By Laurie Tarkan

Shirlie Decostanza, from left, Evelyn Locicero and Marie Rachel at Green Hill Retirement Community.

Toni Davis spent much of her childhood roaming the corridors of a nursing home in West Orange, N.J., where her mother was the director. Even now she recalls the pleas of the residents there: “ ‘Please help me, please take me home with you,’ they’d beg,” Ms. Davis said. “I remember asking my mom, ‘Why can’t we take them home for dinner for just one night?’”

Following in her mother’s footsteps, Ms. Davis is now director of Green Hill Retirement Community, a nursing home and assisted living facility, and she is determined to make it into a place where residents feel little reason to leave. She has added fish tanks and bird cages, hung pictures on the walls carpeted the corridors, and brought in dogs for pet therapy.

Toni Davis, right, director of the Green Hill Retirement Community in West Orange, N.J., played bingo last week at one of the four Green Houses on the campus.

Still, the nursing home looks like… a nursing home. “No matter what you do, you can’t get that homelike feeling in an institution because it’s too big,” she said.

So now Ms. Davis, along with two dozen other nursing home operators across the country, is trying something different. This year, behind two large institutional buildings on the Green Hill campus, she has opened four small Arts and Crafts-style houses for elderly residents.

Just 10 residents live in each so-called Green House, which looks nothing like a traditional nursing home. The front door opens onto a large living and dining area; on one side is a hearth surrounded by upholstered chairs, and on the other is a long communal dining table where meals are served. An open kitchen faces the table, so caregivers can chat with elderly residents while preparing meals.

Private bedrooms and baths surround the main living area. The house has a front porch and back deck with tables and chairs. There are no corridors, no nursing stations, no medicine carts (each room has a locked cabinet containing the resident’s medications) and no trays of food delivered to the rooms.

There are 117 Green Houses across the United States now, part of a quiet but intriguing effort to de-institutionalize elder care. The movement has its roots in the 1987 Nursing Home Reform Act, which declared that residents of long-term care have the right to be free from abuse or neglect. Nursing homes across the country have tried a variety of strategies to become more “resident-centered.”

“It’s happening all over the country, in a lot of different models,” said Sarah Wells, executive director of the National Consumer Voices for Quality Long-Term Care, an advocacy group based in Washington.

The Green House concept is the most comprehensive effort to reinvent the nursing home, experts say — including the way medical care is delivered. In traditional nursing homes, employees typically have narrowly defined jobs: Some give baths, some cook, some do laundry. It’s a system based on efficiency that tends to ignore individuals’ preferences and needs.

In a Green House, each home is staffed with two certified nursing assistants who perform all of these jobs, but for fewer residents. In addition, one registered nurse typically supports two or three houses.

“If you have one person doing everything, they can spend more time with the residents and get to know somebody as a real person,” said Robert Jenkens, a director at NCB Capital Impact, a nonprofit community development finance institution that has partnered with the Robert Wood Johnson Foundation to provide consulting and loans for organizations developing many Green Houses.

“You’re also less locked into a rigid ‘wake, meal, bath’ schedule, and you can reorganize someone’s day based on her preferences,” he said.

If nurses’ aides aren’t feeling rushed to dress and bathe residents, the thinking goes, they’re more likely to let them perform more of these tasks themselves, fostering independence.

Erika Dickens, a certified nursing assistant, worked in the traditional nursing home at Green Hill for 20 years but recently was transferred to the new Green House.

“I used to feel like my hands were tied. I had to get the elders out of bed at a certain time, even if they didn’t want to,” she said. “Now if someone doesn’t want to get out of bed for breakfast one day, I’ll bring her a milkshake.”

The notion that elder care should be de-institutionalized is a popular one. According to a poll released in September by NPR, the Robert Wood Johnson Foundation and the Harvard School of Public Health, 82 percent of pre-retirees (adults over age 50 who have not retired but plan to) and 78 percent of retirees are somewhat or very concerned about being in an institutional environment that is not as comfortable as a home.

