A Constellation of Elder Care Options in Vermont’s Communities

By Cindy Ellen Hill

Vermont is getting older, fast.

Fortunately, the state is far ahead of the curve in providing compassionate home and community-based care for its elders. Those seeking to “age in place” – to live their last years at home, or as near to that environment as possible – have a constellation of options and dedicated caregivers. Other states’ eldercare services pale in comparison, blighted by overcrowded nursing homes, expensive assisted-living facilities, and lack of economic or social support for in-home care providers.

But for-profit health care businesses, demographics, politics, and the economic squeeze are all impacting Vermont’s eldercare environment. Will our eldercare star continue to shine so brightly when the need for services skyrockets while available dollars plummet?

Bubbles of Baby Boomers

The U.S. population is aging rapidly. As in many Asian and European countries, ample food, clean air and drinking water, and advances in medical care are all extending life expectancies – while the birth rate is dropping. According to the American Association of Homes and Services for the Aging (AAHSA), the national population over age 65 will double from 7.7 million to 14.5 million between 2010 and 2040, and those who are severely disabled will increase from 3.3 million to 6.3 million.

Vermont’s aging effect is heightened by an already-older population and an exceedingly low birth rate. In 1990, most Vermonters were under age 45, but that bubble of baby boomers has moved ahead. In 2006, only seven states had a population older than Vermont’s. The Vermont Agency of Human Services (AHS) predicts that the state’s population under age 55 will decrease precipitously between 2000 and 2017, while the over-55 group will climb from 134,430 to 224,053. And the number of Vermonters between the ages of 65 and 74 is predicted to grow 63 percent from 2007 to 2017.

Meanwhile, the 35-to-54-year-old bracket – the bulk of workers in health care and elder care, as well as the bulk of taxpayers whose incomes support public services – will decrease by 18 percent, says the AHS’s Department of Disabilities, Aging and Independent Living.

Vermonters, like 97 percent of elders around the nation, overwhelmingly desire to age in place. The costs of that choice often go unseen. According to AAHSA, family members and other unpaid caregivers provide more than two-thirds of at-home elder care. Each works an average of 35.4 hours per week and incurs an average of $5,531 in annual out-of-pocket expenditures. When it comes to long-term nursing-home care, Medicaid usually foots the bill. The federal assistance program has a long-term-care budget of over $100 billion a year.

Medicaid administrators are learning, however, that providing the in-home care elders want is cheaper than paying for institutionalized nursing-home care. They’ve learned this in part through demonstration Medicaid waiver programs, like Vermont’s Choices for Care.

Approved by the Vermont Legislature in October 2005 after ten years of effort, Choices for Care was designed to help Vermonters stay in their homes as they age rather than move to a nursing home for long-term or end-of-life care. The program allows Medicaid-eligible, nursing-home-eligible elders to obtain Medicaid funding for services in their own homes.

Since October 2005, the nursing home scene in Vermont has changed: the number of nursing home residents with Medicaid assistance has decreased by about 200, according to the program’s most recent quarterly report to the Agency of Human Services. And the length of nursing home stays, both Medicaid-funded and privately paid, has decreased since 2006. (Nursing home days paid for by Medi care have increased, which reflects more nursing-home use for Medicare-covered rehabilitation than for residency.)

At the same time, the number of Medicaid-eligible people residing in other modes of enhanced residential care in Vermont has risen from under 200 to over 300. The number of people in the highest needs category being cared for at home rose from 988 to 1436. An additional 1400 persons with moderate need for assistance, such as homemaker services, have received support under Choices for Care, where no support was previously available.

Choices for Care initially offered two service options, 24-Hour Care and Flexible Choices. The latter allowed qualifying elders to use their Medicaid payment to cover a menu of options, such as day programs. In 2007, Choices for Care added PACE, the Program for All-Inclusive Care for the Elderly, a program just beginning to be implemented in Chittenden and Rutland counties. A fourth, long-awaited Choices for Care option was adopted by the Vermont Legislature in May 2007 and has just been implemented with regulations effective in 2009. This option permits Medicaid funds to be paid to one spouse for providing personal in-home care to the other, if that elder would otherwise qualify for nursing-home care.

