Spotlight on the American Rescue Plan

By definition, a naturally occurring retirement community (NORC) is “a community or neighborhood with a growing population of older adults in which the dwellings were not purposefully intended for older adults when they were originally designed and/or built.” This term was first coined in the early 1980’s in New York City, where older adults were recognized as beginning to comprise majorities in urban areas. Today, in 2023 NORCs are in fact developing in communities all over America in urban and suburban areas, and Bucks County is no exception. 

With American Rescue Plan Act funds from Bucks County, the Care Without Walls (CWOW) program provides services to Bucks County residents aging in place in what equates to an evolving NORC. The difference between a NORC and a traditional retirement community is that traditional communities, such as a continuing care retirement community (CCRC), are residential communities or housing developments designed for older adults wishing to age in place (AIP). Most residents are able to care for themselves, however assistance from homecare agencies is readily available when needed, and community social activities are often provided. Such recognized retirement communities provide designated services under a set fee schedule ranging from $5000-$15,000 per month, and many have substantial entry fees as well – fees that are out of the reach for most of us. Conversely, and driving the need for innovative community services, the vast majority of NORCs do not have organized support for the significant population of older Americans living in emerging NORCs. Providing these services has been a challenge under the traditional homecare model.

CWOW recognizes the fact that to successfully age in place, any senior, will at some time need some assistance. For low-income seniors, public assistance for homecare is readily available for personal care and support as well as other supportive services. For high income seniors, these services are provided via private funds or long-term care insurance programs. However, for “lower to moderate” income folks, (up to 300% of federal poverty level), there are few if any resources available to assist them in the aging in place process. This disparity puts a huge segment of our population at risk of failing to live independently thus competing for limited healthcare dollars. The purpose of the CWOW program is to go outside the box to efficiently, effectively, and continuously provide support, connections, and community to this needy population. With effective application and use of the system, CWOW members cost, on average, under $2000 per month, or over a 50% savings, at a minimum, compared to CCRC and other traditional options.

Once a qualified member is identified, they are introduced to the program and determine how they and the care team will work together.  Personal care and support services are, like in many care plans, the starting point. In fact, CWOW does not do anything new with members, the program just does it differently. For example, CWOW participants must agree to work with the care teams simple technology support.  If we are going to provide quality services that are effective, affordable, and accessible, we need to assure best practices in care communications and continuity.

At plan inception each member is interviewed to identify personal life goals – not just medical history/condition. Patient assessments also include simple surveys such as the Healthy Days Measure, Loneliness Scale, and WHO Quality of Life questionnaires and other subjective goals and aspirations measures that are as critical to the program outcome monitors as traditional clinical data. As a better, more “whole person” assessment is critical to success, CWOW personal care and support aides are trained to work in concert with the aging in place experts at Full Circle America (FCA). FCA is a Maine-based, physician founded company that has pioneered use of simple, proven technology. When this model is consistently applied to the AIP process, with progressive scheduling and use of care team, the outcome is the backbone of a NORC. 

Critical success factors for the CWOW program include the open scheduling of personal care and support aides, regular vital monitoring/sharing, communication in real time of any wellness concerns/issues, all designed to address an issue before it becomes something serious. Regarding service delivery, another critical success factor is the acceptance of different access channels – whichever makes best sense for the member at the time. Aides take vitals regularly and input data to the patient’s Life Health Record (LHR) where data is kept, trended, and shared with appropriate team members. The LHR creates a patient-centered medical home effect, and is a tremendous yet simple tool to augment care communications. The aides assist with a multitude of services, work short shifts if needed, and are all cross trained to support every community member.  Some members receive as little as two to three hours per week to keep them focused on managing whatever conditions they live with – others receive progressive services ranging to near nursing home level of care. Whatever level of care is provided, each member experience relies on engaged patients, flexible focused personal care, and keeping the care team and person connected at the center of the process all informed in near real time. 