“Loneliness, helplessness and boredom are the three plagues of nursing homes,” Mr. Jenkens said. “Arguably, much of the institutionalized practice induced this.”

Still, it’s not clear that the Green House model can be widely duplicated. Though the day-to-day costs are no greater than those of larger nursing homes, the homes are typically built in clusters of two or more and require comparatively large initial capital investments. “It would increase long-term costs if it were implemented to replace every nursing home in the country,” said Dr. Catherine Hawes, director of the program on aging and long-term care policy at Texas A&M Health Science Center.

Perhaps more important, whether the Green House model improves care for the elderly, compared with institutional settings, is not known. Several small studies, none particularly rigorous, have found that Green Houses deliver similar care for no more money than traditional nursing homes. The homes do this largely through reducing supervisory positions and training certified nurse assistants to take on more responsibility.

Green Houses also have a lower vacancy rates than conventional nursing homes, and they accept patients on Medicare and Medicaid, making them an option for low-income elderly. On average, about 54 percent of Green House residents are on Medicaid, while the rest pay for the care privately.

Residents of Green Houses experience fewer bed sores than those in conventional nursing homes, according to one survey, and each day they get 24 minutes more of direct and personalized care and 1.5 hours more of nursing staff time than those living in traditional nursing homes. Residents say they feel like they have deeper relationships with the staff, and family members report higher satisfaction with the physical environment, privacy, their own autonomy, health care and meals. Employees, too, report less stress. The turnover rate is significantly lower than in a traditional nursing home. Green House certified nursing assistants are paid on average about 5 percent more than those in institutional settings.

Even if this model of elder care turns out to be impractical on a large scale, Ms. Wells said, “we can learn a lot from what the Green House is doing and can translate these methods into things that existing nursing homes can use.”

Many residents and their families find the Green House to be a substantial improvement over standard nursing home care. Diane LoCicero moved her 88-year-old mother, Evelyn, from the traditional nursing home into one of Green Hill’s Green Houses this year. Her mother is far more relaxed now, said Ms. LoCicero, and she actually enjoys visiting the place.

“Before, it was like a hospital and I hated to visit,” Ms. LoCicero said. “Now, I’ll stay here for hours.”

On a recent day in September at Green Hill, Jane Larkin, 82, a retired home economics teacher who suffered a stroke in 2007, sat in her wheelchair at the long dining table and marveled at the differences between this residence and the traditional nursing home in which she’d once lived.

“There’s more opportunity to be social here. We can get outdoors easily, and people like to visit more,” she said. “Sometimes, I give the girls advice when they’re cooking, like I’m their teacher. There was no opportunity to do that in the other place, because we were isolated in our rooms.”

By Dan Frosch

Ron Lennon stands outside his home at the Palms of Manasota in Palmetto, Fla. Mr. Lennon is the president of a homeowners' association in his gay and lesbian retirement community, which has had some of its properties taken over by a bank.

SANTA FE, N.M. — Like so many others who have settled here, Janice Gaynor and her partner, Barbara Cohn, wanted to retire somewhere where they could be themselves, whether that meant holding hands in public or making decisions about each other’s end-of-life health care.

Barbara Cohn, left, and Janice Gaynor at home in Santa Fe, N.M. Ms. Gaynor said the RainbowVision retirement community, which has filed for bankruptcy protection, “was our safety valve.”

These days, that promise is all but forgotten. RainbowVision has filed for Chapter 11 bankruptcy protection, racked by financial problems and an increasingly bitter dispute between residents and management. Its problems mirror those of many other gay retirement communities around the country that have either failed to open or fallen on hard times, victims of a weakened housing market, a deflated economy and, in some cases, poor business decisions.

They were once hailed as havens where the so-called Stonewall generation — the first “out” group of senior citizens — could age without being treated with hostility or forced back into the closet. But such communities in Austin, Tex.; Boston and in the Phoenix area never opened because of a lack of finances and a decline in real estate values. A development near Portland, Ore., is struggling at 25 percent of capacity, and another near Sarasota, Fla., has, like RainbowVision, filed for bankruptcy.