Vermont initially set the goal of providing out-of-nursing-home long-term care services to 40 percent of Vermont’s eligible elders. Last year, state agencies elevated that goal to 50 percent. Eight Vermont counties already exceed that benchmark. Of these, Addison County provides aging-in-place support to the highest number of Medicaid-eligible elders by far – and a significant percentage of non-Medicaid-qualified elders as well. In the state’s biggest dairy county, community care is an ingrained part of life.

Addison County: A Caring Community Creates a Web of In-Place Aging Opportunities

In a state that is already ahead of the curve, Addison County is ahead of the state. Middlebury-based Project Independence, a program of Elderly Services, Inc. (ESI), is a model for the nation for adult day program services. The county’s single nursing home, the 105-bed Helen Porter Healthcare and Rehabilitation Center, works hard to support home care of elders, even when it means loss of paying customers. Addison Home Health and Hospice interacts positively with hundreds of area families, intersects effectively with other care-giving service providers big and small, and manages to pull off an elegant annual fundraiser, which is the pinnacle of the Addison County social season.

Each eldercare entity arose individually in response to a community-identified need. Although they are not part of an institutionalized umbrella system, they work together in a network of cooperation and mutual respect with a firm focus on serving the needs of the area’s elder residents. Like fried dough and maple cream at Field Days, it’s an Addison County thing.

“If you think about who the people are in this county, it’s an agrarian county. People have it engrained in them to look out for one another,” says Neil Gruber, an administrator at the Helen Porter nursing home. “It’s a small county with some good history. The agencies have continued to work very closely together. There is good leadership, all committed to our missions.”

That leadership is not only visionary but graced with “enlightened thinking and positive energy,” says Margaret Conklin, ESI’s Planning Coordinator. ESI operates the Project Independence day programs for elders from its bright, windowed, spacious home building on Exchange Street in Middlebury. The organization also hosts ESI College, providing adult education courses to elders on subjects ranging from the history of 20^th-century China to Hollywood film romance. And it provides individual and family counseling, and hosts a family caregiver support group.

“Part of our mission is providing safe care and ensuring that when people are here every engagement is full of joy,” Conklin says. “But the other part is taking care of families who are caregivers. In the support group, people help each other out with ideas, support, contacts, sharing. The day program provides respite, and the group also helps connect with other respite providers.”

ESI was born in a church basement in 1981, when Addison County Counseling Service personnel realized that elders needed a place to socialize during the day while their caregivers were at work. In the 1990s, ESI hired executive director Joanne Korbett, whose broader vision took Elderly Services out of the church basement. A capital campaign raised significant support from the Robert Wood Johnson Foundation, grants from other foundations, and local donations, resulting in a massive, multilevel facility with spacious kitchens; private rooms for meetings, counseling, and visits; and living rooms for music, games, talks, and classes.

Project Independence is an important node in Addison County’s web of care. “Someone will go into Porter Hospital, then to rehab at Helen Porter, then they have social workers who say they should not be left alone, so they come down here during the day. We get referrals from Addison Home Health and from nursing homes and residential facilities,” says Conklin.

A substantial portion of the funding for Project Independence comes from Choices for Care, and a small amount from Veterans Affairs covers some participants. “Our private pay rate is $15 an hour but we have a sliding scale fee and scholarships, so few people pay the full fee. We are not really in competition for funds with other agencies. If someone is receiving Medicaid funding for Home Health services, they won’t pay for adult day care as well, but we refer to each other. It’s cooperation more than competition,” Conklin says. “We support the whole community regardless of economic resource.”

Options in Housing

Supporting the whole community is also the guiding beacon of the Helen Porter nursing home, which exclusively provides long-term care. Affiliated with Porter Hospital, Helen Porter has been around since the inception of Medicare and Medicaid in 1964.

When administrator Neil Gruber arrived in 1997, the exclusively long-term care facility was full with a waiting list. “People came here when they were frail and elderly, and here they stayed,” he recalls. Eighteen months after his arrival, the Vermont Legislature gained approval for the first Medicaid-waiver programs for home-based care for the elderly, and Helen Porter’s waiting list vanished. When Choices for Care went into effect in 2005, the nursing home suffered a precipitous loss of customers and had to “re-engineer [its] business plan,” says Gruber. The facility began offering short-stay rehab, hospice care, and respite stays for elders in home care during their caregivers’ days off.

