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Not A Primary Concern

Dr. Gina Luciano

Dr. Gina Luciano says there are many reasons why medical-school students are shying away from primary care, but she finds the specialty rewarding on many levels.

The problems causing a nationwide shortage of primary-care doctors — ranging from pay to prestige — are well-documented. Perhaps lesser-known are the reasons why medical students do choose this challenging, multi-faceted niche of medicine. Several young, local doctors have plenty to say about why they took the primary-care path at a time when a growing, aging population needs them most.

When asked about why students in medical school are shying away from careers in primary care, Dr. Gina Luciano was ready with an answer that would indicate she’s addressed that question more than a few times.

And she has.

That’s because, as co-director of the Primary Care Residency Track at Baystate Medical Center, the Springfield area’s only teaching hospital, she has chosen that field, she instructs those who have done the same, and, well, she promotes it as not merely a highly rewarding specialty, but one that is obviously critical within the broad healthcare system.

As for that answer … it comes it two parts basically, the first having to do with finances, and the second focusing on what she called the “culture of medicine.’ And they both help explain what most consider to be a problem and others are calling a crisis when it comes to attracting people to primary care.

“When most students graduate from medical school, they are hundreds of thousands of dollars in debt — I’ve had friends who are close to half a million dollars in debt by the time they graduate,” she noted while addressing the former. “And when you look at how people are paid, primary care physicians are near the bottom when you compare it to other specialties. So if you’re hundreds of thousands of dollars in debt, you may not want to go into primary care from a financial perspective.”

As for the latter, “many students and many residents, especially those who are excellent students, will be pushed to go into the most competitive fields,” she told BusinessWest, putting cardiology, gastroenterology, and other specialties in that category. “People will actually say to a year-two resident things like ‘why would you want to go into primary care? You’re so smart, you could go into ‘x’ or ‘y.’ I think there’s some sway from mentors and advisors in some institutions to go into something, quote, more competitive, unquote.”

As things turned out — although the decision certainly didn’t come easily, and, in fact, not until after she completed her residency at Baystate, one that included considerable work at the system’s High Street Health Clinic in Springfield, among other facilities — none of the above really mattered, or mattered enough to dissuade her from following what her heart told her she should do.

“The reason I chose primary care was because I realized that what I valued in my work was a continuous healing relationship with patients,” she explained. “I had developed these very important relationships with patients I had at High Street, and for me what’s most joyful about medicine is seeing people progress over time, and really understanding them — not just their health problems, but their whole person.”

Using that word relationship and the term whole person, or words to that effect, both early and often, other young doctors currently in or recently graduated from Baystate’s Primary Care Track, talked about why they chose the same career path as Luciano.

Dr. Kathryn Jobbins was actually roughly half-way through a residency in general surgery at the Cleveland Clinic, when she decided to not only switch gears career-wise, but return to the area where she grew up and the hospital where she worked years earlier.

“I thought I wanted that fast pace, but I missed talking to patients — and I missed my parents,” she said of her decision to begin another residency, this one in primary care, at Baystate. Fast forward more than three years, and she is now the internal medicine chief resident at Baystate and thus an instructor. Which means that, like Luciano, she splits her time between teaching and taking care of a number of patients at High Street, and, also like Luciano, greatly enjoys both aspects of her job description.

Among those she works with is Dr. Nicolas Cal, a second-year resident in the Primary Care Track who started down a path to be a neurosurgeon, but after some deep soul searching, changed course toward internal medicine, and specifically primary care.

“I decided to be 100% honest with myself … I didn’t think that neurosurgery was going to make me a very happy person 20 or 30 years from now, so I decided to change to primary care,” he said, adding that he has no regrets about that decision.

Dr. Kathryn Jobbins

Dr. Kathryn Jobbins says working in primary care offers a unique opportunity to work with patients over the course of many years, even decades.

Nor does Dr. Amulya Amirneni have any about hers. The native of India who immigrated here when she was 9 and later returned to her homeland for medical school, said she enjoys the very personal nature of primary care medicine, and said it amounts to “treating someone as an individual, as a person, and not as a disease.”

For this issue, BusinessWest talked with these young doctors about their decision to pursue a career in primary care, and about how and why they won’t be part of any problem or crisis in this field.

Course of Action

As she talked at length with BusinessWest, it became clear that Luciano has become as versed in talking about why she chose primary care as she is in explaining why increasing numbers of young people choosing to become doctors are not.

The relationship factor has a lot to do with it, she explained, noting again, that people in this field get to see the same patients over a span of years, if not decades, rather than perhaps a few days or even hours for those in other specialties. And thus they get to know those patients, and, as she said, the whole person.

“You get to see how their socio-economic background fits into their health, and how their family fits into their health, and how their culture fits into their health,” she explained, adding that the High Street facility, and Baystate Health in general, treat a wide demographic group and many challenged populations.

But there are several other aspects to this field that appeal to her, especially the variety of the work.

“The other reason I really like primary care is that it’s extremely broad,” she went on. “The pathology I see is really quite phenomenal; I see a variety of medical conditions at any given time.

“We have patients who have lived in the United States their whole lives, we have patients who have recently immigrated … this specialty really gives you the whole gamut of medicine,” she continued. “I enjoy that broad flavor.”

She also greatly enjoys teaching, and that’s why roughly half her time is spent seeing a portfolio, or panel, of perhaps 200 patients at the High Street facility, and the other half is spent helping young doctors navigate the three-year primary care residency track, which is part of the larger internal medicine residency.

There is room for 12 students in the program, or four a year, and there are currently seven enrolled in it, a number that speaks to the popularity of primary care, or lack thereof, said Luciano, adding that those who enter it understand those issues she detailed earlier, especially those involving finances and student loans.

But the doctors we spoke with said their choice has to do with passion, not money or prestige.

“I didn’t become a doctor for money … I became a doctor because I’m a bit of a science nerd and I like helping people,” said Jobbins, who probably spoke for everyone with those comments.

And that passion is a necessary ingredient in overcoming still another potential deterrent to those considering possible career paths within health care. Indeed, Luciano said those who enter a primary care track like Baystate’s often wind up working in residency clinics like High Street, which serve what she described as challenging populations for young doctors.

“Residency clinics have historically been places that have limited resources, the patients are disadvantaged, there’s a lot of pathology — there’s just not a lot of support for those patients,” she explained. “It’s generally Medicaid and Medicare patients, and taking care of those patients can be very tricky and challenging. So I think it’s very difficult for a resident who’s just starting out to navigate that system, but also to see how patients get better over time.

“It takes a longer time to see how you’ve had an impact,” she went on. “It’s much easier to be in the hospital and have someone come in to the hospital; you treat them, they get better, they leave — it’s much easier to see the impact that you’ve had on that patient. You don’t necessarily get to see that if you’re in a residency clinic.”

Dr. Nicolas Cal

Dr. Nicolas Cal transitioned into primary care after deciding that neurosurgery was not going to lead to the rewarding career he desired.

Jobbins agreed, but said she’s been motivated and energized by those challenges, and finds working in the High Street facility quite rewarding, and also intriguing.

Indeed, she said she’s very limited when it comes to Spanish, and doesn’t really know any of the other languages she encounters there, including Vietnamese, Chinese, and Nepalese, but has become quite adept at working with an interpreter in the room.

“I love the interpreters, and they do a great job,” she explained. “They do it almost live action — they’re talking while I’m talking. Some of my best relationships are with Hispanic patients, and we establish that through an interpreter.”

Overall, she’s looking forward to the prospect of treating the same patients for maybe 20 or 30 years, caring for them and being with them as different chapters in their lives unfold. And she said she’s already had a taste of how rewarding that can be.

“It’s wonderful, really,” she explained. “And it’s something you don’t really expect until someone stands up and hugs you or says ‘I just got my green card,’ or ‘my daughter is getting married.’ You see this very intimate snapshot into their life, which is very rewarding and a big part of why I decided to stay in primary care.”

Motivating Factors

And it is the unique nature of the primary care track, one that exposes residents to sub-specialists in their offices and teaches them not only about a wide range of medical conditions, but also teamwork and how and when to refer, that prompted her to pursue a teaching component through chief residency.

In that role, which she chose rather than moving directly into private practice, she serves as junior faculty and attending physician — essentially teaching while still learning.

“I fell in love with the program from an academic standpoint, and that’s why I decided to stay on as chief resident,” she said. “The goal is to do academic medicine with a focus on primary care when I’m done.”

For Cal, a native of Uruguay and graduate of New England Medical School in Maine, the immediate goal is to complete his residency and continue serving patients at the High Street facility.

While doing so, he envisions a career in primary care, hopefully in the Northeast. Like Luciano and Jobbins, he said he enjoys interacting with patients, seeing them over a long period of time, and helping them achieve progress with whatever health issues they may have.

“I love seeing my patients over and over and over again,” he explained. “I like dealing with different disease processes and knowing that I will have the time to follow up on my patient and adjust the treatment options to make the patient healthier.

“For example, yesterday, I had a patient at the clinic, a 34-year-old male, and I had to tell him he had colon cancer,” Cal went on. “As his primary physician and having to set up all the various specialists and appointments that he will have to go through — to me that’s very fulfilling.”

Delivering such news is one of many aspects of the job of a primary care physician, especially one in a setting like High Street, he went on, adding that another is being both “stern and compassionate,” as he helps patients within that constituency to understand various health problems and issues and compel them to take ownership of their own health.

“That’s a fine balance, and sometimes it can be frustrating for the physician knowing the patient may not be listening or fully grasping what will happen if he doesn’t change his habits,” he explained. “Our job is to motivate, and I like that part of the work.”

Amirneni hasn’t had many opportunities to motivate yet, having just started her residency a few months ago, but she said she’s looking forward to the opportunity.

“I definitely enjoy talking to patients and seeing them progress over time,” she said. “I know I’m more or less going against the trend when it comes to primary care, but the prospect of working that closely with patients and making a difference in their lives is what motivates me to stay in this field.”

“I’m really just getting started, so I’m hoping that I maintain that enthusiasm moving forward,” she went on, adding that, like Cal, she sees herself working in an outpatient setting when she completes her residency. “I really don’t think that will be a problem.”

Dr. Amulya Amirneni

Dr. Amulya Amirneni says primary care allows physicians to see their patients progress over time, something not afforded by other specialties.

Having enthusiasm and a desire to work closely with a patient are only a small part of the equation when it comes to the elements that make for a successful primary care physician, said Luciano, adding that these are simply pre-requisites.

“When I interview, I look for people who are compassionate, who are good team players, who want to make a difference in the world, who value relationships, and who want to see a continuous healing relationship with their patients,” she noted, adding that, like the passion that drives one to this specialty, many of those things can’t be taught.

“You can help people develop those skills, but for the most part, you either have them or you don’t,” she went on, adding that this is perhaps another reason why such individuals are in short supply.

Bottom Line

As she talked about her work and why she enjoys it so much, Jobbins said she’ll often challenge young residents thinking about sub-specializing to consider a different career track — hers.

“I’ll say, ‘why wouldn’t you do primary care? This kind of work is great,’” she told BusinessWest, adding that she gets a wide variety of responses to that query, most of them reflecting those two major points of concern that Luciano mentioned.

Whether more people will heed her advice in the years to come instead of following the money or the prestige remains to be seen. For now, there is a problem attracting people to this specialty, and, depending on one’s viewpoint, a crisis.

A solution will be hard to come by, but some young doctors are only interested in being part of one. They say they like forging relationships and treating the whole person.

So they have no primary concerns about their chosen field, literally or figuratively.

George O’Brien can be reached at [email protected]

Business of Aging Sections

Dementia and Will Contests


Talia K. Landry

Talia K. Landry

Most people have had some experience with a family member or friend who suffers from dementia. The term is used broadly to include a wide array of symptoms relating to decline in mental abilities. This often includes deterioration of both short- and long-term memory, along with lessening of cognitive and language skills, reasoning, and judgment.

Dementia can cause extreme stress and frustration not only for the individual affected, but for family, friends, and caretakers as well. Individuals experiencing dementia must often rely heavily on others for tasks they once accomplished independently. Some may even have difficulty communicating their needs and wishes. While the onset of dementia raises many questions related to daily life, it also raises special concerns in the context of estate planning.

It is important to note that, even when experiencing dementia, individuals are still capable of making many of their own financial and estate-planning decisions. The law presumes that we are competent unless a court declares otherwise. The law also recognizes that even individuals with severe dementia can have moments of clarity and lucidity sufficient to make decisions regarding their own affairs.

It is imperative, however, to use extreme caution when a person with dementia embarks upon the process of making or changing their end-of-life plans. In some cases, a dementia diagnosis received prior to executing documents can open the door for challenges down the road.

Consider the following example. Your mother is diagnosed with mild dementia — a diagnosis that appears in her medical records and history. She lives alone, and while she experiences some limited physical and mental decline that affects almost all seniors, she is still fiercely independent, albeit forgetful. Several years, grandchildren, and many happy memories later, she decides that she wants to update her last will and testament, which has not been addressed since her husband’s passing over a decade ago.

Your mother contacts her lawyer and has a new will prepared — one significantly different from the prior document. She leaves her house to your brother, who has helped maintain her home and yard over the years. She leaves you a sum of money equal in value to the house. She makes a decision not to leave anything for your estranged sister, who has not been in contact with her for many years. After your mother’s death, your sister becomes aware she will not inherit, and she decides to challenge the validity of your mother’s will. Although you feel sure that your mother was competent and lucid when she signed her will, the years-old diagnosis of mild dementia has the potential to undo her planning.

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Specifically, the law allows will challenges based on lack of capacity, undue influence, and fraud. If enough uncertainty can be shown, a court may decide that an individual suffering from dementia was not competent to understand what she was signing, or was pressured or tricked into signing it. These challenges can often turn into heartbreaking and protracted legal battles between family members, involving tremendous amounts of time, energy, money, and emotion for all involved.

No one likes to think about their family fighting after their passing, especially over money or personal items. Unfortunately, the courts manage this type of case all too frequently. Many families do not believe a legal battle will ever affect them, but sometimes even the best situations can turn sour. This possibility should be considered in many cases, especially when distribution may not be equal. Many potential heirs may feel that unequal bequests are unfair, and therefore ripe for challenges.

In order to pre-empt or refute possible future challenges, there are several precautions available when an individual with dementia seeks to complete an estate plan. First, it is important to hire an attorney. Forms available online are not ‘one size fits all’ as they often claim, and do not come with the benefit of advice tailored to your unique needs. Not only will an attorney be able to provide specific advice in accordance with the law, but the attorney can also serve as a witness attesting to the individual’s competency and the reasons why there may be a deviation from a previous estate plan.

Second, no one should be present in the room when the individual is discussing their affairs or wishes with their attorney, other than unrelated witnesses and a notary at the time of signing. This protects the proposed heirs and makes it more difficult to challenge a plan on the grounds of undue influence. Third, when capacity may be an issue, it is a good idea to have witnesses prepare written statements the same day, explaining the circumstances and what they observed. Fourth, with permission of course, it may be a good idea to record the meeting, so there is some clear evidence of the elder’s competency and ability to express her wishes at the time of the meeting.

Finally, it is important to keep records, including recent medical records, so there is some written or documentary evidence, should an issue ever arise in the future.

While we can never completely anticipate what will happen after death, taking some of these simple precautions can serve as formidable defense against later challenges, and may help in honoring a loved one’s final wishes.

Attorney Talia K. Landry is an associate attorney with Bacon Wilson, P.C. and is a member of the firm’s litigation department. She assists clients in all areas of litigation, with a specialized focus in probate litigation, including will contests, and other estate disputes; (413) 781-0560; [email protected]

Business of Aging Sections

Ready or Not


While rates of smoking and excessive drinking have declined among older Americans, prevalence of chronic disease has risen, and many older Americans are unprepared to afford the costs of long-term care in a nursing home, according to a report from the U.S. Census Bureau commissioned by the National Institutes of Health (NIH).

The report highlights those trends and others among America’s older population, now over 40 million and expected to more than double by mid-century, growing to 83.7 million people and one-fifth of the U.S. population by 2050.

Population trends and other national data about people 65 and older are presented in the report, which documents aging as quite varied in terms of how long people live, how well they age, their financial and educational status, their medical and long-term care and housing costs, where they live and with whom, and other factors important for aging and health.

Funded by the National Institute on Aging (NIA), part of NIH, the report draws heavily on data from the 2010 Census and other nationally representative surveys, such as the Current Population Survey, the American Community Survey, and the National Health Interview Survey. In addition, data from NIA-funded research was included in the report.

“This report series uniquely combines Census Bureau and other federal statistics with findings from NIA-supported studies on aging,” said Richard Suzman, director of the Division of Behavioral and Social Research at the NIA. The collaboration with Census has been of great value in developing social, economic, and demographic statistics on our aging population, with this edition highlighting an approaching crisis in caregiving — since the Baby Boomers had fewer children compared to their parents.”

A key aspect of the report is the effect that the aging of the Baby Boom generation — those born between 1946 and 1964 — will have on the U.S. population and on society in general. Boomers began to reach age 65 in 2011; between 2010 and 2020, the older generation is projected to grow more rapidly than in any other decade since 1900.