“It’s very concerning to see places like RainbowVision having trouble, both because older people need them and because they’re an important community institution,” said Michael Adams, executive director of Services and Advocacy for G.L.B.T. Elders. The group, which is known as SAGE, is pushing for improved housing options for elderly gay men, lesbians, bisexuals and transgender people.

Many are growing older without the support of children or extended family members. Gay and lesbian seniors are twice as likely to live alone, according to SAGE. A 2010 report by the group also found that nursing homes often failed to protect gay men and lesbians from hostile treatment by staff or other patients. In a study released in April by the National Senior Citizens Law Center, many older gay men and lesbians and their family members reported instances of mistreatment at long-term care centers. The study also noted that social service providers said it was unsafe for residents to be openly gay at such facilities.

Potential residents of retirement communities, however, may be less inclined to sell their homes and move away during tough economic times. And because developments for older gay people have emerged only within the last 15 years or so, they may not have the financial reserves to weather an economic crisis, Mr. Adams said. As a result, housing options tailored to the estimated 1.5 million elderly people in the United States who are gay are especially limited.

Before buying a condominium at RainbowVision, Ms. Gaynor, a former school administrator, toured a traditional retirement community in Florida, but left with the distinct feeling that she and Ms. Cohn were not welcome.

The fear of suddenly being hurled back into a world that is not always friendly has divided residents at both RainbowVision and the Palms of Manasota, a small community near Sarasota on Florida’s Gulf Coast whose developers filed for Chapter 7 bankruptcy last year. A local bank foreclosed on unfinished buildings and a number of empty units at the Palms, and there is uncertainty about who will buy the foreclosed land.

“There was a lot of contentiousness, and the bank hasn’t given any indication on what they plan to do,” said Ron Lennon, president of one of two homeowners’ associations at the Palms. He said his support for the bankruptcy angered fellow residents who feared what could happen to the community. “There are still people here who won’t talk to me.”

For those who have invested, both emotionally and financially, in retirement communities that never got off the ground, the prospect of having to drastically change their plans is daunting.

Alice Fisher, a retired caterer, is weighing her options after plans for Boston’s first retirement community geared toward gay people were abandoned in 2008 after a major investor dropped out.

Ms. Fisher, 70, lost her $10,000 investment in the community. The developer, Stonewall Miner LLC, has since filed for bankruptcy. Ms. Fisher, who is single and owns her home, is contemplating moving into a rental for the first time, or to another retirement community.

“I thought it was really, really too bad,” she said. “This felt important because it felt like we were the last generation who were going to be able to do something like this because the economy has changed so much.”

Mr. Lennon supported the development's bankruptcy filing. “There are still people here who won't talk to me,” he said.

The battle at RainbowVision has unsettled the once-harmonious group of about 100 residents, about half of whom are straight. It involves reduced services and the steeply rising monthly fee for use of a popular common building that includes a restaurant, a salon and a gym. The fee increase has strained the finances of some of the residents.

RainbowVision’s chief executive and president, Joy Silver, said that the cost of running the community had skyrocketed and that the flailing economy had slowed leasing activity for the community’s condominiums.

Many condo owners, including Ms. Gaynor and Ms. Cohn, began refusing to pay the common building fee and have been banned from using the building.

Ms. Silver, who founded RainbowVision with help from other investors, attributed much of the ill will to speculators who bought units but never lived there. “What’s difficult is watching people who are full of fear worry about what’s going to happen to them and watching them go through the challenges of aging,” she said. “If it were up to me, everything would be free. But that’s not pragmatic or realistic.”

In June, an arbitrator in the dispute between residents and the management decided that though RainbowVision had not broken any laws, it was overcharging residents based on the services it was providing. (An attorney for RainbowVision responded that the arbitrator had not taken into account how expensive it had become to operate the community.) In the bankruptcy court filings, RainbowVision’s lender described the atmosphere at the community as “terrible and openly hostile,” and called for the management to be replaced.

“Every one of us had this starry-eyed vision of what we thought RainbowVision was going to be, and we thought we were working toward a common goal,” said David Garrity, 62, who also stopped paying the disputed fee because of the lack of services.

