weight of federal and state statutes and regulations. For example, in addition to federal Medicare/Medicaid requirements many other federal and state government agencies also impose standards on hiring, utilizing, and separating personnel from service. These include the Wage and Hour Division of the Department of Labor, the Equal Employment Opportunity Commission (EEOC), the Hawaii Civil Rights Commission, the Immigration and Naturalization Service (INS), the Occupational Safety and Health Administration (OSHA) and (HIOSH), the related state agency, the National Labor Relations Board, the Social Security Administration, the Internal Revenue Service, and the state office of employment security, to name a few.
In 1999, the State of Hawaii promulgated regulations for Assisted Living as a new category of community based residential care. The regulations establish minimum standards and requirements for licensure to protect the health, welfare and safety of residents in assisted living facilities. The purpose of assisted living facilities is to provide a combination of housing, meal services, health care services and personalized supportive services designed to respond to individual needs based on the principles of (i) aging in place; (ii) a negotiated plan of care; and (iii) managed risk.
In this regard, the State notes that the purpose of Assisted Living is to encourage and support individuals to live independently and to secure services and assistance to maintain independence. The regulation also defines an assisted living facility as a building complex offering dwelling units to individuals and services which allow residents to maintain an independent assisted living lifestyle (emphasis added). Meals must be provided, staff must be available on a 24-hour basis with services based on the individual needs of each resident. Each Resident, family members and significant others work together with Arcadia staff to assess what is needed to support the resident so that the resident can achieve his or her greatest capacity for living independently.
Under Arcadia’s Assisted Living Facility license, medication management and /or assistance with certain activities of daily living are provided for residents in their apartments. And, there are 13 Assisted Living apartments located in the Diamond Head wing of the third floor which provide an intermediate level of care for residents who are able to reside in an apartment setting but require ongoing monitoring and frequent non-scheduled assistance calls.
The Assisted Living Regulation also recognizes the possible need for, and allowance of, discharge to a higher level of care when (i) a resident’s behavior imposes an imminent danger to one’s self or others; (ii) Arcadia’s assisted living program cannot meet the resident’s needs with available support services, or services are not available; and, (iii) a resident or responsible person has a documented established pattern of not abiding by agreements necessary for assisted living.
Skilled Nursing/Intermediate Care
In 1985 the State of Hawaii established, by regulation, minimum requirements for the protection of the health, welfare and safety of patients, personnel and the public in skilled/intermediate care facilities.
In 1987 Congress passed The Omnibus Budget Reconciliation Act of 1987 (OBRA-87), also called the Nursing Home Reform Act, which effected major changes in the operation of nursing facilities.
Skilled Nursing under state regulation means that Arcadia can provide to its residents, who are referred by a physician, skilled nursing, that is, nursing which cannot be provided in a facility other than a hospital, and related services in its Health Care Center to residents whose primary need is for 24-hours of skilled nursing care on an extended basis, as well as regular rehabilitation services.
Intermediate Care under state regulation means that Arcadia can provide its residents who are referred by a physician appropriate care in Arcadia’s Health Care Center when the resident (i) needs 24-hours a day assistance with the normal activities of daily living; (ii) needs care provided by licensed nursing personnel and paramedical personnel on a regular, long-term basis; and (iii) does not need skilled nursing or paramedical care 24-hours a day.
Arcadia is presently licensed to provide Skilled Nursing and Intermediate Care (SNF/ICF) for 66 beds on its second and third floors. Arcadia also provides long term care in its SNF/ICF for those who have developed Alzheimer’s and dementia to such a degree that they are no longer able to maintain an independent assisted living lifestyle in an independent living unit at Arcadia. This type of long term care at Arcadia is sometimes referred to as Special Care which also includes providing hospice care to our residents. In addition, Arcadia’s Health Care Center provides two boarder rooms, which enable residents to be observed and assisted for a short period (1 –5 days for each separate illness) without the requirement for a referral by a physician.