The report points out some critical health-related issues:

• Rates of smoking and excessive alcohol consumption have declined among those 65 and older, but the percentage of overweight and obese people has increased. Between 2003 and 2006, 72% of older men and 67% of older women were overweight or obese. Obesity is associated with increased rates of diabetes, arthritis, and impaired mobility, and in some cases with higher death rates.
• Research based on NIA’s Health and Retirement Study suggests that the prevalence of chronic diseases, such as high blood pressure, heart disease, chronic lung disease, and diabetes, increased among older people between 1998 and 2008. For example, in 2008, 41% of the older population had three or more chronic conditions, 51% had one or two, and only 8% had no chronic conditions.
• The cost of long-term care varies by care setting. The average cost of a private room in a nursing home was $229 per day or $83,585 per year in 2010. Less than one-fifth of older people have the personal financial resources to live in a nursing home for more than three years, and almost two-thirds cannot afford even one year. Medicare provides coverage in a skilled-nursing facility to older and disabled patients for short time periods following hospitalization. Medicaid covers long-term care in certified facilities for qualifying low-income seniors. In 2006, Medicaid paid for 43% of long-term care.

“Most of the long-term care provided to older people today comes from unpaid family members and friends,” noted Suzman. “Baby Boomers had far fewer children than their parents. Combined with higher divorce rates and disrupted family structures, this will result in fewer family members to provide long-term care in the future. This will become more serious as people live longer with conditions such as cancer, heart disease, and Alzheimer’s.”

Other areas covered in the report include economic characteristics, geographic distribution, social, and other characteristics.

“We hope this report will serve as a useful resource to policymakers, researchers, educators, students, and the public at large,” said Enrique Lamas, the Census Bureau’s associate director for demographic programs. “We sought to develop a comprehensive reference with up-to-date information from a variety of reliable sources.”

For more information on research, aging, and health, go to www.nia.nih.gov.

Barbara Cire is Public Affairs specialist for the National Institute on Aging.

Business of Aging Sections
Linda Manor Assisted Living Provides a Continuum of Care

Linda Manor Assisted Living was designed to be aesthetically pleasing — but this is an era when senior-living facilities must be much more than that. That explains the center’s focus on a continuum of care, its efforts to engage residents in activities inside and outside its doors, and its insistence on families being involved in decisions about the details of care — making what can often be a difficult life transition a little more like, well, home.
Linda Manor LobbyThe architecture and interior design of the newly opened Linda Manor Assisted Living facility in Leeds is breathtaking — and unusual for a facility of its kind.

The front doors open into a brightly lit foyer with high, coffered ceilings and comfortable sitting areas. A few feet away, a gracious twisted staircase climbs to an enormous, circular balcony on the second floor that surrounds the living area, and is punctuated by a large number of nooks with game tables and inviting couches and chairs, as well as a country kitchen.

The facility, which opened last October, has 85 units for residents, who can choose to live in a studio apartment or a one- or two-bedroom unit with their own kitchenette and private bath.

The 76,750-square-foot building features plenty for people to do, with activities that run the gamut from book clubs to art classes and exercise sessions; from volunteering at Kate’s Kitchen in Holyoke, which provides free meals to needy people, to day trips, such as a recent visit to the Sterling and Francine Clark Institute in Williamstown.

The lineup is dictated in large part by residents, who make decisions about what they want to do via committee, which they share with the activity director and write about in their newsletter.

“Our residents are civic-minded and want to be active; they may need some help, but they want to lead full lives,” said Kathy Herman, registered nurse and executive director of Linda Manor Assisted Living, or LMAL. “A few weeks ago, some residents wanted to spend the day going to tag sales, so we let them pick out locations and took them there. Having choices about what they do is important and makes them happy.”

But it is the continuum of care and philosophy that was established long before Linda Manor opened that sets it aside from similar senior living centers, she said.

Kathy Herman

Kathy Herman says Linda Manor’s small greenhouse was built for residents to enjoy.

It was built by Berkshire Healthcare, the largest not-for-profit company in Massachusetts, with 15 affiliates across the state and two hospices and a pharmacy serving clients. “We also have our own temporary staffing agency called Integra Nurse for our nursing homes,” said Albert Ingegni II, vice president of Housing Services. “This is more than bricks and mortar; we care about our residents, and, because we are a not for-profit corporation, we are driven by our values. Our residents always come first, and we try to make a connection with every one of them.”

Herman agrees. “It’s not just the resident who moves in. It’s the family that comes with them, and we stay in close touch with family members,” she said, adding that it’s important for children to know their parents are happy and that they can call whenever they have a concern. LMAL also boasts a van that is used to transport residents to doctor’s appointments, church, and other places they need or want to visit, which relieves stress on families.

The campus includes Linda Manor Rehabilitation and Nursing Center, so seniors who make their home in the new assisted-living facility have access to the above-mentioned continuum of care. Herman said it comes into play if a resident is hospitalized and needs short-term rehabilitation; staff from both buildings hold joint meetings about the resident’s health and well-being, and they can be easily moved back to their home when they are ready.

“Having both facilities on the same grounds allows us to integrate services and provide people with the most appropriate care,” she told BusinessWest. “We’ve established relationships between people in both buildings, which is wonderfully helpful to families, as they don’t have to coordinate care for their loved ones.”

Resident Berta Gauger enjoys living at LMAL. “It’s nice to have people around, and we travel and go places,” she said, adding that she looks forward to volunteering at Kate’s Kitchen.

Ingegni said a service plan is created for every resident that is assessed every six months or whenever the staff observes a change in behavior.

“We work to accommodate each person’s needs, and if they need more help than we can provide in the assisted-living section of the building, they can move into our Life Enrichment Program,” he added, referring to LMAL’s specially designed memory unit (more on that later).

Schooled by Experience

Before Linda Manor Assisted Living was built, Ingegni said, Berkshire Healthcare had decided to expand its housing component, and the Leeds campus, which already housed Linda Manor Rehabilitation and Nursing Center, was quickly identified as the ideal place to grow.

Many areas at Linda Manor

Many areas at Linda Manor are set aside for conversation.

“We wanted to provide post-acute-care services to this community and supplement the services Linda Manor was already providing,” he explained, adding that it is one of only a few senior-housing communities in the country designated by Medicare as a five-star facility, and was feted with the Gold American Healthcare Assoc. Award two years ago, which Kimball Farms in Lenox has also received.

Kimball Farms is a retirement community operated by Berkshire Healthcare, and offers housing that covers the spectrum of possibilities: independent living, assisted living, a memory unit for people with Alzheimer’s and dementia, and a skilled-nursing-care center.

Herman said it allows people to age in place, but, more importantly, the philosophy is one of “habilitation,” which means doing everything possible to help people maintain the level they are at when move in.

“It was developed by Joanne Koenig Coste, who wrote Learning to Speak Alzheimer’s, she noted. “We try to maximize success and minimize failure.”

Herman had retired from Kimball Farms before LMAL was built, but Ingegni talked her into returning to work so she could bring the successful program at Kimball Farms to LMAL and make sure it was well-established.

The Life Enrichment Program is an important component, and was created to take advantage of principles gleaned and perfected through years of experience at Kimball Farms.

“People with dementia often develop low self-esteem when they realize they can no longer do things they used to do. They get frustrated and bored, and, if they are dependent on others for all of their care, they feel like they have failed,” Herman said. “But if you provide them with an environment where they can be successful, they are happy, and it limits adverse behaviors.”

She explained that the Life Enrichment unit has a large kitchen that is central to the floor, a living room, and a sunporch that leads to an enclosed walking path bordered by gardens. “The residents can go in and out whenever they choose.”

Before new residents arrive, the staff obtains a detailed history of their habits, which includes the time they usually get up, if and when they eat breakfast, their daily routine, what they did during their lifetime, and activities they enjoy.

“We establish a plan of care around their schedule,” Herman noted. “They don’t have to do anything based on the clock, and if they want to eat lunch at 2 p.m. instead of noon, they can do it. If you have established a pattern in life, it’s hard to change when you’re 85.”

Special Measures

The staff undergoes continual training and holds frequent meetings to assess how each resident is doing.

“Our residents may have lost some of their cognition, but they don’t lose their emotions, so that’s where we meet them,” Herman noted. “We make them feel good about themselves, and if they don’t understand our words, they do understand body language, so if we are smiling and happy, it is reflected back.”

Resident Berta Gauger

Resident Berta Gauger enjoys volunteering at Kate’s Kitchen, among other activities at Linda Manor.

She added that staff members are carefully chosen, as not everyone has the temperament to work in a dementia unit, which requires thinking outside the box and coming up with solutions.

When Ingegni spoke with BusinessWest, 15 of 20 available spots in the unit were filled, and although it could have been built to house more people, he said it was designed to be small for a reason. “We found that, if there are more than 25 or 30 people, you lose your effectiveness.”

Although people with dementia are sometimes put on anti-psychotic medications while they at home, Herman said, when they are moved into an environment with people trained to meet their needs, in some cases, they can stop taking them.

“Alzheimer’s and dementia are a disease of the family, and the drugs are often given to make people sleepy, which allows the caretaker to sleep at night,” she said. “We look at the medications each person is taking and work closely with their physicians.”

Ingegni added that the way residents are treated starts with the behavior and attitude of management and filters down to each employee. “They set the example.”

For example, on a recent day Herman found a resident in the memory unit sitting inside while everyone else was outdoors. “I went to her room, got her sunglasses and hat, put them on her, and made a big deal about the way she looked. Then, I asked if she wanted to go for a walk,” she recalled. The technique worked, and Herman explained what she had done to the staff so they could emulate it if needed in the future.

“All of my managers are hands-on,” she said, citing another example that occurred when the dietitian was told a woman wouldn’t sit down to eat dinner. “The dietician responded by telling me she would prepare special finger foods so the resident could walk and eat at the same time, and she got creative with things like a salmon sandwich.”

In another instance, a woman who had been required to have a private aide at another facility because she was deemed a fall risk no longer needs one.

“She could still walk, but wasn’t participating in activities before she came here; she used to stay in her room. But now she is out all the time and hasn’t fallen yet,” Herman said.

Ingegni said the improvements registered by residents go back to the facility’s philosophy of habilitation.

“We want to keep everyone at their highest level,” he reiterated, citing examples like providing a typewriter for a woman in the memory unit who used to be a secretary and giving her paperwork so she felt she was needed.

Herman said the dedication of the staff is exemplified by the facilty’s bus driver.

“When he found he shared a love of poetry with one of the men in the memory program, he began coming back at night to read with him,” she said, adding that the driver also leads a support group for families of residents on the memory unit.

Moving Forward

LMAL has space available for additional residents, and Herman said the process of filling the complex is still ongoing.

But she and Ingegni are obviously proud of the new facility and believe it is off to a very solid start.

“It’s safe, it’s secure, and we are innovative and open to suggestions, so families can play an active role in what happens here,” Ingegni said. “And the fact that we offer different levels of care helps them and helps our residents.”

Which is exactly what everyone wants for aging parents who can no longer live in their homes: a place that caters to their needs and does everything possible to keep them healthy and engaged.

Business of Aging Sections
Mini Dental Implants Provide a Permanent Solution to Lost Teeth

Dr. David Hirsh

Dr. David Hirsh calls mini implants a fast, affordable way to replace missing teeth and stabilize dentures without surgery, pain, or bleeding.

More than 40 million Americans have missing teeth, and studies show the main reason is the cost: they simply can’t afford to replace them.

But thanks to advances in medicine, today people can replace their pearly whites with mini dental implants, which offer a permanent solution to the problem.

“They’re a fast, affordable, and permanent way to replace missing teeth and stabilize dentures — they don’t require surgery, there is no pain or bleeding, and they are half the cost of traditional implants,” said Dr. David Hirsh of Hirsh and Associates in Springfield.

This development is important because, in addition to detracting from a person’s cosmetic appearance, failing to replace missing teeth leads to other problems. Hirsh said the remaining teeth tend to migrate to fill in the space, which puts so much pressure on them, they can also be lost. “Filling in the spaces not only corrects how someone looks when they smile, it protects the remaining teeth and prevents the bone loss that occurs when they are not replaced.”

Mini dental implants, or MDIs, offer people with dentures a lasting solution to the problem of slippage because they provide an anchor to hold dentures or partials in place and gives them the strength and stability they need to eat foods such as corn on the cob or apples, which they would otherwise have to forego as they are too difficult to chew.

“When a person can only eat soft food because their dentures don’t fit well, being able to eat whatever they want in a restaurant is a tremendous change. If mini implants are holding the denture in place, they don’t have to use paste or powder, which they end up tasting more than the food, and there are no sore spots as the dentures don’t rub against the gums,” Hirsh said, adding that, when they are used to stabilize upper dentures, the palate portion of the denture can be cut away, which makes it much more comfortable and improves the taste of food.

MDIs are solid, one-piece, titanium-coated screws that take the place of a tooth root. They are much thinner than traditional dental implants and were originally designed to hold dentures in place. However, they have other benefits, including the fact that they stimulate and maintain the jawbone, which prevents bone loss and helps to maintain facial features. In addition, they are stronger and more durable than crowns and bridges that have been cemented into place.

They were first used in the ’90s and have been approved by the Food and Drug Administration for long-term use for fixed crowns and bridges and removable partial and full upper and lower dentures.

When Hirsh first heard about MDIs, he was skeptical. But after conducting research and learning more, he became convinced they could change people’s lives, so he attended classes in the Shatkin Fabricated Implant Restoration and Surgical Technique in Bufffalo, N.Y. and received his certification.

Six months ago, after rave reviews from patients, he said, he opened one of 27 Mini Dental Implants Centers of America. He told BusinessWest it is associated with the Shatkin Institute, which is the largest training center in America and has the largest lab and dental office in the country.

Dr. Todd Shatkin, who founded the institute, is president emeritus of the International Academy of Mini Dental Implants, and Hirsh is a member of that organization as well as the American Dental Assoc., the Massachusetts Dental Society, the Valley District Dental Society, and the prestigious Crown Council.

Hirsh said that, although traditional implants, which require surgery and months of healing time, were the standard of care for many years, a study by Shatkin that involved placing 10,000 mini implants in patients and following them for 10 years showed they had a 95% success rate, which is exactly the same rate as traditional implants.

The total cost of a single MDI in his center is $2,500, which includes the temporary and permanent crowns, while the cost of the four MDIs needed to hold a partial or denture in place is $4,000.

Something to Chew On

The process in Hirsh’s implant center begins with a panoramic X-ray, which allows the dentist to check the bone density and make sure there is enough room to place the MDI. Next, an impression is taken of the area that will be restored, which is sent to the Shatkin Institute.

“They fabricate a surgical stent that will be used to determine the exact spot where the MDI will be placed,” Hirsh said, noting that the institute also determines the size of the drill bit that needs to be used and the length and width of the implant.

When the patient returns to the office, the area is numbed, and Hirsh places the surgical stent, which is made of plastic, over the surrounding teeth. Next, he drills a hole through the gum into the bone and screws the implant into it, then secures a temporary crown onto it. “The color of the temporary is matched to the surrounding teeth,” he said, adding that, if any modifications need to be made, the information is sent to the lab before the permanent crown is created.

If the MDIs are being used to hold a denture or partial in place, it can be snapped onto the MDIs immediately after tiny holes about the size of a pen tip are drilled into the bone through the gum where the implant will be placed.

“Although a denture can contain about 12 teeth, you only need four implants to secure it,” Hirsh said, adding that, in cases where the denture doesn’t fit well, it may need to be modified before it can be used with the implants.

Losing a lot of weight can cause dentures to stop fitting properly, and if that occurs, people often find it difficult to keep them in their mouths. However, if the denture is secured by mini implants, it is not a problem. It will stay in place, and although people may want to get it realigned, Hirsh said the MDIs will never have to be adjusted.

MDIs have also helped many people with partials because they snap onto the mini implants, eliminating the need for metal clasps on adjoining teeth that hold them in place.

In addition, if people who are replacing a tooth have gum loss, crowns attached to the MDI can eliminate the cosmetic problem. “We put pink porcelain at the bottom or top of the crown so the tooth doesn’t look like it’s too long; it can be matched exactly to the color of a person’s gums and looks very natural,” Hirsh said.

He told BusinessWest the only instance in which a traditional dental implant works better than a mini is if someone has a very low maxillary sinus. “There may not be enough bone to put in the two implants that are needed, and in that case, we refer the patient to a local specialist. But it’s very, very rare.”

Evolving Science

Hirsh said misinformation has been circulated about MDIs in the general community, including the belief that MDIs can’t be used to replace molars or used for a full-mouth restoration, and only last about five years.

“They can last 20 years or a lifetime, just like traditional implants,” he noted, adding that they can be placed in people aged 17 and older once their jaw has stopped growing.

“I believe in 10 years, more dentists will use mini implants than traditional ones,” he said. “It’s a wonderful procedure that results in a wonderful cosmetic appearance. It’s just a matter of education; they’re life-changing.”