Mr. Garrity, who has not fully moved into his condominium yet, said he had overlooked red flags about the company’s finances because he was excited to be part of a project he called “a dream” for gay men and lesbians. “Here we are, the victims, victimized by their own,” he said.

Not everyone here has sided against RainbowVision’s management. John Wojtkowski, who is disabled, has been renting there since the summer and praised the company for being responsive to his needs.

But Mr. Wojtkowski, who worked on Wall Street for nearly 30 years, said he was worried. “We used to kid around when we were younger and say, ‘Are we just going to sit around on a porch?’ There was no place for us,” he said. “I don’t hide the fact that I’m gay. When I came here, I felt like I could be myself.”

“I don’t want to go back in the closet again,” he added. “Without RainbowVision, there’s no other place to go.”

By Brian Johnson

Welsh Cos. and Walker Methodist hope to break ground this April on a downsized senior housing project in Blaine. (Submitted rendering: Welsh Cos.)

“We have reduced the size and scope of it for one purpose: We know we can finance this,” Bob Erickson, senior development associate with Minnetonka-based Welsh Cos., said at an Oct. 20 City Council meeting.

The current $13.5 million project, which Welsh is developing with Minneapolis-based Walker Methodist, was scaled down from 142 units to 84 units.

In a separate interview, Erickson said an 80- to 100-unit project is “becoming the industry standard” as opposed to larger projects. In the current market, he said, banks are less willing to take a chance on big projects that might be sitting with vacant units. “That is pretty universal in the Twin Cities now,” he said.

But it’s not just that financing is hard to come by in a difficult economy.

Independent living units are filling up less quickly than the more need-based products such as assisted living, in part because buyers in the independent living market are able to delay their decision to move, said Bill Kauffman, managing director of senior housing for St. Paul-based Oak Grove Capital. And during hard times for residential housing, buyers may choose to do just that if they are having difficulty selling their homes.

“I would not be surprised that a developer is scaling back plans, particularly if they have a component of independent living,” Kauffman said. “And it’s not just in the Twin Cities; it’s all over the country.”

The Blaine project, which has been in the works for three years, got a one-year extension on plan approvals from the City Council last week. Welsh and Walker Methodist hope to begin construction in April.
The 125,000-square-foot facility will bring 34 skilled nursing units, 16 memory care units and 33 independent living units, along with a guest suite, to a site near 125^th Avenue and Jefferson Street in Blaine.

Developers are “being a little more cautious,” said Mary Bujold, president and director of research for Minneapolis-based Maxfield Research. “And of course bankers are being conservative as well. So [the smaller scope] is probably a combination of those two things.”

Lending requirements, including down payments in the range of 20 percent or more, “have increased dramatically,” Bujold said. “It’s a lot more difficult than it was before.”
About 688 senior housing units are recently completed or under construction in the seven-county metro area, she said.

Patty McCullough, principal of Health Planning & Management Resources Inc., an Edina-based market research company, said downsized projects are “sometimes the solution” in tough economic times.

“I think that there have been a number of projects that have been scaled back or are being done in phases, and it mostly relates to financing,” McCullough said in an email to Finance & Commerce.

Moreover, Kauffman said, senior housing operators are finding that those who move into assisted living facilities tend to be older and frailer than they were in the past — a sign that they are putting off the move as long as they can.

Blaine officials say the facility will be the first in the city to offer “skilled nursing” beds.

“The 34 skilled nursing beds is something we don’t have, so we are anxious to see it happen. And we believe there is a strong need for it,” said Bryan Schafer, Blaine’s community development director.

Erickson said there’s no question about the demand for senior housing in Blaine, particularly the skilled nursing variety. Anoka County is “the most under-bedded skilled nursing county in the state,” he said.

In 2009, the city approved plans for the larger project proposed by Welsh and Walker Methodist. On Oct. 20, the city extended approvals for the 84-unit proposal.

Erickson said at the council meeting that he still sees market demand for the more ambitious project, but the development team “came to the conclusion and simple reality that it’s just not feasible in these difficult economic times.”

