Systemic Change Occurring To Keep Seniors Safe

In last week's blog, we pointed out that the AARP reported that over 160,000 COVID-related deaths have occurred among nursing home residents and staff. As we continue to analyze these statistics, it is becoming increasingly evident that much of this carnage could have been prevented through government regulators paying more attention to nursing home providers who have shouted for decades that there existed gaping holes in the long-term care system that were in plain sight but conveniently ignored.

A broken system exploited by COVID

Although COVID and the resulting pandemic drew attention to these "gaping holes", the reality was that on any given year during flu season, the seniors in these facilities died at higher rates than the general public. A 2017 report published online at the National Center for Biotechnology Information (NCBI) ominously predicted how the shortcomings in our antiquated long-term care and health delivery system was a tragedy waiting to happen. This report was clear and to the point;

"Long‐term care facility environments and the vulnerability of their residents provide a setting conducive to the rapid spread of influenza virus and other respiratory pathogens. Infections may be introduced by staff, visitors, or new or transferred residents, and outbreaks of influenza in such settings can have devastating consequences for individuals, as well as placing extra strain on health services. As the population ages over the coming decades, increased provision of such facilities seems likely. The need for robust infection prevention and control practices will therefore remain of paramount importance if the impact of outbreaks is to be minimized...including vaccination of residents and staff, and the use of antiviral drugs for treatment and prophylaxis, based on currently available evidence."

But government regulators, including the CDC, ignored the reality despite requests from providers to improve these conditions through an increase in reimbursement rates and other funding to bring conditions in these facilities into the 21st Century-- until the pandemic. Finally, the concerns of staff and administrators are being heard, and grant money has now been made available to begin making a systemic change in the way we deal with our seniors from the community level to placement in long-term care.

Long-Term Care Needs Are Being Addressed

Rick Gamache, CEO of the Aldersbridge Communities in Rhode Island, in speaking about a grant his organization received that is designed to address this concern, pointed out the weaknesses in the current model that contributed to the rapid spread of COVID-19 across the country. “Nursing homes like ours were built in the 1970s and haven’t changed much architecturally over the years,” noted Gamache. “Our most vulnerable population – elders – are the most susceptible to illness and viral spread, yet they often share rooms and washrooms in institutional settings.”

Finally, state and federal governments are acknowledging that changes need to be made and have begun to address this through grants designated by the federal Coronavirus Aid, Relief and Economic Security (CARES) Act. These grants support the "transformation" of nursing facilities into more resilient environments where risks associated with the coronavirus can be more easily controlled and invest and grow a more robust system of community-based services as alternatives to care settings like hospitals, nursing homes, or assisted living residences. This will include a new model of primary care services for older adults and community support services that are aimed at keeping seniors independent and safe in their homes in the community as long as possible. Just how will this be done?

The grant at Aldersbridge's Linn Health & Rehabilitation will include transforming eleven skilled nursing and long-term care rooms from semi-private to private, each equipped with the latest in ventilation, lighting, and technology for infection control, and an ensuite private bathroom with a shower. The renovated rooms will be kept separate from other rooms, helping to control the spread of germs and for potential use as an infectious disease isolation unit should the need arise. This is the future of long-term care, which, in fully utilizing the options within the community and using primary care medicine as a way to stave off institutional care as long as possible, can reduce the load on our nursing facilities.

"This is not a way of eliminating long-term care providers," said Attorney RJ Connelly III, a certified elder law attorney. "We know with the aging of the United States, we will need these facilities more than ever, but we also recognize the fact that our current system is broken and must be repaired. It's imperative that we ease the burden on the administrators and staff by improving the community care supports for seniors and their families and stop using our long-term care facilities as step-down programs for hospitals."

The Oak Street Health Model of Success

In reviewing literature specific to the provision of primary medical care for seniors, this appears to be the key in keeping seniors in the home and out of institutional care. In looking for a model that addresses this, we need to look no further than in our own backyard and a provider named Oak Street Health, who saw this problem long before COVID existed and began working on ways to improve the system in 2012.

The new Woonsocket Office

On our February 18th edition of Southcoast Seniors Radio Magazine sponsored by Connelly Law, heard on am790 WPRV, the featured guests were from Oak Street Health, which now has four offices in Rhode Island. Dr. Solmaz Behtash, Medical Social Worker Wilmaris Soto-Ramos, and Outreach Director, Ashley Stokes discussed the Oak Street model of primary care that fits into this new continuum of post-pandemic community care.

