Stuck in the Middle

June 02-- Jun. 2--Editor's note: Caregiving -- and taking -- is a complicated, constantly evolving concern for many in the Grand Traverse region. "Taking care" is the Record-Eagle's ongoing exploration of how this high-dollar, high-stakes issue impacts our community.

TRAVERSE CITY -- Aging comes with a variety of problems. Math shouldn't be one of them.

Senior citizens who need some form of additional healthcare can find it difficult to make financial ends meet, trying to find a way to turn a lower- to middle income (Social Security plus pension) of between $1,200 and $1,700 a month -- plus any savings -- into assisted living housing costs that can soar to $5,000.

Chris Milowe, the regional operations director at Baruch Senior Ministries, said a lot of people are caught in this middle space between not having enough retirement savings to pay for assisted living, but too much to qualify for Medicaid.

"There's a large class of people that have too much money and also too little money," Milowe said of Baruch, which operates Cherry Hill Haven in Traverse City and Kalkaska as well as Effie's Place in Leland. "They have too little to live in assisted living for the rest of their life, but too much to qualify for Medicaid."

The remaining burden falls on retirement savings and/or long-term care insurance. But insurance isn't that common and savings can quickly be depleted. Then it falls on families to contribute, who may not have enough savings of their own to fill in the spaces.

"There's a gap," said Dee Wilkinson, the housing coordinator at the Area Agency on Aging of Northwest Michigan, putting a complicated situation into the simplest of terms.

Cecille Smoker is finding herself in that squeeze as she moves toward her sixth year of living at French Manor Residential Care on Seventh Street. Smoker thankfully had a 401K in addition to Social Security and a pension of $761 a month from working downstate at Blue Cross Blue Shield.

Smoker said her retirement plan and that pension -- which fewer and fewer people have anymore -- allowed her to stay at French Manor where the monthly rates range from $3,000 to $5,000 a month, according to Rusty Ackerman, who along with his wife, Kelly, owns four of the company's five facilities and manages the other.

"That money has gone so quickly," the 85-year-old Smoker said.

When that savings goes, Smoker said she will likely go to a facility like a nursing home in her hometown of Jackson. Ackerman told Smoker that the facility will work with her so she can stay in Traverse City, but Smoker understands it's a business and insists, "I'm not afraid."

"When that (money) goes, I have to move," Smoker said matter-of-factly to Ackerman. "You have to have an income, too and you can't run all these facilities unless the rooms are full."

The Alliance for Senior Housing, LLC and Options for Senior Living, LLC are two area companies that make free referrals for placement in senior housing. The two organizations try to place seniors in facilities that works for their finances.

"We need homes that work with low income, willing to accept straight Medicaid," said Connie Hintsala, founder and president of the Alliance for Senior Housing. "This is a huge need ... beyond huge. I can't express this one enough."

"There's a lack of availability across the board, especially in the lower-income range," added Kim Bauml, senior care consultant/president at Options for Senior Living.

Other than overall availability, there doesn't seem to be a problem on the higher end of senior housing. Retirement living communities and some of the higher-end assisted living facilities in Grand Traverse County and the region are frequently full and often come with extensive waiting lists.

But these are also private-pay facilities because residents don't meet Medicaid requirements.

Other assisted living facilities -- more of the middle level of housing between independent and adult foster/nursing home care -- have openings and not enough residents to fill them because of staffing, costs and care.

Having a Choice

The Michigan Medicaid MI Choice Waiver Program is one of the biggest ways seniors can meet their needs. The waiver program is only for care, not room and board, but it can help go toward the overall cost. The waiver can also reduce overhead in facilities for the purchase of care products.

To be eligible for MI Choice, one has to qualify both medically and financially. Wilkinson said a person has to be eligible for or on Medicaid plus need a "nursing home level of care" to meet the medical component.

Financially, a single person has to have an income of less than $2,313 a month plus less than $2,000 in assets.

"People that are in assisted living and are running out of money and if they qualify financially, this is a great program for them," Hintsala said.

Most facilities in the region accept MI Choice. First and foremost, it puts people in beds, which means more money for the facilities.

"We will work with any facility that desires to with us on the MI Choice Waiver Program that can meet the standards for (Michigan Department of Health and Human Services)," Wilkinson said.

The waiver varies by the amount of care each person needs. The Area Agency on Aging assesses an applicant with a registered nurse and a social worker. Wilkinson said care within the agency's 10-county area ranges from a halfhour to 10 hours a day and that "the AA reimburses providers $18 an hour for care of community living support."

As more people learn about MI Choice, another problem is popping up. There is also a waiting list of 10-12 months for the program, Wilkinson said.

Making the money work

Nonprofit facilities like the county-owned Grand Traverse Pavilions and Cherry Hill Haven can make up the difference other ways.

The Pavilions has 78 assisted-living apartments over three different cottages at the Grand Traverse Commons. Mack said Evergreen and Hawthorne are more high-functioning assisted living facilities and the price, based on the square footage of the rooms, ranges from $1,600 to more than $4,000. Willow Cottage, with a higher level of care, is just over $4,000.

