Long-Term Care
Price of Paradise · Hawaii Public Radio · aired 1995-03-12
Guests: Oscar Kurren (Professor of Social Work, University of Hawaii); Patricia Blanchette (Professor of Medicine, University of Hawaii); Stanley Snodgrass (care facility administrator)
Duration: 1:08:56

[00:00:02] Randall Roth: Good morning. This is Randy Roth, host of the Price of Paradise Radio Show. Our topic today is the aging of Hawaii's population and the challenges it presents with respect to long-term care. With me in the studio are Oscar Kern, a professor of Social Work at the University of Hawaii, and Stanley Snodgrass, a licensed nursing home administrator and instructor in long-term care administration and management. Also with us by phone is Patricia Blanchet, professor of medicine and director of the Geriatric Program at the University of Hawaii. Oscar, why don't you begin this conversation by telling us a little bit about what long-term care is? What does that term include?
[00:00:46] Oscar Kurren: Well, good morning, Randy, and good morning, Stan.
[00:00:49] Randall Roth: Good morning.
[00:00:50] Oscar Kurren: You know, I thought I'd, we need to get into long-term care to understand it, but let me identify what I hope to we, we can accomplish in the very short hour that we have here. First of all, we need to understand why our long-term care approach is out of sync with the needs of the elderly and, and we get into the history of that very briefly. And then we want to get into the new thinking on long-term care, which really is assisted living. And maybe we ought to replace the term long-term care with long-term living, living in place and explain why that's so important. And then, since many of you are listening in on this program and many of you are beneficiaries of assisted living, or have known people who have benefited from assisted living, as we will describe it to you, if you could then, uh, provide this information to all of us listening in.
[00:01:58] Oscar Kurren: And before we leave today, uh, particularly with the help of Stan Snodgrass, to tell all of you what's going on in the state legislature and how it's terribly important today to move forward with assisted living. Now let's get on to long-term care, you know. I was reading a magazine the other day and it had to do with, um, um, financial needs, etc., and it said the mantra of the long-term care investor is stocks, stocks, stocks. Well, the mantra for long-term care is fear. It's based on a fear of growing old. It's based on a fear of going financially broke if you become a a person involved in in receiving long-term care. And by long-term care, much of us think it has to do with nursing home care as the major.
[00:02:55] Oscar Kurren: And it's a fear of giving up our lifestyle, of really isolating ourselves from society. And it's uh, and we have to ask ourselves, why did we get into this box of long-term care? Briefly, it goes back to 1965 when President Johnson and his advisors initiated two amendments to the Social Security Act. As you know, the Social Security Act was enacted in 1935, primarily as an economic security measure. In 1965, we moved in into Medicare and Medicaid. Title 18 is Medicare, which is providing medical care for the elderly. And, regrettably, that program restricted its services only to those who needed acute care. It provided little or nothing for long-term care and Stan can probably pick up on that point in his experience as an administrator of a convalescent center.
[00:03:55] Oscar Kurren: Medicaid, interestingly enough, was the program for those who were living at the welfare level, and it was a program that was totally comprehensive. It covered acute care to all aspects of convalescent and long-term care. And as a consequence, the elderly, who were in need of support services, and perhaps institutionalization, uh, uh, could only turn to Medicaid. Well, as a consequence of, uh, a an approach that relied on uh, a medical model and there are three things that stand on my mind, we can go over those. The basic problem with long-term care is it is over medicalized. We rely on a system of care that's very expensive, uh, and and inappropriate to the needs of the elderly. So we can look at this overmedical situation. We have over commercialized the situation.
[00:04:59] Oscar Kurren: We're the only country in the world where 98% of all long-term care is in the hands of the open market situation and commercial providers. And related to that is that we have institutionalized the elderly. And the elderly, if you talk to anyone, and I, I fit in that category, I'm, I'm about to retire, and uh, and uh, uh, I'm looking to uh, another way of life as an elderly person. Um, and my desire is to live in place, to be part of the community and to be contributing to the community. The last thing I want is being in a nursing home, and I think that's the way most of us want to approach our life needs.
[00:05:46] Oscar Kurren: So, how do we get out of this over medical box, this over commercialization of the long-term needs of the elderly and institutional. And that's, that's the dilemma, and maybe, Stan, can comment on that.
[00:05:59] Randall Roth: Stanley, why don't you share your thoughts on that, and then we'll see what Pat has to say.
[00:06:02] Stanley Snodgrass: Okay, fine. I agree with what uh, Oscar has just talked about relative to the background of Medicare and Medicaid and how we got to where we are today. For a long time, those of us who have been intimately involved with long-term care said there's got to be another way to do it. And the other way to do it is, is to recognize that nursing homes have a position in the community, but there's another development, and the other development is called assisted living facilities. In this particular area, the state of Hawaii is at least 10 years behind our sister states on the mainland. The movement started out in in uh, Florida in the early '80s. And the concept is that people want to age in place.
[00:06:49] Stanley Snodgrass: They want to control their destiny. They want to be treated with dignity. They want to have their own sphere, their own, their own piece of the earth. Assisted living facilities then, are institutions that essentially relate to the social side and the activity side of life. They, they are individual apartments that serve where uh, central meal service, activities, religious religious uh, activities, transportation, the doctor to outside activities. It's an opportunity for the individual who is older, and now I'm talking about, the profile on the mainland is elderly widows in their late 70s on up into their hundreds. Uh, the ratio of of women to men is about five to one because that's the ratio of that particular generation.