Helen Porter goes far towards dispelling the dead-end, abandon-hope nursing-home image. Over 90 percent of residents are from Addison County. The atmosphere is homey, and in beautiful courtyards, wheelchair-accessible raised garden beds are tended by residents, many of them lifelong gardeners. A walking path extends from the back garden gate through fields overlooking Otter Creek. Lunch in the cafeteria might include live music from area folk and bluegrass bands.

Two other elder residences loom large on the Addison County landscape. Shard Villa is a massive stone French Second-Empire-style mansion in rural Salisbury, built in 1870 by Harriet Smith. Widowed by wealthy local attorney Columbus Smith, Harriet began taking in area elders who could no longer live on their own. Her will established a trust requiring the mansion to be perpetually maintained for elder care. Now listed on the National Historic Register, it serves as an elegant home for up to 15 seniors at a time.

At a short crow flight across the Middlebury town line sits The Lodge at Otter Creek, a senior living community of over 100 mixed residential units that is still waiting for the paint to dry on its newest buildings. The two interact with the county’s eldercare community in very different ways.

Shard Villa serves as the “Bed and Breakfast” option for elder care in Addison County, providing inhabitants with comfortable bedrooms, parlors graced with astonishing murals, and fabulous food. Shard Villa is a Level III residential facility, meaning it provides limited assistance with daily needs, under the watchful eye of a nurse supervisor, to elders who cannot live by themselves but do not require full nursing-home care. Most residents privately pay the $155 daily fee for care, but the facility has one Medicaid bed and anticipates adding more.

Deb Choma, Shard Villa’s Executive Director, explains its coordination of elder care with the other area providers. “We take people here when they are going to or from the nursing home; we have residents going five days a week to Project Independence; or people will come here for a while if they can’t go home after a hospital stay but don’t really need nursing care, just help with washing or getting to the bathroom and so on.” Shard Villa also provides respite care.

The place feels more like a second home than a facility, with staff throwing another place setting on the table for whoever comes to dinner. “The smaller you are, the better the care,” Choma says. “Here, there’s a lot more individual care. We have a couple living here together in their 90s, and another couple just looked at the place. We are very involved with the families. The bulk of the families are very involved with the residents. We host a lot of parties; there are family members here for every meal. We are one big family here.”

The Lodge at Otter Creek is the new for-profit face of residential elder-care: a community unto itself, providing 62 independent living apartments, 22 duplex cottages, 24 assisted-living apartments, and 16 memory-care unit apartments, security, dining services, snow-shoveling, transportation, exercise classes, and a host of hotel-like amenities. The project has been open about a year and is at 60 percent capacity. Their assisted living units and memory care units are effectively full; vacancies arise only with the death of a resident.

Unlike the residents at Shard Villa or Helen Porter, most of the Lodge’s denizens have moved in from elsewhere. “I’d say 60 percent of our residents have come from out of state,” says Michael Manley, the resident activities coordinator at the Lodge. “It’s expensive to be here. It’s unlikely we will see a retired farmer.”

Despite the lack of local ties, Lodge residents have swiftly integrated into the area eldercare community in a variety of ways, says Manley. “[Addison County] Home Health [and Hospice] has been in here. Some of our memory care folks go to Project Independence, and we host some of the ESI courses here. We have a good relationship with them, which is very nice. Some of our residents volunteer there at Elderly Services.”

While Manley is quick to point out that Lodge residents bring money to the area and support local businesses and cultural venues, the development remains an interesting twist on Vermont’s elder-care landscape: it brings elders in to enjoy Vermont’s amenities and elder services instead of arising out of the need to serve Vermont’s own rapidly growing elder population.

At the heart of the county’s homegrown elder services is Addison County Home Health and Hospice (ACHHH). The private non-profit arose in 1968 when community leaders realized that elderly and sick people at home did not have a way to get their needs met other than through nursing homes. The organization has 550 or more clients on its rolls on any given day, served by 180 employees.

