Memory Care Stories

The change in management from Provision Living to Cedarhurst has brought into focus how memory care is specifically actually done. The best practices standout as the most experienced, skilled, and trained personnel remain or leave.

They are observing Margaret’s behavioral changes and changing how they work with her.

Margaret likes to eat, but she delays eating. A good drink starts her eating. Always put the ¾ full glass near her left hand for an accident free meal.

Eating once took 30 minutes. Then an hour; and even longer. Yesterday they fed her first; even though we were at a table at the back of the room. She finished just a bit after the others. 

Food is served from the front of the room to the back, so food is not carried by unserved residents. Also, anyone tending to wonder is served to keep them in their chair.

Transferring from bed to the wheelchair requires moving a 200 lb horizontal object to a vertical position and then folding into a chair. A caregiver noticed that, “Put that walker in front of her and she stands up by herself.” 

She may need some assistance, but it works. Bed to walker to wheelchair with little to no lifting.

Other caregivers have mastered the art of “sweet talking” her to stand up, turn, and sit down. It grieves me to see (two to three) new hires trying to lift her bodily, or go through learning the timing, talking, and touching needed to pull this off almost effortlessly. Just saying, “One, two, three, stand” does not do it. Until you get that “Yes” nod of the head, you must do the lifting.

Medication pacing can be a pain. Memory care residents have the “right” to refuse their medications. This morning I again saw that turn into acceptance. “Here is your morning meds, Miss Maggie.”

The spoon was held about six inches from her mouth. Just held there. Nothing more said. Just held there. No motion. Her lips slowly parted; and in went the medicine. The distance and the choice of technique were perfect for this morning. Again, the caregiver must be able to read the resident and pace accordingly. 

Is Margaret telling us she is not ready for bed or is she teasing? You have to catch the grin. 

Place and person have been found to be important. Margaret is changed in the common activity/dining bath and in our apartment. One pair of caregivers found that Margaret would stand up by herself in the common bath for one of the pair of caregivers and for the other when in our apartment.

The above stories give a glimpse into what real actual memory care is all about. As I have said from the beginning, it is grand theater. The result is a safe, secure, and happy resident.

It takes people who are more concerned about supporting the residents for a shift than about personal matters (social media, games, and nicotine addiction). These are intermissions. They are lost opportunities to create feel good moments (and hugs). It takes long term staff that are consistently assigned to the same memory care residents for optimum effect.

It takes time. The reduction in staff, that once provided these services (on time and personalized), results in unhappy behavior rarely observed before, “I am hungry” and residents approaching me with, “I need help . . .” There is not the staff needed to have the time to maintain the theater.

Time costs money. Time reduces profits. Each caregiver makes about a one percent change in profits. Management needs long term, well trained, and experienced staff to be successful at a full memory care level of care.

Expectations and a resident’s health dictate what full memory care is and what people are willing to pay for such care. Both change over time. We have been here over three years. [We have outlived most of the people we started with.]

1.    We are secure. Margaret has not wondered out in over a year.

2.    We are about as safe here as at our last house. Acceptable falls are part of memory care.

3.    A two-hour watch is adequate for accident and incontinence checks.

4.    Allowing Margaret to roam in her wheelchair gives her happiness.

5.    Being positive with caregivers and events creates helpful bonds.

I have again met with Home Instead; if we need help between normal aging and Hospice. Several skilled and experienced caregivers have left to work in Hospice and other home health agencies.

Selecting a memory care facility is much like selecting a school or college. If you feel it will work and have the money: go with it. There is no guarantee that marketing knows what really takes place. Is camera monitoring used for safety and training? Is personal family sharing allowed?

My monarch butterfly Arlo video clip camera gives me a few minutes of the start and the end of the day; how Margaret interacts with her caregivers. Those interactions are memory care. [I can view them free for seven days If the Internet is up.]

   

Memory Care Financial Management

The marketing of memory care promises many things that can have several different realities. Corporate management must play a profitable tune on an installation using the keys of the facility, the employees, the services and the absent persons responsible for each resident.

How this is done has been a mystery to me until I went through several dozen e-mails I have received from a company in Lenexa, Kansas. It wants me to invest in long term care restricted to assisted living and memory care (a subclass of memory care in Missouri).

“When you need these services, you have no choice but to use them. Therefore, these services tend to be very recession resistant.” (June 12, 2017) Lower levels of senior care fluctuate with the economy and higher levels with government subsidies.