[00:07:47] Stanley Snodgrass: And what it does is, it gives the opportunity of the individual to live in a protected environment where he or she controls that environment. A contract is executed between the individual and the the operations. And and it's up to that, up to the organization then and the individual to decide what he or she wants out of her life. That's the genesis of it. The cost is approximately half the cost of a nursing home. It relates to the fact that nursing homes are enormously overregulated, they're overbuilt, and so this is where the substantial savings comes in. I'm working on two different organizations or activities right now. A 111-bed assisted living facility on the Punaluu side and an 87-bed assisted living facility in Maui.
[00:08:41] Stanley Snodgrass: Hopefully, we'll break ground before the end of this year on each of these. And, so, with that, Randy, why don't you pick it up.
[00:08:49] Randall Roth: Okay. Uh, Patricia, I believe you're there on the line. You've been hearing our other guests talk about long-term care in a way that makes me think that that they believe some major changes have to be made. Uh, am I hearing them right?
[00:09:02] Patricia Blanchette: I think we just don't have enough of um, options for people. If you take a look at sometimes it's so easy to just blame the nursing home for the problem, it's like blaming the victim. Um, there are always going to be people who are much too frail, much too ill, to be cared for in anything but a nursing home environment. The if you take a look for example, um, about 25 to 35% of all hospital beds today are occupied by people waiting for nursing home placement. If you went through each hospital and interviewed and met with every person there, waiting for a nursing home, there is a relatively few of them that would uh, be well enough to be cared for in an assisted living facility.
[00:09:51] Patricia Blanchette: So, you come to the conclusion very quickly we're we need nursing homes, they're always going to need nursing homes. What we don't have are a a a a wide enough array of options. Uh, assisted living facilities usually means a person leaves their own home, buys a rental unit in a facility designed to provide care for them within that unit, but still with a lot of privacy and a lot of independence that they don't have in an institutional setting. Some people are going to much rather stay in their own home, um, being uh, living by themselves or with their family, and having uh, all kinds of assistance brought in to help them do that. And what we don't have are options.
[00:10:31] Randall Roth: Are are we facing some sort of crisis? I've I've heard that word used and I don't know if it relates to the cost of long-term care or the availability of of appropriate places to go. Um, would you describe where we are now as at a crisis point?
[00:10:46] Patricia Blanchette: I think so. Uh, and we're getting worse. The um, if you tell me that 25 to 35% of hospital beds designed to do something very different, are occupied by people waiting for nursing home placement, and consider the millions and millions and millions of dollars that costs. And it would be fine if you'd say, okay, well, it's a it's it's horribly expensive, but the people are getting great care and it's a wonderful place to live, I'd say, uh, excuse me, would you and I like to live in the hospital? It's not a residential setting. Uh, it's a it's a great place to be if you have a bleeding ulcer or if you just had your heart attack, but I don't want to live there and neither do those people.
[00:11:27] Patricia Blanchette: Okay. So, and we do know that the population is aging very quickly, um, in Hawaii, and in most other places. That's not so such a bad thing, you know. That means that we are seeing an extension of the healthy middle years. And Oscar just said he's about ready to retire, from my point of view as a geriatrician, he belongs in the pediatric clinic. He's way too young for me to be concerned about. Uh, I'm dealing with people in their 80s and 90s, and uh, so it's a good thing that people are living older, more of us are living out our human life potential. And so that's not a bad thing considering the alternative, but it just means we need more options.
[00:12:15] Randall Roth: Okay. In case you joined us late, you're listening to the Price of Paradise Radio Show. The topic is long-term care in Hawaii, and my guests are Oscar Kern, a professor of Social Work at UH, Stanley Snodgrass, a nursing home administrator, and Patricia Blanchet, a professor of medicine and director of the Geriatric Program at the University of Hawaii. We're being broadcast live Sunday morning, March 12, on KHPR 88.1 FM and KKUA 90.7 FM with a replay this evening on KIPO 1380 AM. Your phone calls are welcome. To ask a question or make a comment, just call 955-8821. Neighbor Islanders are always invited to call collect, the number again 955-8821. Stanley, I think you had something to say about uh, Pat's comments?
[00:13:02] Stanley Snodgrass: I want I want to pick up on Pat, and she's absolutely right. We need more options. We need more nursing homes. I wouldn't argue that at all. Specifically, the state of Hawaii has fewer nursing home beds per 1,000 population over the age of 65 than any state in the United States. About three years ago, plans were made for almost 800 beds of new new construction. Just this week, 320 beds that were originally planned were canceled. So of the almost 800 beds that were planned in 1992, fewer than 300 of them will ever be built. We're already in a crisis situation. Our population is growing, our elderly population is growing at two and a half times the national rate.
[00:13:56] Randall Roth: So we have more uh, in the elderly category here in Hawaii than in other states, and it seems to be uh, growing daily.
[00:14:05] Stanley Snodgrass: Absolutely.
[00:14:06] Randall Roth: And we have fewer facilities available than elsewhere. Oscar, why is this?
[00:14:12] Oscar Kurren: Okay. It's not an easy answer to the situation. Um, what I think is interesting and and puzzling in one sense that with the movement into assisted living by many other states, Oregon, Washington and Ohio are the two main leaders. Now this gets to the observation that uh, Pat said uh, made, that um, there are many uh, uh patients in the hospital need nursing home care. Um, yet the assisted living program has uh, demonstrated that individuals who are nursing home certifiable, which means under the existing rules and regulations, they are eligible for nursing home because they seemingly need the kind of intensive care the nursing home provides. Yet these individuals who are nursing home certifiable are able under the change in the regulations, through a process called the waiver of regulations, which um, the Department of Human Services would petition the federal government to set aside existing regulations, so that individuals who are nursing home certifiable could live in an assisted living facility, which means living in place to a large extent, or a place like Pohanani, or Arcadia or something similar to that, and live effectively, even though they are nursing home certifiable.
