Exersize 2

Exersize 1

Certificate of Need

The setup is simple. A facility has a hundred rooms or units. Ten have two bedrooms. That can count as 110 beds.

Rent a two-bed unit to one person and you have one extra bed. Rent a one-bed unit to a couple and you loose a one-bed unit to rent.

No one, it seems, foresaw the increase in the need for couples. Three companies were at the Missouri Health Facilities Review Committee (MHFRC) hearing yesterday to request additional rooms to adjust to the changing market with no additional cost or change in rooms or units.

Provision Living at Columbia was tenth in line. The company before us asked for 30 additional beds. The presentation seemed to be a perfect introduction for Provision Living’s request. Couples moving into memory care was far more common than I was aware of. My wife and I were not very unique in doing this. Then, something when wrong.

Asking for so many beds made it suspect of “dirty tricks” that I will discuss later. The issue was decided by granting half the requested number of beds.

Kim made a clear short presentation, building on what had already be presented.

A short discussion followed Kim’s presentation among the committee about having set a precedent of granting half of such requests for correcting bed counts for couples. We were in trouble.

The committee was about to vote when the attorney reported they had one more person: me. Most presenters, like me, had been cut off at a three-minute time limit.

I replaced my one-page discussion with the suggested talking points by the attorney plus my wife’s request:

1.    Married 59 years, in another month.

2.    Cared for wife at home, with health care for one year.

3.    “Don’t put me in an institution.” We stay together.

4.    Residential Care for Two blog on our struggles to find care.

5.    A reasonable second person fee makes this possible.

“You are out of time.”

Immediately the person who makes the motion for the committee to second and vote on, did so. "Second." Vote: All yeas. The five-hour wait was over. The attorney knew what we needed to do.

The Certificate of Need was created in 1974 when hospitals were building far more rooms than needed. To remain profitable, they had to divide the cost of the empty beds among those that were used.

So; simple; control the number of hospital beds and lower the cost to patients. The federal law was repealed in 1987. Several states then dropped their CON law too. In general, normal business competition will determine what companies will thrive or go bankrupt. The rest retained the Certificate of Need.

The Certificate of Need, in Missouri, adds another layer of competition and politics. The committee is composed of state representatives and senators and a few other people who seemed to be well versed in the law. They seemed to work very well with one another. Their humor livened up a long meeting.

In general, each company was able to find lawyers and expert consultants to verify the validity of their requests. One attorney even took a position for one company and against the same position for another company!

One case took about two-hours with many people presenting. They had everything in order to start building except for the Certificate of Need. Their manipulation of the facts and non-facts was highly creative.

This left them open to the only presentations we heard that were against granting a Certificate of Need. Their ten million dollar investment was deigned a certificate.  

Those speaking against the request, provided a fascinating insight into the residential care industry in St. Louis. The labor market is in trouble. There are not enough people to staff new assisted-living facilities. (Assisted Living here includes Memory Care.)

This results in new facilities hiring away from existing facilities. Wages rise. Worker satisfaction increases. Overtime increases. And turnover goes from 100% to as high as 125% a year. They like the work and the money but not the hours.

This has an effect on residents in assisted living but is crucial for residents in memory care. You need to ask a facility, “What amount of overtime is needed in memory care?” and “What is the turnover rate in memory care?”

I ran into the entire set of our caretakers this morning on my way to breakfast. They were visiting at the change of shifts. I was concerned if my wife’s weight was a problem when she got up from a bed. How much had she gained? Two ounces in the last month. They each commented on their observations. They were way ahead of me. This could not be possible with a high turnover rate.

If the facility with 100 rooms with 10 with two beds (110 total beds) has 80% rented (88 beds) is granted 20 more beds (130 total beds) it then changes rank from 80% occupancy to 68% occupancy.

Dirty tricks is to request a large number of beds to prevent other companies from building in competition, or adjusting beds, to meet the need for couples. The committee seemed to make projections on need based on the fixed average of past years rather than on the every increasing rate of need for couples.

One must wait two years before another request can be made. This forces one to request the most beds the committee will possibly accept. Dirty tricks thus contains two games.

One of the committee members brought up a third game that may be being played but which they question the legality: Rent a bed in a room that falls under their jurisdiction and then rent the same room (and possibly the same bed) to a spouse as a second person, independent care; that does not fall under their jurisdiction.

We learned at the Residents Council meeting this afternoon that the additional beds Provision Living at Columbia were granted will allow several waiting couples to move in over the next few months. An equilibrium in bed use between couples and singles may not exceed the new bed assignment limit during the next two years or it may.