Actual experience with student housing and multiple single family funds have yield about a 13% return on investment. Senior housing yields about twice that rate at 12% to 21%. (May 25, 2017)

“The one-year return for Senior Housing through Q1 2017 equaled 12.05%, far outpacing the NPI (National Property Index) at 7.27%. Senior Housing consistently outperforms all other commercial asset classes over the last 1, 3, 5, and 10 year periods.” (June 27, 2017)

[Our building in Columbia is not rated as a commercial building. It is actually less expensive home construction. Each tornado proof cell holds two apartments.] 

And now, two years later, things are going so well that the Class B offering in 2019 shows an incredible after-tax net estimated investment rate of return between 38.1% and 41.7%. (Jan 29, 2019) The lowest investment amount is down to $50,000 for a qualified investor. 

I am not a qualified investor as I do not have $1,000,000. We put our house funds into an annuity (2016) that is less than 1/5 of that amount and pays about 2%. The difference between the rate of return between these two investments is staggering.

At present Building, Filling, and Selling Senior Housing has been more profitable than owning and operating. BFS has greater risk and thus a greater return; for those who win. Building in the mid-west “wealthy farmer” zone may prove problematic now that there are more bankrupt farmers since the last presidential election than in many years.

“The Senior Housing sector addresses a clear need while delivering attractive returns. Deploying capital in Senior Housing is an investment in the local community. Senior Housing strengthens communities by allowing individuals to retire and live in the same place where they have established business and personal relationships.

Senior Living Fund focuses its investments with operators who don’t just look at the bottom line, but rather on those individuals that impact the bottom line – our senior citizens. Their care and well-being is [sic] vitally important. When you focus on the happiness and health of the senior, the bottom line usually takes care of itself.” (February 21, 2019) 

The above two paragraphs are excellent examples of the best in memory care marketing. I have lived with my wife in memory care for the past three years. Memory care residents will never see this nor be aware of what it means. There is only a bond of trust between the facility and the individuals responsible for the resident’s welfare and bills.

That trust is earned by the caregivers who are assigned consistent care of a memory care resident to the point they can anticipate the resident’s behavior and can take preventative measures when appropriate. Almost all situations can be managed in a positive manner; that promotes happiness and health: the big family atmosphere in which each resident feels comfortable. 

Caregivers are an asset, or a hazard, based on assignment, experience, and training. The largest operating cost for memory care is payroll (53% of total expenses) in a five-year projection of net operating income (NOI) for a facility in Champaign, Il. (June 29, 2017).

“. . . the bottom line usually takes care of itself”, marketing, is next at 12%; followed by kitchen (food?) at 6% and utilities at 5%. We can now look for a direct relationship between payroll and the profit needed to return the original investment (higher risk) and to maintain the established facility (lower risk). 

The payroll is estimated as $1,200,000 for year three and for year four. To keep things simple, I have chosen a worker unit to cost $20,000/year. The facility director gets three units. A few others get two units each. The 60 units are then distributed among 50 to 75 full and part time employees.

$20,000/$1,300,225 = 1.5%. One worker unit saved would add 1.5% to the Net Operating Income. The yearly Net Operating Income percent is estimated at 36% during the last three years.

The investors are receiving about the same amount as some 60 employees are costing the company; $1,300,225 on a $10,074,141 investment (1.3%) vs $1,200,000 payroll (60 x 35 x 50 = 105,000 hr or $11/hr. The number of worker units, of hours per week, and of weeks worked per year can be adjusted as needed.  

Another interesting relationship is with a $10,074,141 investment divided by 60 $20,000 work units each one is backed by $168,000. Then $168,000 at 12% interest earns $20,000 annually. Each caregiver is worth about $504,000 invested at 4% interest.

Investors expect an internal rate of return (IRR) of 28% from this facility on the money they put in; when the facility is sold or the fund matures. This is 20 times the 1.3% annual earned on the total cost of the facility. This bit of magic is accomplished by the company getting low cost loans to finance about 90% of a higher risk project.

Management must then hire qualified caregivers with the required training and experience, or hire people who can be trained, in a lower risk operating environment that earns at about half the rate for creating a new stable facility.  

In two days, we will be one month after the sale of Provision Living at Columbia to Cedarhurst at Columbia on February 1, 2019. So far little has changed other than for the best tasting orange juice and the continuing of a slow reduction in staffing that started last year.

Assisted living residents are anxious to see what things will look like after the 30-day notice period ends. Memory care residents are happy with new table service, place mats, and flowers on their tables. 

We are getting the opportunity to actually experience the handoff, from developing to optimizing operation, for the residents and the investors. Employees seem to have little input other than the traditional vote; to stay or to move on to other opportunities.

It is my understanding that in Columbia, MO, there are no recognized unions or facility bargaining groups. There is some selection by good workers picking good workers on their shift. This frequently results in two new hires working together as a potential hazard and new ways of doing things.