[00:15:42] Oscar Kurren: Which means as I look at it, we have to make an extraordinary change in our understanding and perception of what is the nature of living arrangements for people who are growing older, and not to quickly adopt this medical model.
[00:16:00] Randall Roth: Well, what Patricia was saying, we need more alternatives, but I think Stanley was saying we need more of everything. In other words, we simply don't have enough places.
[00:16:08] Stanley Snodgrass: You're absolutely right. And and the audience has got to recognize, the legislature's got to recognize especially, the the crux of the problem, which is the aging of our population and the fact that that long-term care has been such a neglected subject for the last 20 years. Oscar was absolutely right and Pat was right relative to assisted living. The patients are waiting at Queen's Medical Center right now and there's over 100 of them who could be transferred to a nursing home if there were beds available in a nursing home. I was just last week at the Convalescent Center in Honolulu which I ran for 11 years. There are people there who have been there for 25 years.
[00:16:51] Stanley Snodgrass: They are nursing home certifiable. They could go to an assisted living facility, creating a bed at Convalescent Center to take some of the overflow from Queen's Medical Center. There would be a reallocation of services and facilities within the community. It would be an absolute it would be an eye opener for everybody.
[00:17:13] Randall Roth: Patricia, why why isn't this happening? I assume that the physicians are are major players in making these decisions. Why isn't it happening?
[00:17:21] Patricia Blanchette: Oh, not at all. Um, physicians are primarily involved in providing the um, medical care and making a diagnosis, uh, finding the right treatments, uh, working with an a a team of other health professionals to make sure that the person um, gets the kind of medical care that they need. These other decisions about where does a person live when they don't need the hospital anymore, are not physician decisions in the least. They're they fall into the area of that um, requires all of us to participate in. The physician may be defining as well as possible for other people just what does that person need to um, to remain as safe and healthy as possible, but then everyone else has to come in and and help make those needs um, uh a reality.
[00:18:13] Patricia Blanchette: When when Oscar talks about, uh, nursing home certifiable, one of the things that unless you work with these patients on an everyday basis, you don't really have a concept of is that there's a wide range of dependencies within the realm of what we call say intermediate care. There's the skill nursing facility or skill, uh, patient, which is the patient who requires some fairly high level intervention, usually uh, in a large indwelling IVs or special treatments that only a nurse can do. Then then there's a whole broad range called intermediate care. For example, but within that intermediate care level, there are people who are relatively light care.
[00:19:00] Speaker 1: and people who are relatively heavy care, and so a lot of these social programs that could be brought online, would be very good answers for people who within the intermediate care level, are are what most of us would consider light care ICF. Um for example, you may have somebody who has a stroke, who actually just needs um a bit of assistance when they transfer say from the bed to the chair or or when they start to walk, they may be able to walk with a cane, they may have some dementia from that stroke, and so may not have the where with all to make good decisions for themselves uh without being supervised, but they're not really heavy to take care of, and they participate easily in social activities.
[00:19:46] Speaker 1: Then you have people who are can be in the ICF category who require two, sometimes three people just to move them from the bed to the chair and believe it or not, these two people would be in the same general nursing home category of ICF. In one case, on the heavy care patient, I don't think that person's ever going to be um somebody who can be managed um in efficiently in an assisted living facility. In the former case, somebody who requires relatively light care uh for now, is going to be somebody who'd be ideally suited for assisted living.
[00:20:23] Speaker 2: Mhm. Uh Oscar, earlier you brought up the the topic of Medicaid and Medicare. How does that fit into this equation?
[00:20:31] Oscar Kurren: Well, Medicaid is now the primary financing agent for long-term care. And as I mentioned earlier, it was never intended to be that way. The reason for that is um nursing home costs range anywhere from $4 to $6,000 a month. There are not too many elderly in America who can afford that that expense. As a consequence, they are admitted to nursing homes, they spend down their resources, so they become poverty stricken, and at that level, then the state steps in with Medicaid to to pay for their long-term care. Now, what's happening today under assisted living is that through this waiver arrangement where a state can petition the federal government, and by the way, Donna Shalala, who is the head of the Department of Health and Human Services in the federal level, is a great supporter of assisted living and would like every state to move in that direction.
[00:21:26] Oscar Kurren: That means then that the state of Hawaii could create a series of alternative arrangements where people can live not a nursing, but in something that's a residential.
[00:21:40] Speaker 2: And I assume that that would be cheaper and in other words, it seems to me ultimately, uh limited resources are going to be a a major factor, and if if we've got more and more people getting older, and if we're having trouble providing enough facilities as it is right now, then there are financial as well as perhaps other reasons to try to move in a direction where more can be provided with less.
[00:22:05] Oscar Kurren: Yes, for as I understand, at least a third of all nursing home patients today are patients with dementia problems, Alzheimer's disease, etc. And as you know, that's a problem of management, and so families are forced to seek nursing home care. Interesting enough, in people who have visited Oregon and Washington and state of Washington and then Ohio and other places, have discovered that many patients with Alzheimer's symptoms can be effectively and happily cared for in assisted living facilities. Now, we we've changed our whole notion of really how to respond and understand [unintelligible — audio glitch] work with people with problems. And we do not have to institutionalize people.