Business of Aging Sections
Innovative Method Helps Caregivers Engage with Clients with Dementia

Christina Vernon

Christina Vernon shows off just a few of the items she may include in ‘engagement boxes.’

As the over-65 generation is set to dramatically expand, so will the number of Americans suffering from Alzheimer’s disease and other forms of dementia. For those struggling with the cognitive and memory loss associated with these conditions, it’s beneficial to keep their minds active as much as possible. But how? Research by an intern at Homewatch Caregivers into a concept called ‘engagement boxes’ is setting a local standard for helping people with dementia hang on to memory, identity, and quality of life.

Christina Vernon calls it the “beach box.”

Inside are dozens of items that evoke the seashore — a jar of sand, a toy shovel and rake, a plastic bucket, a miniature beach ball, collections of seashells and sea glass, even a CD of beach-themed music.

To the average person, this array might evoke memories of a pleasant day soaking in the sun and the surf. But to someone suffering from dementia, the beach box may be nothing less than a catalyst for recovered memories and identity.

And it’s only one of dozens of such ‘engagement boxes’ that Vernon, a social-work student at Elms College, has carefully assembled for Homewatch Caregivers in West Springfield, where she works part-time, with the goal of focusing the minds of dementia patients through sensory stimulation and memory retention.

“These boxes hold items that trigger memories based on the five senses and promote conversation with people with dementia. It keeps them connected to conversation and lets them enjoy moments where they remember the past,” said Vernon.

For example, one brightly colored box might contain an old pair of white gloves, a child’s book of nursery rhymes, a small tea set, a beaded purse, and a jar of cold cream. “We might begin the activity by asking the client, ‘did you ever have a tea set?’ It may surprise you what your loved one comes out with.”

Sensory activities, she explained, involve many parts of the brain, including emotional, motor, and cognitive areas. They can allow someone with dementia to reawaken personal memories and help maintain the person’s quality of life, increase engagement with loved ones, and improve mood, behavior, and cognitive functions.

The key is to make sure the activities and conversations between caregiver and client are meaningful and individualized for each family.

“Nobody else is doing this, exactly,” said Judy Yaffe, co-owner of Homewatch Caregivers. “They’re very specialized for every client we’re working with. What happens is, we do a client history, get to know them a little more. We find out what they like and don’t like.”

Hence, the beach box would be ideal for a client who used to enjoy the beach or water activities. Other themed boxes contain baby-care items, art supplies, and vintage jewelry and toys — and Vernon often mixes and matches items to create individualized boxes to bring to clients. Caregivers engage the client with the items during visits, and, afterward, complete assessment sheets detailing what worked and what didn’t.

“The point of developing activities through the use of these boxes is to promote cognitive stimulation as an intervention for people with dementia,” Vernon said, noting that the roots of the philosophy can be traced back to 1950s research into ‘reality orientation,’ which was developed in response to confusion and disorientation in older patients in hospital settings.

Sensory exercises like the boxes Vernon maintains at Homewatch are coming more to the forefront in elder care as demographics are trending dramatically older. In short, Americans are living longer than ever before, with the massive Baby Boom generation heading into its golden years, and the number of patients with dementia — and, therefore, demand for services to assist them — are on the rise.

“Unfortunately, Alzheimer’s and dementia are going to increase,” Yaffe said. “We’re looking at a Baby Boomer tsunami.”

Engaging the Past

Engagement with dementia clients takes a variety of forms, Vernon said, showing off a pack of picture cards she uses during visits. She also shared a video of a session with a client in the early stages of dementia. Holding up a picture of stacks of coins,” she asks the client, “what is this?”

“It’s money.”

“Do you have money?”


“Where is your money?”

“The children took it.”

“The children took it? How many children? A boy or a girl?”

“Girls. The girls took it.”

“The girls took it. Hmm,” Vernon says, while switching to a card with a picture of a game of jacks. “Did your girls ever like to play with these?”

And so on — each image, each conversation pathway leading to another cue to engage the client. The boxes Vernon has assembled take the concept a step farther, by providing something to touch, feel, hear, even smell, in addition to viewing.

“She did this as a project for her school, an internship she developed,” Yaffe told BusinessWest.

“I was responsible to do a full research project for the company I was interning for,” Vernon said, referring to Homewatch. “Basically, I found myself working with dementia clients. So I decided to do my research on sensory stimulation boxes and memory.”

Judy Yaffe

Judy Yaffe, with a few of Homewatch Caregivers’ dozens of engagement boxes, says matching boxes with clients is a matter of learning their history, likes, and dislikes.

She bought several boxes worth of items on her own to test the concept. “I visited clients daily with boxes and researched what worked and what didn’t work. At the end of 16 weeks, [Homewatch] offered me a position 10 hours a week to create this program and run with it. It’s been very exciting.”

Since then, Yaffe has purchased most of the items for subsequent boxes. They include a collection of vintage toys, like a yo-yo and an original Slinky; to a “baby box” ideal for clients who love children; and a box of clip-on earrings from the ’20s, ’30s, and ’40s, which Vernon brings to a client who loves jewelry. “I made it a game; I ask her to put the pairs together, and then ask if she wants to try them on. It just keeps her active.”

In addition to the boxes, Homewatch has a growing collection of books, DVDs, and CDs of various genres and topics, all aimed at helping clients with dementia keep their minds stimulated.

“The items aren’t always cheap,” Vernon said. “When I go out, I make sure the client has at least three options, and if those don’t work, I go back and find something that does work.”

Sometimes that involves a bit of role playing. “When you’re working with a dementia client, if you’re comfortable entering their world, it really works,” she said.

Yaffe agreed, noting that each client is at a different place in their disease progression and how far back their memories lie. “We’re looking at where they are in their dementia. It could be back to their childhood, could be back to their first job, and that’s where we go. Entering the client’s world, to us, is really important.”

For clients at less-advanced stages, the more hands-on the activity, the better. “One was an avid artist in sculpture, so we bring him books about sculpture,” Vernon said. “We’ve bought sketch pads and watercolor pastels, just things to keep his mind as active as possible.”

It’s all about giving caregivers tools they can work with, Yaffe said. “We’ve developed quite a library here.”

Peace of Mind

While researching the effectiveness of engagement boxes at an assisted-living facility, interviewing five people over a period of weeks, Vernon — who will graduate in May and go on to pursue her master’s degree at Springfield College — came to understand the detrimental effects of an inactive mind.

“When you’re bored, when you’re not doing anything, when a client is sitting idle, their memories are fading faster than when they’re engaged with someone,” she said. “It’s better for the client’s overall well-being to be engaged. It’s great to see people light up, to see people talk about things based on the items we take out. It’s rewarding work.”

Yaffe said eliminating isolation and loneliness are two of the goals of her agency, and the engagement boxes are now a major component of that — not to mention a practice that family members can continue after a professional caregiver has ended a shift.

“Activities bring pleasure to people with Alzheimer’s,” Vernon told BusinessWest. “Keeping people involved in prior hobbies and interests that once gave them pleasure is important. Family members should take a flexible approach that is broad-based. Read the newspaper, look at books, cook, watch family videos — and remember to concentrate on the process of an activity and not the results. Perhaps develop your own engagement box for your loved one. It’s the joy of doing and discovery that can make the difference in their quality of life.”

Many clients don’t have dementia, but do suffer from some memory impairment, and the boxes — which can be checked out and brought back to Homewatch by families — can be effective tools for them as well.

“It’s really great for a family when they see mom or dad remembering something; it really gives the family a sense of purpose, as well as direction,” Vernon said. “We constantly exchange items and find out what’s working, find out what activities are good for a client.

“A lot of it is based on the individual person,” she continued. “I talk to the client and caregiver, spend an hour getting to know them, and after the initial meeting, I have a greater idea of what I can do to enhance their experience.”

Yaffe said Homewatch has long embraced other forms of sensory engagement with clients, especially music, which the Alzheimer’s Assoc. calls one of the main catalysts to recovering memory.

“We do a lot of music with our clients. If they remember something, it’s usually music from their teenage years, and they often remember it word for word,” she said. “It’s all about engaging people in the moment — but that moment can last the rest of the day for some people, and that’s important. It’s an easy activity if you can engage them.”

Added Vernon, “you see people light up when they hear their music. I think that’s an essential thing. That’s why most of our boxes have a CD with it. For the beach box, there’s beach-themed music. For the baby box, it’s lullabyes, softer music.”

Of course, she reiterated, the best boxes are the ones that engage all the senses. “It’s so worth the time and effort to make life better,” she said. “It works. We’ve validated it, and we know that it works.”

Joseph Bednar can be reached at [email protected]

Business of Aging Sections
Aging Population Creates Myriad Healthcare Challenges

Dr. Rebecca Starr

Dr. Rebecca Starr says the role of geriatricians and others who treat the elderly will become even more important as the over-65 population dramatically expands in the coming years.

It’s no secret that the nation’s demographics are skewing older. Paul Judd doesn’t think that’s all bad.

“People talk about aging of America, but it sure beats the alternative, which is not aging,” said Judd, vice president of Talent Acquisition and Workforce Planning for Baystate Health.

That said, the aging trend is no laughing matter for the healthcare industry, which faces a number of challenges directly related to the fact that Americans are living longer, often with multiple and chronic health conditions, than ever before, and the massive Baby Boom generation — all 75 million of them — will continue to swell the ranks of the over-65 crowd.

“In 2012, there were 40 million people over the age of 65. By 2040, it’s expected to double to 80 million. Really, that’s tremendous growth,” said Dr. Rebecca Starr, a geriatrician with Baystate Medical Center.

The cause isn’t solely generational; the fact is that modern medicine keeps sick people alive much longer than in decades past.

“We’re doing a great job treating heart disease, diabetes, COPD [chronic obstructive pulmonary disease],” she continued, “and as a result, people are getting through these very significant things that they didn’t used to survive, and people are growing older. And because they’re living longer, that means we’re seeing more dementia as well.”

All of that comes with a cost. In 2010, senior citizens accounted for 13% of the population but 34% of the heathcare costs, according to the Centers for Medicare & Medicaid Services. But national health expenditures are projected to grow at an average rate of 5.7% through 2023, and older Americans will drive the largest percentage of that cost.

At the same time, the role of geriatricians is expected to become more prominent, Starr said.

“We have extra training, we’re fellowship-trained, and we specialize in taking care of people over 65,” she explained. “Our goal is keeping people living independendly as long as possible, and healthy as well. We look at the whole person. We take a look at all their diseases and all their medications, and we make sure their medications are appropriate for them and don’t cause adverse side effects and also that we’re not treating the side effects of their other medications, what we call a prescribing cascade.”

That said, there’s a “tremendous shortage of geriatricians,” Starr said. “I think it’s pretty significant.”

In fact, many health fields may face shortages in the coming decade, because at the same time an older population is placing more demand on the industry — for both acute care and myriad services aimed at seniors’ health maintenance and quality of life — Boomers are aging out of the healthcare workforce as well, posing what could be a difficult recruiting landscape for health organizations large and small.

Age-old Concerns

It’s an issue Judd is deeply involved with, but Baystate isn’t waiting around for that coming wave of retirements.

“If there were a silver bullet, everyone would be doing it. It would be an easy fix, and it’s certainly not,” he told BusinessWest. “With the aging of the workforce, the approach we’ve taken is to truly understand where our aging is. So we’ve done a lot of workforce planning, to try to understand where we’ve got issues and what we need to do to fill these pipelines, if you will, well in advance of it becoming a problem.”

So Baystate has launched a number of workforce-development programs with area schools and colleges, and partnered with other health systems through the Regional Employment Board of Hampden County on worker-training initiatives.

“Instead of trying to steal from each other, we’re trying to take a look at the healthcare needs of the whole Pioneer Valley and say, ‘here’s what we all need; let’s create pipelines to fill all of our needs,’ instead of Baystate doing the training and everyone tries to steal them from us.

“We have to look at it from a community perspective,” Judd added. “You see we have all these healthcare offerings in the community, and they’re all important. From a community perspective, we’ve been somewhat successful at building some healthcare pipelines, working with places like HCC and STCC, developing programs and creating oppportunties for jobs. Some of the demand to do with aging, some with changing regulations with healthcare. We’re trying to get ahead of it, create these pipelines before it gets to where there’s an issue.”

Internally, Baystate has identified a number of areas where an aging workforce and other factors could come into play — operating-room nurses, for example.

“They can be a little difficult [to recruit], because a lot of nursing schools don’t have a rotation through the operating room anymore, as they did in past years,” Judd said. “Getting young nurses interested in going into the OR can be a bit of a challenge. So we created an internship, a nine-month orientation, for any registered nurses interested in going into the OR. That’s an issue I anticipate will become more acute over the next 10 years.”

Shortages are expected to be especially high in primary care, an issue that’s already rearing its head. In its most recent Physician Workforce Study, the Mass. Medical Society listed family medicine and internal medicine atop its list of specialties facing shortages already, and new recruits into primary care aren’t expected to match the anticipated retirements of older doctors.

Keeping the Pace

That’s one reason why keeping older people healthy has taken on a new importance in America — a reality that has seen the emergence of a number of programs to help families do just that.

Take, for example, Mercy Life, a PACE (Program of All-inclusive Care for the Elderly) program run by the Sisters of Providence Health System. Medicaid oversees PACE programs, which are on the rise in the U.S. because the role they play — providing a range of adult-day health programs aimed at keeping seniors out of nursing homes — is becoming more prominent.

Since Mercy Life opened its doors a year ago on the former Brightside for Children and Families campus in Holyoke, it has expanded its census to 82 seniors who come for primary care; physical, occupational, and speech therapy; and the services of a social worker, dietitian, nurse, and other care providers as needed.

“From anecdotal comments from people, the sense is that, in a really short period of time, people who come to the PACE program are experiencing an awakening of sorts,” said Chris McLaughlin, chief operating officer of the Mercy Continuing Care Network, which encompasses a number of independent-living, assisted-living, and skilled-nursing facilities, as well as home-care, hospice, and adult day programs.

He told of one man, about 60, who had been living with his father and never ventured out of his room. “He was kind of a curmudgeon. His brother-in-law said he reawakened when he came to the program. He didn’t think he’d like it — he wasn’t a social person — but he made friends, he’s smiling, he’s happy. His brother-in-law told me, ‘we’re seeing the old Bob we used to know come out.’”

Another woman whose husband was participating at Mercy Life told McLaughlin, “‘you’ve improved the quality of my husband’s life. He walks better, he’s not afraid he’s going to fall, and he’s regaining limited use of his hands via therapy and other work done with him.’

“People love the fact that their loved one can continue to live at home,” he continued. “We run some great nursing homes, but we never have anyone walk through the door and say, ‘geez, this is wonderful. I’ve always wanted to come here.’ They want to stay with their loved ones, in their own environment. And this has improved people’s vitality so they can continue living where they’re most comfortable.”

In a way, McLaughlin said, PACE programs are a form of accountable care, the model becoming more common at hospitals nationwide, which involve teams of providers being paid by insurers to keep patients well over a period of time, rather than being paid for each treatment, test, and hospital stay. It’s a model that becomes more challenging when dealing with an older population grappling with chronic conditions.

“As hospital stays decline, more care is being provided in people’s homes, where most of us prefer to receive care,” he told BusinessWest. “In a PACE program, we’re at risk for outcomes and at risk for managing seniors’ health within their means. The goal is to manage someone’s care and get them to a better state in terms of wellness and overall health.”

Hospital to Home

When she considers the aging of America, Starr recognizes a range of needs — specifically, growing demand for home care, residential care, adult day health, and various other services along the continuum for senior citizens. Part of her role is coordinating patient transitions into these various programs.

“That’s the goal, but it’s very difficult to put into place,” she said. “We have these multiple transitions of care; we have people transferred from one hospital to another for more acute care, they can go to rehab, perhaps home — that’s three or four transitions where you can have errors in medication, can lose track of follow-up … it can be a real problem.”

The key is communication between the different providers, especially at a time when the accountable-care model of healthcare is forcing hospitals to emphasize population health and reduce readmission rates — a task that becomes more challenging as the aging trend in America means more people living with chronic conditions.

“I think it obviously starts at home, and making sure that primary-care physicians have some geriatric training,” Starr said. “Then hospitals have to make sure the care of older adults meets the standard of geriatric care.

“Our goal is to keep people healthy by preventing and managing disease and helping people maintain function, the things they should be able to do — get out of bed, shower, get dressed, toilet themselves — because if that’s not maintained, that means extra care, that can mean nursing home as well.”

To better meet those goals, she explained, “one of the things we’re starting now is an acute-care floor dedicated to providing care for older adults, with the goal of maintaining function, preventing delirium, and having get them back home so they don’t need short-term rehab or, even worse, long-term care.”

It’s a model that might become more common over the next decade, she added. “It’s not as common as I think it should be, but where it’s been taken up, it’s shown things like reduced readmission rates, reduced length of stay, and reduced delirium. Getting people back home is really important.”

