Be A “Noticer”: Questions to Ask Assisted Living Providers & Notes to Take Part 2 of 5
By David Hahklotubbe, gerontologist
Welcome back! I am excited that you returned for more insight. As a reminder, the questions you will be asking are important, but the reasoning behind WHY you are asking them is most pertinent. With that in mind, we will pick up where we left off.
At this point, you have assessed your first impression based on a number of factors in the initial reception. You have drilled down on some specifics such as current availability, levels of care offered and cost. Now that the basics are taken care of, let’s dive deeper still and ask the questions no one ever asks, the one’s that providers either cringe over or can’t produce a solid answer to, because they don’t know the answer themselves. These are the questions that separate the flops from the tops. Shall we then?
First out of the gate that will hit any sales director between the eyes and may be more suited for the executive director is….
1. What is your community’s philosophical approach to elder care?
WHY: As a leadership coach, I always ask my teams what success looks like. They often look around the room. Someone invariably blurts out, confidently, “it’s reaching our goal”. RIGHT! So, if we want to reach that goal, what do we need first? In unison, they scream, “an agreed-upon common goal, coach!”. Exactly. So, it stands to reason that when you speak to any member of even an average team, and you ask them what their team’s goal is, they should not hesitate and they should be able to recite the exact same thing. Clearly, I’m going somewhere with this. Where I’m going is that I predict that when you ask this question, you will get confusion, hesitation and a different answer from different people on the same team. What you are looking for is a centrally-focused goal of caring for seniors to improve their quality of life. However, given that most providers are not driven by gerontologists, nurses, social workers or credentialed health care workers, and more driven by hospitality, business administrators, hotel or restaurant managers, you will get a disjointed and unimpressive, off the cuff response. This will not, and should not, instill confidence. Listen carefully when you ask this question and take copious notes to compare to the other people you speak with. No quality team can reach a common goal if they are all shooting the ball in different directions.
Now, before we continue, don’t be surprised if this line of questioning makes a few people squirm or appear otherwise uneasy. And here’s the sad part of that reality, it shouldn’t. The questions you are asking are perfectly reasonable, it’s just rare to have an informed consumer in their midst. Stay true to your mission and continue to drill down. Always keep in mind what is at stake here… the quality of life of everyone involved. Let’s forge ahead…
2. What are the qualifications of your administrator?
WHY: Shockingly, this is rarely asked, it’s assumed. More disturbing, because many of the team members don’t see the importance nor relevance, crazily enough, they may not even be able to tell you. Or at the most, will be able to ballpark the amount of time they have been in the field, vs. any formal education. Often, the reason for this is that the administrator lacks any formal education. Truth be told, in the state of California, to become an RCFE (Residential Care Facility for the Elderly) aka Assisted Living Administrator, all that is required is that the person be over the age of 21, have a high school diploma or GED and go through an 80-hour course and pass a 100-question exam. To recap, that means, no college degree, no advanced degree, no professional degree, no specialized clinical training. And yet, this person is at the helm of the Assisted Living your loved one is living in and receiving care from? One word comes to mind: Terrifying. Obviously, you would desire someone who has not only applied experience, but a degree in the field, or at the very least, a degree in a related field, preferably a master’s or above. I’m pretty sure you’ll be hard-pressed to find that. But, happy hunting.
3. What are the qualifications of the staff?
WHY: As you may have surmised from the last revelation, it’s not uncommon to have department heads or middle managers without credentials. You may have a “wellness coordinator” who has no formal degree in health care, or an activity director who has zero formalized training and just likes to play with or entertain seniors. Keep in mind, the goal here is not to expose the lack of qualifications of each provider, on the contrary, you are performing due diligence by vetting each team to validate their abilities to meet your central goal. And, while you may find a qualified department head or coordinator here and there, it will be super-rare to find credentialled or licensed hands-on caregivers. The reason for this is that Assisted Living is licensed by the Department of Social Services, and therefore not a medical model. However, over the past two decades, the licensing restrictions have loosened up a great deal and those who have medical conditions that were previously prohibited are now commonplace and require advanced care. And while the operators are given the autonomy to practice anywhere on the continuum, within the confines of licensing, they don’t always provide the required level of knowledgeable staff to perform the tasks, nor supply the manpower it takes to care for the level of acuity in their community. Am I suggesting that some communities don’t hire the right personnel nor enough of them? Clearly, you don’t watch the news, which is where the next flurry of questions comes from.