[00:22:51] Stanley Snodgrass: Let's pin down this this comment that uh Oscar made relative to Medicaid paying the the bill as far as long-term care. In the state of Hawaii, about 85% of the occupants of nursing home beds are Medicaid beneficiaries. That is significantly greater than the national average. The national average is about 55%. So that's the biggest single factor. Recognize we got 3500 nursing home beds in the state. 85% of those are being paid for by Medicaid. Half of which comes out of the state's coffers. I want to pick up on what Oscar just about talked about on Alzheimer's. We're going to have Alzheimer's units in every one of our facilities. We're going to have special units for Alzheimer's in our assisted in our assisted living facilities, and a special Alzheimer's unit in our nursing home because we recognize that's what's taking place in the United States today.
[00:23:50] Stanley Snodgrass: We're looking forward to it very much. It it it's the it's the cutting edge as far as we're concerned. We've looked at Oregon, Washington, Ohio, um Florida, California, and we've we've looked and and I've site visited most of these places. And as I started out saying, the state of Hawaii is at least 10 years behind our sister states. Now, where were we going on this? Well, Medicaid is has got to recognize the changes they're taking place. They're beginning to and I'm tickled to death. But I want to pay a special salute to Oscar's wife and an and a gal by the name of Mildred Ramsey because they put together an assisted living options task force.
[00:24:37] Stanley Snodgrass: To and and they researched this whole thing. I got into it a little bit later and I'm I'm very active in it now. Just what they're doing is they're as a citizens group of people who are active in in social welfare and health care of the elderly, they've said there is a better way to do things than is taking place in the state today. They sponsored a whole raft of things at the legislature. I'm the legislative committee forum and and I'm sure we'll get into that.
[00:25:11] Speaker 2: Okay. In case you joined us late, you're listening to the Price of Paradise Radio Show. The topic is long-term care in Hawaii, and my guests are Oscar Curren, a professor of Social Work at UH, Stanley Snodgrass, a nursing home administrator, and Patricia Blanchette, a professor of Medicine and director of the Geriatric Program at the University of Hawaii. We're being broadcast live Sunday morning March 12 on KHPR 88.1 FM and K KUA 90.7 FM with a replay this evening on KIFO 1380 AM. Your phone calls are welcome to ask a question or make a comment, just call 955-8821. Oscar, we've been talking about Medicaid earlier uh before the show, you mentioned to me that with Medicaid, it's all or nothing. What did you mean by that comment?
[00:26:00] Oscar Kurren: Well, by all or nothing is, um, if you need what we call long-term care, the only alternative is to place that your relative in a nursing home. So it's a uh a a a total institutional philosophy and approach buttressed by our policies. We know that there are gradations of care, levels of care. The system has to be fine-tuned so the person can as much as possible live in place, age in place. And so under the waiver arrangement, as you as I previously explained, it's a change in the rules and regs by Washington DC, the states can provide alternatives, not the all or nothing. But we're not doing that in Hawaii.
[00:26:51] Speaker 2: We're not doing that in Hawaii. Okay. We have a caller from Honolulu. Terry, good morning. Good morning Terry. Are you there? Okay. How about James from Manoa?
[00:27:04] James: Hello?
[00:27:05] Speaker 2: Yes, you're on the air.
[00:27:06] James: Yes, I'm wondering, I may have missed this already. Are there any changes in the building codes or zoning codes required to accommodate these type of facilities you're talking about?
[00:27:16] Stanley Snodgrass: The the answer is no. The uh this is Stanley Snodgrass, and I'm working with a developer on two assisted living facilities. No, the existing building codes will cover the whole thing. Plus the fact that in our particular case, we're building to the codes of the housing and urban development, because our facilities will be insured by that particular organization. So we'll be meeting all kinds of building codes. There are no special building codes that are required for assisted living facilities.
[00:27:47] Speaker 2: Thank you. Okay. Thank you, James. Uh Oscar, you were talking earlier about this all or nothing thing, and we could get a waiver, but we haven't. Why haven't we? It seems to me really obvious that a family ought to have a a choice other than to to pay every penny themselves or to put someone into an institution.
[00:28:05] Oscar Kurren: Well, at the present time, there is a resolution going through the state legislature uh that will urge the Department of Human Services to apply for this waiver. That's regrettable in a sense. They don't need a resolution for that. They have the freedom. They have the obligation, the responsibility, as many states have done, to reach out for a waiver. Now, the this waiver business is not new to Hawaii. We've used that in the past, and very successfully. Queen's Hospital has a community long-term care program um which enables nursing home certifiable people to be cared for in their homes um through uh a special arrangement called community care and Medicaid pays for that, that's the waiver system.
[00:28:55] Oscar Kurren: I think one of the problems, Randy, is that the state of Hawaii has been engaged perhaps a little too much. I'm using a a quote from a book called um Reinventing Government, and it says the government should be more in a position of rowing than steering, which means that government should be Steering rather than rowing, right? Should be steering. All right. Steering rather than rowing, right, right. By steering, we mean that the government is in position to um um help create public awareness, to define policies, to implement policies, to uh create community support coalitions for essential changes. As you know, we have to make extensive changes in our way of thinking about the elderly, the way we approach the problems and so Okay.
[00:29:51] Oscar Kurren: But we are investing too much money in direct services. And just a brief illustration, um Calvin Say, in the state legislature recently um arranged for converting 18 positions in Project Malama to Civil Service. Now, Project Malama is a good program. It's a direct service program whereby they attempt to help families function effectively in the community. I feel, however, that the state Now, that program originally was funded by the federal government, and it was a demonstration effort to provide case management. I feel that same investment by the state should be in terms of helping the community and the the various communities throughout Hawaii to mobilize their resources to create options for assisted living. Again, this matter of steering as versus rowing.
[00:30:48] Speaker 2: Okay. All right.