"There is a broad range," Mack said. "The first question I ask is 'What is the level of care?'"

Mack said a foundation at the Pavilions as well as working with Medicaid and MI Choice Waiver can make up the difference, especially for someone that is already on campus and maybe have seen their funds dwindle.

"It kind of hurts them in the middle (class)," Mack said. "The mission of Grand Traverse Pavilions is to meet that need for the lower and middle class."

Milowe said the company's founder, Tom Nobel, had a great understanding of the gap when it came to paying for assisted living, which can range from $4,000 to $5,000. Originally a for-profit company that is now nonprofit, Milowe said there is an income-based program in place now at Cherry Hill and Effie's Place where if someone pays for two years and sees their savings dwindle to the point of qualifying for Medicaid, payment becomes income based.

Milowe said this 48 months of payments allows the parent company "to keep the lights on" while still allowing a resident to age in place at one facility.

But most facilities in the area are for-profit. These places want to make money and have to deal with the rising cost of food, insurance and staffing.

"I've seen the prices go up $1,000 in less than 10 years," said Wilkinson, who understands the increase.

"We try to work with them," said Ackerman, using MI Choice as one of those methods. "Our problem is costs are rising ... and now we have a super-competitive market for employees, or a lack of employees."

While assisted living facilities are not inexpensive, Wilkinson said families also have to weigh what comes with it. She said there are no taxes to pay as well as not having to pay for lawn care or snow removal, cooking, cleaning and even laundry.

The call for more

Two aspects of senior housing on a lot of minds were staffing and space -- and the thread connecting the two.

Culver Meadows Senior Living and Adult Foster Care co-owner Trina Jewett said staffing seems to be a problem across health care. Culver Meadows has been owned by her family for the last 27 years.

"Dependable, compassionate people can be a lot harder to find now than they were a few years ago," Jewett said. "I think they are out there, they're just not committing to positions.

"We're all struggling with the same things; I'm not sure what the answer is."

"Everybody has a staffing issue," Hintsala said. "Some of the homes have even contracted with in-home care agencies to provide extra staffing. And the in-home care agencies sometimes don't have enough people."

At places that didn't have rooms available -- or even ones that did -- was a prevailing trend across the county, which could bog down a system that can feature a lot of paperwork.

"The need is very high with our aging population," Mack said. "Yes, Grand Traverse (County) has multiple facilities, but what I'm hearing, just by word of mouth, is there is a wait list."

"Most places there is a wait list for rooms, no matter how much they cost," Wilkinson said.

Bauml said there are proposals to add independent living facilities in particular on Hammond Road, one on the corner of LaFrenier Road and another closer to Three Mile Road, but there are still wait lists of up to a year at other like facilities in the area.

"There's more coming, but they're not going to be fast enough to handle the need and not have all those wait lists," Bauml said.

Independent of each other, Hintsala and Wilkinson said a group of pods would seem to make sense for both the facilities and the residents. That just needs a sizable investment on the business side and government that will allow its construction.

"... I could see where that would be extremely economical for them ... if zoning would allow it," Hintsala said.

Wilkinson said she has a clover-design in mind and just needs the funds to build it.

"All I have to do is win the lottery," she joked.

The Michigan Medicaid MI Choice Waiver Program began in 1992 and became available in all Michigan counties on Oct. 1, 1998.

The MI Choice Waiver Program is a nursing-home diversion where eligible adults who meet financial and physical requirements can receive Medicaid-covered services provided by a nursing home in their home or another residential setting like assisted living.

According to the Michigan Department of Health and Human Services website, MI Choice Waiver can cover:

StrokeStyle/$ID/Japanese Dotsn Community transition services

StrokeStyle/$ID/Japanese Dotsn Community living supports

StrokeStyle/$ID/Japanese Dotsn Nursing services (preventative nursing)

StrokeStyle/$ID/Japanese Dotsn Respite services

StrokeStyle/$ID/Japanese Dotsn Adult day health (adult day care)

StrokeStyle/$ID/Japanese Dotsn Environmental modifications

StrokeStyle/$ID/Japanese Dotsn Non-medical transportation

StrokeStyle/$ID/Japanese Dotsn Medical supplies and equipment not covered under the Medicaid State Plan

StrokeStyle/$ID/Japanese Dotsn Chore services

StrokeStyle/$ID/Japanese Dotsn Personal emergency response systems

StrokeStyle/$ID/Japanese Dotsn Private duty nursing

StrokeStyle/$ID/Japanese Dotsn Counseling

StrokeStyle/$ID/Japanese Dotsn Home delivered meals

StrokeStyle/$ID/Japanese Dotsn Training in a variety of independent living skills

StrokeStyle/$ID/Japanese Dotsn Supports coordination

StrokeStyle/$ID/Japanese Dotsn Fiscal intermediary

StrokeStyle/$ID/Japanese Dotsn Goods and services

Source: MDHHS website

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