Home-Grown Innovations In Senior Care AGING SERVICES OF CALIFORNIA ANNUAL MEETING May 4, 2010 Long Beach, CA

1. Home-Grown Innovations In Senior CareAGING SERVICES OF CALIFORNIA ANNUAL MEETINGMay 4, 2010Long Beach, CA Presented byPamela S. Kaufmann, Partner Hanson Bridgett LLP (415) 995 5043 pkaufmann@hansonbridgett.com Presented by Scott E. Townsley, Principal ThirdAge, a division of LarsonAllen, LLP (610) 594-8100 Stownsley@larsonallen.com

2. Presentation From 5,000 Feet • Current senior care options • Challenges in meeting seniors’ needs • classically • in current economy • Home-grown innovations • Challenges for providers

3. Current Senior Care and Living Options • Facility-based • Nursing facility • Assisted living facility / RCFE • Continuing care retirement community • Multi-level retirement community • Program-rich senior housing

4. Current Senior Care and Living Options • Community-based • Adult day care • Home health care • Home care • Hospice care • PACE – comprehensive services/public funding • Focus of our presentation is facility-based models

5. Seniors’ Needs • Physical • care and access to care • specially designed housing • transportation • Financial • affordability • financial security

6. Seniors’ Needs (cont.) • Spiritual/Personal • Companionship • Dignity • Autonomy • Mental stimulation • Spiritual expression • Individuality

7. Challenges of Existing Facility-Based Models • Classic Challenges • Affordability/limited market • Concerns about long-term financial commitment (especially in CCRCs) • Impulse to remain at home

8. Challenges of Existing Facility-Based Models • Classic Challenges (cont.) • Inability to relate to “older” residents aging in place in an established care facility • Failure to value service program • Concerns about provider’s ability to meet senior’s spiritual and psychosocial needs

9. Challenges in Current Economy • Same as above, plus: • Anxiety about personal finances • Concerns about provider’s financial stability • Doubts about future of public reimbursement programs (Medicare, Medicaid) and impact of health care reform • Reluctance to sell home in depressed market • Continuing frugality in face of recession

10. Evolution of Home-Grown Innovations • Started with informal efforts to create less expensive, more tailored alternatives • remain at home; access doctors, hospitals as needed; lean on family, friends • Evolved into independent movement among seniors to create their own care models and exploration by providers of “care without walls” • mission- and business-driven

11. A Survey of Home-Grown Innovations • Cooperative arrangements • Care at home / continuing care at home • Town squares • Intergenerational programs • De-licensing, down-licensing & supplemented affordable housing • Café Plus & virtual neighborhood models

12. Cooperative Arrangements • E.g., Beacon Hill Village (locally, Avenidas, Ashby Village) • Membership org enables senior to remain at home by organizing and delivering programs & services • Membership fee entitles members to: • information and referrals • grocery shopping • walking groups and exercise classes • members-only events

13. Cooperative Arrangements (cont.) • Membership fee covers (cont.): • service provider discounts • rides home from MD-prescribed procedures • Other services include: • meals • care referrals and management • social, cultural, educational events

14. Cooperative Arrangements (cont.) • Advantages: • low cost • promotes access to care, autonomy, mobility • Limitations: • may not meet financial security or housing needs • designed for seniors living independently • dependent on charitable giving

15. Care at Home / Continuing Care at Home • Models have sprung up in several states in past decade or so • Models vary from care coordination to services; may include an insurance/ prepayment feature • Can be sponsored by facility or be freestanding • Key is to allow senior to remain at home and to receive supportive care/assisted living at home or in care facility

16. California’s Care at Home Bill • Vetoed by Governor during budget battle • Defined “care at home” and “continuing care at home” and exempted home from RCFE Law • Set forth minimal standards for care agreement • DSS supports variations on theme even w/out law • Need for bill persists • Safe harbor; protection if new regulators are hostile to concept

17. Care at Home – Out of State: • CCRC Without Walls – life care program regulated as a CCRC • Includes Entrance and Monthly Fees • Full continuum of LTC services provided in home and at facility, including home care, assisted living and nursing care at a fixed price • Access to wellness center, social events at facility • Little financial support needed from parent org

18. (cont.) • Services: • Care coordination • Home inspection • Transportation • Home nursing care • Home health aide • Companion/homemaker services

19. (cont.) • Services (cont.): • Live-in assistance • Emergency response system • Adult day care • Assisted living • Nursing care • Social and wellness programs

20. (cont.) Illustration of cost$38,000 Ent. fee$15,000 Ent. feefor 75 year old $500 Monthly fee $250 Monthly fee

21. Care at Home (cont.) • Advantages: • lower cost than facility care (no bricks & mortar) • satisfies senior’s desire to remain at home • may provide access to licensed facility • may allow senior to test facility without large fee commitment (but different market?) • may afford companionship (if facility-based) • may increase socialization through technology