[00:34:31] Terry: thing to the percentage is higher, I wonder if there's might be some aspect of the very high percentage of people having to use Medicaid, because we, a people in the state, are educated to use the state services, the federal services and therefore they do not let the their families, their community or their individual communities support them, and I'd like to I have another question. I'm one of these I wondered how much input you got. I'm one of these patients who is kept in the hospital and in a nursing facility. Wait I I'll rephrase your answer to the first question.
[00:35:15] Speaker 2: Okay. Stanley Snodgrass, why is it that such a high percentage of our long-term care patients are, um are funded by Medicaid?
[00:35:24] Stanley Snodgrass: Well, part of it is economic, because the the cost of living in Hawaii is so great that they expend most of their funds in the acute care institution because all of the nursing home patients started out in an acute care facility.
[00:35:38] Speaker 2: So you don't think it's so much a political philosophy in Hawaii, more a it it's part of political philosophy is part of economic and uh it's part of the fact that um the government has been fairly liberal in interpretation of the spend-down regulations. I see, and spend-down regulations, that's what people have to do in order to qualify for Medicaid.
[00:35:56] Stanley Snodgrass: Absolutely, impoverishing them themselves is what it amounts to.
[00:35:59] Speaker 2: Okay, Terry, I believe you had another question.
[00:36:01] Terry: Yes, well I was I was uh what I my call now a victim of of what happens, I was in the hospital for what I thought might should be a uh a period of maybe five days, and instead I was there for five weeks because they didn't know what to do with me. They were afraid. They are so afraid of older people getting broken hips, and also um uh elder care facilities built by the state and the city county, uh they're not helping us. We want desperately to be able to maintain our status. Yeah. We want to be able to take care of ourselves and um uh we're we're not getting much. We we don't want to go to assisted living or other we want to just maintain our independence and support ourselves, and they're not helping us do that uh by not having elevators or well other things that um that might be true. And also [unintelligible — audio glitch] thing that bothers me is politicians wanting to be elected at the age of 75 when so much deterioration occurs, that's enough of that. Thank you.
[00:37:14] Speaker 2: Thank you for your call, Terry. We have another caller. This is Carol from Manoa. Good morning, Carol.
[00:37:20] Carol: Good morning. I was really curious to get more information on how uh single family residences can be transformed into arches, adult residential care homes. Uh I think it's comparable to the need for uh licensing homes for child care, the the need for babysitting is great as the need for care of our elderly who who don't need skill nursing facilities. What are the barriers? What are the hoops that one would have to go through besides a is there building zoning code requirements and other kind of medical requirements to transform into arches.
[00:37:56] Stanley Snodgrass: Okay, Stanley Snodgrass? Yeah, we're going to license our are assisted living facilities uh have relates to Alzheimer's under the Arch regulations so I'm familiar with them and the answer is yes, there are significant building code requirements, there are significant requirements in terms of clinical records for your residents, for uh all sorts of of uh consultant, dietician, all that type of thing. I simply don't think it's practical on an individual home basis, because the cost of the administrative structure would be so prohibitive. Plus the fact that the cost of the retrofit of the average home would add to it. I just don't think it's practical.
[00:38:39] Patricia Blanchette: Well, I can understand retrofitting, you know, doing ramps and and other safety devices, but administrative costs, um why aren't uh the non profits or whomever um helping in in providing like incubator services to to help people get started up and and train people and in workshops or or package deals to to do these kinds of um paperwork, record keeping.
[00:39:06] Stanley Snodgrass: Well, I don't know the answer to it. Uh I'm not that familiar with how the non profits work, but I'd guess that there's no particular incentive to do it because it it there's no question that's a problem, but it's a problem whose magnitude is is very insignificant relating to the extent of the major problems that we're talking about.
[00:39:29] Patricia Blanchette: As as I understand it, this is a a tremendously growing population, so I would think the need is great.
[00:39:37] Stanley Snodgrass: I I I wouldn't argue the point at all. All I'm saying is that that in the uh uh in the the listing of things, it's probably out of the 10 major problems in long term care, it's probably number seven or eight.
[00:39:53] Patricia Blanchette: So the greatest problem is the actual building of more nursing homes?
[00:39:58] Stanley Snodgrass: Or institutions of one kind or another because recognize that we got we have a a very odd kind of society over here. We have the highest number of working wives of any state in the United States and almost everybody has to work in order to live. Therefore, there isn't a somebody at home to take care of Grandma when she comes back from the hospital or a nursing home. Ergo, they end up in an institution, like it or not.
[00:40:27] Patricia Blanchette: Well that's why I was trying to draw an analogy to uh licensed day care, whereas there are mothers who need to work, yet if that mother stayed home and babysat up to I guess four other children and could earn uh supplemental income that way as well as care for the child, couldn't that be applied to caring for elderly if these administrative requirements were facilitated or made easier. Um, it just seems to me real costly to go out and build these kinds of institutions and care homes when when family residences could easily be converted for adult care.
[00:41:07] Randall Roth: Okay. How about Oscar Kern?
[00:41:09] Oscar Kurren: Yeah, uh, a number of experts have been coming to Hawaii to help us with our thinking on this thing. And they acquainted us with really three broad models for looking at assisted living. The first one is housing with services, and you have talked about that uh Terry when Uh this is Carol. Carol. Um, and with housing with services, people who are living in their own apartments do not have to live or depart from their apartment. They can bring in to that apartment personal care services and making certain retrofitting changes in their apartment. And so the state can play a key role and the community can play a key role in helping elderly secure in a very orderly systematic way, essential services in their present home. That's housing with services. And in the states we talked about, there is a very systematic effort of helping families maintain housing with services. The second model is assisted housing, specialized units. Pohanani and Arcadia are at present the only two examples of assisted housing of a significant nature in Hawaii. And understanding mentioned and those who recently visited those facilities on the mainland uh discovered there's a wide range of arrangements similar to Arcadia and Pohanani, but serve families with far less economic resources than required in those two facilities here in Hawaii. So that's assisted housing. Then there is a third movement, which I find very interesting. It's called nursing home replacements. And that is in an effort to help nursing homes who have organized themselves around a medical model or a hospital model with all its high cost and unnecessary arrangements and uh and helping these nursing homes to replace their policies and their procedures so that it resembles to a great extent residential type living arrangements. So we need changes at all levels and we need a lot of help from the total community to do this.