Schafer said the property includes sufficient land for future expansion, and Erickson left the door open for that to happen.

A second phase with 30 more skilled nursing beds could happen as soon as two years from now, and an additional phase “beyond that” is anticipated as the market dictates, Erickson said.

Erickson said the downsized plans won’t sacrifice any amenities.

“It’s just the sheer size of the project, going from four stories to two stories,” he said.

Ziegler, a specialty investment bank, is pleased to announce the successful closing of a $62,200,000 fixed-rate issue for Episcopal Senior Communities (ESC). ESC is a California non-profit public benefit corporation providing housing, related facilities, and services for elderly persons on a non-profit, religious, and charitable basis.

ESC was founded in 1965 with the opening of its first CCRC in Pacific Grove. Today, ESC’s obligated group is comprised of five continuing care retirement communities in Northern California and is rated BBB+ by Standard & Poor’s.

The Series 2011 Bonds are being issued to 1) refinance the outstanding Series 1998 Bonds and 2) fund the reimbursement of approximately $10 million of capital expenditures related to the planned repositioning and expansion of ESC’s Spring Lake Village CCRC. The refunding of the Series 1998 Bonds and maturity extensions are part of an overall plan to reduce maximum annual debt service in preparation for the Spring Lake Village Project financing in 2012.

Ziegler is one of the nation’s leading underwriters of financing for non-profit senior living providers and offers investment banking, financial risk management, merger and acquisition services, investment management, seed capital, FHA/HUD, capital and strategic planning as well as senior living research, education, and communication. Mary Munoz, Managing Director in Ziegler’s Senior Living practice, commented, “ESC is among the highest rated and strongest multi-site senior living systems in the country. It is an honor to help them take the next step toward achieving their growth and redevelopment goals.”

For further information on this issuer, please see the Electronic Municipal Market Access system’s Document Archive.

For more information about Ziegler, please visit us at www.Ziegler.com

By Paula Span

Chuck Castro, 68, a woodworker whose art is shown at the Geezer Gallery in Portland, Ore.

Amy Henderson knew the name she chose would be provocative. She was opening an airy 1,400-square-foot space in Portland, Ore., for artists over age 60, and she christened it the Geezer Gallery.

“It’s memorable,” she said. “It’s edgy. Laughing at oneself is a sign of maturity.” I wonder, not for the first time, why so manysmart ideas about aging originate in the Pacific Northwest.

About 60 older artists have been selected to display their work — paintings and prints, sculpture, photography, furniture, jewelry, ceramics — at the gallery itself. But there are many others who lend their art to traveling shows that visit retirement communities or exhibit at local businesses.

“There are so many older artists who found their passion after they retired,” said Ms. Henderson, probably one of the world’s few interior designer-turned-gerontologists. “They’re talented. They want to show their work and be appreciated.”

The Geezer’s exhibitors include Frank Springer, who takes a motorized stairglide to his basement kiln each morning to produce plates, bowls and vases of fused glass. Mr. Springer, a retired vice cop, is 99. Madeline Janovec, a lifelong artist at 76, shows huge, abstract monotypes in brilliant colors; her friends were happy to see her at a benefit for the gallery recently, finally done with chemotherapy for lymphoma. And LeRoy Goertz, a former social worker in his 70s, creates large-scale bronze sculptures.

When their art sells, the creators receive 60 percent of the price; the remainder finances free art workshops and art therapy programs, staffed by licensed professionals, for low-income seniors. The Geezer is offering a popular hat-making workshop at a senior center in suburban Tualatin this week, for example, followed by a three-week workshop in printmaking at a continuing care retirement community called Mary’s Woods and a six-week art therapy program at the gallery.

Ms. Henderson has seen too many facilities, she said, where “people sit around and watch TV and there’s no creative stimulation.” She particularly wants to bring art to homebound elders in Portland’s many small adult foster care residences (much like board and care homes or small-scale assisted living elsewhere).

