Dateline, Orlando Florida
I woke up to sun streaming in off of Tampa Bay and through my windows (where not blocked by the parking garage), had the usual tasteless Hampton Inn free breakfast, arranged for a delayed checkout and set out to explore downtown St. Petersburg on foot. The bay was lovely. The pelicans were soaring overhead and there were herons and egrets breakfasting on the lawns nearby. Or maybe they were ibises. I didn’t have a copy of Roger Torey Peterson close at hand to double check. I ended up walking down the bay front, past the arts center and arrived at the Dali museum just as it was opening for the day. It’s the largest collection of his surrealist works outside of his own museum in Catalonia so I popped in to take a look.
Seeing somewhere between eighty and a hundred of his canvases arranged in chronological order, it was possible to see his development from his early classical work (influenced heavily by the impressionists and the fauvists) to academic studies from art school to his rapid transition to surrealism in the late 1920s to his more dreamlike enormous canvases of his later post war career. I hadn’t seen a lot of his earlier work before and that’s one of my favorite things to do, trace a visual artists development over time and see how they are influenced by other artists or social movements so I now feel I have a better understanding of Dali than just floppy watches. (Although I must admit I did buy a pair of Persistence of Memory socks in the gift shop). The museum is encased on the harbor end in a multitude of triangular glass tiles that look like they were put together by Buckminster Fuller after a three day bender. I was wondering a bit about the wisdom of having a museum made of glass in a hurricane zone but the collections themselves are in another part of the building constructed in a style best described as concrete bunker.
A further walk through downtown and then a battle with the valet to retrieve my car from the overnight parking as they had mislabeled my key as belonging to a large black van looking like it had been driven last by Ted Bundy but we eventually got it straightened out and I headed a little further to the west to St. Pete beach in order to spend a little time on white sand and dip my toes into the Gulf of Mexico. The Gulf beaches really are some of the nicest in the world and, being a Monday morning, there was next to nobody there. Then, back in the car and across I-4 and the flat lands of central Florida to Orlando, arriving late afternoon. I had dinner this evening at a very good Indian restaurant in Winter Park with an old friend from early UAB days whom I have not seen in person for seventeen years and we caught up on each others lives. I am now stretched out and conserving strength before theme parking it tomorrow.
I’m trying to detach from all things work related but I am in Central Florida and not far from The Villages so there are constant reminders around me about the clinical geriatrics part of my life. When I travel alone, I people watch and have spent the last few days observing the Florida retiree in their native habitat and have been busy diagnosing gait disorders, memory issues, and various neurologic complaints in the passers by. Many years ago, after UC Davis decided in a fit of pique to eliminate their clinical geriatrics program, Steve and I found it necessary to relocate away from the west coast. Our initial plan was Florida. I interviewed for a number of jobs in Miami, Fort Lauderdale, Orlando and some other town whose name I don’t even remember at this time. I left almost every one of those interviews with a very bad taste in my mouth. It was clear that the purpose of Florida geriatric medicine was to maximize reimbursement at all costs and that the actual clinical needs of patients was much lower on the list of priorities. (There was one exception – Mount Sinai in Miami Beach. I nearly took the job there but the finances of the program were tenuous at best and it was clear it would collapse in a few years – it did).
The Villages, just up the turnpike from Orlando, is the largest senior living development in the country – with a population of about 80,000 people in planned communities of homes for ‘active seniors over age 55’. It’s just one of many types of senior living available in the US. These type of communities, popular in sun belt states, are basically subdivisions with HOA rules restricting residence to certain age groups. You’re expected to maintain your own property and, as the majority of the residents are retirees, there’s plenty of people with too much time on their hands running around and ensuring conformity. The larger developments of this type have ‘care centers’ for those who can no longer live an ‘active life style’ where those who might remind the healthy residents of the inevitability of illness, incapacity, and death can be safely tucked away out of sight.
More popular than these behemoths in most places are independent senior living facilities, usually large apartment buildings with some central services such as dining facilities and recreation rooms. They may also have campuses with independent houses. Again, you’re supposed to be able to live your own life, just as you would in your own condo or house. The community may offer services such as housekeeping or meals for additional fees. You generally must be able to care for yourself (independent in your ADLs (activities of daily living) as we say in the biz) and have ways to maintain your IADLs (instrumental activities of daily living – the big four are meals, wheels, bills, and pills). Senior living isn’t cheap (usually 2500 to 4000 a month depending on the amenities) and is not paid for by Medicare or other health insurance as it is not medical care. There are some facilities that are run by charitable institutions for certain social groups and there are buildings which offer submarket rents to low income seniors through federal subsidies known as Section 8. Some states also allow for senior boarding homes or board and care homes which can function in this way on a much smaller scale. Regulation is left up to each state with different licensure, inspection and support programs. In some states, Medicaid dollars can be used for this sort of support, but not in Alabama.