Mythos and Logos

I just finished reading “The Battle for God, A History of Fundamentalism” by Karen Armstrong. The book was mentioned in the Columbia Tribune last week. Karen Armstrong was the recipient of a high award in Spain for her books on religion.

Living and working in an academic environment, I have experienced part of the events she reviews. It is like having lived the past 70 years looking out at the world through a square inch hole. The book presents the entire view in a perspective that I was not at all aware of. I knew of events, but had no idea of how they may fit together.

My response to students from the monastery near Maryville, who did well in the General Biology course until the word evolution came came in to view, was to say, “Don’t limit your God. Because we now know something about how creation works, that does not take anything away from God. Actually it makes creation more marvelous as we can now appreciate how it works. AND is still working. The creation is not finished.”

I got a surprise this morning from the little robot that lives with us. I carry it in my pocket. It evolved just a decade ago.

Last night I clicked the alarm for 6:00 am. This was about the fourth day. I wanted to get to breakfast when it opened. Since about six of us eat about the same thing each morning, the server greets us with “special” or “the usual”. We do not have to wait to be waited on as is the case later on with the dining hall filling up.

Click. A menu popped up requesting me to respond to a bedtime application. My iPhone was smart enough to know what I was doing. I filled in the need information and went to sleep.

This morning I was partially awakened by someone’s music. It varied from soft to louder, with each cycle getting a bit louder. This went on for six minutes before it occurred to me what was happening: this was my wakeup call. The genie in the sleep number bed reported that I actually woke up at 6:00 and then waited six minutes (restless time) to get out of bed.

We need myth and logic: religion and reason; God and science. Our relatives in San Antonio introduced us to the Saturday afternoon non-denominational community mega-church. Provision Living at Columbia streams the Crossroads community church here in Columbia into the theater. Members of the church, who now view the service with us in the theater, report that the theater overstuffed chairs are a great improvement over pews for the elderly.

Myth looks back in time. Logic looks forward in time. Each has it place in human existence. Some people believe in myth, some in logic, and others in both. There is nothing wrong in believing in both. In fact, what I get from the book, is believing in both is healthier than in just one.

The book makes a good case that modern man has great difficulty in thinking like the pre-modern myth thinkers. More than one event in the Middle East was pulled of with the expectation that the end result would spontaneously develop as expected with the actors only starting the event. Applying myth where logic is needed can get yourself killed (and a lot of other people too).

During the time I have been reading, I have also been attending a meditation class three times a week.

God spoke to the Jews in dreams. The Moslem tradition is based on meditation.

I have reached the point where time is lost. It is also difficult to tell when I am asleep or just suspended inside an empty shell of my body. The number bed reports that I am asleep for say 30 minutes when I judge the time to be less than five minutes. I really need to get something to replace the BASIC body monitor that includes heartbeat, sweat, and skin temperature.

Also my inward directed experience is still pretty much a swirl of grey clouds. I have yet to get a clear color picture of the things mentioned in the guided medication.

The most puzzling thing is that before, I would go directly back to sleep if I got up in the night. Now that I am interested in defining sleep, it may take several minutes. It seems that wanting to got back to sleep quickly may produce the opposite effect. I think I am having that same problem with meditation. "Relax."

The sleep number bed can sense heartbeat, motion, and breath rate. This produces restful, restless, and out of bed. This is logical. The leap to sleep is myth.

The report states that it took me 45 minutes to fall asleep. It also shows that the first hour in bed was 49 minutes restful followed by eight minutes restless. This means being restful does not require me being asleep.

The three red out of bed bars are of uniform size but represent different times of being out of bed and restless: 1 minute out of bed/3 minutes restless; 3 minutes out of bed/3 minutes restless, and 2 minutes out of bed with 1 minute before and 6 minutes after restless. [The blue shaded one-hour slider provides these details.] That means it takes 45 minutes to define sleep the first time and 3 to 6 minutes later on. The software "learns" based on averages, to my knowledge.

The facts are interesting but they do not define the time I am asleep. It took 45 minutes for the sleep number bed to figure out that I may be asleep at the start of the night. It then calls sleep after just a few minutes after being up at night. My experience with meditation doubts this call. To say that I went to sleep AT 45 minutes is a myth. Marketing often includes easy to accept myths.

I am truly asleep when I am unconscious. When a weight falls from my hand at night, I figure I must be asleep. I will give it a try. I will also see what happens during meditation in the same way.

Maggie's Milkweed Mystery

This is one of the most difficult posts I have written. It has taken a week. Up to now I could play the part of independent observer as my wife and I traveled this tangled path from health to passing. Even after being on this journey over three years, it was not really real.