That will require more money than individual art sales can produce in a soft economy, even when the gallery space itself is donated. So the Geezer is applying for grants and cranking up efforts to interest corporations in buying its art for offices and lobbies. Meanwhile, Ms. Henderson, who is 40, said she’s been working without a salary for two years and getting a bit tired of it.

But she’s otherwise unflagging. “When older adults participate in ongoing, professionally led art programs, they reap physical, mental, social and spiritual benefits,” she said. “Memory improvement. Fewer falls. Less depression.

“Art is really preventative medicine.”

By Adam Clark

Country Meadows Retirement Communities, which already has two locations in the Lehigh Valley, is looking to expand to Forks Township.

A facility similar to the ones in Upper Macungie and Bethlehem townships is planned for a 37-acre open field near of Newlins Road East and Richmond Road, said David Leader, Country Meadows chief operating officer.

The township passed a new zoning ordinance last month allowing a continuing care facility as a conditional use in the township’s employment center zoning district.

The ordinance defines a continuing care facility as a residential facility designed to house people older than 65 whose health requires special services and support available on site. The facility must be made up of two or more of the following premises: nursing home, assisted living residence, personal care home and independent living facility.

A facility would be allowed a maximum of 250 dwelling units with no more than two beds per unit. Parking requirements are one space for every two full- or part-time employees, one space for every two residents and one visitor space for every five dwelling units.

Forks drafted the ordinance after Country Meadows presented a preliminary sketch plan, township zoning officer Tim Weis said. Weis called a continuing care facility a perfect buffer between the employment center district, which also allows manufacturing and commercial use, and nearby residential districts.

Leader said he wasn’t sure if the purchase of the land has been finalized yet, but expects the sale to be closed within the next two weeks.

Country Meadows hopes to start development in 2012, Leader said, but still must present land development plans to the township in order to secure approval for a facility. The plans would also be the subject of a public hearing.

By Patrick Egan

This fall, my father sat down for a semi-annual assessment with staff members at his assisted living facility in Tinton Falls, N.J. They decided his condition — at 72, he has advancing Parkinson’s disease — necessitated an upgrade to the next level of care.

The meeting yielded an upgraded bill, too: a nearly 18 percent bump, about $12,000 a year.

Most assisted living residents foot the bill on their own or with help from family. Cost increases typically come in two forms: annual upticks to cover rising expenses, and more significant hikes accompanying a move to the next tier of care, such as help with bathing or dressing.

The annual rises can be daunting enough. The MetLife Mature Market Institute recently reported that assisted-living costs climbed 5.2 percent from 2009 to 2010, to a national monthly average of $3,293, outpacing both inflation and the interest earned on savings and bonds — a problem for the elderly on fixed incomes.

But add a more expensive service package, and the bill can become prohibitive. And as the costs soar, relations between families and the facilities caring for elderly relatives can sour, said Miriam Oliensis-Torres, who runs a geriatric care management firm, Geriatric Support/Pathway Care, in Milwaukee.

Sometimes the reasons for the new status can be apparent, as when a resident becomes incontinent. But the decision can also seem arbitrary. If they disagree with it, residents and their families have to work at maintaining quality care while simultaneously challenging the policies of the institution providing that care. It’s a tricky balance.

The institutions often urge families to approach assisted living a bit more realistically. “It’s important for people to remember that their loved one is moving into assisted living because they need services,” said David Kyllo, executive director of the National Center for Assisted Living. “They’re not moving in because of a change in address. It’s needs-driven.”

Those needs can change quickly. Residents average just 28 months in assisted-living facilities, and their health almost always declines.

Such deterioration may shock the family; the consequences don’t have to. Families should know ahead of time what will happen, and when, as a resident progresses through care levels.

“In my experience, families at the time of admission are pretty stressed,” said Ms. Oliensis-Torres. “It’s really worth their while to step back and say, ‘Explain this contract in plain English.’ ” Lawyers often prove helpful by reviewing a contract prior to moving in, she added.

Still, even due diligence won’t prevent genuine dissent over appropriate care. When the effort of managing an elder’s care threatens to overwhelm a family, professional expertise, though expensive, can pay off. An external review of the new price structure by a geriatric-care manager may lead to a money-saving solution.