Augmenting care with FCA technology and service personnel, a connected staff and constant communication establishes an informed environment for members, their families, and friends to grow in. Additionally, regular, online doctor visits with Dr. Allan Teel, the founder of FCA and a recognized thought leader in aging in place, can access all current information noted in the patient’s unique real time record so the doctor speaks to the “whole” patient. The whole patient refers to chronic care management, medication management, life issues, friends and family, etc. – each of whose input is important to patient condition and personal plans. This process and continual documentation will eliminate the problem of care data gaps that are all too common in the traditional system. 

The key difference is Attitude: listening and hearing what the client is telling you about what matters to them and what they miss the most and then trying to help them achieve their wishes. Sometimes it is just feeling heard or having your concerns validated makes all the difference.

Another critical piece is timely access to caregivers: not always according to the schedule arranged some time ago. Regular check-ins go a long way toward building trust and appreciation. Conveying “actionable information” to the person who needs to know it on short notice happens all too infrequently.

Simple video technology adoption grew exponentially during the Covid pandemic. It can be used to bridge care gaps and to connect clients to other medical providers. Facilitated by caregivers when necessary, technology can connect clients to family, friends, community, and personal interests. Technology is also applied in a way that is not as overtly clinical – some therapy is about entertainment, or reminiscence, or even just something to battle the type of “locked up” isolation that came with Covid. For example, members can take virtual reality ‘trips’ and ‘experiences’ using the MyndVR program taking them to New York or Paris, or ski, or go to a Broadway show. CWOW also provides different video connections for clinical and social interactions that can go a long way in keeping members in touch and informed as they age in place.

Thus far, CWOW is proving that a little help does go a long way to keep folks well and aging in place. Each member served so far is experiencing positive care and economic outcomes – a few examples…

E and D, married for over 62 years, have lived in their home for nearly as long, and they would like to age in place right there. However, D, the 83 year-old spouse of 87 year-old E, is dealing with moderate dementia, several chronic conditions, and depression. With all this, it was getting more difficult for E, at 87 (who has his own medical issues, and is his wife’s primary caregiver), to get her up and active for the day and then have any time or energy for himself. D was in decline when we entered the picture and E was getting tired; some sort of forced separation seemed imminent. CWOW assessed the situation and accepted the couple as clients. Just two hours a week for E and 10 for D spread across 4 days has made a huge difference. A routine was quickly established for D that included support for her personal goal (to get up each day and do her PT) and E was free a few mornings to do simple errands or just relax. The success of the program in quality of life has been rewarding to observe, and from a system cost perspective, the fact that D and E are able to continue living in their own home, versus a forced move to assisted living, has saved thousands of dollars and will continue to do so as they go forward. 

Another example of the program impact is B, a 94 year-old woman living alone just a few miles from the E and D. She manages several chronic conditions, moderate dementia, and an ailing knee. CWOW provides 10 hours of support per week as well as the attention of the FCA team with bi-weekly calls and on call support. B has friends nearby who help from time to time and communicate with the CWOW team staying current with any changes in B’s situation. Critical to B’s support has been CWOWs policy to provide unscheduled aide visits if necessary. Recently, she reached out on a Sunday morning confused about her meds; she called her aide to ask what she should do.  The aide knew that B was frustrated and decided to drive to her home, review her new meds, and call the doctor-on-call service number to confirm the regimen and assure B that she was on the right meds.  Had CWOW not been available and intervened, B would likely have “taken the chance” and ended up with a trip to the emergency department - the negative outcome potential is massive in such a situation.

The final example pertains to a new patient in the program. She, like the others, is low-income but is not qualified for public assistance. Her adult daughter and son-in-law are her primary support. This is difficult at best as S has several chronic conditions and is morbidly obese due to that. When we explained our program and that we could provide some additional support for her including a Hoyer Lift-trained aide to help her in and out of bed for PT and to give her family a slight respite, she simply shed a tear and thanked us. Her goal is not to burden her family and to stay out of the hospital and rehab where she has been since November 2022. The staff facilitating the CWOW program looks forward to making that happen.