Twenty-five years ago, ACHHH was the first organization to participate in a nascent Medicaid waiver program, a forerunner to Choices for Care, and it remains a leader in obtaining a broad range of funding sources. Today, 50 percent of its funding comes from Medicare, 35 percent from Medicaid, and the rest from an amalgam of private pay, long-term insurance, and private medical insurance. Community donations and fundraising efforts also play a role, including an elegant annual art auction and dinner at the Basin Harbor Club. Says Executive Director Larry Goitschius, “We’re a good investment because we keep that person from going back to a hospital, which is the most expensive [option].”

Like Project Independence, ACHHH views its mission as supporting the whole of the community regardless of economic status, so it provides some services for free. “The entire population is my concern. High-level, high-quality services should be the case for all, regardless of income,” says Clinical Director Sharon Thompson, who has been with the non-profit for over 35 years.

But, she adds, “As soon as profit factors in, quality and dignity declines. We’ve tried so hard, we’ve been like a wall – try to protect the flame of real comprehensive health care until it comes back,” Thompson says. Vermont is the only state left with all non-profit home health agencies.

ACHHH dispatches a registered nurse to evaluate all new clients in their homes to determine which services are needed. “The goal is to return the person to their optimal level of wellness,” Thompson says. “There’s no such thing as ‘We don’t want this person home because it’s too much work for us.’ We craft a plan, whatever it takes.”

Again, the free flow of communication among Addison County elder-service entities is what makes those plans work. “When someone comes in to Helen Porter, they talk to Home Health about how to get that person home. We talk constantly. People actually respect your opinion both ways,” Thompson says. “The difference in Addison County is that we respect one another and people stay in their jobs here a long time, so we have long-term relationships. The hospital and nursing home, the Counseling Service, Project Independence, even the state agencies – although they are part of larger entities, their local offices have always acted as active shareholders in our community service. We are shoulder-to-shoulder walking forward with eyes on our patients.”

Elder Care in Vermont’s Urban Core

While rural Addison County’s services have evolved organically into a web of interacting entities, Chittenden County is creating supportive infrastructure fresh out of whole cloth. The relatively urban county’s elder-care landscape is taking shape through the sheer enthusiasm and drive of its leaders – from Rachel Cummings, the young owner of Armistead, a for-profit, rapidly expanding non-medical home assistance service, to Betsy Davis, a retired RN who works around the clock spearheading elder-care options in the greater Burlington community.

Cummings had already worked in elder care for years when she started Armistead in 1999 as a senior studying sociology at the University of Vermont. “I started in high school and I just loved it,” she says. “I remember I dragged all my friends to the Converse Home all dressed up before the prom so I could show my residents our dresses.”

Cummings lived with an elderly couple to help defray her college housing costs. The experience led her to believe there was a need for non-medical home assistance for elders. “I talked to the Vermont Agency on Aging to ask, ‘Is there really a need here? Am I off my rocker?’ Now I’m on their board!” she declares. With help from the Small Business Administration and her mother – Cumming’s parents owned Cobbs Corner Natural Foods – Cummings conceived a business plan and gradually built up a staff of more than 150. Employees work one-on-one to provide in-home, non-medical services to elders – light housekeeping, companionship, bathing, feeding, turning, even travel companionship.

Armistead’s Shelburne office serves Northwest Vermont – Chittenden, Lamoille, Addison, Grand Isle, and Franklin Counties. Their new Lebanon, New Hampshire, office serves the Upper Valley. Cummings selected Lebanon as the site of her second branch because it was within a day’s commuting distance to Chittenden County – an important factor with small children at home. And, she adds, “Dartmouth Hitchcock is there, and it was a welcoming community.”

Because of Cummings’ experience as an eldercare provider, she has as much concern for her staff as her clients. A monthly caregivers’ dinner provides the opportunity to “share our joys, sorrows, tears, frustrations, problems. We have to come together because caregiving is very isolating,” she explains. Employees get accumulated paid time off, which Cummings believes is unique in the field, as well as worker’s comp and disability – and a variety of other perks not available to Vermont’s estimated 4000 self-employed in-home elder assistants.

In a field that sees 70 percent turnover each year, Armistead’s turnover is less than 10 percent. “I don’t want a revolving door,” she explains. “It takes time to hire and train people and for our customers to get to know them. My caregivers are gold.”