Typically, a geriatric-care manager gathers information about the resident’s needs and abilities and the types of changes he or she is experiencing. Hourly rates range from $80 to $200, varying by geographic location and service type, said Linda Fodrini-Johnson, board president of the National Association of Professional Geriatric Care Managers. Ms. Oliensis-Torres estimated that a review typically requires three to five hours.

Don Heape turned to a geriatric-care manager for help with his eldest sibling, Marcella Festner, after she entered assisted living more than two years ago. (She died this summer.) Ms. Festner, 80 at the time, lived in Laguna Woods, Calif.; Mr. Heape lives hundreds of miles north. With another brother and sister helping, the family found a place that looked nice (the dining room had a maître d’) and fit their budget.

“When they first sign people up, it’s affordable, it’s doable,” said Mr. Heape. The rent started around $2,200 a month. After a few months, however, the facility upgraded Ms. Festner’s care level, and the rates reached $4,000. Her health had declined, he conceded, but he felt the facility was aggressive in its care assessments and billing.

One issue particularly rankled: The facility insisted on having staff members supervise Ms. Festner’s insulin injections, which added to her tab. Yet Ms. Festner, a diabetic for 30 years, had given herself thousands of injections.

“It was such a subjective approach,” said Mr. Heape. “But you’re dealing with a corporation, and their assessments are weighted in favor of the company.” With a geriatric-care manager, he succeeded in appealing one price increase.

While a reputable geriatric-care manager can bring a wealth of experience to the table, not everyone can afford one. As an alternative, Ms. Oliensis-Torres suggested getting in touch with a state ombudsman for long-term care.

She also recommended bringing a friend or family member, especially one who’s been through a similar situation, to meetings at the facility. “When people are under stress, they don’t always hear all the questions or process the answers,” said Ms. Oliensis-Torres.

It’s vital, she added, that family members attend regular care planning meetings (my father normally has two per year), especially in the aftermath of a setback. “After a blip in health status, you should ask for a care conference every two weeks to see if you can ratchet the fees back down,” said Ms. Fodrini-Johnson.

In my father’s situation, we disagreed with the facility’s new assessment. We prepared our argument and appealed on our own (my sister is a social worker, and her skills proved invaluable). The chief nurse listened, in the end reversing the decision. With $12,000 at stake, we had plenty of reasons to make the case.

By Philip Moller

Making the decision to enter a full-service, continuing care retirement community (CCRC) may not be easy. It can be triggered by the conclusion, often reached with reluctance, that keeping up the old homestead is just too much work. Then there’s the process of selling and moving out of a place that may hold decades of precious memories, plus lots and lots and lotsof stuff. Selling a home these days is no snap, either. Entrance fees at CCRCs can be steep. Most people pay between $250,000 and $400,000. On top of this, monthly fees for meals, upkeep, and other services can easily run from $3,500 to $6,000 per couple.

So, there is a lot on the line. And often there’s a lot of family pressure. As older people move into their late 70s and early 80s, sons and daughters get worried. The decision to seek an institutional housing solution may be accelerated by emerging signs of frailty and cognitive impairment. Sure, you still can live independently. But maybe it’s not such a good idea to be dealing with stoves or handling knives and other cooking implements. A CCRC may be a godsend not only for new residents but also their family members, who may have become increasingly involved caregivers over the years.

Plus, haven’t some CCRCs had serious financial issues? Didn’t a big company file bankruptcy? Yes, Erickson Retirement Communities did so last year but residents did not lose their entrance fees and a new company now owns its communities. And wasn’t there a government report about industry problems? Yes, the U.S. Government Accountability Office issued a report on CCRCs earlier this year. It cited problems at several communities in an industry that is largely regulated by the states. But CCRC supporters note that having a few issues in a universe of more than 1,850 communities may actually represent a pretty good performance record during a once-in-a-lifetime downturn in the economy and real estate values.