To do that effectively, Judd understands that hospitals and other providers need to be well-staffed, so he continues to cultivate programs to ensure a healthy future for Boomers in Western Mass.

“We’re taking a planning approach to it, getting in front of it, working with the local community colleges to build programs, and creating pipelines of people in the future,” he told BusinessWest. “I think, for communities like us, this will continue to be an issue.”

Joseph Bednar can be reached at [email protected]

Business of Aging Sections
Hospice Brings Quality of Life to Dying Patients, Families

Sarah Jackson, left, and Carol Lewis

Sarah Jackson, left, and Carol Lewis say the team aspect of hospice care is one of its most important features.

There’s a big difference, Leslie Hennessey said, between giving up on life and accepting that the end is near.

“Hospice simply gives people more support toward the end of life,” said the volunteer coordinator for Holyoke VNA & Hospice Life Care. “It’s not giving up; it’s changing the way we look at life. Do you want to go to your beach house one last time? Do you want to go see the Red Sox? We’re really focusing on quality of life, not how many days, weeks, or months you have left. The perspective changes; what’s really important to you? Because now is the time to do it.”

In short, families that choose hospice care for their dying loved ones “aren’t throwing their hands in the air. They’re saying, ‘this is what’s really important to us.’ A lot of times, that’s just spending time together as a family, saying the things they need to say.”

Most hospice programs follow the same format, Hennessey told BusinessWest. “The family and the patient generally meet with their physician about the diagnosis they have, and the physician has to certify that they have less than six months to live if the disease follows its normal prognosis. When we get the referral, we can admit them to hospice.”

It’s also a team approach to care. “Every patient gets a hospice nurse. They can also have a social worker if they’d like, a home health aide, or volunteer services if they choose. On top of that, we have other complementary services; we have a therapeutic heart program, a harpist to play at the bedside for the patient, and a pet therapist who visits patients in nursing facilities. I have a couple of volunteers who practice Reiki and energy work; we can offer that to patients as well.”

Carol Lewis, director of hospice at Spectrum Home Health and Hospice Care in Longmeadow, explained that “we’re looking for patients who have a terminal diagnosis that requires symptom management by nurses who have expertise in that area, and are educated in taking care of the holistic needs of that community. That’s the broad picture of what we do.”

She also stressed the team aspect of hospice care. “That’s the unique aspect of it; it’s a team of trained professionals that address these needs, and it’s not only about the patient, but supporting the family as well.”

For this issue’s focus on the business of aging, BusinessWest takes a look at an area of healthcare that has been growing in prominence as America’s 65+ demographic soars to record numbers — and the many ways hospice care is providing, if not hope for recovery, a measure of peace and acceptance for those approaching the very end of life.

Rising Tide

Indeed, 2009 saw 1,341,391 patients access hospice care; last year, that figure had risen to 1,542,737, a 15% increase.

There’s some statistical evidence that palliative, or comfort-only, care brings real benefits to the dying or critically ill. A study several years ago at Massachusetts General Hospital divided a group of stage 4 lung cancer patients into two groups; all of them received traditional chemotherapy through a physician, but half also enjoyed the services of a palliative care team.

The results, published in the New England Journal of Medicine, showed a measurable difference in the amount of anxiety and depression, while patients who had received palliative care from the start averaged a three-month survival advantage.

While some palliative care includes curative treatment, however, hospice is reserved for patients who forgo all but comfort-centered care; in other words, they’re no longer fighting to get better.

Sarah Jackson, executive vice president of Spectrum, explained that patients can receive hospice care in any community setting.

“Wherever you are, you can select a hospice benefit,” added Paula Boss, executive director of Holyoke VNA & Hospice Life Care. “At home, a nursing home, assisted living, a friend’s home — you can receive hospice care.”

At the heart of hospice care, Hennessey said, is a cadre of volunteers who spend time with the patient, particularly when their loved ones aren’t able to do so.

Leslie Hennessey, left, and Paula Boss

Leslie Hennessey, left, and Paula Boss say hospice services are available to patients wherever they live, whether at home or in a community care setting.

“They can’t provide any personal care or give medications, but they can be a presence in the house, sitting vigil with hospice patients. When a hospice patient is considered to be in the last hours of their life, and especially in nursing homes, if the families are far away and traveling to get to the person, our volunteers will sit with them until their loved ones get there. Families don’t want their loved ones to be alone.”

She said Holyoke’s volunteers hail from all walks of life. “A lot of folks have had experience with hospice in the past and loved ones in a hospice program, and they felt like they wanted to give something back; they realized how important it was, that extra support, how much they appreciated it, and they want to do that for another family.”

Hennessey said she conducts trainings twice a year for people who want to help in this manner. “Sometimes they say, ‘I don’t know if I can do this, but I want to try.’ They’re very special people.”

After all, she noted, “if you’re a hospice volunteer, you have to understand that every patient will die. That’s what we tell them on the phone before we even send them the information packet; I need them to know that every person they meet will die, and I ask, ‘how do you feel about that?’ It’s something they really need to consider. They know what they’re getting into when they walk through that door. They’re amazing.”

Lewis said Spectrum’s program also offers the services of a harpist with a degree in thanatology, the study of death, as well as service dogs that provide comfort to patients and their families.

“We also have a chaplain as part of the team,” she said. “When I say holistic care, I mean we meet physical needs, emotional needs, and more. Sometimes the chaplain is looking at some life review with the patient and the meaning of life, providing some comfort, or maybe just some reading at the bedside.”

Whether it’s the nurse, social worker, home health aide, chaplain, or volunteer at the bedside — and families can call for help 24/7 — hospice care is just as much a benefit for the family as it is for the patient, Jackson said. “We can be helpful for families, giving the caregiver a little bit of respite, by sitting vigil with their loved ones, having a volunteer come in for an hour or two so the family can take a break.”

At the same time, Lewis said, hospice staff takes time to educate the family so they can provide more effective care when hospice workers and volunteers aren’t nearby. “That really helps in the grief process, to look back and know you helped provide the comfort.”

Typically, hospice care includes a full year of grief counseling for the family after the patient dies, Boss said. “Often, the grief really hits them after the funeral, and they have continuing needs.”

Setting the Record Straight

Lewis said families often have misconceptions about what it means to elect hospice care. For instance, “a lot of people think they can never go to the hospital. But any time they need a level of care that isn’t offered in hospice, an emergency situation where they might need short-term help, they can go to the hospital.”

Also, Boss noted, “some people think they don’t receive any medication anymore, but that’s not the case. Yes, we often discontinue medications that are not needed for comfort or pain. But some cancer patients receive chemotherapy if there’s a comfort purpose and not a treatment purpose. We’re very strong on keeping people comfortable.”

Hennessey told BusinessWest that hospice benefits are typically covered by Medicare and Medicaid, as well as most private payers. “It’s not always something you’re looking for in your benefit package when you sign up, but most insurances have a hospice benefit, and it can be a huge benefit to families.”

The question for those families is when to take that step and admit that quality of life is more important than fighting an uphill battle for recovery. The growing ranks of older Americans have made end-of-life care a hot topic these days, and a tricky one.

That’s because, while doctors can extend life, often by artificial means, to a greater degree than ever, that intervention is often prohibitively expensive, and the quality of that life often dubious. So, increasingly, patients, families, and caregivers face hard questions — not about whether doctors can add weeks, months, or years to the life of a dying patient, but about whether they should.

“Awareness of hospice has increased, but barriers are still there — a lot of cultural barriers,” Boss told BusinessWest. “Some cultures really don’t understand the hospice benefit; they don’t understand all the things we can bring to them. There’s still a long way to go. A large number of patients are eligible to benefit from hospice, but never elect it.”

Hennessey cited a statistic that about 21,000 patients receive hospice care annually in Massachusetts, about 40% of all deaths. “It’s a good number, but it would be great if it was all patients, or close to 80% of patients.”

She also noted that the median length of hospice care is only 23 days, which means patients and families are often opting for it much later than they’re eligible. “We’re working with doctors and facilities to identify folks who could really benefit from these programs,” she said. “The benefit is for a life expectancy of six months, but in 23 days, we’ve just got things arranged, and then, unfortunately, we lose the patient.”

Lewis agreed. “Unfortunately, some families wait until the very end to contact hospice, but we’re able to get involved six months before the end, when there’s time to develop relationships with the team and to provide quality of life while the person is still here.

“It’s a chicken-and-egg situation,” she added. “A lot of times, people call us at the end, so the community sees us coming at the end and think we’re heavily associated with the end of life. But it’s earlier in the process that hospice really has its true benefit.”

So hospice advocates continue to get the word out to doctors and the public.

“It’s not giving up hope, throwing your hands up, saying, ‘I can’t cure this,’” Hennessey said. “I want to put you in the hands of people who can manage your pain symptoms so you can get the best life you can out of your last months.’”

Joseph Bednar can be reached at [email protected]

Business of Aging Sections
Emeritus of East Longmeadow Caters to Residents’ Requests

Philip Noto

Philip Noto says the Emeritus of East Longmeadow building was carefully designed to accommodate the needs of aging seniors.

Philip Noto says the difference between Emeritus of East Longmeadow and other local assisted-living facilities can be found in the details.

“It’s easy to get the big things right, but small things play a major role in the happiness of residents,” said the facility’s executive director, noting that this is the reason why he fought to get granite countertops and full-size refrigerators installed in every unit when the building was under construction.

“I had managed other assisted-living facilities and listened to complaints from residents who wanted to keep ice cream in their freezers, but couldn’t do so because of their size. It might sound like a small thing, but paying attention to small things is what sets us apart from other communities,” he told BusinessWest, adding that his insistence on granite countertops was based on the knowledge that many people who move into residential communities are leaving upscale homes and don’t want to downgrade their kitchens.

Nathan Grenon, regional director of sales and marketing, agrees that small measures make a significant difference, and says everyone employed at Emeritus does their best to cater to residents’ requests. He cited an example of a 97-year-old woman who had been a gourmet cook who told them she hoped their chef would make homemade cream of carrot soup.

“She told us she had requested it for five years in another facility, but it was never prepared,” Grenon said. “So, we introduced her to our cook, who made it exactly the way she wanted, and today it is the most popular soup on our menu.”

Noto and Grenon cited myriad other examples of resident suggestions that have led to change within the state-of-the art, two-story, 90,000-square-foot building that opened April 21 on 10 acres of land on Parker Street. “Emeritus is a 25-year-old company; we recently merged with Brookdale Senior Living, and we now have more than 1,150 properties across the country,” Noto said, adding that decades of feedback from seniors were incorporated into the design of the East Longmeadow facility.

The building is airy, spacious, and well-lit. Comfortable chairs surround a cozy gas fireplace near the entrance, where residents gather to socialize or take part in activities. There is also an expansive dining room with a cathedral ceiling, a library, several courtyards, a business area equipped with computers with large touchscreens, a private dining room that can be reserved for family functions, a café where residents can prepare foods they like or enjoy snacks throughout the day or evening, a game room, a movie theater that seats up to 20 people in full-size armchairs, and a plethora of other common living spaces.

“We have 71 assisted-living units and one of the largest, most expansive memory-care neighborhoods in Western Mass.,” said Grenon. “There is a nurse on duty from 8 a.m. to 11 p.m., and we offer physical therapy, occupational therapy, and speech therapy on site.”

In addition to enjoying a full roster of activities, many residents stroll daily on a quarter-mile pathway that circles the building. Benches are set along it so they can stop and relax, and many gravitate to an outdoor gas firepit that burns brightly during inclement weather. In fact, residents enjoy going outside so much that a number of activities scheduled to take place inside are now held outdoors in response to their feedback.

Changing the Landscape

Noto reiterated that seemingly small details, including the food choices on the menu and the daily activities, make a difference in how happy residents feel on a daily basis.

To ensure that staff members know what residents want, Emeritus holds three monthly meetings and invites everyone who resides in the building. One is focused on general suggestions to improve the facility, the second gives people an opportunity to suggest new foods they would like to see served in the dining room, and the third allows them to vote on activities they want to engage in, as well as destinations for day trips.

“This is their home, and we want to get their input so we can adjust our program to meet their needs,” Noto said. “Our residents have a voice. Their concerns are heard, and we change things that are important to them.”

Grenon concurred. “We want to make their experience here as pleasurable as possible.”

Indeed, many changes have been made as a result of the meetings, which range from creating an area in the dining room where male residents can eat together, to rearranging the furniture in a common area and game room.

“The residents wanted to move the poker table into a room of its own, so we did it,” Noto said.

Grenon added that new activities have also been instituted, such as a Bible-study club that meets every Thursday. “The idea came from residents who were interested in spiritual activities,” he noted.

Brittany Sheehan

Brittany Sheehan shows off a life station in the memory unit at Emeritus at East Longmeadow, designed to evoke memories in residents who have children.

The fact that Emeritus does not require people to buy into the facility and residents rent on a month-to-month basis also gives them peace of mind. And although there are scheduled meal times, residents who miss a meal can be served at any time in the dining room. In addition, each unit has its own thermostat, which allows people to adjust the heat or air conditioning to their personal comfort levels.

These factors, combined with the dedication of employees, have led to success, and although the facility has been open only eight months, 45 of the 71 assisted-living units are occupied. Residents range in age from 66 to 99, and the ratio of females to males is about 50-50.

The assisted-living units include one- and two-bedroom suites with one or two baths. Each one contains a microwave, a full-sized refrigerator, and several large closets with a lockbox. The bathrooms have spacious showers with heat lamps and no lips, reducing the risk of tripping. In addition, the transitions between carpeting and wood floors are very smooth, making it easy for people to move through the community.

But Noto said the way residents are treated trumps the beauty and functionality of the real estate, and added that every member of his staff is passionate about their job. “We have an extensive interview process for job candidates. Every employee needs to feel they make a difference in the lives of our residents every day.”

Enhanced Memory Unit

Space has also filled quickly in the Acres, the memory-care unit, and Grenon said having it within the building allows people to “age in place,” giving them the option to move into it if they need extra help or support.

In fact, having assisted-living units and a memory neighborhood under one roof is ideal for some couples, he noted, explaining that one resident who lives in an assisted-living suite visits her husband every day in the Acres, where they stroll down the wide hallways within the secure neighborhood.

The thought that went into the design of the building can be seen in the layout of the shared rooms in the Acres. Although they were built for two people to live in, the only thing they actually share is the bathroom, which is situated between their private suites. Each person has their own door that opens into their living space, and shadowboxes are stationed outside that families fill with photos or mementos to help their loved ones easily recognize their personal entranceway.

Again, Grenon said families appreciate the attention to detail that is part of the program as much as the enhanced real estate.

“An example of this is that, when staff check on the residents every hour throughout the night, they have to enter each person’s bathroom and press a button to signal that they have actually been there,” he noted, explaining that the signals are recorded, which alleviates any anxiety as to whether the hourly checks actually occur.

The Acres also contains unusual ‘life stations,’ designed to promote activities that are familiar to residents. One contains a crib filled with baby dolls, a changing table with doll clothing, and a rocking chair. “Many of our residents are mothers, and when they see the dolls, they pick them up, change them, rock them, and even bring them to meals,” Grenon said.

Another life station contains a map and globe and was created to spark memories about places residents have visited, while a third has a collection of men’s and women’s hats, scarves, and jewelry they can don at a dressing table with a mirror.

“The life stations are part of our effort to keep them engaged and keep their brains stimulated. We don’t want people staying in their rooms,” Grenon said.

A special ‘quiet room’ was also built into the unit. It doesn’t have windows and is used by staff members as a place to bring residents who are agitated or suffering from the confusion that can occur when the sun sets. “They can turn on relaxing music and calm the person down in this quiet, secure place,” he explained.

Memory Care Director Brittany Sheehan says caretakers in the Acres are trained in how to deal with memory loss, and get to know each resident well. She added that the caregivers serve the residents’ meals and help them with daily tasks of living, such as dressing and showering, which allows them to build solid relationships through continuity and familiarity.

“It also helps them learn what each resident likes and dislikes,” Sheehan said. “But before they even move in, I have their families fill out a detailed, six-page questionnaire so we can provide personal touches they would have enjoyed at home. For example, a resident might like a cup of tea every night before going to bed. We do our best to customize our care to fit each individual’s needs.”

She runs a monthly support group for families and meets with them on a regular basis. “I call them if their loved one is having a bad day or a really good day. And every month I mail them ‘A Moment in Time,’” she said, explaining that it is a handwritten letter with pictures of their loved one engaged in activities.

Quality of Life

Grenon said Emeritus has quickly become a valuable community asset.

“Before it was built, many people were apprehensive because they didn’t know what to expect,” he explained. “But officials in East Longmeadow and people in the surrounding towns have been very supportive since we opened, as they appreciate what we have to offer.”

Noto agreed, and said the facility’s staff will continue to focus on improving small things that make a difference.

“Our residents have a voice, and we change things in response to their requests,” he said. “Everything we do is aimed at providing quality care, which is important because this is their home.”

Business of Aging Sections
Cardiac Rehabilitation Helps Patients Get Their Lives Back

Patrick Schilling

Patrick Schilling, right, says Cooley Dickinson’s cardiac rehab program has helped Dennis Vandal recover from heart surgery.

