Older Adults in Long-Term Care

A Policy Statement Adopted by  the House of Delegates, North Carolina Council of Churches, October 28, 1998

The plaintive cry of the Psalmist, “Cast me not off in the time of old age” (Ps. 71:9), demands renewed attention by the church as the number of older citizens escalates in American life. North Carolina’s 65 and over population is estimated to reach 1.2 million by 2010, more than 14% of the population. In 2011, the first of the “baby boomers” will reach retirement, with the percentage of older people in our population soaring to between fifteen and twenty percent.

This figure is high because people are living longer than ever before. During this century, the life expectancy has been increased by twenty-nine years. It is a new phenomena, never before faced in history. Older adults are pioneers of an extended life-span. The population of those over 85 is expected to grow by 62% between 1990 and 2000, and the fastest rate of growth in the United States is that of persons who are a hundred years old or older. In addition, we are all pioneers in this aging society. The retirement age was originally set at 65 in part because most people did not live far beyond that age and thus they were on pension for a very limited time. Now we are all learning to deal with retirement plans and Social Security programs that are based on many years of post-retirement life.

A special subgroup of the elderly is the elderly poor. The 1990 census found that 20% of North Carolinians over 64 and 30% of those over 84 lived at or below the federal poverty level. For a single person, that means an annual income of $8,050 or less. For a couple, the poverty line is $10,850. With some nursing home care now costing more than $40,000 per year, it is clear that many elderly people will be unable to pay for needed care from their own resources.

Many aging folk can be found in our churches. Go into any typical congregation, and you will see a host of gray heads. Many of these are people who have been active in their faith communities for their whole lives. Now they look to those faith communities to share their anxieties and fears and to support them if they enter a time of declining health.

The Bible, written in a time of much shorter life spans, actually offers little guidance about aging beyond the Levitical command to “show respect for old people and honor them” (Leviticus 19:32). The Bible reassures us, however, that God loves us always, that one’s life span may exceed “threescore years and ten,” and that goodness and mercy shall follow us “all the days of our lives.” The Bible also calls for justice for the vulnerable, whatever their age.

The fulfillment of this promise of goodness and mercy for senior adults may in large measure depend upon the faithful, caring response of people of faith. This will involve considerably more than friendly visitation and meals-on-wheels, though it does include such acts of direct ministry. It will require Christian citizens to become advocates for justice for the elderly in many dimensions of our corporate life.

The Need for Advocacy

As the number of older persons increases in our society, there is already evidence of an emerging prejudice being expressed toward them. As ageism is on the rise, deprecating labels like “old geezers” are heard. As seniors claim their just benefits from Social Security, younger people become resentful of the strain this places on our economy and the threat it poses to their own aging years. As the elderly claim the benefits of Medicare and Medicaid, there are complaints from younger people about limited health care resources.

It is a disservice to lump all older persons into a single category, for there are various stages of aging, each of which has special needs. We sometimes forget that as many years separate 65- and 90-year-olds as separate 10- and 35-year-olds. By far the majority of people over 65 are active and generally well. Only 5% are in rest homes and nursing homes. (Fifty-eight percent live with spouses, and 29% live alone.)

Older adults prefer to remain at home and often can do so longer with some assistance from in-home or community-based services. (The use of a home health aide or an adult day care center are examples of these services.) Although the state’s funding for these services has increased in the last two legislative sessions, the state should place much more emphasis on this use of state dollars. There are long waiting lists for home and community services for low-income adults. In most cases, these services are less costly than institutional care.

As aging progresses, some are no longer able to live at home. Numerous institutions for “assisted living” have emerged in recent years. (Recently the state has begun using “assisted living” as an umbrella term that includes these new facilities and adult care homes, formerly known as rest homes.) Finally there are those who are so frail that around-the-clock care is required in a full nursing care facility.

Increased longevity also leads to new problems for others in the population. It is becoming common now for persons who are themselves old to be taking care of a parent who is much older. Seventy-year-olds often are confined by their care of 90-year-old parents. Couples in their middle years, more than ever before in history, feel caught between the generations, responding to the claims of the young on one side and the needs of the old on the other.

Adequate care is a paramount concern, especially when immediate and extended family no longer live nearby and may actually live on the other side of the country. Constant monitoring is required because we now live in a society that has made a business out of caring for the elderly. All too often, the bottom line is the bottom line, not quality care but profit. The for-profit long-term care industry has become one of the most powerful players in North Carolina politics. Generous campaign contributions (some of which have had to be returned) have guaranteed ready access to the state’s policy makers.