To simplify a tough set of decisions, break the process down into smaller pieces. The first three questions you need to answer about moving into a CCRC require little direct knowledge of these communities:

1) Is it time for you to make the move? The average age of new entrants to CCRCs has been creeping higher and is now about 82 years. That’s mostly the result of a good trend — people are staying healthy into much later ages and thus defer the decision to move into a community setting.

2) How much money will you have to support yourself in a CCRC? This does require some knowledge of the services covered by CCRCs in general and by a specific community in particular. Most CCRC contracts generally cover an apartment or cottage, housekeeping services, at least one meal a day, exercise and activities, and lifetime medical care. The degree of care and possible out-of-pocket costs can vary among CCRCs, so details about services and required health insurance are important to understand.

3) Where in the country do you want to live? There are CCRCs all over the place. This location decision often reflects the desire to be near family and friends.

Once these questions are out of the way, there are many specific questions about a community’s facilities, its residence packages (increasingly, CCRCs offer multiple plans), staffing and resident support levels, and financial resources.

Before asking these questions during a visit or information call, there is a very helpful annual report on the CCRC industry that is prepared by a major trade group, the American Association of Homes and Services for the Aging, and a major consultant and investment adviser for CCRCs, Ziegler Capital Markets.

Their annual guide surveys the largest CCRCs in the country and provides helpful industry trends as well as a detailed statistical look at individual communities. This data provides a useful set of operational benchmarks on situations a typical consumer would be hard pressed to know — staffing levels, size, financial strength, management stability, and the like.

Here are some of the most important benchmarks that can guide your fact finding at a specific community:

Among the CCRCs with the most living units (spread over multiple locations), the average long-term debt per unit was $74,750 in 2009 and $73,909 in 2008. Spreading long-term debt only over a system’s independent living units — which generate most CCRC revenues — average debt was $181,565 in 2009 and $177,205 in 2008. Because a CCRC has to have enough money to provide services, pay staff, and service its debts, its debt load can be a key measure of its financial viability.

Average revenues per unit for the 25 biggest systems was $54,011 in 2009 and $53,600 in 2008. For independent living units, it was $184,205 in 2009 and $155,623 in 2008.

Among the 100 largest systems covered by the report, the average CCRC had 2,213 residents in 2009 and 1,257 staff members (expressed as full time equivalents). This worked out to 57 employees per 100 residents. That’s a key service ratio, although you need to also ask about a particular CCRC’s services and staffing duties to better understand its staffing ratio. Also, keep in mind that these figures cover all campuses that a single system operates. You’ll need to find out more about the specific campus you are considering. Generally, the bigger systems have lower staff-to-resident ratios.

On average, the CEOs of the 100 biggest CCRC systems had been in their jobs an average of nearly 10 years at the end of 2009. The average tenures for chief financial officers was nearly 7.5 years, and it was 5 years for chief operating officers. Management stability can be another important measure of the quality of a CCRC’s oversight.

The report also provides details on the types of living units at each CCRC, including independent living, assisted living, nursing home care, and memory support units for people with Alzheimer’s or dementia.

By Monica Staton

Many of America’s middle-class has concerns over where they will spend their golden years. In the past, those who could afford it would move into continuing care facilities, many of which resemble resorts.

Today, however, with a failing economy, and internal problems cropping up within some of the communities, these same individuals are thinking twice before making that commitment.

At the present time, there are nearly two-thousand continuing care facilities in operation in the US. Nearly one-million people are currently residing in these communities. Most communities are run by non-profits, but some are profit-driven and owned by private corporations.

At issue at this time are the fees that are charged by some facilities. These are called entrance fees and they can easily run into the hundreds-of-thousands of dollars. The Government Accounting Office (GAO) has begun looking into complaints from several buyers and family members of buyers.

The GAO findings concluded that some facilities may be using entrance fees to pay for debts or to pay for costs associated with operating the facility. This is not the intended purpose of these fees, which are normally held in escrow and refundable if the person moves from the facility.

The concern is that the money may not be available for those who decide to move. State regulators are also expected to begin their own investigations. This may lead to new regulations.

By Elizabeth Olson