1. How does the Assisted Living Regulation affect Arcadia?
With the completion of Arcadia’s renovations in 1998, we began with 13 assisted living apartments in the Diamond Head wing of the third floor. In January, 2001 we received the first assisted living license in the State of Hawaii for our 13 assisted living units. Our first licensure survey for our assisted living units (the first survey in the State) in the later part of 2001 showed Arcadia that our assisted living residents had a much higher acuity level than what the new assisted living regulations generally contemplated.
We reviewed our assisted living program in light of the higher acuity level of its residents and in light of the regulatory requirement that we license each apartment at Arcadia for assisted living if Arcadia was to provide assisted living services in any given unit.
Our active participation in 2003 in the Assisted Living Work Group, spearheaded by the Health Care Assurance Division of the Department of Health, was very beneficial in refining and further developing our assisted living program at Arcadia.
Through the Work Group, the following procedure was developed so that a facility like Arcadia can license all its apartments even though the overwhelming number of residents are at a senior independent living level:
a. In addition to the medical examination performed by Arcadia’s Medical Director as part of the admission process, an assessment is performed by Arcadia’s Geriatric Nurse Practitioner to determine if the applicant requires any assistance with any of the activities of daily living.
b. 30 days after the first day of occupancy at Arcadia, a new resident will be reassessed to assure that the transition to independent living at Arcadia has been made and that assisted living services are not necessary. Thereafter, annual assessments must be done for all independent living residents at Arcadia. Of course, should concerns arise about one’s ability to handle the activities of daily living at anytime, an assessment would be conducted and, if appropriate, an assisted living service plan would be developed for that resident.
2. Will the licensing of every apartment in Arcadia for assisted living create a huge assisted living facility and abrogate Arcadia’s status as the premier senior independent living residence in Hawaii?
No, but we must understand how federal and state laws and regulations affect Arcadia’s approach to marketing its continuum.
The Fair Housing Act is federal law. In essence, it requires that the criteria for living in an independent unit take into consideration that living independently in such a unit can be met with some assistance in one’s Activities of Daily Living as long as the prospective resident poses no harm to himself/herself or to others.
The State’s Assisted Living Regulation encourages and supports individuals
to live independently and receive services and assistance to maintain an independent assisted living lifestyle. (emphasis added)
In fact, over the last three years, while limited in number, several new Arcadia residents have demonstrated through our pre-admission assessment the ability to maintain an independent assisted living lifestyle in their independent living units.
And, of course, many residents, as they “age in place” have also demonstrated through Arcadia’s assisted living assessment their ability to maintain an independent assisted living lifestyle in their “independent living units”.
The key is to accurately assess and then provide services to maintain what the regulation calls an independent assisted lifestyle. (emphasis added)
3. What are the parameters under an assisted living assessment for determining if a resident needs to participate in an independent assisted living program, or reside in the Health Care Center, and what are the limits for providing assisted living services in one’s independent apartment?
Arcadia has developed a simple and pragmatic functional assessment to determine if an independent assisted living lifestyle is an appropriate level for a resident. The form of assessment has been endorsed by the State through the work of the Assisted Living Work Group. A review of the areas of the assessment and the expected levels of function within each area is helpful in understanding: (i) when assisted living services become appropriate in one’s independent living apartment in order for one to maintain an independent assisted living lifestyle, and (ii) when nursing/intermediate care services requiring a relocation to Arcadia’s Health Care Center become appropriate.
The assessment looks at and grades one’s ability to function with respect to the Activities of Daily Living (ADLs) which are:
1. Mobility, transfers and ambulation;*
2. Dining and eating;*
4. Grooming and hygiene;
5. Bathing; and
6. Toileting and continency.*
And, the assessment also looks at and grades one’s ability to function with respect to the Instrumental Activities of Daily Living (IADLs) which are:
1. Use of the telephone;*
2. Housekeeping and cleanliness of apartment;
3. Doing laundry;
4. Using transportation;
5. Responsibility for one’s medications;
6. One’s ability to handle finances; and
7. One’s ability regarding meal preparation.
Finally, the assessment will look at and grade the following:
1. Your risk of falls and your risk of injury and safety judgment;
2. Your nutrition in terms of weight status and stability, weight loss, and body mass;
3. Your hearing deficits;
4. Your vision deficits;*
5. Any psychosocial issues regarding:
(a) Your behavior and the interventions which may be required if you are anxious, hostile and demanding;
(b) Your mental status;
(c) Your social judgment and safety awareness; and
(d) Your support system.