After Cindy Mahoney suffered a heart attack early in 2013 — an event attributed to a rare condition called spontaneous coronary artery dissection — she was treated at Cooley Dickinson Hospital and, several weeks later, was taking the right medications and otherwise felt fine.

But she’s a runner at heart (no pun indended), and had run about 30 minutes a day for the past 35 years, and worried about how much exertion she could handle — and whether another heart attack would occur if she pushed herself too hard or soon.

However, after entering a cardiac rehabilitation program at CDH and exercising, twice a week for two months, under the supervision of cardiac exercise physiologist Patrick Schilling and two cardiac nurses, Mahoney set aside her anxiety, convinced she could get back to what she loved doing.

“The entire rehab experience was hugely reassuring to me and my family,” said Mahoney, who finished two 5K races in the months after completing the program. “The cardiac-rehab program helped me realize I could do what I love again — safely.”

That confidence boost, Schilling said, is one of the major benefits of cardiac rehabilitation, a customized program of exercise, education, and support designed to help individuals recover from a heart attack, cardiac disease, or heart surgery.

“There’s a lot of anxiety. They’re wondering, is this going to happen again? It’s so fresh in their minds, how they felt when they were getting treatment a few weeks ago,” he said. “We can help rebuild their confidence, not only about how well they’re going to do, but their ability to take control of their lifestyle.”

According to the Mayo Clinic, cardiac rehabilitation is typically recommended for patients who have experienced a heart attack, coronary artery disease, heart failure, peripheral arterial disease, angina, cardiomyopathy, certain congenital heart diseases, coronary artery bypass surgery, angioplasty and stents, heart transplants, and heart valve replacements.

“The benefits of a cardiac-rehab program have been nationally proven,” not just in its initial benefits, but in patients’ long-term compliance with taking recommended medications, changing an unhealthy diet, and controlling issues like diabetes and high cholesterol, said Elaine McCaffrey, a nurse clinician in Baystate Medical Center’s Cardiac Rehabilitation and Wellness Program.

That’s not surprising, she added, considering how much of a wake-up call a heart attack or heart surgery can be.

“There’s so much folklore around the heart, a lot of religion centers on the heart — people have a lot of different feelings when it comes to the heart,” she noted. “So a major surgery or major event like this does lead to some anxiety — ‘how can I get back to what I really want to do in life?’ That’s where cardiac rehab comes in.”

Four-pronged Approach

Cardiac rehabilitation — which is covered by virtually all health insurance when a patient is referred by a primary-care doctor or cardiologist — is comprised of four main components:

Medical evaluation. The rehab team — which might include a cardiologist, nurse educator, dietitian, exercise rehabilitation specialist, physical or occupational therapist, and psychologist — will assess a patient’s physical abilities, medical limitations, and risk factors for heart disease, stroke, high blood pressure, and other conditions. They will also continue to track the patient’s progress over time, along the way tailoring a safe, individualized rehabilitation program.

Elaine McCaffrey

Elaine McCaffrey says the exercise, education, and support components of cardiac rehab are all important in helping patients reclaim their lives.

“The program is designed in such a way that it helps the patient reduce fatigue and improve energy levels,” Schilling said.

Physical activity. Cardiac rehabilitation improves a patient’s cardiovascular fitness through walking, cycling, rowing, jogging, strength training, and other activities.

“Many activities we do in the gym are cardiovascular in nature, but it also includes strength training. We use treadmills, walking bicycles, a rowing machine, upper-body exercises,” Schilling said, noting that this component of cardiac rehab is a relatively recent development. “Heart recovery is fairly slow, and 30 years ago, patients were put on bed rest.”

The Mayo Clinic recommends supervised exercise three to five times a week, adding that it’s important to teach proper techniques, including warming up, stretching, and cooling down.

Lifestyle education. This may include guidance on everything from managing pain and fatigue to making healthier food choices aimed at reducing fat, sodium, and cholesterol; from understanding medications to getting back to sexual activity.

“There’s definitely an educational component to it,” McCaffrey said. “They don’t leave cardiac rehab without knowing what they need to do to stay heart-healthy. When we talk about the risk factors for diabetes, high blood pressure, hypertension, these are things that can be controlled. We talk about a healthy diet, monitoring blood glucose to keep diabetes under control, exercise, and getting to a heart-healthy weight.”

Of course, the number-one risk factor for coronary disease is smoking, so when a patient is a smoker, programs educate them about the dangers and develop strategies for quitting. “They need to make that big social change — for themselves and the rest of their family,” she said.

Support. Depression and anxiety are natural reactions to a major heart event, which is why cardiac-rehab programs stress the emotional and social components of recovery as well as the physical and educational aspects. These might include anything from counseling to occupational therapy to help patients return to work.

“We get you to understand what you need to do to take control of your life, and make it a very beneficial, productive life,” McCaffrey said. “And the whole time, you have companionship; you’re meeting people who are going through it with you.”

Schilling agreed. “Rehabilitation rebuilds confidence, so they realize it’s not a sentence, but something they can live with,” he said. “You really see their improvement, and see their confidence go up.”

Full Speed Ahead

Schilling was quick to add that recovery from a cardiac event — particularly in the case of a heart attack or stroke — begins with the emergency response as it’s happening.

“The gold standard from onset of symptoms to the cardiac catheterization lab is 60 minutes,” he noted. “Time is definitely the enemy in this case; the quicker a person gets treatment, the more heart function gets preserved.”

But once the initial crisis has passed, a team springs into action to help patients fully recover for the long term. McCaffrey and Schilling both came back repeatedly to the phrase ‘activities of daily living,’ emphasizing that the goal isn’t for patients to return to a life that’s a shell of what it was before their sickness or surgery, but, rather, resume the same lifestyle they enjoyed before.

“We have patients ranging in age from 24 to 90,” McCaffrey said. “So we need to know, what are your activities of daily living? Is it returning to a job? Is it being a mother to your young children? Or, if you’re a little bit older, is it just living as healthy as you can?”

Of course, some patients want to return to a high-stress career, and others want to get back to playing sports or, like Mahoney, running every day. No matter what the goal, McCaffrey said, it’s the rehab staff’s responsibility to tailor the program to the goals and needs of each individual patient.

“Cardiac rehab is for anybody and everybody,” she said. “It really does help with recovery, and that’s the key; that’s the whole purpose — that feeling of confidence that they can get on with their life.”

Schilling agreed. “It’s gratifying to work in cardiac rehab. We definitely do it with the onus of wanting to help people. It’s a real passion for me and my co-workers,” he said, adding that he’s amazed at how different patients look at the start and end of rehab — not just the condition of the bodies, but the level of confidence on their faces.

He’s grateful, in short, to be doing life-changing work. “I’ve been here eight years, and I’ve never had a boring day.”

Joseph Bednar can be reached at [email protected]

Business of Aging Sections
Things to Know When Your Child Is Also Your Caregiver


It is very common for a child to provide care to an aging parent in order to allow the parent to continue to live at home. A child is most commonly the caregiver because the parent will not agree to hire professionals to assist with the activities of daily life. Typically, the parent has concerns regarding privacy, and their child is the only caregiver they will trust.

Gina Barry

By Gina M. Barry, Esq.

When a child provides care to a parent, it is best to establish a care agreement. A care agreement is a contract that outlines the care to be provided, as well as any payment to be made for that care. The care is typically provided until the parent passes away or is in need of care that cannot be provided at home. Tasks performed by the child usually include personal-care assistance, grocery shopping, meal preparation, accounting services, transportation to and from appointments, housecleaning, and laundry services. It is recommended that the care be paid for on an ongoing basis as the care is actually provided.

The care agreement should set forth the exact services that the child will provide, as well as the location where the services will be provided. The parent’s ‘space,’ as well as any ‘common areas,’ should be detailed. Additionally, the agreement should set forth whether the parent or the child is responsible for paying monthly utility charges, as well as yearly expenses, such as property taxes and homeowner’s insurance. The agreement should also address responsibility for property maintenance, such as needed repairs, mowing the lawn, additional landscaping, and snow removal.

It is crucial to value the services to be provided in the care agreement. Services may be valued as a package or individually. The package rate is useful when the care provided is substantially similar to that of a facility, such as an assisted-living facility or nursing home.

When using the individual pricing method, the child must keep a record of the services performed and receive payment based on the actual amount of service provided. All payments to the child are taxable income to the child and should be reported on the child’s personal income-tax return. In this regard, it is also important to realize that most caregiving children will find their availability to work outside the home greatly reduced or eliminated.

The parent and child should also set forth the circumstances under which the child is willing to provide care for the parent and the terms upon which the agreement may be cancelled. In order to avoid the appearance of an illusory promise on the child’s behalf, the agreement should provide that cancellation will occur only upon the occurrence of specified conditions — for example, if it becomes unsafe to continue to provide care in the home. The agreement should also allow for written amendments, so that the agreement can be changed if the situation changes.

The impact of a care agreement with respect to the parent’s options for financing nursing-home care is substantial. Currently, nursing-home care costs approximately $13,000 per month and is most commonly paid for by accessing long-term-care insurance, privately paying, or obtaining MassHealth benefits.

When applying for MassHealth benefits, MassHealth will ask whether the applicant has made any gifts in the last five years. If gifts are found, MassHealth will assess a penalty that prevents the applicant from obtaining benefits for a certain time period based on the amount of the gift. When assets are transferred to a child as payment for care provided, it may be possible to avoid this penalty, as the money was transferred to pay for the services provided and was not a gift.

It should be noted that caregiver agreements are subject to intense scrutiny by MassHealth. If a MassHealth application is anticipated in the future, the care agreement must be carefully drafted and must take into account MassHealth’s current position as to these agreements.

Although there are many issues to address when establishing a care agreement, outlining the responsibilities of both the child and the parent will prevent most disagreements, as the agreement will lay the framework for success. A successful care agreement will allow the parent to remain at home much longer. In addition, a properly drafted care agreement can be financially beneficial to both the parent and the child. As such, the benefit of having such an agreement in place far outweighs the effort involved in establishing the agreement.

Gina M. Barry is a partner with the law firm Bacon Wilson, P.C. She is a member of the National Assoc. of Elder Law Attorneys, the Estate Planning Council, and the Western Mass. Elder Care Professionals Assoc. She concentrates her practice in estate and asset-protection planning, probate administration and litigation, guardianships, conservatorships, and residential real estate; (413) 781-0560; [email protected]

Business of Aging Sections
Why You Need to Plan for the End


Physicians undergo years of education and training to promote wellness, cure and heal, and protect life. Yet, we also know that death is inevitable, and we are increasingly recognizing the importance of advance care planning. We urge patients to do the same.

Advance care planning is the term for the planning we do as our healthcare becomes complicated and we need to make challenging decisions about our care, often toward the end of life. Planning becomes an integral part of most people’s lives at an early age, and most of us are always planning ahead. We plan for education and careers; we create wills, buy life insurance, and establish retirement accounts.

Advance care planning can be thought of in the same way, as a medical part of the future, because one day, despite how intense our will to live may be, the end will arrive. Planning makes your wishes known ahead of time and ensures that they are fulfilled.

The planning begins with the simple act of talking with your healthcare provider and family members to let them know what your wishes are about end-of-life issues. Once those decisions are reached — and it can be appropriate over time to revisit the discussion to change or refine previous decisions — patients then complete certain forms to specify their wishes.

Two of the most important forms are the healthcare proxy and a MOLST form. A healthcare proxy indicates which person you choose to make healthcare decisions on your behalf should you become unable to do so. The MOLST form — an acronym for medical orders for life-sustaining treatment — outlines your preferences for such areas as whether or not you wish to be resuscitated in certain situations. Copies of completed forms should be distributed to family members and all your healthcare providers.

Advance care planning isn’t recommended just for elderly patients or those with terminal illnesses. Physicians recommend that the conversation and planning for everyone start earlier rather than later because of the uncertainty of when that final moment might arrive.

End-of-life care may also include palliative care and hospice care, and patients are urged to learn about these areas of medical care as well. Palliative care refers to the type of care that is delivered when someone is diagnosed with a life-limiting illness. Hospice care is care for those entering the last few months of life, usually with a prognosis of six months or fewer to live.

Getting the conversation started is the first step, and getting it started early is important. Not only will that make your wishes known, but it has benefits for family members as well. Letting your family know what you want in these serious circumstances can prevent your loved ones from carrying the burden of deciding your course of care. It may also avoid family turmoil, as each family member knows exactly what your wishes are and how they are to be carried out.

Healthcare can get more complicated as we age. We may accumulate more illnesses, get frailer, and become more susceptible to injury. Advance care planning makes us think about what we want, what’s most important, and then communicate that with family members and the healthcare team.

Physicians certainly recognize the persistent hope patients can have, even in the most dire of circumstances. But in addition to being a healthcare advocate throughout life, physicians are now able to play an important role in end-of-life care as well.

Many patients who face terminal illness tell us that they are praying for a miracle. We believe in miracles, too: the miracles of dignity, comfort, love, and peace. If patients work together with their healthcare team, physicians can help to make those miracles happen.

If you or a family member wants to talk, and your healthcare provider doesn’t open the conversation, we urge you to take the first step and ask. The topic is too important to ignore.

More information, including a free brochure, Planning Ahead: What Are Your Choices? which lists a number of resources, is available free from the Mass. Medical Society at www.massmed.org/advancecareplanning. For a video discussion, visit www.physicianfocus.org/advancecareplanning.

Dr. Eric Reines is a geriatrician with Element Care in Lynn, and Dr. Beth Warner is a geriatrician with Cooley Dickinson Health Care in Northampton. Reines is chair, and Warner is a member, of the Mass. Medical Society’s Committee on Geriatric Medicine. This article is a service of the Mass. Medical Society.

Business of Aging Sections
Armbrook Village Helps Seniors Navigate Stages of Life


Executive Director Beth Cardillo

Executive Director Beth Cardillo

In the sleepy northwest corner of Westfield lies a winding path marked by a sign that reads “Armbrook Village: A Senior Living Residence.” But that description only tells part of the story.

This modern, 109,000-square-foot structure, which looks like a recently finished condominium complex with its siding, flowerbeds, and bleach-white balconies, is part of a growing wave of senior-living communities that offers older citizens a variety of options along the continuum of aging, its 122 units encompassing independent living, assisted living, and what’s known as Compass Memory Support Neighborhood, which allows residents with memory loss to receive constant treatment and supervision in a secure setting.

The result is an interactive community in the best sense of the word, said Beth Cardillo, executive director.

“We’re not going to get any bigger; we were built to operate at a very manageable size,” she told BusinessWest, adding that the facility, which serves seniors from age 60 to 100, is nearly three-quarters full. “We know everyone in the building. We know everybody’s daughter and son, we know everybody’s grandkids, and we work hard to provide a community atmosphere.”

Armbrook Village was built by East Longmeadow developer Michael McCarthy, along with other investors, in 2012 after he saw the benefits his late mother, Jean, experienced at a senior-living residence in Springfield. However, without any background in elder care or independent-living arrangements, he hired Senior Living Residences (SLR) — a Boston-based company specializing in senior housing operations with a special emphasis on dementia and Alzheimer’s disease — to manage the facility.

Managing 12 communities from Boston to Milford, SLR is affiliated with Boston University’s Alzheimer’s Disease Center, and seven of the chain’s communities feature Compass Memory Support Neighborhoods. With most of the residences located in Eastern Mass., Armbrook Village is the only SLR community on the Bay State’s western region, but it operates with the same goal as all the company’s properties — providing cost-effective care to all residents, whether they’re living independently and going to work each day or need assistance getting up in the morning.

Modern Living

For those living in the studio, one-bedroom, or two-bedroom apartments, Armbrook provides perks that allow residents to be totally on their own, “but not completely,” Cardillo said. Those perks include services ranging from emergency pull cords in each unit to transportation to doctor’s appointments.

The facility also makes it a point of encouraging its residents to get out into the community by providing transportation to restaurants, symphonies, and museums, among other destinations throughout the year. Independent-living residents also have access to three meals a day, prepared with an emphasis on ‘brain-healthy’ foods, as part of Armbrook’s affiliation with BU’s Alzheimer’s Disease Center.

According to Cardillo, SLR emphasizes such a diet throughout its communities, with a number of menu items built around a Mediterranean diet of fish, whole grains, and other foods that are both nutrient-rich and contain omega-3 fatty acids, a fat believed to help reduce the risks of dementia.

“Our statistics show it’s good for the brain,” she said. “A lot of olive oil, a lot of vegetables, a lot of fish, a lot of chicken — all studies point to certain herbs and foods not curing dementia, but adding to the mix of prevention.”

Independent-living residents enjoy other amenities as well, with apartments equipped with kitchens, washers and dryers, and walk-in showers. The apartments are designed to be “desirable,” said Cardillo, breaking away from the past industry standard of small, converted rooms.