22. Care at Home (cont.) • Limitations: • lack of constant provider presence – greater possibility of undetected injury • but remote monitoring can address issue • service model is not as suited to higher levels of care (e.g., nursing), but coordination and insurance models may be • senior may still feel isolated when at home

23. Care at Home (cont.) Risk: • DSS has been open to model in recent years, but risk remains that future regulators may: • treat model as traditional insurance and impose large reserve requirement • real risk if CCRCs are regulated by DOI? • resist regulating additional care settings • hyper-regulate model

24. Town Square • “Mini”- city center is designed to meet seniors’ needs on a usable, walkable scale • Includes many nearby services, amenities • Advantages: • may meet transportation needs • promotes feeling of autonomy • may meet spiritual and personal needs

25. Town Square (cont.) • Limitations: • still a facility-based model with challenges identified above: • affordability / limited market • desire to remain at home • failure to value service program • not truly “home-grown”

26. Intergenerational Programs • Deliberate programs to bring school-age children, adults & seniors together in housing, programming • Advantages: stimulation, companionship, benefits of intergenerational contact and activities • Limitations: • typically a facility-based model with same challenges • not all seniors enjoy the company of children

27. De-Licensing, Down-Licensing, & Supplemented Affordable Housing • De-licensing and down-licensing designed to: • reduce operating expense; • eliminate regulatory burden; • increase flexibility of operations; and/or • provide care in least institutional environment • Often motivated by economic necessity; might also reflect desire to change product to meet demand

28. De-licensing, Down-licensing, etc. (cont.) • Can involve conversion of • Skilled nursing to assisted living • Assisted living to unlicensed housing • Might involve elimination of a level of care in multi-level facility • Might also involve placing housing and services in separate legal entities • beware control issues; will not be approved if deemed an evasion of regulation

29. De-licensing, Down-licensing, etc. (cont.) • Housing plus services (e.g., meals on wheels, IHSS, PACE) paid by charities or government • AB 123 (Portantino) promotes affordable model • Exempts from RCFE/CCF licensure affordable housing for elderly or disabled persons that makes available optional supportive services • Housing must qualify under HUD or federal tax credit program • Owner/operator cannot contract for or provide supportive services; however, it can coordinate services or help residents access them

30. De-licensing, Down-licensing, etc. (cont.) • Advantages: • cost (& fee) savings • saving an otherwise troubled project • potentially less institutional environment • service for a less acute population

31. De-licensing, Down-licensing, etc. (cont.) • Limitations: • potential loss of a level of care • marketing challenges without license in place • legal exposure without license in place • dependence on public/private safety net • still a facility-based model

32. Café Plus Model • Model to increase providers’ outreach, visibility • Might be facility-based or senior center-based • Services include: • restaurant/cafe w/Internet • social connections, learning center, lectures, continuing education • health and fitness facilities • network of community resources

33. Café Plus Model (cont.) • Advantages: • reduced isolation; enhanced wellness • spiritual and educational enrichment • resources, referrals, discounts • Limitations: • may not address more acute care needs • not necessarily designed to provide care delivery or funding

34. Virtual Neighborhoods • Two types of consumer: planners and users • Model coordinates services – few of which may be provided by sponsor • Key staff: marketing; service/care coordination • Services may be “brokered” with other credentialed orgs providing service • Social & service connections are key: value derives from ability to receive quality service w/o effort & maintain enhanced social network

35. Virtual Neighborhoods (cont.) • Financial models are evolving • Offer similar advantages to Café Plus • Contain fewer limitations than Café Plus • Geographic scope can be broader • Design anticipates delivery of service

36. Challenges for Facility-Based Providers • Need to anticipate future demand and funding • How to introduce new model if all resources (human resources, hard assets, funds, borrowing capacity) are dedicated to current model? • How to get residents to embrace new programs? • opening up their home to strangers who may be in a different socio-economic class • sharing limited resources

37. Challenges for Providers (cont.) • How to overcome lack of track record? • Potential resistance of lenders/donors to untested models -- but foundations may be open to community-based care • Board’s potential lack of familiarity with model • Lack of training of staff • Risk of financial failure – need for involvement of savvy businessperson

38. Recommendations If Interested • Study and visit alternative models; review financial viability • Compare notes with other providers • Explore the need (if any) for more flexible legal models • Educate your board regarding alternative care options and future trends • Be creative!

39. Recommendations If Interested (cont.) • Take “baby steps” – E.g. • Offer a limited care at home program • Consider down-licensing a wing or floor (only if circumstances warrant) • Create an intergenerational activity program • Form a (resident-led?) task force to study residents’ spiritual and personal needs & housing and care preferences

40. Q & A