* Primary criteria to be considered by Arcadia’s interdisciplinary team in determining a resident’s transition from Assisted Living to Arcadia’s Health Care Center.
As previously noted, we think that each Arcadian “ages in place” in his or her own way, so that any determination about movement in Arcadia’s continuum is based on a case by case evaluation. Assessments and statistics do, however, provide a point of reference for each of us from which a realistic personal determination about the possible need for services in assisted living or a possible transfer to the Health Care Center can be viewed.
Upon admission to the Assisted Living Program, a service plan is developed to address the unique needs of each resident. Service plan meetings are routinely held on an semi-annual basis, or, in the event of a significant change in condition, to review the resident’s status and revise the service plan as needed. The resident and family are notified of these meetings in a timely manner and are encouraged to attend.
While one is in the Assisted Living program, medication reviews are performed quarterly and an annual Health and Physical examination must be performed by the resident’s physician and submitted to the Assisted Living Program Director. The resident is responsible for payment to his or her physician for the examination.
The key for moving to a higher level of care in Arcadia’s continuum depends on the changing acuity level of each resident as determined by the resident, his or her physician and family and Arcadia’s multi-disciplinary team, including its Medical Director. That independent assisted living costs more than independent living and that long-term care costs even more is a harsh reality that we must accept with a victor’s attitude!
4. What documents at Arcadia describe its continuum and the transfer process to higher levels of care?
1. The Residence Agreement each of you signed upon entry into Arcadia. Specifically: (i) your residency at Arcadia can be terminated if you develop a severe infirmity, mental illness or other incapacity such that, in the opinion of Arcadia, the Health Care Center cannot properly care for you or that you pose a substantial risk to the health or safety of yourself or others; (ii) your residency at Arcadia can be terminated if Arcadia, in its sole judgement, determines that your continued residence at Arcadia will have a serious adverse effect upon the peace or contentment of the other residents; (iii) Arcadia, after consulting with its Medical Director or your personal physician, may require that you relocate to the Health Care Center when, in Arcadia’s sole judgement, you are no longer able to live as an independent and active member of Arcadia; and (iv) Arcadia’s General Rules.
2. Arcadia’s Assisted Living Handbook.
This Handbook provides, among other things, the basic criteria for
entering into Arcadia’s Assisted Living programs and for transferring to a higher level of care in Arcadia’s Health Care Center.
3. Arcadia’s Skilled nursing/Intermediate Care Facility Handbook.
4. Arcadia’s Brochure and Marketing Materials.
Through regulations, surveys and growing experience, we are shaping the phenomenon of successful aging at Arcadia.
In light of our mission to provide senior living excellence in a gracious, compassionate and dynamic environment with a superior continuum of assured lifetime care to meet the spiritual physical and social needs of every resident, I know we are moving in the right direction. But, implementing and continually refining our operation of a satisfactory continuum requires understanding, compassion and cooperation by, between and among staff, resident, family and friend alike.
Today, we know that the most effective programs for achieving excellent “independent living” as well as an “independent assisted living lifestyle” and quality long term care involve daily observation by persons trained (as are Arcadia’s personnel) to recognize the small and early symptoms of decline, who then can offer immediate support and care, and preclude or, at least, diminish a more precipitous or rapid descent into greater dependence.
Perhaps the most important sense for each Arcadian and prospective Arcadian to glean from this article about successful aging at Arcadia is a realistic recognition that in varying degrees everyone will travel an unknown path that requires continuous adjustment to the encroaching frailties and infirmities that inevitably come with growing older.
As we all know, the privilege of living a long life does not come easily, but with a thankful attitude we will all be victors, no matter where we lodge in the continuum during our life at Arcadia.