Neither Medicaid nor Medicare covers non-medical home care, so Armistead customers pay privately or through long-term care insurance. “We are creative in finding ways to pay for care,” Cummings adds, “and we do offer discounted care for some people who really need it and cannot fully pay.”

Despite being in the home-care business, Cummings maintains ties with the area’s eldercare residences and facilities in the interests of her customers. “I hear from my clients all the time that ‘This is my home, I’ve lived here 40 years, I know where everything is, I want to be here.’ But that is not always the best place for them,” she explains. “Being at home in a rural community especially can sometimes be isolating. Or sometimes the home is not maintained, or is lacking in other things. So it’s great to be able to take one of my clients over to one of the facilities and say, ‘Just look around and explore this option.’”

Cummings rejects the notion that Vermont’s health care environment will collapse with the expansion of for-profit elder services like Armistead. “We are offering a service that non-profits can’t always do. We offer non-medical home care 24/7. What we’re good at is hiring and retaining employees, and responding quickly to clients. If someone calls at 4:15 in the afternoon and something has come up that evening and they need someone there in the home, I can have someone there by 5. ”

She also points out that non-profits can’t provide services like housekeeping and travel companionship. “Although I’m a for-profit and privately owned entity, I think we work really well with Home Health agencies. We partner and collaborate, so I’m grateful for my relationship with my ‘competitors.’”

Innovative Programs

A 72-year-old retired nurse, Betsy Davis could be resting on her laurels or even be a consumer of elder services. Instead, the former executive director of Vermont’s Visiting Nurses Association represents the new face of what passes for retirement: living on her own in Burlington, traveling, gardening, hiking, swimming, sailing, and – her favorite hobby – building new programs to serve Chittenden County’s elder community.

Davis holds a Master’s degree in public health from Columbia Presbyterian and worked as a visiting nurse for over 40 years. “I’m on several boards, too,” she says. “This keeps me young.”

At present, she is under contract to develop two different programs.

The first, PACE, the Program of All-inclusive Care for the Elderly, is a national combined Medicaid/Medicare program that brings onsite day programs, rehabilitation, and fully integrated primary care practice under one roof – or in this case, under two roofs, one located in the old convent building at Fanny Allen and the other in Rutland. “The objective is to keep people in the community and not in hospitals or nursing homes,” Davis says. “PACE addresses the problem of inadequate coordination of care. Studies showed the most difficult times were transitions from one place to another, i.e. from hospital to home, from home to nursing home.”

For now, PACE is administratively lumped with Choices for Care, although the billing structure is quite different. “The payment system is that they pay per member per day,” Davis explains. “As a visiting nurse, I saw the effects of all this silo financing where one thing pays for one service, another thing pays for something else, and so much time is spent on the question of who do we bill for this and how do we do that. Here, it’s not traditional billing of piece-by-piece. Our primary care doctor is just paid a flat amount, a salary. He can then spend the time anywhere, so he can spend two hours with one person if necessary; when he visits a person in the nursing home, he can consult with their nurses, or home care providers, and get a better picture of what’s going on. It’s the kind of system change we need to see in terms of coordination of services and financing,” she adds.

The goal of the PACE team is to provide daily service to about 70 elders in each of the two locations. It’s been up and running two years in Chittenden and one in Rutland, and reaching those goals is in sight. But the program has met with some resistance, including from elders who dislike having to give up their own primary care physician and declare PACE as their primary care provider.

Davis is also elbow-deep in a second project: SASH, or Seniors Aging Safely at Home. The premise behind SASH is that seniors prefer not to move from one residential setting to another as their needs change. In any case, as the elderly population reaches and exceeds 25 percent of the area’s residents, long-term care facility space will be reserved only for those whose needs absolutely cannot be met in the community.

Davis is working with housing managers like Cathedral Square – a non-profit senior housing corporation run by the Burlington Diocese – to use housing tax credits to pay to hire a services coordinator. Ultimately the coordinator will act as a focal point for volunteers, PACE staff, the Champlain Agency on Aging, the Fanny Allen falls response team, doctors, nurses, pharmacists, and emergency medical personnel. One key will be working out how to keep each resident’s complete medical records available on-site for use by all service providers, without violating medical privacy guidelines. Davis points to Fletcher Allen’s electronic health records system as one possible direction.