The next step up (or down) is Assisted Living. This is for individuals who have difficulty maintaining their own bodies without assistance. (Their ADLs are compromised – the usual one being that they need help to bathe or shower safely). Assisted Livings are not that different from Independent Senior Living facilities architecturally and often both sorts of facility are housed in the same building or community on different floors or in different wings. In some communities, services, can be adjusted without someone having to move to a different unit. In general, to qualify for assisted living, you need to have no needs that would require a skilled nurse (such as a catheter), enough wits to know your medications (as they generally don’t have a nurse to dispense), and enough physical ability to exit the building with the assistance of no more than one other person. Again, this is not paid for by Medicare or health insurance, is more expensive than senior living, but can be covered by long term care insurance, if you’re lucky enough to have purchased it. As it has proven actuarially unsound, it’s difficult to find these days.
Similar to assisted living, is dementia living for those who are still physically active but who have lost their cognitive abilities. These facilities are licensed to keep the doors locked and to prevent residents from leaving against their will for their own protection. (In regular assisted living, you can walk out anytime you want – the facility may have rules but it’s not a jail). They also must take custody of medication to prevent misuse or errors. Again, it’s even more expensive than regular assisted living and, again, is not paid for by Medicare or medical insurance.
What we tend to think of as a nursing home (although all of these places might be considered such) is the skilled nursing facility or SNF. These are tightly regulated by both federal authorities (as Medicare dollars are spent here) and by states (as they are a major cost center for Medicaid dollars). They are designed for people who cannot care for themselves (in general missing multiple ADLs) or who have complex medical care needs such as indwelling catheters, feeding tubes, or major wounds requiring dressings and treatments. They, in general, offer three kinds of stays. Acute rehabilitation (such as after a serious accident or stroke). For this, a person must have the stamina for four or five hours a day of physical and other therapy and is generally reserved for younger people with a good chance of recovery. This is covered, to a certain extent, by health insurance with various terms and conditions. Subacute rehabilitation, which has far less intensive therapy and is the most usual kind of short term stay for an older person following a hospitalization for a serious illness or injury. It is a Medicare benefit which can be accessed as long as there has been a hospitalization of three days duration (defined as being admitted over three midnights) and generally lasts for up to twenty days. (It can be extended beyond if additional rehab will be helpful and the patient is willing to pay additional copays up to a total of 100 days). Lastly, custodial care, admission without plan for discharge. This is not paid for by Medicare. It can be covered by Medicaid if you are impoverished but most states are looking for ways to recoup those costs from families. SNF care is quite expensive (generally more than 6000 a month) and a good argument for long term care insurance as the average stay in a SNF for someone admitted for custodial care is four and a half years. People in these facilities are required to have medical care and evaluation on a monthly basis.
Lastly, there is Long Term Acute Care (LTAC). These are specialized hospitals for those who are critically ill but medically stable (think long term coma or ventilator patients). You never want to see the inside of one. Again, there may be some insurance coverage as it’s considered ‘medical’ in nature.
Most people think of these places as being populated by nurses. They’re not. As there has been a move away from not for profit to for profit in this sector as in every other, there has been more and more consolidation in the industry and most senior living facilities of whatever stripe are now owned by for profit corporations whose eye is on the bottom line, not on the comfort or needs of the residents. The average facility usually has an RN on duty day shift whose job it is to complete the paperwork that only an RN can do under federal and state regulations. Below them there will be a couple of LPNs whose job is mainly medications and more complex care such as catheter care. The fast majority of care is provided by CNAs, certified nursing assistants, who generally have a twelve week course in the basics to obtain their certification. They have traditionally been paid not much more than minimum wage.
The pandemic has upset this model. The women (they’re nearly all women) who generally filled the CNA jobs are no longer taking them. In some cases, they are finding easier jobs at higher wages. In others, they’ve been called back home to take care of children or elders due to changes in family structure due to the death or disability of a prior caregiver. We used to import a lot of women for these jobs through immigration but anti-immigrant sentiment has cut that way down. Whatever the reason, 98.5% of senior facilities in this country are currently short staffed just as the Baby Boom is beginning to age to the point where they will need them. This is obviously unsustainable. There’s going to be a major disruption in senior living, sooner rather than later. I have no idea what form it’s going to take but I expect that in another twenty years when I will need to consider such a facility, they won’t look like the ones of today.
Life, The Universe, and Everything 