Long before the COVID-19 ravaged our seniors, Oak Street Health had identified the broken system and began to find ways to change it. Founded in 2012, the Chicago-based company's clinical model falls neatly into place in 2021 as we seek ways to keep seniors out of institutional care and living comfortably and healthy in their homes. This approach involves a primary care focus featuring longer, more frequent visits supported by integrated care teams and sophisticated IT tools that are used to develop and carry out individualized care plans. Something providers are now saying could have changed the deadly trajectory of this novel coronavirus.

“We see the changes in the long-term care model being made by Aldersbridge Communities,” said Connelly. “Their CEO Rick Gamache was on our show in January and discussed another major part of that grant, called the Linn Health Navigator, that is aimed at keeping seniors in the community and living independently within their homes, something we have advocated for years. A perfect community partner in making this happen is the Oak Street Health model, which fits perfectly into this goal."

What is so different about Oak Street Health and why, in our opinion, are they the future of primary care. Let's take a look at a typical patient. According to an article in, written in 2019, all Oak Street patients have complex care needs and all are Medicare patients, and here are some numbers:

  • 42% are also dual-eligible for Medicaid and their average income is less than $21,000.

  • 52% are between 65 and 74 years old.

  • They have an average of four chronic conditions such as hypertension, diabetes, congestive heart failure, or chronic obstructive pulmonary disease.

  • They take an average of 7.2 medications.

  • They have complex behavioral and social needs, with 35% diagnosed with depression and 20% with a substance-use disorder.

Given this patient profile, one would think that the treatment goal would be placement planning for long-term care, but this is not the case. In Rhode Island, one of Oak Street's Medical Social workers, Wilmaris Soto-Ramos, described just how the team works to keep seniors home and out of institutional care.

“The Oak Street care teams hold daily meetings to plan for patients coming in on any given day with structured reviews of those patients who are high-risk,” said Soto-Ramos. “We see our patients much more frequently and for longer periods of time. They are not rushed in and out according to the clock, our patients spend quality time with clinicians who listen to their needs and develop plans to address them.” But does spending more time with patients work? And what about outcomes? Well, they are indeed impressive.

Dr. Solmaz Behtash discussed some significant achievements of the Oak Street Health model of primary care. “Our delivery of care has resulted in a 50% reduction in hospital admissions, a 52% reduction in emergency room visits, and a 35% reduction in readmission rates,” said Dr. Behtash. “The hospital reduction rates are a direct result of the time we spend with our patients providing primary care.”

And one additional piece of information that speaks to the level of satisfaction a patient has with Oak Street Health’s model of care, they have a 90% retention rate with patients, according to an article on the website.

These outcomes are especially important when we consider that the institutional care setting was one of the major contributing factors in COVID deaths and transmissions. Plus, it is also cost-effective when we consider the minimum cost of an older adult being admitted for hospital care can cost upwards of tens of thousands of dollars just walking into the emergency room door.

“What impressed me about the Oak Street model, besides the individualized care they provide, are the social supports they offer, something that does not happen at the majority of primary care settings,” said Attorney Connelly. Those things that Connelly is referring to are activities such as yoga, exercise classes, and even Bingo.

Oak Street Health's vans provide transportation

“We offer all types of social and physical activities at our offices,” stated Ashley Stokes, an Outreach Director for Oak Street Health here in Rhode Island. She went on to describe an impressive range of social activities including yoga, exercise instruction, nutrition classes, and more. "And," said Stokes, “we offer transportation to and from appointments.”

Using the Oak Street Health primary care model to keep seniors out of hospitals and long-term care and in the home is part of the fix for the broken system, and making single room occupancy in long-term care settings is another fix that is a long time coming, but what about the basic day-to-day living needs and other support services that a senior needs to remain independent within the community, a need that has been identified by the Coronavirus Aid, Relief and Economic Security (CARES) Act? In this, Connelly Law Offices can assist.

Connelly Law's Comprehensive Community Support

“We have a program called “Safe Harbor Services” that we initially put into place several years ago to help build a supportive model of care around a person who has been newly diagnosed with Alzheimer’s or other forms of dementia,” said Connelly. “This now seems to fit in the care model being brought forth to keep seniors home and out of long-term care as identified by the Coronavirus Aid, Relief and Economic Security (CARES) Act.”

Attorney RJ Connelly III

Connelly Law’s “Safe Harbor Services” utilizes a multi-disciplinary approach that includes expert legal advice, professional fiduciary services, and care coordination that allows the firm to be unwavering advocates for their clients, regardless of their living situation, diagnosis, or means.