[00:43:22] Randall Roth: Carol, thank you for your call.
[00:43:24] Patricia Blanchette: You're welcome.
[00:43:25] Randall Roth: We've got several other people on the line. First Bill from Maui, you've been waiting patiently. Good morning.
[00:43:30] Bill: Oh, yes. Hi. I have a very interesting program. I'm finding that it dissolve this problem. At the age of 80, I have signed up with a unit that's managed by the Life Care Services Corporation. And I'll have to move to Hilton Head in South Carolina. But what you do is you convert your home, you you insert you turn your home in here, sell it, and you put the money in a home there, and you still own the home so that when you die, the home there is a part of your estate. But it seems to me that the key to this Life Care Services Corporation is that you've got to move into a concentrated area to get an efficient rendering of these services. If this if you have it spread all over, then the state has to step in and that's so expensive. The only way that it can be handled on on a private economic basis is to concentrate.
[00:44:24] Randall Roth: Well, let's see what Stanley Snodgrass has to say about it.
[00:44:27] Stanley Snodgrass: Bill, before you make that final signature, let me suggest to you that we're building an assisted living facility on Central Maui and it's designed to do exactly what you're talking about. It it is not a buy-in, it is a rental kind of arrangement. And um I I think it's very exciting. Yeah. I I'm I'm delighted that you're calling from Maui because our our uh research told us that the greatest net outmigration of people over the age of 65 was coming from the island of Maui, which is exactly one of the reasons that we're building a facility there.
[00:45:06] Bill: What's the name of this? What?
[00:45:08] Stanley Snodgrass: It will go on the land that belongs to the Methodist Church in Central Maui at Alalani. It's it's midway between Kahului and Wailuku. Hopefully, we'll break ground about the first of July.
[00:45:19] Bill: That's kind of a miserable part of the island.
[00:45:22] Stanley Snodgrass: Well. I I've got I've had people who would argue that point with you, Bill, but I understand what you're saying. Thank you.
[00:45:31] Randall Roth: Thank you, Bill. Uh, we have another caller on the line. Dick Miller from Kailua. Good morning, Dick.
[00:45:36] Dick Miller: Good morning, Randy. Uh one of the things you fellows haven't been talking about is how to finance all of this. You know, uh Medicaid is great when it's there, but it means you have to get rid of all your assets. You have to be poor in order to uh get Medicaid. Now, I'm sure this is going to be true under assisted living, which may be less expensive, but nevertheless, still has to be financed. And nursing homes are what four to 6,000, so assisted living is maybe two uh two to $3,000 a month. Uh who's going to pay for it? Now I I I think you ought to address the question of insurance. There are all kinds of insurance plans out there and so that people who have the resources uh may be able to buy insurance now which will finance their their assisted living care later on, and they won't have to get rid of all their assets. Their assets can then go to their children and they can use them for whatever. So, let's uh, why don't you address yourself? I'd appreciate it, uh if you talk about insurance.
[00:46:42] Stanley Snodgrass: Dick, the people in your facility, um, you know, a lot of them are on Medicaid, how many of them have uh insurance that they're relying on now, and and if not too many, uh is this something that younger people ought to be buying? There are very few of them that actually have the insurance. I know what Dick is talking about because uh when I was heading the the Health Care Association of Hawaii, we introduced the idea of long term care insurance to the state of Hawaii. The penetration is very, very light so far. I don't think there's over 5% of the people over the age of 65 that are carrying long-term care insurance. I would certainly recommend it. It is a it is, as Dick Miller says, it's a very important issue. It's an option that Pat was talking about. It's something that is brand new. It is something that everyone should know about and especially the younger generation because they're the ones that will inherit whatever the older folks have that can be protected by long-term care insurance. I it it's an excellent idea.
[00:47:45] Dick Miller: Uh let me just uh add this. I know that uh USAA for example, uh offers long-term care. I know that some organizations, for example, particularly the American Bar Association offers a very good long tea-term care program. Uh, and TIAA, which is the teachers insurance association offers long-term care. Do you know offhand whether uh that uh AARP offers it? I'm not sure whether they do or not.
[00:48:15] Stanley Snodgrass: I I don't think they do. I would rec- I would say that there's something like 15 insurance plans in the state of Hawaii that offer long-term care, not the least of which is HMSA.
[00:48:28] Randall Roth: Okay.
[00:48:29] Stanley Snodgrass: They offer one too, huh?
[00:48:30] Randall Roth: Yes, sir.
[00:48:31] Stanley Snodgrass: Yes. Good, good. Now what we plan to do on in our assisted living is is work with a master contract with one of the insurance companies or another, that will give us a break on price so that we then can pass it along to to our clients, our our guests, our residents and say, look, you can save 10% or 20% by going into a group. [unintelligible — audio glitch] exploring that uh that kind of thing now.
[00:48:58] Dick Miller: Great, great. I think it's so important because most people just won't be able to get any care unless they uh just uh spend down all their assets and that happens very fast if you're in a nursing home, let me tell you.
[00:49:11] Randall Roth: You bet. Thank you, Dick. Oscar Kern?