The need for coordination of services is great. “We had a recent medical student survey in senior housing here,” Davis says, “And it’s amazing the amount of medications people are on there, the number of falls, the number of trips to the emergency room, the degree of frailty of people trying to remain in their homes. We can do more prevention, try to keep people healthier.”

This is a design year for the project, which Davis is hoping to launch at Heineberg Senior Housing, an 82-apartment complex in Burlington’s New North End, followed by five more demonstration sites across the state. Meanwhile, she is writing grants and hustling through endless meetings to build a national model where people can get the services they need to remain safely at home in Vermont’s urban communities with dense populations of aging residents.

Changing Rules and Challenges Ahead

Change is in the wind and challenges lay ahead for all of Vermont’s eldercare systems, urban and rural. The state’s organically-grown non-profit Home Health agency structure was confronted with a U.S. Justice Department anti-trust investigation in December 2004. While they cited no specific event that triggered the investigation, Vermont’s home-care provider community widely assumes that complaints were lodged by for-profit companies looking to muscle in on the state’s non-profit elder-care environment. The investigation did not question that Vermont’s home health entities provide stellar care. Rather, it took umbrage with the fact that they did it so cooperatively.

“They said we had two options to avoid an anti-trust finding: compete with one another or have the state set up a state-sanctioned monopoly system like they do with utilities,” explains Larry Goitschius of ACHHH. Vermont’s home-care community and the state Legislature were both wary of out-of-state, profit-minded businesses that might cherry-pick the wealthiest home-care customers, leaving the local non-profit providers unable to support their free and reduced-fee services.

“This was under the Bush administration, whose policy was that competition is good for health care,” Goitschius continues. “We said we were not going to compete with one another. So the state adopted statutory franchises and the Justice investigation went away. But now instead of being independent local entities, there’s another layer of rules we have to follow.”

ACHHH and others worked with the Vermont Department of Disabilities, Aging and Independent Living over two years putting together the regulations for state-sanctioned home health care. The final rules have now gone into effect, and ACHHH is “just beginning to understand the implications of it,” Goitschius says. “We are in serious discussion with the Department of Aging and Independent Living over rules interpretations.” In addition to new rules compliance, all the home health entities in the state now have to re-apply for that state sanction every four years – and could potentially be bumped from their slots.

The new rules have hit the ground at the same time that funds are diminishing. Medicaid cuts have left the administration of Helen Porter explaining to their staff that there will be no cost-of-living increases in pay this year. The prospect of Obama Administration health-care reform is at present too distant and vague to reassure Vermont’s eldercare providers of secure continuation of funding.

That balloon of baby boomers will continue to age, on into their eighties and nineties. Less money and more consumers means Vermont’s elder-care providers have to switch the speed on their thinking caps to hyperspace. Helen Porter nursing home has leapt into the future by transforming to electronic medical records systems, “the most advanced of any nursing home in the state,” Gruber says. “It saves enormous amounts of time and costs with paperwork.”

Addison Home Health is also looking at ways technology can enhance their mission, such as providing what Sharon Thompson calls “the low-tech, scholarly method” of a new phenomenon called “telehealth.” “We put equipment in the household and train a family member how to use it or monitor it in a regimented way, then we call and talk to that person,” she says. “We have an excellent track record on controlling the fear and anxiety that often lead to ER visits.”

But Thompson worries about the future of elder care. “There’s a huge group of people in the community who are at home now, but they may need nursing-home care in the future,” she says. “Addison County is aging fast. Have we just deferred that need for nursing-home care and now when those people hit 90 they are going to need it? I have overwhelming fear for us. There are many factors at play, including the skills and abilities of the professionals coming after us.”

No matter the challenges, Vermont’s eldercare community will continue to work from its strengths of cooperation, creative leadership, and dedicated flexibility. “I think there has been a very deliberate process of creating this environment in Vermont, this cooperative environment where everyone involved works together, keeping the best interests of the people we serve in mind,” Cummings says. “That environment doesn’t necessarily exist elsewhere outside Vermont; I’ve worked in a number of other states and have contacts and colleagues in other states. A lot of good things are happening in Vermont. It’s really a great place to age.”

Cindy Ellen Hill is an attorney and freelance writer in Middlebury.