“We collaborate with families at this most difficult time to ensure their loved one is receiving the best possible care in the least restrictive environment possible, a goal we had long before the pandemic arrived. In doing the work we do, we have built professional and lasting relationships with our senior care community partners, allowing us to better serve our clients and their families," said Connelly.

“With the current fixes to the long-term care and primary care delivery models, keeping seniors home will be a shared journey of the patient/client, families, financial and elder law professionals and medical practitioners, all working as a team, with trust and confidence in each other, planning for the best outcome possible,” continued Connelly.

Keeping seniors home is the goal

"Once a diagnosis is made and a family reaches out to us," said Connelly, "we begin a series of discussions about things that must be planned for in order to keep an aging loved one at home." These things include the following;

  • Building the appropriate service plan needed to keep the loved one in the home.

  • Ensuring that all healthcare needs are being addressed through referrals.

  • Seeking all benefits the client is entitled to.

  • Making arrangements for finances and property.

  • Naming someone to carry out the loved one's wishes when they no longer can.

  • Assessing home needs so that the loved one can live safely and independently as long as possible.

  • Finally, making sure all arrangements are in place for long-term care should it be needed.

When it comes to finances, what can the firm do to assist an individual or couple who are aging in place? According to Connelly, the daily money management services ease the stress on the senior and on family members who often are tasked with paying bills and monitoring accounts, sometimes from the other side of the country. These services include:

  • Paying bills, including utilities, credit cards, taxes, etc.

  • Maintaining financial records.

  • Preparing budgets for the senior.

  • Balancing checkbooks and monthly reconciliations.

  • Negotiating with creditors when needed.

Connelly Law also prepares checks for clients to sign, helps seniors organize their bank and financial records, gather documents for tax returns, help decipher medical bills, and review bank statements in order to detect potential financial abuse or fraud.

From a legal standpoint, the Connelly Law team will assess what documents are needed such as the power of attorney, a healthcare proxy, a living trust, and other healthcare documents that an older adult should draw up and sign so that if his or her decision-making capability is diminished as they age, healthcare and financial decisions are made by someone that he or she trusts.

Medicaid planning is an important component

Medicaid planning is also an important component of these services. A full-time Medicaid Specialist focuses on helping individuals or families become Medicaid-eligible. As the senior ages and if long-term care appears to be something that is needed, Medicaid plays a large role in paying for this care, so financial planning to become Medicaid qualified (and prevent a spouse from becoming indigent while living in the community) is a major part of financial planning for long-term care. And because Attorney Connelly practices in Rhode Island, Connecticut, and Massachusetts, he has intimate knowledge of each state's Medicaid eligibility laws and addresses issues such as owning property in multiple states.

How does Connelly Law help develop these plans? It starts with an assessment. "It begins with a meeting here in our office where we look at what the goal is for the client and the family. We can address financial planning, such as putting daily money management services in place, planning to sell the home and property if needed, and setting up trusts. Then we discuss what legal documents the family wants," said Connelly. "We then send out a staff member who will do an assessment of the living environment, looking for areas that need repair or perhaps safety improvements or upgrades."

And who does the work? "We have a comprehensive list of licensed and certified contractors who we have vetted and we negotiate with, looking to keep the price affordable and ensure that the work meets the standards required by law," said Connelly. "This could include everything from electrical work to snow shoveling or cutting grass and trimming hedges. It's our goal to provide the best quality of life a senior can have while aging in place."

Successfully aging in place requires a team approach

Connelly also pointed out that the firm maintains a solid and collegial working relationship with a plethora of community service agencies that offer assistance to seniors and those with disabilities for little or no cost. "We always look to find how we can meet the needs of our seniors in the most cost-effective and professional way possible," he said.

Connelly cited an example of how seniors can be taken advantage of and why they need other supports to remain in the home. "Recently, one of our elderly clients who we provide fiduciary services for called and told us about a relatively new washing machine that had stopped working. She stated that she called a repair person who wanted a minimum of $75.00 for a service call plus parts. We sent our facilities manager down and it turned out that a blanket had caused the washer to become unbalanced, shutting down the computer. All we had to do was unplug the machine and plug it back in to reset the computer, thereby saving the client a substantial sum of money."

As devastating as COVID has been, it finally brought to light the struggles that our senior care providers have dealt with for decades. We are now seeing consensus that by supporting our seniors within the community, we can ease the burden on a long-term care system that was woefully outdated. This will be done by supporting primary care models like Oak Street Health and building and maintaining a team of supportive services around the senior living in the community.

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