It was scary.  The heart fibrillation in December was real scary. The line between life and death was razor thin (three to five minutes). But it was not really real as she recovered. She still continues to talk in the morning, to laugh, to tease, to be pretty much herself until the “worries” catch her. Her drift from her world, in and out of our world, in the activity area is now “normal” for both of us.

Her world is most characterized by the random collection and distribution of anything she can put in her pocket, or at times, pick up and move anywhere in memory care. She shares with a few others the need to be given notice, and time, before having something of interest removed from her or her table space. A violation can bring a quick punch. “May I take this? May I wash this? May I . . . “, yields a safe way to proceed. [A few other similar residents express themselves by a loud yell or a strong grip.]

Part of 300 Milkweed Plants

Then I became active on the monarch butterfly sanctuary (see previous post). We needed milkweeds to feed monarch caterpillars. It took three years for my wife to create the milkweed garden in our backyard from seed. It produced over 300 plants each year. We needed a faster way to do that here.

I found two packets of seed at Wal-Mart for butterfly weed. One with just seed and the other with coated seeds (experiment!). I also got a 36-cell seed starter kit.       

Milkweed Seeds

I put a few seeds of each kind on a shallow dish of water. The coated seeds sank to the bottom. The uncoated seeds floated until I touched them. The floating seeds germinated in three days on the south window ledge (17 April).

I added a piece of white paper towel to the dish with all the seeds on top. Now all had maximum access to oxygen in the air. The remaining seeds then germinated over a period of more than a week. They also endured several trips to various parts of our apartment; some times more than one trip a day.

Two Expanded Disks

The seed starter kit was watered. The little disks of compressed peat expanded into little brown haycocks. I transferred the very new seedlings and added enough uncoated seeds to fill all 36 expanded disks. 

Another Missing

A few days later two of the disks were missing. I found them in her bathroom toiletry tray (23 April).

A week later another went missing. I did not find it. There was fiber on the bathroom sink drain (2 May).

Crumbs on Daybed

Then one of the best three plants, that was first to germinate, went missing. Crumbs were on the daybed sheet (7 May).

Third Best Missing

The third best plant is missing (9 May). Why did she pick the three best plants; about an inch taller than the rest?

A caregiver was in the apartment as Maggie turned from the window behind the daybed. She had an expanded disk in hand with part of it in her mouth. I was shocked (The caregiver was amused. This was nothing new to her). Maggie could not tell the difference between a chocolate candy haycock (?) and the expanded disks?

Yet another plant is gone (19 May). I found it under the heat exchanger behind the daybed (20 May). [It is still there.]

The next day the entire tray traveled to the dining room table during the night (20 May). She has not bothered the remaining plants, since part were transplanted outdoors (29 May).

We have removed everything in the apartment that she can eat that could be harmful or it is locked in the file cabinet. Newly purchased garden tools are all in the car trunk that is parked by our apartment and milkweed patch.

She fell as I was writing on this, this morning. Her legs were badly twisted. Once again she seems unharmed. We will know in a couple of days. Time to go to lunch (dinner in the old days).

We will never know if Maggie ate one of the disks including a milkweed. We may still find one on our next through search of the apartment.

Last night, Maggie said, “I don’t know what I want to do”, when we went on a walk after supper. She really is now a creature of the moment. We need to clear out the apartment down to things she still likes and that can be seen on the shelving. The things in the sorting boxes have served their purpose and are now extra baggage.

[Back in from watering the milkweeds. The nurse said the flower decorations from the Monarch Butterfly Sanctuary on the memory care tables were removed because Maggie was eating them.]

I must now accept that all of this is real. Happiness is now dependent upon the environment skilled caregivers create in this building, fully restored (and improved) from the flood. I still have a role to play here in, “I need your help, getting these pills down and getting . . .’ when there is not another caregiver to hand Maggie off to when things do not go as expected for the present caregiver.

From time to time during the day, she still misses me. I seem to love her more each day. For now our bond grows stronger as I spend several hours a day staging getting dressed and other daily activities (including all hours of the night). [I get in lots of naps.]

Ruth and Esther

Sunday my wife and I attended the 11:00 am video presentation of The Crossing church in the large screen theater on the third floor on Provision Living at Columbia. This was our third consecutive attendance. She did not identify with the same type of service on our TV or the big activity area TV from The Community Bible church in San Antonio, Texas. We had attended this service several times when visiting relatives in past years.