Memory Care Operation Boundaries

When is a resident safe and secure? When is a resident enjoying the best quality of life? These questions become: What is safe ad secure? What quality of life can a resident enjoy?

The last question can only be answered by someone who observes and knows the resident well and interacts on a daily basis. A memory care resident can be a different person from day to day. The “State Operation Manual for Long Term Care Facilities”  defines a rapid change of caregivers as a hazard.

The past three posts review other information, situations, and operations that also influence whether a resident is safe and secure within the boundaries of the “State Operation Manual for Long Term Care Facilities”: manual restraints, chemical restraints, and accidents .

During 2018 the minimal, 0.25 gram, dosage of Xanax was doubled in February to 0.50 gram per day. 

Three major falls requiring the emergency room occurred in June, July, and August. Margaret was becoming unsteady on her feet. An ER attendant in July described her behavior as, “Her legs are turning to mush”, when she wanted to walk as we waited to be released.

Her plastic eye glass frame was imbedded in her eye brow in June. This required some stitches. In July she fell backward to the floor, out of her walker, with no visible injury; just unsteady on her feet. These were observed falls and counted as expected.

Did Xanax have any part in these falls? Does the warning from our health insurance company have any bearing here?  “Xanax increases falling in elderly persons.”

Was the August fall just a fall; an expected fall? The first two falls were observed and happened on a flat floor surface. The August fall was not observed and happened on a sloping grass surface that propelled her into the iron bar fence.

The third fall resulted in a concussion and injury to the right shoulder. She lost the use of her fingers on both hands. She was in pain for several days. She taught herself to be left handed.

Now, four months later, the neurologist reports the occupation therapy for the past two weeks is most encouraging. Her right hand is becoming useful again during therapy.

Is the third fall still inside what is acceptable? Is the EMT “unobserved fall in an unsupervised area” outside the acceptable limits of operation? Does the magnitude of the injury make a difference? Was this an avoidable accident? If it happened again with another resident would it be an avoidable accident?

Is an unmarked sloping grass surface a hazard that needs correcting? Considering that Margaret was not found for about 10 minutes (which is acceptable for falls in apartments), does the same limit apply in the memory care patio area that has totally unrestricted access for residents to enjoy during daylight hours?

These questions have a bearing on what risks to expect when living in a memory care facility. What does safe and secure mean to the resident and to the one paying the monthly bill for care? Isolated falls in the normal indoor activities, day or night, are expected and acceptable.

Medication Audit

Work on chemical restraints made me aware that Margaret was taking two other medications on a daily basis as well as the one on an as-needed basis.

This purchase audit, that anyone can do, draws from the pharmacist and insurance records (which are identical). The audit is adequate to determine that the right number of pills is being purchased. 

During Margaret's 50-year carrier as a surgical nurse, it seemed that more people lost their licenses from diverting patient prescriptions than about anything else.

This (and errors in the system) has led to a new business that packages pills, by the patient and by the time of day, in bubble packs. Currently a computer program announces when to dispense the pills. The bubble packs are made in St. Louise and installed in the medication carts by the same company. 

All of this work is paid for, in part, by salvaging pills that are not dispensed and by changing from a 3-month supply co-pay to billing on a 1-month supply co-pay. We were not accepted by the new system.

Our pills are still ordered and dispensed the old fashion way. I drive one mile to the pharmacy our insurance uses. We have used this store for over 10 years.

Therefore the rate of use is affected by how soon a refill is requested. Both Sertraline (Zolft) for depression and social anxiety disorder and Sotalol for heart rhythm are taken daily.

The charts show the rate of use from one purchase to the next purchase. In general, the rate of use is below one/day as new orders and refills are, in general, made when the last pill in the bottle is used. This system has been used many many years by long term care facilities.

We always reordered or refilled before we ran out before moving into memory care. That happened only once here at Provision Living in 2018, producing a usage rate over one  per day for Sotalol.

At least 11 bottles of pills should have been purchased in 2018 for each medication. That did not happen. Only 9 bottles were purchased. 

Margaret may have refused to receive her daily pill. The facility records would show this. The pill may have been returned to the bottle.

She may have refused the pill, but it was not put back into the bottle. Most of her pills are now taken with a carrier that changes the flavor: yogurt, pudding, ice cream, etc. These can not be put back into the bottle. (Assisted living residents often comment on the terrible taste of their pills and what they use to help take them.)

This audit shows no excess purchase of pills, in fact, it suggests an alternative source. A copy of the pill passing record would be needed to actually know what happened each day. The bubble packs are designed for a more accurate system.