Armbrook-Village “Years ago, I think, when assisted living became popular, they were taking the place of older buildings, maybe a converted school, a converted monastery. So the rooms were a lot smaller,” she told BusinessWest. “But now, when families are starting to look for apartments for their elders, they’re thinking, ‘just because Mom is 90 doesn’t mean she has to live in a small apartment.’”

Meanwhile, assisted-living residents receive help with many activities of daily living. Among those services are assistance with getting up in the morning, showering, getting dressed, as well as help with taking medication. Three meals a day are provided.

“Our assisted living is almost the same, only a little bit smaller, because they don’t need a full kitchen because we’re supplying the meals,” she explained.

Then there’s the Compass Memory Support Neighborhood, which features everything found in assisted living, plus some additional services. A smaller neighborhood with 25 units, it’s “the world in a smaller place” for residents with certain memory-related disorders, Cardillo said. “It’s a world that’s easier to negotiate, and it’s filled with activities all day long.”

The rooms were designed to be compact, she continued, since a number of residents there have a hard time finding their way around in bigger spaces. At the same time, the neighborhood’s activity rooms were designed to be larger, allowing residents to conduct activities and ensure that they are not isolating themselves in their own rooms, but staying involved in the community.

“We know that, with dementia, structure and socialization are key,” Cardillo said. Part of that socialization includes bringing out residents for art, photography, and adult learning activities, said Brenda Lopes, director of the Compass Memory Support Neighborhood.

“Here at Armbrook, we do a lot of adult learning, including a program called Reconnections,” Lopes said. “In it, we bring the memory-support residents back into the past with, say, imagery of Frank Sinatra and the Rat Pack or from World War II, and it works to help them connect the past with the future.”

That, along with a number of individualized programs and daily exercise, are among the routines that not only keep the residents active but also work against the effects of dementia and Alzheimer’s.

To enhance their care of residents, SLR involves staff in joint training operations through Boston University and, in Armbrook’s case, participation in a graduate study program with American International College’s occupational-therapy students. Part of a research project conducted by the students, the goal is to have residents in the Memory Care wing increase their daily activities through interacting with music as the AIC students observe its effectiveness and results.

Making Westfield Dementia-friendly

As part of its efforts to improve life for people with memory issues, Armbrook has launched a campaign to make Westfield one of the first ‘dementia-friendly’ communities on the East Coast.

Specifically, inspired by the story of Watertown, Wis. and its own drive to make the town friendlier and safer to those who are experiencing dementia, Cardillo set out earlier this year to coordinate with businesses and departments across Westfield to create an environment where, if an individual with memory loss were to wander into a restaurant or other establishment, staff would know the right steps to handle the situation.

“We’re trying to have more people learn more about dementia, so that, say, if an 85-year-old woman walks into the bank and is very confused, the tellers will be able to know what to do, properly identifying any confusion or memory issues,” Cardillo said. “I would like to do trainings throughout the community and here at Armbrook to teach people a little more about dementia, so that they can embrace it and not be scared by it and have the resources to know what to do.”

In addition to local banks, grocery stores, and other places of business, Cardillo wants to include the city’s police and fire officials, who sometimes find themselves dealing with people, either on the phone or at a scene, with some form of memory loss.

Already, a “virtual dementia tour” has begun involving the Fire Department, said Cardillo, a short (10-15 minutes) explanation of the symptoms of dementia. Hoping to include Noble Hospital and the local senior center, among other organizations, she plans to produce a PowerPoint in the near future as she continues to meet with officials such as the mayor and Chamber of Commerce.

“It’s about giving people the tools they need in order to know what to do when they come across somebody with dementia,” she said — tools her team at Armbrook Village provide to residents every day.

Business of Aging Sections
This Growing Model Bridges Gap Between Primary, Emergency Care

Rick Crews, left, with partner Jim Brennan

Rick Crews, left, with partner Jim Brennan, says there are many reasons — from affordability to its ability to save individuals time and aggravation — why urgent care has become so popular.

Rick Crews has been heralding the benefits of urgent care since he and Jim Brennan opened their first afc Doctors Express practice five years ago.

“We’re treating many people who traditionally used to go to the ER — but a lot of that was not appropriate,” he said of patients whose illness or injury didn’t rise to the level of an emergency, yet had no access to primary care.

“This is an alternative — a place you can go with really high-quality care that’s much more affordable, and get that care in a more timely fashion. That’s why urgent care is so successful right now.

“Hospitals need to concentrate on doing what they do best — the sicker patients, the more labor-intensive patients,” he continued, adding that patients who crowd the ER with less pressing matters cause a backlog, which elevates waiting times and frustration levels for everyone. Several area hospitals have recently renovated and expanded their emergency departments, but Crews said that’s not always the answer.

“I think we’ve provided relief for the hospital so they don’t have to build a new facility, and we’ve provided an outlet for patients, who can be seen for something in a much quicker fashion.”

If it sounds like hospitals consider afc Doctors Express and other urgent-care facilities a competitive threat, think again. In fact, hospitals are increasingly opening urgent-care clinics of their own to provide a level of care between the doctor’s office and the ER, with hours that often extend well into evenings and weekends, unlike the typical primary-care practice.

In some cases, hospitals are even teaming up with urgent-care practices, as evidenced by the recently announced affiliation between Boston-area afc Doctors Express franchises and Steward Health Care, a network of 11 hospitals and other facilities.

“The way our affiliation is set up is really cool,” Crews told BusinessWest. “When a patient walks in the door, we ask them, ‘do you have a primary-care provider?’ If they say ‘no’, we will refer them to primary-care physicians with the Steward group. And their family-practice physicians will refer their patients to afc Doctors Express after hours and weekends for urgent-care needs.”

Through the affiliation, 45 family-practice, emergency-medicine, and internal-medicine physicians employed by afc Doctors Express will join the Steward Health Care Network, and afc Doctors Express physicians will have access to Steward’s patient portal to evaluate a patient’s clinical history prior to commencing treatment. Clinical notes from an urgent-care visit will be communicated back to a patient’s primary-care physician or specialist for necessary follow-up.

“The hospitals are embracing urgent care; they see it as a great thing,” said Dr. Richard Freniere, co-owner, Urgent Care of Wilbraham, which opened last year. “We really have some good relationships with both Baystate and Mercy, open communications with doctors and emergency rooms in both hospitals.”

The pair know something about hospital ERs, since they’re both employees in the Wing Memorial Hospital Emergeny Department in Palmer, although Freniere devotes the bulk of his time these days to the Wilbraham facility.

“Baystate opened up an urgent care; they see the value of it,” Freniere said, citing just one of the area’s hospital-affiliated practices. “But we’re starting to see other competition coming in — little mom-and-pops, with one doctor, taking a shot at urgent care.”

Growing Model

According to the New York Times, the proliferation of those tiny practices makes it difficult to determine the exact number of urgent-care facilities in operation, but the Urgent Care Assoc. of America pegs the figure at around 9,000 — and growing.

Dr. Ateev Mehotra, associate professor of Health Care Policy at Harvard Medical School, told the newspaper that greater patient awareness of urgent care is causing a cultural shift.

“We expect to do our banking 24 hours a day, seven days a week, and to shop 24/7,” he said. “So now we want our healthcare to be 24/7.”

The cost of urgent care, with its much lower co-pays than emergency care, also appeals to patients — not to mention commercial insurers. By any measure, Freniere said, Wilbraham Urgent Care has been a success.

“We definitely way exceeded our one-year expectation. We are basically at our max volume right now. For the size of the facility we have, I really don’t want to burden the system any more than we do. If we go much more than this, we’ll have what happened in hospitals, getting too many people, and we won’t be able to provide what we set out to do in the first place.”

And seeing patients quickly is a hallmark of urgent-care clinics, with wait times typically averaging a half-hour or less, compared with several hours at some hospital ERs. So is time flexibility; according to the American Academy of Urgent Care Medicine (AAUCM), only 29% of primary-care doctors offer after-hours coverage, but urgent-care practices are generally open evenings and weekends, with some offering around-the-clock care.

Dr. Richard Freniere

Dr. Richard Freniere says hospitals are embracing urgent care, rather than viewing it as a threat, because it enables them to focus on what they do best.

That’s a relief for patients who would rather not deal with the emergency room to have a minor injury or illness treated. According to the AAUCM, the number of emergency-room visits increased by more than 1 million per year between 1994 and 2004, while the number of hospitals and ERs decreased by 9%.

Today, emergency departments handle 110 visits annually, and many are clearly not emergencies. A 2009 RAND Corp. study reported that up to 27% of ER visits could be easily handled by urgent-care centers or retail clinics, saving up to $4.4 billion per year in health costs.

“We’ve all experienced the five-hour wait at the ER — it’s not good,” Crews said. “We’ve all experienced those long waits and frustration in crowded ERs, so we are providing an alternative.” In fact, across the four practices he and Brennan own and six others for which they are master franchisees, patients’ average door-to-door time last year was 49 minutes.

“That’s a huge differentiator,” Crews said. “Then there’s the cost — in the emergency room, the average deductible is $100 to $200.”

Freniere agreed. “Being ER doctors for the past 20 years, we’ve seen all the people coming in and getting frustrated at times. And many of them really don’t need to be coming into the emergency department and incurring a high cost of care.”

The fact that a successful urgent-care practice can be very profitable isn’t lost on private-equity funds, which have purchased many urgent-care networks over the past few years. Insurance companies have also gotten into the ownership game. “Clearly there’s more competition now,” Freniere said.

Still, the Wilbraham practice has been such a success that the partners are preparing to open a second location in Worcester County. “And I’m not sure that’ll be the last place we do.”

Catching On

Massachusetts is especially fertile ground for urgent care, said Freniere, because the Bay State lagged considerably behind much of the country in adopting the urgent-care model, although that’s clearly changing.

“I think Massachusetts is a little late to the game,” he told BusinessWest. “We’re advanced in high-end care, but we really took the slow approach to urgent care. Everything was done in the hospital; everything was done in the big medical center. It never felt as if we had to cater to the patient. I think that’s a big change.”

That change includes the attitude of hospitals, which increasingly see the value in this relatively recent model. “They’re saying, ‘hey, guys, we want to get you to work with us. You’re complementary to what we’re doing.

“Doctors are coming around too,” Freniere added. “Initially they saw us as competition, but now they see us as supplemental. We’re not out to take anyone’s patients from them. We’re helping to unburden the system, basically.”

Crews has seen that shift as well. “There’s been a lot of change over the past four or five years since Jim and I opened up our first one,” he said. On the national level, afc Doctors Express — which was recently purchased by American Family Care — will boast more than 160 sites by year end, and Crews and Brennan expect to increase their total from 10 to 18 by the end of 2015.

“We continue to grow every year as patient volumes increase,” Crews said. “It’s because we focus on providing an exceptional patient experience, great quality medical care, convenient hours, and low prices — all those things together.”

Since affiliating with Steward, he said the partners have been busy meeting with the system’s hospital presidents and talking strategy. “These hospitals out there are embracing us.”

As for Freniere, he said he has been contacted by a large urgent-care company, but has no plans to sell — in large part because he finds delivering healthcare in this way a gratifying experience.

“The way the model is set up, the way it’s working right now … it’s attracting attention,” he said. “I think it’s the future.”

Joseph Bednar can be reached at [email protected]

Business of Aging Sections
Fallon’s Summit ElderCare Sets a New Standard

Pam White and her mother, Helese

Pam White and her mother, Helese, in the library at Summit ElderCare in Springfield.

Pam White is an only child, and is still many years from being in a position to retire.

Which means that she faces some significant challenges in her role as caregiver for her mother, Helese, who has several health issues, but is neither ready nor willing to move into a nursing home.

Pam told BusinessWest that, as she launched a search for a solution to her dilemma, she did so with a specific mindset. She was looking for a facility that was a step above adult day care and two or three steps above a community senior center — a place where medical care was available in the form of an on-site geriatrician, but where there was also a strong social component with a host of activities for a diverse group of seniors.

She has found all this and a lot more at Summit ElderCare, a PACE (Program of All-inclusive Care for the Elderly) facility operated by Fallon Community Health Plan in Springfield’s North Medical District.

The facility, which opened its doors roughly a year ago, now serves 53 individuals with roughly the same needs as Helese. They are called ‘participants,’ rather than ‘clients,’ ‘patients,’ or ‘customers,’ because that term best describes what they are, said Kristine Bostek, vice president and executive director of Summit ElderCare.

Elaborating, she said they are participating in a program, based on a national model of coverage recognized by both Medicare and Medicaid, that provides medical care, geriatric case management, care coordination, adult day health services, full insurance coverage (including Medicare Part D prescription coverage), and in-home support in a personalized setting that features interaction with other seniors and a host of activities.

All of this resonated with Pam White.

“My mother is a very social person, and what appealed to me is that there would be other seniors involved in this program,” said White. “I wanted to engage my mother in a program where they have activities, and where it’s obviously a safe environment.

“It’s like one-stop shopping,” she went on, referring to the range of services offered at the facility. “They have a primary-care physician that specializes in geriatrics, and if my mother needs lab work, that can be done. And if I were trying to do that as caregiver, I’d be running here and running there, and that’s difficult with my work schedule.”

Kristine Bostek

Kristine Bostek says Summit ElderCare calls those it serves ‘participants’ — rather than clients, patients, or customers — because that word best reflects what they are.

The Springfield location is one of five now operated by Summit ElderCare in Central and Western Mass., said Bostek, adding that the company started with a location in Worcester in 1995 and eventually added a second facility in that city before eventually expanding into Charlton and Leominster. Further expansion into the Merrimack Valley is now under consideration.

An assessment of the Western Mass. market several years ago revealed a need for a PACE facility there, said Bostek, noting that, after consideration of several possible landing spots, the company eventually chose a location in Springfield in a new medical building on Wason Avenue built to Fallon’s specifications.

One year after opening that site, the company is on target with regard to growth, said Mary Woodis, RN and site director, adding that this location will likely hit its goal of 250 participants within three years.

For this issue and its focus on the business of aging, BusinessWest takes an in-depth look at Summit ElderCare’s Springfield facility and how it is improving the quality of life for both participants and their caregivers.

Senior Moments

Bostek told BusinessWest that the PACE concept is gaining considerable traction across the country, with more than 100 sites currently operating nationwide.

Fallon is now the fifth-largest PACE provider in the nation, with 900 total participants, and the largest in New England, she said, adding that the company is a firm believer in this model of healthcare because it provides a viable option to more expensive nursing-home care, and will only become more popular as the population ages because of the many benefits it provides for people like Helese — and the peace of mind it offers to those like her daughter Pam.

The concept was described by both Bostek and Woodis as a “community-based alternative to nursing-home care,” and one with two critical elements: a healthcare component and a social component, which are both considered critical in the delivery of complete care to a participant.

Elaborating, Woodis said Summit ElderCare provides geriatric case management, care coordination, and a host of additional services that include:

• On-site medical care;
• 24/7 emergency access to a staff member;
• Physical and occupational therapy;
• Adult day services;
• Medically necessary supplies and equipment;
• In-home assistance;
• Medically necessary transportation;
• Nutritional counseling;
• Caregiver education and support; and
• Full medical and prescription drug coverage.

The model has met with a good deal of success in Central Mass., as evidenced by the steady base of expansion, said Bostek, adding that, by the start of this decade, the company was actively pursuing opportunities to bring the concept to other parts of the state.

“Based on experiences in Central Mass., we felt there was a huge opportunity to take this model into this part of the state,” she said of the Greater Springfield area. “So we embarked upon a plan to expand in Western Mass.”

The 14,500-square-foot Springfield facility is licensed to serve residents of Hampden County and a few communities in Hampshire County, said Woodis, adding that, while many of the current participants are from Springfield, several other communities are represented. To be eligible for the program, individuals must by 55 or older and meet clinical criteria that Bostek summed up with the phrase “nursing-home-eligible.”

Mary Woodis

Mary Woodis says people come to the program for their medical care, but also for the social aspects.

The current mix of participants includes individuals across a broad age spectrum, said Woodis, adding that many are in their 60s, while a few are in their 90s, and there’s one centenarian. Some have cognitive issues, such as dementia or Alzheimer’s, while others do not, and there is a growing number of what would be considered younger seniors with neuromuscular disorders such as MS and ALS.

“A PACE participant, in general, is a frail, older adult,” said Dr. Alison Grover, the on-site gerontologist at the facility. “They probably average in their low 80s with multiple medical problems and usually some difficulty with mobility and self-care.

“It’s not at all unusual to have some level of memory impairment as well,” she went on, “and it’s our mission to keep such individuals in their home as opposed to in a nursing home.”

Summit Eldercare makes this possible by providing that one-stop shopping Pam White described.

Care Package

Elaborating on this concept, those we spoke with all used the phrase ‘integrated model of care’ to describe what’s offered, meaning both medical care and the many social aspects of the PACE program available at the Wason Avenue facility.

“People come here for their medical care,” said Bostek, referring to everything from visits with Grover to occupational and physical therapy. “But they’re also here for the social aspects of this program, doing things with other participants.”

It is this “complete package,” as Grover called it, that separates Summit ElderCare from a typical senior center and adult day care facilities, and also enables older adults to stay out of nursing homes.