The Crossing singing and speakers seem to capture her attention. The music is familiar. The message is simple. They have the ability to bring scripture to life in the world as it is today without having to know much about theology or history.

My wife wanted to wander after the evening meal. We toured the entire first floor. Then she headed for the front door. We sat down with several other residents near the waterfalls. A number of topics were reviewed.

“And what have you two been doing today?” We mentioned we had been to church for three Sundays in a row. “What is different?” I related the above and added that the sermon was based on one of the woman in the Bible.

“Which one?” “Ruth.” My mind went blank. I had an aunt Ruth, but that was not right.

It was one of those “most embarrassing moments”. I knew the name was the same as a relative. I could not recall it. I also could not recall anything about the sermon.

Back in our apartment, I picked up Maggie’s mother’s 1978 New International Version: the book of Esther!! Maggie’s mother’s name is Esther!!

Two strings of information became entangled. The result was embarrassment, paralysis and anger.

I wish the BASIS body monitor had not been recalled. It would have recorded skin temperature, heartbeat, and sweating. I have avoided reactions like this most of my life by being “scientific”.

Feelings and emotions lead to a world I could never trust or feel comfortable in, with one exception: marrying Maggie. I always plant more than one plant or more than one variety in our milkweed garden. The truth is in the comparison.

 [The new meditation class takes me to the world of feelings three times a week. I can relive many moments of my childhood. Floating on a spider web held up by my breath carried me back to when I could see myself from a perspective of being above, behind and to the right side of my head. I played this game many hours.]

- - - - - - -

The sermon emphasized that God is at work in our lives even though we are not aware of it. The book of Esther does not include the word God. Esther took some time to realize that the sequence of events going on around her were not just chance or a lucky set of coincidents.

 [Just now (1:46 pm) as I am writing, a caregiver returned Maggie to our apartment for a rest. I glanced out the window as I cleared the daybed for her to lie down. The repotted milkweed plants we raised from seed where in full sunlight on their first day outside. I went out and moved them to the east side of the pine tree in the shade.

Maggie wanted the door propped open. I knew where it was as I had just helped another caregiver search Maggie’s four sorting boxes for the erasable marker missing from the laundry. Found it in the last box she was working with.

Is this coincidence? Or is there a hand at work here? Our caregivers seem to show up at exactly the right time on many unique occasions.]

From the sermon, I got the impression that Esther and Mordecai were talking to one another, “. . . came to her and says . . .”. In the Bible they were trading messages because of the limited access to the palace. This does not change the message; just the style of the storytellers has evolved.

My first reading of the Book of Esther many years ago impressed me with the 75,000 people killed by the Jews. That is how things were done in Old Testament times. (And still are in that part of the world.) God’s work (evolution) is taking a long time to civilize human beings. It took two world wars (where Christians fought Christians) to produce the European Union.

Somehow I did not get it; that one of the most important Jewish celebrations, Purim (March 9-12, 2017), helps Jews to remember the fact that the entire Jewish nation may have been wiped out except for Esther’s actions. The sermon got it.

- - - - - - -

For a moment, I thought that I may be experiencing what some memory care residents do on a daily basis; a degree of being lost, loneliness, and anger in an inability to understand and to express in words what they are experiencing.

Fortunately for me, I can still read, use the Internet, and relearn (update) what is now appropriate for our times. An inability to do this, for many valid reasons across the nation, may have produced the votes needed to elect our president in training.

Now to see what God does next. I would pray that the time for wars (that created the digital age and smart robots) is about over.

What is in our brain may be stored for eternity within the lifetime of the next generation. The ability to activate this information then ends the need for quarrelsome humans on earth to continue evolution (God’s work}.

Most of the plants and animals that ever lived on earth are gone. They prepared the environment for the present plants and animals, including human beings (creations that are aware of God).

Are huge masses of human beings the final information, awareness, climax? I doubt it. An all-powerful, unlimited, God, that I believe in, must have other plans that we can only dimly discern.

Milkweed and Monarch Therapy

Milkweed and Monarch Therapy

Slope Flowers Looking Northeast

This field of Coreopsis at Provision Living at Columbia in the spring of 2017 is the result of two years of succession; the natural process of plants competing. The first arrivals in the area create the conditions for other species to thrive. 

It is beautiful to most people. At $7 per plant in a nursery, this is what several thousand dollars looks like today and for several months to come.

The beauty was so overpowering that two caregivers made table decorations for memory care.

Table 1

Table 2

Table 3

Table 4

Purchased

These decorations cost about $20 each from a florist. They last about a week.                         