An overriding problem is the staffing of institutions where older people are residents. These staffing issues take several forms. One is the ratio of staff to residents. Prior to late 1998, regulations for staffing in adult care homes had not been changed since 1977, though the needs of residents have dramatically increased. These homes are required to have 1 aide for every 20 residents during first and second shifts and, until recent changes, only 1 aide for every 50 residents on the third shift. In October 1998, the third shift ratio was changed to 1 aide for every 30 residents. The dangers of this low staffing on overnight shifts became tragically apparent in 1996 when seven non-ambulatory residents died in a fire in an adult care home in Laurinburg. There simply were not enough staff people to evacuate all residents quickly.

Residents of adult care homes who are unable to pay for their care receive Special Assistance (SA), a mix of state and county funds. The state currently pays SA at a rate of $956 per month. Since 1995 all SA recipients have been eligible for an additional $245 per month in Medicaid funds directed at their personal care. Higher payments are allocated to residents whose needs exceed basic care (so-called “heavy care” residents”). Unfortunately, there are no data to indicate that these payments are in fact being used specifically for residents’ personal care. Anecdotal evidence suggests the contrary, that little additional staff have been hired since these Medicaid payments began. A state study now under way may provide better information on this point.

Another staffing problem is that of inadequate training. Training requirements range from a minimum of 20 hours to a maximum of 75 hours, depending on the type of facility and the care tasks being performed. Adequate training reduces abuse, incontinence, falls, and a host of other preventable events. Training requirements are essential because there is no requirement for any health care professional (registered nurse, etc.) to be on an adult care home’s regular staff. Unfortunately, a 1996 survey conducted by the state showed that 25% of staff had not completed, started, or even scheduled this training.

The difficulty in knowing the quality of care being given at a particular facility is made more complex by the fact that not all adult care home beds are even inspected regularly. Adult care beds that are part of a nursing home (and there are about 5,500 of these beds) are not being inspected regularly, though state law seems to require that they be inspected just like freestanding adult care homes. The state acknowledges that these facilities should be inspected but notes that recent budget cuts at the federal and state levels mean that inspection staffs are stretched too thin.

With the increasing longevity of Americans has come an increasing incidence of Alzheimer’s disease. There are currently an estimated 4 million people with this progressive, degenerative brain disease. It affects 1 of every 10 people over the age of 65 and almost 50% of those who live to be over 85. About half of all nursing home residents have Alzheimer’s or a similar disease. Many long-term care facilities now have special units for Alzheimer’s patients. However, there are no state-mandated standards for these special facilities.

While many long-term care facilities have more staff than the required minimums and provide good care for people in the last years of their lives, it is the facilities that fail to do so that must be improved. Surely the Christian community cannot stand by while older people are neglected and exploited. Instead, the church must encourage the state to fulfill its responsibility to protect all of its citizens.


In our churches
Our first recommendation is so obvious as to be self-evident, but it is where we must begin. We call on churches to be more sensitive to the lives and needs of their elderly members and their families. This includes finding meaningful places for service in the life of the church for those who are able. It also means being present to assist as appropriate when elderly adults, and their families, face hard decisions, such as choosing the best place for an adult in declining health. It means visiting those who are living in long-term care facilities and being attentive to the conditions in which they live and sensitive to the difficult work expected of staff. And it means knowing the community resources that can be called upon if you are concerned about residents’ rights or residents’ care.

In the community
We support adequate funding for in-home and community-based services which enable elderly adults to live in their own homes and communities for as long as possible.

In long-term care facilities
For the benefit of those who need to live in a long-term care facility, we recommend the following:

  • In order to protect residents’ safety, we support changing the current minimum staffing requirements in adult care homes to one aide per fifteen residents for first and second shifts, as recommended by Friends of Residents in Long Term Care. Legislation should guarantee that extra funding be used to hire additional staff and that past rate increases, especially for heavy care residents, also be used as intended.
  • We support a balance of resident advocates and industry representatives on relevant legislative and regulatory committees and commissions. We also support the creation by the Legislative Study Commission on Aging of a Subcommittee on Long Term Care, again with balanced representation. (Because many residents are unable to be effective advocates for themselves, resident advocates may be family members, friends, or other concerned parties.)
  • We support adequate funding at the state and county levels to insure that current laws and regulations, including those regarding staff qualifications and training, are effectively monitored and enforced. Monitoring should be consistent across county lines.
  • Adult care home beds in nursing facilities should be inspected just like freestanding adult care home facilities, as the law already requires.
  • We recommend that the Legislative Study Commission on Aging establish standards for Alzheimer’s units.

The New England Journal of Medicine reports that those of us who live past the age of 65 have a 43% chance of needing long-term care at some point. If we haven’t already encountered the need for long-term care for ourselves or our loved ones, we will. If we haven’t experienced any of the problems discussed above, we will. The church surely has a responsibility not only for the well-being and protection of those who have already entered the final stages of life, but also for those who will soon follow.

Friends of Residents in Long Term Care
Performance Audit, Office of the State Auditor
The Alzheimer’s Association (USA)

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