4. What are the credentials of your hands-on caregiving team and what type of training do they receive? Same question for those handling medications.
WHY: Obviously, since our field is considered a “non-medical model”, you’re going to be hard pressed to even find CNAs (Certified Nursing Assistants) like you would in a Nursing Home. However, it is important that you ask the question to show your level of diligence. Which brings up a great point, you aren’t just asking these important questions for yourself, you are sending a very loud and clear message to the provider that you are intensely involved. Why would that be important, you ask? Well, sadly, and this is the absolute truth, the family members who appear more involved will garner more attention to their loved one under care, this is not even disputable, it’s fact. The squeaky wheel gets the grease in most cases, but particularly in health care. Expect to hear that the staff are given mandatory training, which is true if they want to stay in compliance, but that very few, if not zero, have any formal degrees or credentials in the field. This includes the medication handler. Are you nauseous yet? Well, if you can stomach it, I have one last question to ask in this session, and it’s a doozie. Here we go…
5. What is your staffing ratio for those under your Assisted Living Care, how about Memory Care?
WHY: So, while in one breath I’m telling you that your line of questioning is purely for vetting purposes, this question is deliberately a trick question. Care ratios are for nursing homes and are an antiquated relic of the past ways of staffing for Assisted Living and Memory Care. You are hoping to hear that they don’t staff to ratios. What you are hoping to hear is that they have sophisticated software that takes the comprehensive geriatric assessment and breaks down every aspect of the care needed, then distills it down into the amount of time that it will take for the caregiver to perform and spits out a numerical value, called acuity. That number is now taken and put into the collective group of all residents and the total level of acuity is established. This then becomes another value which dictates how many man hours each shift will need to be staffed. The old method of staffing to ratio is so obviously and ridiculously flawed, here let me show you…. If I said that I have a 6:1 care ratio, obviously, 6 residents per caregiver on the floor, that may seem impressive to you. And, perhaps it would be if all my residents were more or less self-sufficient, aka, low acuity. However, if I had 6 residents who required heavy incontinence care, constant wandering re-directing, assistance with feeding, grooming and dressing, that ratio would be criminally low. In other words, ratios mean nothing in respect to quality of life in shift coverage. But what they do represent, is a distinct and likely possibility that your loved one’s needs may not be effectively met OR that you are being over-charged for your care. Let me show you how that works…. The ratio method relies upon “levels of care” again, an antiquated method. These levels of care are divided into ranges of points – let’s for the sake of ease, posit that the levels are divided by 100 points each, and these points represent the corresponding types of care required. For instance, a 10-minute shower may be 20 points. Whereas a 40-minute shower would be 50 points. These care points are then tallied and you will fall into a “Level of Care”. Each level of care has a corresponding rate. Again, keeping this simple, level 1 might be $500.00 a month. Level 2 $1,000, Level 3 $1,500. Let’s say your loved one needs minimal assistance in bathing and an occasional reminder to get dressed. Well, that’s only 15 points. But it lands you in Level 1, and you are now paying $500.00 for that minimal level of assistance. Whereas, your loved one’s neighbor is receiving the lion’s share of attention because their care values come in at 95 points, which means they too are in Level 1, but you are both paying the same rate. The new standard allows for you to pay for exactly the care you are receiving and therefore not subsidizing other people’s care. We all know you are nice, but there’s no need to do that now, is there?
Well, look at the time, more specifically, look at the fact that 3 pages seemed to populate with minimal efforts. I look forward to seeing you in segment 3.