What happens on this slope will also now follow two paths with very different costs. Past tradition is a bulldozer, haul in good dirt, and plant whatever is in fashion. This is high maintenance. Water, water, and water. Only a few people can now afford to live in an artificial world that defies succession year around.

The new tradition is to learn what belongs here; what has evolved to thrive here. Engineering is being replaced with husbandry. Invasive non-native plants must be carefully removed. Engineering still plays a role in killing everything above ground and starting succession over again.

[However this construction site filled a valley over 70 feet deep with an 18-foot mound on top. Any seed bearing soil was either removed or deeply buried. What is growing here now comes from a prairie seed mix applied in the fall of 2015; and a truck load of dirt added on top of the mound (the lighter area on the east side of the property). Succession then starts with this seed mix and dirt containing unknown species.] 

Pre-Provision Living at Columbia (Mapquest)

Provision Living at Columbia (2017)

The contractor did not clear, in any way, a three-acre area along the north boarder that was approved for clearing. This kept the view of neighbors from the north being a fortress on a hill and kept the view of residents in the building as a natural woods on the cliff side (with no extra charge).

A Couple of Plants

The sloping field of yellow Coreopsis points out the need for a canvas of appropriate size for each desired effect; thousands on a hillside, a dozen in a vase, and only one or two plants in a garden or a small naturalized area.         

Our next job is then to remove any undesired plants and to add plants that can compete with little maintenance. Each plant has more interactions with the environment than just its contribution to the beauty of a landscape.

The milkweed is a good example. There is one species where one plant can feed many monarch butterfly caterpillars. There are several that are ornamental and currently becoming popular in landscaping. It may take several of these to feed one caterpillar; that is, if they have not been treated with a pesticide to protect the landscape investment ($7 to $37 plus planting).

[Treated plants kill the caterpillars. The expensive beautiful poisoned plants become death traps. An attempt to help, has the opposite effect! The eggs are wasted. Poisoned host plants reduce the population of monarchs.]

Milkweeds Ready for Fall Migration Monarch Generation

My wife and I raised, indoors, enough monarchs, on our two best years, to tag 100 butterflies. Each year one was found in Mexico. We had over 300 healthy common milkweed (Asclepias syriaca) plants each year. [The author of the scientific name thought the common milkweed, a native of North America, came from Syria.] 

The Monarch Butterfly Sanctuary would return to a forest if left alone; just as it did when the fields were no longer farmed in the past. Milkweeds would be a part of that succession. In time the native trees would prevail; as they did before being cleared for the current use of the land. A stable, climax, community would return. There would be few if any milkweeds. But this will not happen.

Non-native invasive species now disrupt normal succession. Invasive species crowd out, out compete, other species; other plants and the animals that feed on them. Diversity is reduced. We need to manage succession in such a way that milkweeds can thrive in a stable environment.

My understanding is that this is not difficult for this plot of land. Just mow in the spring and again in the fall, at the proper time; before the milkweeds are up in the spring and after the plants are going dormant in the fall (drought, freeze, or deer).

Crown Vetch from Top of Coreopsis Field

The Community Conservationist for the City of Columbia provided invasive species literature on crown vetch and bush honeysuckles. The crown vetch has been pulled from the sloping field of Coreopsis (some root parts still remain). The deer are feeding down the crown vetch on the upper flat northeast area. Both of these areas will require repeated inspections and plant removal until crown vetch is no longer in the community.

The bush honeysuckles are on neighboring property. Their invasive behavior can be managed by mowing, by removing seedlings and by having neighbors replace them with native alternatives. Native Alternatives to Bush Honeysuckle by Alan Branhagen in the spring 2017 Missouri Prairie Journal, Volume 38/Number 1.

A plant survey will determine what is growing now in all areas from the 2015 seeding and new dirt. These plants then serve as indicators of what other plants to add for a stable, low maintenance environment that includes milkweeds, and nectar plants; that turns a weedy area into more than a monarch rearing milkweed patch. It becomes an attractive self-sustainable sanctuary for monarch caterpillars and butterflies, and other pollinators. Residents can have a hand in growing plants for many years.

Milkweed seedlings were provided by the city of Columbia, May 19, from Monarch Watch. Memory Care residents transplanted the 50 plugs under the direction of Danielle Fox, Community Naturalist. The resident's active participation and expectations of what is yet to come was a well-intended result of this project.

Meanwhile we can wait for the fall monarch butterfly migration to lay eggs and feed on these plants. This generation will then fly to Mexico. The plants will then be put out on the sanctuary this fall where they can go dormant and be ready to bloom in 2018; ready for the spring monarch butterfly migration heading again toward Canada.