Woodis said activities run the gamut from arts and crafts to computer classes; from reading in the facility’s small library to healthy-cooking classes. On the day BusinessWest toured the facility, a Mother’s Day tea was in progress. Participants helped create tissue-paper flowers and also baked pies for the attendees.

The key to effectively providing this integrated model of care is teamwork, said Grover, and there are many members on the team, including nurses, physical and occupational therapists, a nutritionist, social workers, a transportation coordinator — who oversee work to get participants to and from appointments — and others.

Each day starts with a team meeting, she went on, one that essentially assesses the immediate needs of the participant population and creates an action plan.

“We talk about our participants — we talk about who may be having problems, who may be in or out of the hospital, who has a caregiver that’s been in the hospital for the past month,” she explained. “We talk about what we can do to help support the family and what the patient needs to be safe at home. We talk about whether we need to go out and see the patient at home that day. And then we go out and do our various jobs.”

This is an effective model, but one that many in this region don’t know about, said Bostek, adding that, to meet established goals for growth, the company must build awareness about the PACE concept. Meanwhile, it must also be diligent and imaginative when it comes to outreach and building relationships with individuals and agencies that might refer potential participants.

Those constituencies include senior centers and ASAPs (aging service access points), agencies that serve the elderly, as well as hospitals, primary-care physicians and specialists, elder-law attorneys, senior housing complexes, food pantries, and others.

“We really work hard to be very visible in locations where there would be a large older adult population, as well as a low-income older adult population,” said Bostek. “We do some marketing, but it’s really a grassroots approach that we take.

“You sit across the kitchen table from a caregiver and/or an older adult to talk about the program,” she went on. “We have that personalized touch, but we need to make sure that we’re out in the community and that we’re building relationships with community partners and resources, because we want to them to readily identify that this program may be a viable option for someone and refer them to us.”

Caregivers are a very important piece of this outreach process, Bostek continued, citing statistics showing that one in three Americans serve as caregiver to a spouse, older relative, or friend, and many, like White, face considerable challenges as they take on that assignment.

Grover agreed, and cited the caregiver of that aforementioned centenarian as a good example.

“That patient has medical problems and mild dementia, and is cared for by her son at home,” she explained. “In order to keep her there, he needs oversight on medical management, assistance in the home with personal care, and help to simply balance his caregiver role with other roles in his life. She needs help with personal care and mobility, and for someone like that, there aren’t many other alternatives.”

Coming of Age

There were not many alternatives for Pam White as she searched for a program that would allow her to keep working and also enable her mother to remain in her home and out of a skilled-nursing facility.

The program offered by Summit ElderCare has proven to be the solution sought by both mother and daughter, and this story is now being repeated on a regular basis at the Wason Avenue site.

These developments clearly show that the company has become a PACE setter, both literally and figuratively.

George O’Brien can be reached at [email protected]

Business of Aging Sections
Marketing to Baby Boomers Poses Challenges, Opportunities

Janet Casey, with Marketing Doctor Agency Director Bill Lucardi

Janet Casey, with Marketing Doctor Agency Director Bill Lucardi, says older Americans comprise a lucrative — and growing — market.

Christopher Rawson has seen a sort of “reset” in the connection between how old Baby Boomers are and how old they feel.

“We do marketing for a number of retirement communities, and they’ve sort of noticed a gap in age. People used to move in at 65; now they’re moving in at 75 or 80,” said Rawson, creative director at Andrew Associates, an advertising and marketing firm in Enfield, Conn.

Compared to what would be considered the older generation decades ago, he noted, “they’re healthier individuals, with better medical care, and people are staying active longer.” They’re also purchasing more, and that’s posed a challenge for companies who want to access Boomers’ deep pockets.

How deep? According to a 2012 study by Nielsen and BoomAgers, nearly 70% of all the disposable income in the U.S. will be in the hands of this group within five years. Nearly 8,000 Boomers turn 65 every day, and with Americans living longer, the ranks of the over-65 crowd will continue to swell for the next 15 years.

“Marketing to seniors effectively, and being adept at the nuances and cultural values necessary for marketing to seniors, can make or break your campaign efforts,” writes Bill Murtha, president and CEO of Roberts Communications, who blogs about societal trends at behaviorchange.net. “Why? As the famed bank robber Willie Sutton allegedly said when asked why he robs banks, ‘because that’s where the money is.’”

Importantly, Rawson said, most Boomers see plenty of life in front of them. “They don’t like someone talking to them like they’re old. The whole mantra that ‘70 is the new 60’ or ‘60 is the new 50,’ that’s really true. Older people are much more active. Some are working just because they want to do something. They’re much more involved with technology than ever before, more informed. It seems like, the last few years, everywhere you turn, you see older people on smartphones and iPads.”

Janet Casey, president of Marketing Doctor, a marketing agency in West Springfield, agrees that older Americans bring rich opportunities for travel, recreation, healthcare, and a host of other industries.

“The way I look at it, people who are 50 and older have the highest disposable income of any market there is,” she told BusinessWest. “An 18-year-old might think he wants a new car or a vacation, but if he can’t write the check, it doesn’t matter, does it?

“This is what I see in the travel industry,” she continued. “They offer so many guided trips for seniors, domestic and international — because seniors can afford it.”

But with an eye on the long term, Rawson and Casey said, they’re not throwing their money around carelessly. Knowing how to reach them — with the right messages on the right media platforms — is the key to tapping into that promising 70%.

Logged On

Take social media, for example. The sole domain of Millennials and Gen-Xers five years ago, Facebook has undergone a remarkable demographic shift. Its ease of use attracted countless parents and grandparents who enjoy keeping up with family and old friends and sharing pictures; as younger users have abandoned Facebook in search of newer and ‘cooler’ platforms, the older crowd — less transient in its social-media tastes — has stayed put.

“Seniors are the fastest-growing group on Facebook,” Casey said, adding, however, that those habits don’t cross over into Twitter, Instagram, or other popular sites. “We place a lot of ads for area hospitals — say, for an arthritis clinic or joint replacement. We know that seniors spend a lot of time on Facebook, because they have more hours on their hands than other people do. But we don’t find them on social media outside of Facebook.”

Rawson said social-media use has picked up in general among Boomers, but agreed that Facebook is ground zero.

Chris Rawson

Chris Rawson says Boomers with disposable income aren’t indiscriminate with their money, but they will respond to ads, including online pitches, for products and services that appeal to them.

“In terms of the Boomers, the 65-plus crowd, they want to see what their grandkids are doing, and Facebook has definitely shifted to an older crowd now,” he noted. “The typical user on Facebook is a 42- to 45-year-old woman with kids. The second-most-popular user is that person’s mother.”

Twitter and Google Plus are also attracting more seniors, writes Tracy Sestili at socialmediatoday.com. But these are different than the family-photo-sharing crowd on Facebook; there are more executives and small-business owners who use social media for marketing purposes.

But older Americans are definitely online. According to Pew Research, 59% of people 65 and over use the Internet, and 77% have a cell phone. Furthermore, according to a study by eMarketers, 49% of Boomer tablet users and 40% of smartphone users made at least one purchase within the past year after gathering information on their mobile device.

Still, Rawson said, “they’re very cautious. They do investigate a lot of stuff on the Internet, whether it’s advertising going on Facebook or other social media. They’re responsive to ads. They won’t click on everything, but if it’s something they like, they’ll click on it.”

And, again, Casey stressed that no social-media site approaches Facebook when it comes to attracting older users. “Many younger people have left Facebook because their parents are on there, but there’s really no other place seniors are — not Instagram, not Twitter.”

Screen Time

What hasn’t changed much is the TV-viewing habits of seniors, who watch, on average, 4.2 hours of TV per day.

“They consume more TV than the other groups,” Casey said, particularly in the daytime hours, when soaps, game shows, and talk shows dominate. Fortunately, she added, advertising during these non-prime-time hours is relatively inexpensive. “It’s a very efficient way of reaching seniors. For literally $30, you can have an ad on a broadcast station, and you can reach them.”

Multiple studies also suggest that direct mail is more effective on Boomers than on younger generations, and while newspaper readership is declining among all demographics, 65% of readers are seniors.

“Most older people are reading a daily newspaper; it’s part of their culture,” Casey said. “If you think about it, our parents wouldn’t start their day without reading the paper. With our generation and our kids, it’s not the same.”

So when targeting the senior crowd, she added, “we have great success through print, through daily and specialized publications. But there’s a huge dropoff under age 50.”

Regardless of the medium, Murtha writes, the message is everything. “As senior lifestyles change, so do their interests. Yes, they are adopting and using social media and the Internet. But they’re using it to share photos and memories with friends and family. They’re spreading and taking in news about their local community online. They’re exploring or expanding their interests and hobbies in a more intent way now that they have the time and the money to do so.

“Want to connect and reach mature markets effectively?” he adds. “It’s not all digital and online, and it’s not all print and traditional.”

And caution still reins among much of this demographic, Rawson stressed. “It’s interesting how they perceive the future; they understand they’re living longer, and they want to make sure their retirement plans last them, so they don’t outlive their money. They are very conservative spenders, but they will spend if it’s the right thing and they have the income to spend on it.”

Joseph Bednar can be reached at [email protected]

Business of Aging Sections
Glenmeadow Renovates, Responds to Lifestyle Changes

Tim Cotz, president and CEO of Glenmeadow

Tim Cotz, president and CEO of Glenmeadow

A few weeks ago, Tim Cotz, president and CEO for the past 20 years at Glenmeadow, noticed one of his housekeepers wished an elderly resident ‘happy birthday’ on Facebook.

Of course, he’s impressed with an octogenarian who is active on Facebook, but he said he’s even more pleased to see one of his staff reaching out to her, because it’s the personal bonds among the staff and residents that make Glenmeadow — an independent- and assisted-living complex in Longmeadow — feel like home.

In fact, Cotz can be found pouring coffee every weekday morning at 7 a.m., walking around opening shades for more light, and pouring glasses of chardonnay at a late Friday afternoon cocktail hour; his daily, hands-on style is a physical illustration of what he expects of his 110 employees in all their different roles. This philosophy, and an open ear to requests for change, have helped Glenmeadow grow successfully over the past 20 years, weather the Great Recession, and recently complete a $4 million renovation (more on that later).

Cotz describes Glenmeadow as “unique” in the business of senior living because it’s a stand-alone, nonprofit facility, while most of its competition is religious-based, for-profit, owned by private entities, or merged into large conglomerates.

He told BusinessWest that, while he’s always worked to enhance services and meet the expectations of his residents and their families, it’s a much more vocal demographic these days.

“I don’t think we can ever be a place where we say, ‘this is what we do, this is what we offer, that’s what it is,’” said Cotz, who noted that the organization’s original managers, which became a board in 1985, was long run by a group of ladies; in its 130-year history, Cotz is the first male to have the leadership role in Glenmeadow. “We’re ever-evolving.”

As another example, he mentioned a new addition to the staff, whose role is to help residents with their technology needs. Requests for assistance with iPads, iPhones, laptops, and the general need to keep up with social media is as important to residents, he said, as it is to everyone else today.

When Glenmeadow opened its new facility 17 years ago, “we had one person here with their own computer,” Cotz explained. “Now we have wi-fi throughout the building, and a majority of the folks have computers, so we’re looking at how we continue to enhance those services.”

For this issue’s focus on the business of aging, BusinessWest toured Glenmeadow to learn more about an elder residence with a long history in Greater Springfield, and how that nonprofit is catering to a demographic requesting amenities and programs reflecting a younger mindset than ever before.

Welcome Home

Working in long-term care since 1970, Cotz started as an orderly in college, and graduated from Hartwick College with a bachelor’s degree in healthcare before earning his master’s from George Washington University.

From 1982 to 1988, he served as executive director of the Geriatric Authority of Holyoke, then led Berkshire Health Systems in Pittsfield for five years, before transitioning to Glenmeadow, which at the time was located in downtown Springfield.

Doorstop Café

Tim Cotz said the $4 million in recent renovations includes the Doorstop Café, a popular meeting place for residents as well as visiting friends.

Explaining Glenmeadow’s history, Cotz said the nonprofit was founded in 1884 with donations and bequeaths, making it the oldest residential nonprofit for the elderly in Springfield. Originally named the Springfield Home for Aged Women, it was created to provide shelter and care for female seniors.

“Every city at the time had a ‘poor farm,’ and that’s where old people went,” Cotz told BusinessWest.  “But the citizenry of Springfield felt that they deserved a better option.”

The first structure was a home behind the current Red Rose Pizza in Springfield’s South End, which then moved to a mansion on the corner of Chestnut and Carew streets (the building is now used for alcohol and drug rehabilitation services), and by the 1960s the name was changed to Chestnut Knoll.

When the facility needed more space, it purchased a 20-acre plot of land from Daniel O’Connell’s Sons in 1993, just over the Springfield line in Longmeadow, and construction for the current facility was completed in 1997. The richly landscaped campus and buildings now boast 113 independent apartments (14 more were added in 2000 to the original 89 units), boasting full kitchens and baths, plus 34 assisted-living apartments with kitchenettes.

Demand for units has been fairly consistent over the past two decades, Cotz said. The recession impacted the nonprofit a bit in 2008 and 2009, causing the waiting list to shrink, but residents have consistently filled the apartments. After the recession, not only did the waiting list fill up again, the changing style of how seniors want to live created demands of a different sort.

Great Expectations

Specifically, Cotz pointed out two societal shifts that have affected Glenmeadow over the past decade. First is the trend toward ‘aging in place,’ which the facility turned into a revenue generator in 2001 with the introduction of Glenmeadow at Home, a non-medical, private-duty, home-healthcare company for those living there.

“People are living so much longer and living healthier, and typically there are periods where they need some additional support. So now we can hire our own staff, train them, do the background, and supervise them,” he explained. Residents also have the option to hire outside workers for those extra services, if they so choose.

The goal is to provide non-medical services that help elders stay comfortably in their home, which includes companionship, handyman service, transportation, meals, dog walking, and more. By 2003, Glenmeadow at Home expanded to caring for anyone 62 and older in the Greater Springfield community. Calls to clients’ personal physicians for medical attention are part of the services, and that eventually evolved into care management in the home to coordinate all the services that an elder would need as their medical care requirements increase. Today, Glenmeadow at Home employs 80.

The second trend Cotz has observed is a renewed focus on fitness and lifestyle programming.

“The population we’re serving is clearly looking for more options for wellness, so much so that 83% of the people in this building exercise regularly,” he explained, which has led to an expansion of wellness services on site.

“When we opened 17 years ago, we had a room about this size, and if people brought an exercise bike, we’d store it in there,” Cotz said, pointing around his office, which comfortably holds a desk, a table, and two easy chairs. “Well, now we have three trainers on staff, Nautilus equipment, and numerous exercise classes each day, from stretching to balance to Tai Chi, PiYo [a blend of Pilates and yoga], and aquasize.”

This attention to physical and mental wellness, Cotz told BusinessWest, is due to behavioral differences among three generations: the Silent Generation (born 1925-1944) and the GI Generation (1905-1924), which together which make up a large portion of Glenmeadow’s older residents, and the older edge of the Baby Boom Generation (1945-1964), who are now entering the facility or on the waiting list.

“They are very different populations; the expectations of people we’re serving are changing,” said Cotz. “My parents’ generation, the GI population, were kind of ‘give me a cot and a cup of coffee, and I’m good to go.’ But the people in their early 70s coming in clearly have higher expectations in terms of amenities, programs, and services.”

The standard independent-living facility — with individual living units, one large dining room, and some separate rooms for a lounge, library, puzzles, and crafts — are from a bygone era. Now, the demand for more contemporary open space and more choices for meal times has changed the entire look and feel of Glenmeadow’s first floor.

The complex recently invested $4 million in renovations to tear down interior walls, open up meeting rooms, add more windows for natural light, expand the wellness area, and split the formal dining room to create the casual Doorstop Café, as well as more administrative space for the growing Glenmeadow at Home.

Living Social

Another concern is the alarming trend of cognitive loss, ranging from general senility to vascular-related dementia to Alzheimer’s disease. Both Glenmeadow and Glenmeadow at Home aim to identify the first signs of impairment and the supports necessary to keep people independent for as long as possible.

While Glenmeadow is a private-pay business, the nonprofit accepts donations through requests and estates, and has an investment portfolio of $15 million. Those investments can help those that outlive their resources; Cotz said the facility has never discharged anyone due to inability to pay.

In addition, a few years ago, Glenmeadow began offering the use of its facilities to non-residents for only $25 per month. With little advertising, membership escalated to more than 80 people after renovations were completed last fall. Members take advantage of the pool, use the fitness programs and equipment, and grab soup or coffee at the Doorstop Café, Cotz said. “It allows the public to realize first-hand what could be their next home.”

That’s certainly worth a Facebook ‘like’ or two.

Elizabeth Taras can be reached at [email protected]

Business of Aging Sections
Breakdown of Cartilage Between Joints Leads to Osteoarthritis

Dr. Leonard Wagner

Dr. Leonard Wagner says the most noticeable symptom of osteoarthritis is joint pain, but people also experience tenderness, stiffness, and loss of flexibility or range of motion.