[00:49:15] Oscar Kurren: Well, uh the state right now is spending at least 80 or $90 million a year in nursing home care. That's out of the state resources. And of course, that's matched by the federal government, who spends another 80 or $90 million. There's no easy solution to the rising financial cost for care, wherever it takes place, assisted living or nursing home. I think we have to approach this from a partnership concept. The state um the public sector has a responsibility for assuring that people have adequate living arrangements as they grow older. And with the high cost of land and cetera, it means the state has to play a role in maybe making land available at lower costs for assisted living arrangements. Um, along with um substantial inputs from the private sector, the nonprofit as well as the profit sector, but we have to approach this from a long range planning basis with the state understanding that it cannot step aside from it. [unintelligible — audio glitch] is not stepping aside right now because they we are spending extraordinary amounts of money for nursing home care and we can develop more adequate living arrangements. So um private insurance is one approach, but we need a whole range of of alternatives worked out on for financial sector.
[00:50:35] Randall Roth: In case you joined us late, you're listening to the Price of Paradise Radio Show. The topic is long term care in Hawaii, and my guests are Oscar Kern, a professor of social work at UH, Stanley Snodgrass, a nursing home administrator, and Patricia Blanchette, a professor of medicine and director of the geriatric program at the University of Hawaii. We're being broadcast live Sunday morning on KHPR and KKUA with a replay this evening on KIFO, that's 1380 AM. Your phone calls are welcome to ask a question or make a comment, just call 955-8821. Well, Pat Blanchet's on the phone. Pat, we haven't heard from you lately. Is there anything you'd like to add to uh the conversation?
[00:51:14] Patricia Blanchette: Well, just a couple of thoughts uh to um add a few things to the conversation. The first thing is I heard Oscar a few times talk about the medical model versus the social model. And that's that's an argument that um that I wonder if we just need to keep uh pounding on because absolutely, we're all in this together, and it's mainly an interdisciplinary model now. Uh we're looking at not over medicalizing people's um living situations, that's for sure. But yet making sure that when people do need the medical care, they get it and it's absolutely first class. So, it's it's not an either or situation. I think you'd find that um physicians are very much in a favor of an improved way of living for people. It is very frustrating for us to know how to diagnose and treat a patient and yet can't figure out how in the world they're going to afford the medicine that they need, or even afford to get three square meals a day. So it's not an either or. Um second thing is, I wonder if people understand that sometimes a lot of blaming of the victim. There's a lot of older people today who are without the means to provide themselves the kind of care that they need in their old age. And it's a failed public policy that has uh that has been changed. What I mean by that is a lot of people who are elderly today, were very hardworking people who worked 30, 40, 50 years, and yet they worked prior to pension reform in this country, and their pensions are absolutely inadequate to provide them the kind of care that they now need in their old age. And in the '70s, we had uh a group called the senior citizens uh law centers, who went around systematically taking class action suits and changed pension law in this country, so that you and I are not going to be in any way near the same kind of straits as people who are today elderly, who can't sustain their old age because their pensions haven't kept up with them. So that's that's one thing I think people need to know before we start blaming people and saying, oh, these people are just on the public dole. And thinking, wait a minute, they worked 50 years, how come their pension is $89 a month? Doesn't make sense. Well, it doesn't make sense cuz they worked before pension reform. Second thing is long-term care insurance is absolutely critically important. We need to reduce the dependency on tax dollars. We can never provide with public assistance the kind of care that people can provide for themselves through adequate pensions and good long-term care insurance. Has to be a private model, and then we use our public funds to sustain only the most dependent, the most needy of our population, those who are incapable of providing for themselves. And I just think that that balance has yet to be achieved.
[00:51:58] Randall Roth: Okay. We have several callers on the line. First Bill from Kailua. Good morning, Bill.
[00:52:02] Bill: Good morning to you all. I have a a room enough on my property to to uh build two rooms and bath. And uh there would be a small garden space for the patient to get out and get some fresh air and for both of them. And uh I wondered what assistance financial assistance I might be able to obtain to to implement this concept.
[00:52:21] Stanley Snodgrass: Bill, I don't think there's any of financial assistance at all. I don't know of any any organization or any other than the fact that you go to the bank and and borrow the money. And I don't think that it's an economic kind of thing even though it's it's um um a very desirable approach and I'm sure you would do a superb job. Well, I Excuse me for interrupting, but I could afford to [unintelligible — audio glitch] them have the the space to two patients at much much less than the than the going price for a care home. I I I agree with what you're saying, but there's got to be an infrastructure, there's got to be some sort of an administrative setup and uh I just don't see I don't see the practicality of it.
[00:53:19] Bill: I was thinking of assisted rather than actual care home.
[00:53:23] Stanley Snodgrass: I I I understand what you're saying, Bill and and I appreciate your comments but I just don't don't think it will work. Mhm. Well, thanks anyway.
[00:53:33] Randall Roth: Thank you, Bill. Our next caller is James from Waimanalo Kahala. Good morning, James.
[00:53:39] James: Good morning. Uh the uh matter of assisted living facilities was discussed for people residing in a place like Arcadia. How about that for people who want to live in their own home who've owned their own home out somewhere here there for many years and want to live there and and have somebody come in and help when they don't need really nursing care, particularly?
[00:54:01] Stanley Snodgrass: Well, there are those those kinds of services that are in existence today. Um part of it is home care and and part of it is uh another kind of thing where you can actually subscribe and have somebody visit you at various points in time.
[00:54:16] James: Is that expensive, Stanley?