More than 27 million Americans suffer from stiff joints and/or pain caused by osteoarthritis, or OA. It is the most common form of arthritis, and although growing older does not cause it, 50% of people over age 65 have some form of OA and suffer from degenerative changes in their joints. Still, the condition is not inevitable, and the pain it causes can often be alleviated.

“There are a lot of people who never develop arthritis, and there are others who do have it whose lives can be markedly improved with appropriate attention,” said orthopedic surgeon Dr. Leonard Wagner of Springfield.

Dr. James Schumacher agrees. “Osteoarthritis a very common disorder, and if you look hard enough, you can find it in everyone 40 or older, particularly in the spine,” said the rheumatologist from Riverbend Medical Group in Chicopee. “But the progression of the disease is very slow and takes place over decades.”

OA can affect the neck, back, hip, knee, shoulder, feet, thumb, or fingers. “Arthritis means inflammation of the joint, and osteoarthritis can affect just one or two joints, compared to other types that can involve the entire body,” Wagner said. The most noticeable symptom is pain in or around the joint, but people can also experience tenderness and/or stiffness and loss of flexibility or range of motion. Some also report a grating sensation or sound in the joint when they move.

The problem is caused by a breakdown of cartilage, which is a tough, elastic, fibrous connective tissue between the bones in the joint that provides them with cushioning. When it becomes too thin, the bones rub together, which leads to inflammation, stiffness, pain, and loss of movement.

But Schumacher says pain increases gradually and is dependent on many factors, such as a person’s weight and how much stress is put on the joint. In addition, what doctors find on X-rays or magnetic-resonance imaging does not necessarily correlate to the degree of pain people experience, he told BusinessWest.

However, some factors, such as obesity, make the problem worse, especially when the knees are affected. Wagner says every extra pound translates to three to four pounds of extra stress on the knee in people with OA. “So if you gain 10 pounds, the knee thinks you gained 40 pounds.”

Keeping active is important, but can be difficult because the more pain a person has, the less likely they are to exercise. “It’s a downward spiral,” Schumacher said. “If you can’t exercise, it’s easy to gain weight, and the more you gain, the more it hurts to exercise.”

Dr. James Schumacher

Dr. James Schumacher says the progression of osteoarthritis can be very slow, gradually worsening over decades.

However, exercising in a pool is a viable compromise and especially useful for people with OA in their knees, hips, or back. “Even walking in a pool will help,” Schumacher said, adding that some people use college or hotel pools rather than joining a gym. “You don’t have to be a lap swimmer. All you have to do is walk around. But it’s hard to get people interested in going to a pool in the winter.”

Progressive Condition

In addition to obesity, which can make OA worse, other factors put people at risk for the condition. “We don’t really know why osteoarthritis develops, but it is believed that genetics may play a role,” Schumacher said.

There is also a correlation between past injuries and symptoms. They include sports mishaps, car accidents, or a bad fall. In fact, the Arthritis Foundation says researchers have determined that 10 to 20 years after a traumatic injury to the knee — such as an ACL or meniscus tear — about 50% of patients will develop OA.

“The knee is very prone to injury,” Schumacher said. “But any joint can be involved, and if there is a deformity or slight variation in normal structure, it may lead to osteoarthritis.”

The condition occurs over time, and is often referred to as ‘wear-and-tear’ arthritis. Wagner explained that cartilage has a very slippery surface. That surface, combined with a small amount of fluid, keeps the joints lubricated.

However, as the cartilage degenerates or thins out, its surface becomes more like sandpaper, which prevents the bones from gliding easily. As the thinning progresses, they can begin to rub together. “It leads to inflammation, and as the body produces more inflamed cells, there is more and more pain and stiffness,” he said.

At first, pain may be infrequent and only occur with weather changes or when engaging in a strenuous activity. “But as time goes on, the symptoms become more of an issue,” Wagner said, adding that knees tend to be particularly painful because they are weight bearing and people cannot avoid using them because they need to walk.

However, there are measures people can take to help prevent OA. They include maintaining a healthy weight, taking care of injuries when they happen, and staying active. “You don’t need to go to the gym four times a week,” he said. “People just need to keep moving. Every walk you take or every time you take the stairs will help.”

Schumacher agrees. “All exercise counts, even walking from the far end of a parking lot. People who do this are actually getting good exercise. If you only do it once in a while, it will be more difficult, but a small amount is better than nothing, because the body does remember.”

Treatment Options

Wagner says there are a number of modalities used to cope with disabling pain. Many people use canes or walkers. “They can also get injections which decrease inflammation. And certain anti-inflammatory medications can also help to decrease inflammation and discomfort and may make your life more enjoyable. A lot of people take ibuprofen or Aleve and find it is beneficial. But it is important to pay attention to the directions because there is a potential of irritating the stomach.”

Schumacher agreed, and said people who take prescription medications or have other medical conditions should check with their doctor before embarking on a self-treatment plan of over-the-counter medications, as drug interactions and stomach inflammation can occur. “The doctor needs to look at the whole picture and decide what is a reasonable risk.”

Both physicians also urge people with pain that continues over time to visit their physician. “It’s useful to talk to your doctor about your symptoms, get a diagnosis, and find out what treatment is best,” Schumacher said. “A physical exam can detect changes in function, range of motion, and tenderness. We also use X-rays and MRIs to test the severity and extent of osteoarthritis, although there is a lot of variation in symptoms compared to these studies. But our aim is do what we can through medical management.”

However, Wagner says many people fail to schedule a doctor’s visit because they assume they know what is wrong with them and what the physician will prescribe.

“But just because you have pain in a joint doesn’t mean it’s arthritis or you need a particular treatment plan,” he explained. “For example, it’s possible to have pain and swelling in a knee from torn cartilage, even though the person may not remember getting injured. Or someone may have worked too hard in the garden and have tendinitis, which rest and over-the-counter medication will take care of.”

Surgery provides relief for many people, but is not scheduled until other treatment options are exhausted. “Joint replacement is usually the last option,” Schumacher said. “It is a big procedure, and it’s expensive, but for those who are barely able to get around, it can be quite helpful.”

Future Outlook

Osteoarthritis stems from a variety of causes, but is definitely associated with aging. “It is seen in younger people, but that is usually the result of injury or previous trauma to the joint,” Schumacher noted.

And although there is a lot of interest in what makes cartilage deteriorate, it is hard to study.

“Our understanding of why and how osteoarthritis happens is not very good, so even when it is detected early, we don’t have a treatment to change the outlook,” he told BusinessWest. “But it definitely pays to protect your body from injury, control your weight, and stay active.”

Business of Aging Sections
Rise in STDs Among Seniors Prompts Calls for Education, Compassion
Suzanne McElroy

Suzanne McElroy says the proliferation of advertising promoting senior relationships comes with little education regarding the dangers of sexually transmitted diseases.

‘Do you have protection for safe sex?’

That’s certainly not an uncommon question to ask these days, given the dangers of sexually transmitted diseases (STDs) and the widespread awareness of these afflictions.

But when Suzanne McElroy asks the same question of her clients, “they look at me with this shocked expression and ask, ‘why would I need that? I’m too old to get pregnant.’”

And that’s a big part of the problem when it comes to a growing — and alarming — trend that has emerged in recent years: a surge in the number of reported STDs among what would be considered older populations, those age 50 and up. Indeed, most of these individuals are probably too old to get pregnant, but they’re definitely not too old to contract STDs and the various health issues that accompany them.

As a franchise owner of Home Instead Senior Care, based in Springfield, McElroy knows the reality of what is happening behind closed doors with her clients, who range in age from the mid-70s to over 90, and the many issues that the aging process brings. But she also knows the disturbing statistics regarding STDs in seniors.

One of the most notable published reports is the American Assoc. of Retired Persons’ “Sex, Romance, and Relationships,” released in 2010. It surveyed a nationally representative sample of middle-aged and older people about their sex lives. These are the major findings:

• Three out of 10 respondents said they had sex at least once a week, including almost half of those who were single but dating or engaged, and 36% of those who were married;

• 85% of men and 61% of women said sex was important to their quality of life; and

• Just 12% of single men and 32% of single women who were dating reported always using condoms during sex.

That last bullet point is the really disconcerting stat, said McElroy, and just one of the reasons the Centers for Disease Control and Prevention recommends that everyone be tested once for HIV, and those who engage in risky sexual behavior should add chlamydia, gonorrhea, and syphilis to their yearly screening tests.

Elaborating, McElroy said there are two myths concerning this subject. One is that seniors don’t have sex, which is untrue, and the other is that they can’t contract sexually transmitted diseases, which is equally false. “We started an initiative around seniors and STDs, and true, it was a little shocking, and some didn’t want to be associated with it because they saw it as ‘unseemly,’ but we have to dispel these myths.”

McElroy said older Americans account for a relatively small percentage of new STD diagnoses overall, and diseases in general are escalating in the Baby Boom generation (born between 1946 and 1964) because there are simply more of them. However, the rate of STD diagnosis in those ages 50 and over has doubled over the last decade, and that constituency includes a large portion of the Baby Boomers as well as what is left of the Silent (1925-1944) and GI (1905-1924) generations.

“Also, many seniors may have married at, say, 19, and never had any other partners, and the only thing they know is that condoms prevent pregnancy,” McElroy continued, adding that it’s the reason her company offers a conversation-starter booklet called The 40/70 Rule, designed to stimulate dialogue between seniors and their children on a host of issues, including sex (more on that later).

Leslie Kayan, Healthy Aging Program coordinator at the Franklin County Home Care Corp., is a strong supporter of any conversation that opens seniors up to talking about sexuality. As a community health educator, she’s taught sex education to teens, parents, teachers, church leaders, and healthcare providers.

A Baby Boomer like McElroy, Kayan grew up during the ‘free love’ generation, a culture with an openness and knowledge about sex and STDs, which she said will carry over to her senior years. “But anyone who is older than I am is extremely unlikely to ever have had any formal sexuality education,” she said. “Many of them have been married for years, and now they are widowed and out there, at risk for the first time. And safe sex isn’t even on their radar.”

“If you look at sexuality as part of the human condition from puberty till the day we die, it just doesn’t stop,” McElroy added. “It goes through cycles, but it doesn’t stop just because we reach a certain age.”

McElroy pointed to the proliferation of senior online-dating services like www.ourtime.com, www.seniorpeoplemeet.com, and www.findseniorsonly.com; the enormous revenues for erectile-dysfunction (ED) drugs like Pfizer’s Viagra ($2.5 billion in 2012) and Eli Lilly’s Cialis ($1.93 billion in 2012); and the growth in senior and assisted-living facilities that promote socialization. The messages are tantalizing, with little education to go with them, she said.

Don’t Sleep on This Problem

McElroy has 35 employees who are fully trained in all aspects of non-medical care of seniors. To keep that training up to date and relevant, she does extensive research into a variety of subjects, including sex and the older populations.

And in many national publications that have addressed that topic, she’s seen the words ‘seniors’ and ‘frisky’ together in the same sentence, and this juxtaposition does not amuse her.

“How demeaning that readers are totally picturing two white-haired people having ‘fun,’” she said in a voice tinged with a mix of anger and frustration. “How about two white-haired people who are lonely because they lost their spouse?”

Dr. Stephen Levine

Dr. Stephen Levine says the issue of STDs is far from the surface, and it’s usually a difficult subject for seniors to bring up with family members.

Her staff knows that respect is to be shown to senior clients’ behaviors because many are living in retirement communities that facilitate socialization among eligible, but also lonely, seniors, McElroy said.

“Maybe it’s romance and maybe they’re just ‘hooking up,’ but it’s not something that is funny or temporary, and it’s certainly not something that is perverse or wrong.”

McElroy’s staff does not diagnose, but rather observes any minute changes in clients like variations in appetite, urination, odors, rashes, etc., that may suggest further investigation by a doctor. According to McElroy, the biggest issue that seniors face is how the outside world sees them. It’s the widespread assumption that they don’t have sex that she said is dangerous.

“Because there is no talk about it, no education, there’s a lot of embarrassment,” she told BusinessWest. “Children will talk about healthcare proxies and living wills, and whether dad can still drive, but don’t think about asking dad about his dating or sex life now that mom is gone.”

Dr. Stephen Levine, who has practiced since 1979 in his Holyoke-based family practice and is affiliated with Holyoke Medical Center, agrees.

“The issue of STDs is far from the surface, and it’s usually the last thing that’s brought up,” he said. “It’s not something that can be allowed to be mistaken or overlooked, and needs to be discussed with the practitioner who is seeing the individual.”

Routinely, said Levine, his elderly patients have questions about physical changes that come with age and ask about ED treatments or lubrication for dryness, albeit somewhat indirectly. “A woman or a man may ask, ‘is there anything you have that can help me?’ and they know what they’re talking about, and I know what they’re talking about, and then the discussion goes in the direction of things that can be helpful, so it’s definitely on the majority of seniors’ minds that I see.”

Times are different, Levine went on, because the advent of ED drugs like Viagra for men and estrogen creams for women over the past decade has solved some of the issues of sex and aging. Now, with medical intervention, seniors are able to perform physically, with little effort, via a ‘little blue pill,’ a tube of cream, or hormone replacement therapy (HRT).

But the conversation has to start somewhere for these seniors when it comes to new sexual partners.

“Having sexual relationships is normal, expected, and OK, but it’s clear that this group is exposing one another to the possibility of STD risks,” said Levine.  “Bottom line, at the start of a life-changing situation like a new relationship, testing for everything one can think of that could be transmitted sexually is a good starting point.”

Ignoring the threat of STDs, especially if they go undiagnosed, can be detrimental, Levine said, because several types of STDs can be harbored without symptoms, including syphilis, chlamydia, HIV, and hepatitis B. Syphilis, in later stages, he explained, could cause dementia, which brings up one of the difficult issues in diagnosing STDs in the elderly: many STD symptoms are similar to the normal aspects of aging.

McElroy admitted that some of her clients who normally have issues with urinating — very common in older ages — would never identify that issue as a symptom of an STD, yet it could be one.

Elaborating, Levine added, “if something doesn’t appear to be anything other than a typical aging problem, the patient will probably have no intention of being tested, but they could be infected and unknowingly be spreading infection to one or multiple partners.”

Conversation Starters

Sherill Pineda, president of Care @ Home in East Longmeadow, has become very familiar with both the concept that seniors need a healthy sex life, and the issues related to STDs.

She started a volunteer Zumba dance group for seniors called Groove and Learn, which offers exercise as just one way to stave off Alzheimer’s disease, but to also learn about other aging issues. At a certain point, the more than 25 participants, mostly senior women, wanted to talk about sex, and Pineda realized there was a definite need for more openness and awareness regarding seniors and their inability, for whatever reason, to find answers for themselves. She also realized that awareness had to spread to the senior healthcare community, which was not nearly as open as it should be, for all the other seniors in the Western Mass. region.

Last May, Pineda staged a seminar called “Never Too Old for Love” at the Western Mass. Eldercare Conference at Holyoke Community College. The symposium, crafted for nurses, social workers, and the public, drew more than 350 people, and 66 of them were seniors. (This year’s event will be held on May 29).

Pineda explained that depression is a big issue with many of her clients, largely due to the loneliness and isolation that seniors feel, especially after losing a spouse. “When I talk about ‘Never Too Old for Love,’ it’s not purely about sex; some people just want companionship, and wherever that leads, that’s their private business. As healthcare professionals, we need to be mindful about what is causing depression and other unusual changes in seniors. They are still longing for the one-on-one emotional needs and the physical aspect of it, and they’re just like us; they don’t think of themselves as old.”

Pineda has found that seniors typically won’t talk about their sex lives with their grown children, “but they are more than willing to open up to healthcare professionals, because sometimes their kids will say, ‘you’re too old for that.’”

McElroy agreed, noting that Home Instead has a resource called The 40/70 Rule, a booklet that contains suggested conversation starters concerning myriad issues in the aging process. “It means that if you’re 40, and your parents are 70, then conversations about all sorts of things should start happening.”

She said the publication has realistic ways of opening that door to at least promote a conversation between a senior and his or her physician.

Her best advice for the children of seniors, their caregivers, and doctors is to not assume anything. Financial issues, end-of-life wishes, questions or concerns about sex … no one knows unless they ask, or at least open up the opportunity for real discussion.

Spread the Word

Research, news articles, education on the part of healthcare providers, and acceptance within immediate families is what McElroy, Kayan, Pineda, and Levine say will help remove the barriers to talking openly about seniors and their sexuality.

McElroy even sees this STD issue as a trend that will likely evolve over the next decade in the form of a welcome decline in prevalence because the more open-minded individuals in their 50s, 60s and early 70s have already integrated the Internet into their lives from their work life, and information and more education will make a huge difference in their knowledge of STDs and the concept of healthy sex.

“It’s all about respect and dignity,” she said, “which dictates that, if something isn’t hurting someone, I don’t care how old you are, you should be allowed to participate in it, safely.”

Elizabeth Taras can be reached at [email protected]