[00:54:21] Stanley Snodgrass: Well, it's expensive from this standpoint because you got to pay the care provider from the time that he leaves his his headquarters until he gets back. So it's portal to portal pay, plus the fact that there's got to be there's got to be an a significant override for the dead time that the people have. So it's it can be
[00:57:00] Speaker 1: done, but I would suggest that the per-visit cost will be fairly significant.
[00:57:06] Oscar Kurren: Okay. Oscar? Every community throughout Hawaii has a large percentage of elderly residing in them. Kaimuki, Kailua, every community has a substantial population of elderly. And I, rather than functioning on a case-by-case basis as what we're doing right now, I and maybe this is not a clear term, but we have to develop a community vision. By community vision, that means relating to each community as a community and bringing together the leaders in those communities, church leaders, lay leaders, public leaders, service providers in the community, and bring them together to address the issue of assisted living in their community. So that many people who have their own homes can secure the services in a very appropriate way in a timely way, rather than having each family reinvent the wheel for themselves as we're faced with right now.
[00:58:18] Oscar Kurren: I had the same situation when I was faced with a need for securing long-term care, personal care services for my mother-in-law. And fortunately, I had a circle of friends and I'm in the field of long-term care, so there was not much of a problem. But for those who do not have access to that resource, it is a serious problem. So that the Department of Human Services, you know, I child them for being more concerned with, uh, rowing instead of steering, might play a very significant role in helping community to develop a community vision for assisted living and helping each community create the services, facilities, and coordinating and integrating these services. And then on a state level, developing policies that facilitate land utilization and access to, uh, necessary financial instruments, etc.
[00:59:16] Oscar Kurren: We can do this if we pool together as a as a community of people.
[00:59:23] Speaker 1: Thank you, James.
[00:59:24] Speaker 2: Yes, a quick where can we get information about uh, these facility, these services?
[00:59:31] Oscar Kurren: Oscar Word would be a good place to go to get some information. Well, there, um, Motod Ramsey with the Honolulu Gerontology Program. She's with child and family of service agency. I don't have a number off hand. And and I think, um, uh, a call into the Department of Human Services and to, um, stir them up a little bit. They have got to provide a leadership role and not wait for someone to pass resolutions urging them to get waivers so they can do something about this.
[01:00:00] Speaker 1: Speaker 1, do you have that number?
[01:00:01] Oscar Kurren: Yes, I have the number. It's the Assisted Living Options Task Force and the telephone number is 538-3400. I repeat, 538-3400, and it's 245 North Kukui Street, K-U-K-U-I, suite 201-96817.
[01:00:27] Speaker 1: Thank you, James.
[01:00:28] Speaker 2: Thank you very much.
[01:00:29] Speaker 1: We have another caller and we're down to the last few minutes. Fred from Hilo. Good morning, Fred.
[01:00:33] Fred: Uh Randy, can you hear me?
[01:00:34] Speaker 1: Yes.
[01:00:35] Fred: Yeah, this is Fred Holschu. I'm an emergency physician from Hilo. Um, I was driving down the Hamakua Highway listening to the show and I Randy, I really appreciate the show and it's an excellent topic and very timely. I just wanted to make one point and forgive me because I lost your signal, forgive me if it's already been said. I wanted to say a lot of my friend Pat Blanchet, but one of the points, uh, is that we at Hilo right now as I'm sitting here have, uh, admitted patients backed up in the emergency room. We have 30% of our beds filled with long-term care patients who are waiting placement. Uh, we have a great shortage of nursing homes on the Big Island in spite of uh, one under construction right now.
[01:01:12] Fred: But the point I wanted to make is I think we really need to stress the ability to take care of people in their homes, uh, not only with nursing care per se, but with chore care and and people that just go in two or three times a day and help people bathe and take their medicines and that sort of thing. And I think if I, for instance today, during my work day in the ER, I'm sure I'll admit people to the hospital who probably don't need it as much medically as they need it for the uh, lack of having this kind of care given in the home.
[01:01:44] Speaker 1: Mhm. That's a pretty expensive way to go. Okay. Thank you, Fred.
[01:01:48] Fred: Okay, thanks a lot.
[01:01:50] Speaker 1: Well we're we're down to the last uh minute and a half which means about 30 seconds each. Uh Pat, is there anything that hasn't been said that that you need briefly to to put on the table before the show's over?
[01:02:02] Patricia Blanchette: Well, I think we've talked a lot about long-term care insurance and people being able to do for themselves. I think all of us would rather be able to direct the kind of care we want and the kind of care we don't want. And the only way we do that is if we individually control the funds and the resources for that. And so we need to take a look at all of those things that's going to help individuals be in in the driver's seat with regard to what they want and don't want. And also, when we do provide public assistance to people, to make sure that those people are empowered with the same kind of control to accept only what they want and reject what they don't want, so that people individually are in control of their own destinies.
[01:02:46] Patricia Blanchette: I think we need that focus very much so. I think sometimes when we're when we're in the helping professions, we try to help a little bit too much. And um and that means we need to shift locus of control to where people have the right to choose what they want. And only when they're completely incapable of doing that do we step in and and impose um our judgment rather than theirs. But let's let's make sure that whatever we do, individuals keep control.
[01:03:22] Speaker 1: Okay. And I want to thank my guest this morning, Oscar Curran, a professor of social work at UH, Stanley Snodgrass, a nursing home administrator, and Pat Blanchet, a professor of medicine and director of the Geriatric Program at the University of Hawaii. The price of paradise is produced by Suzy Roth. The technical director is Jeff Hilardy. You've been listening to the Price of Paradise radio show. I'm Randy Roth, Aloha. This is listener supported KHPR 88.1 Honolulu, KKUA 90.7 Wailuku, and serving Central Oahu and the North Shore at 88.7 translator K204BB, Haliewa, Schofield Barracks.