New families for the frail elderly; adult foster care in Franklin County, Mass

Knowing that families are the greatest resource for providing long-term care to the elderly, the Commonwealth of Massachusetts has found a way to create family supports where none or few exist.

Since 1979, the "Adult Family Care" program has placed approximately 400 elders in new families across the state. Over the past six years, the adult foster care effort has grown from one demonstration project to 12 programs serving 75 percent of Massachusetts.

One of these programs is located in rural Franklin County, an area of more than 900 square miles of thinly-populated western Massachusetts towns. Sponsored by the Franklin County Home Care Corporation, which both administers state Home Care services for the elderly and includes the Area Agency on Aging, the program is finding new homes and families for frail elders as an alternative to nursing home placement.

For Leon Lenois, a 67-year-old farmer with severe respiratory difficulties who had previously lived alone, Family Care has meant a new home on a farm owned by Jeff and Ruth Sterling in the town of Leverett. Although the rhythms of farming are familiar, Leon has found that, in other ways, his new environment is quite different. "My life has changed considerably in all ways from where I was," he comments, "because I don't have to sit alone anymore." Mr. Lenois tends 20 chickens, takes part in the daily life of the family, and shares his knowledge of farming with the Sterlings, thus helping them to establish their farm.

For the Sterlings, the rewards are more than monetary. "Leon's presence adds to the feeling that our home is really a base, a center," says Ruth Sterling. "My son Ben missed the benefits of having an older person in his life--until Leon came."

Under the terms of their agreement, the Sterlings receive $17.50 a day for providing Leon with room, board and certain aspects of personal care. Since Leon is receiving Medicaid, the state pays $9.50 towards his daily care, and he pays the remaining $8 a day directly to the Sterlings.

The state also reimburses the program's sponsor, the Franklin County Home Care Corporation, for administrative costs and the salaries of the Family Care program's two staff members--a social worker/manager and a part-time registered nurse

Elders participating in Family Care who do not receive Medicaid pay the full $17.50 a day--a sum considerably less than the daily cost of intermediate-level nursing home care. According to a recent study of adult foster care in Massachusetts conducted by PM Associates of Quincy, Mass., the financial side of Family Care is as attractive as the services side--not only for private pay participants but also for the state Medicaid program. The average daily cost to the state for assisting elders on Medicaid in Family Care is 37 percent lower than it would be to maintain them in a Level III nursing home.

Franklin County's program currently has 11 elders in new families. Although the program receives roughly five new referrals each month, some of them are not appropriate for Family Care. Sometimes, the health problems are too severe. In other cases, the elder and the relatives finally decide on nursing home placement because it's a more familiar concept than Family Care. The staff has found that for some families, it's easier to say that "Mom got sick and we had to put her in a nursing home" than it is to say, "Mom is living with the Joneses down the street." Attitudes, however, are changing and natural families are beginning to view Family Care as a very acceptable alternative to nursing home placement.

Finding willing families has not been an issue--with over 45 homes now on a "ready list" to accept an elder. While some participants require a considerable amount of custodial care, others are quite active. The PM Associates study of the Family Care population revealed that 10 percent of the placements move on to more independent life styles after a recuperative stay in the program.

Although nearly 40 percent of all participants have remained in Family Care for at least one year, the program can also serve to provide short-term respite for natural family caregivers who need residential 24-hour support for an elder in order to get a break from the stress of daily care.

Family Care is also expected to play an increasing role in post-discharge recuperative stays for elders leaving hospitals under the Diagnostic Related Groupings system, which only began in Massachusetts in October of 1985. Franklin County Home Care recently placed three elders with approved families for short-term recuperative stays to regain their strength in order to return to independent living.

When it was first established and caseload levels were low, the Franklin County program was dependent on start-up funds from the state's Executive Office of Elder Affairs (EOEA) and also received support from a private foundation, the Fred Wells Trust. This year, Family Care in Franklin County is expected to meet its operating costs solely with Medicaid and private-pay revenues.

Finding the Right Family

One of the chief roles of the program staff is to function as matchmakers. An elder's medical, psychological and emotional status--as well as any special needs or preferences for a style of home living--is assessed as part of the eligibility determination. The older person must have a doctor's approval to join the program, must be continent, oriented, able to transfer with minimal assistance, and be medication-controlled for all medical and psychological problems. Prospective families are also carefully assessed--for their interest and caregiving capacity as well as the strength of their own family relationships. Finally, the home itself must comply with standards for cleanliness, safety, comfort and accessibility for the elder.

Once the matchmaking starts, a series of short meetings and overnight visits are arranged and monitored by the staff. These meetings allow all parties to "try each other out" to see if the placement feels appropriate. Participants are matched with families for similarities in life style, personal preference and practical needs.

Before the elder stays for any length of time with the new family, the staff uses a brief care plan to teach family members about the elder's medical and social needs. If the elder and family agree to live together, staff arrange and facilitate the move, develop a more extensive care plan, and begin family training. Within three days of the relocation, Family Care staff visit to assess and assist in the adjustment process.

Weekly staff visits follow for six weeks, and then staff visit monthly for the duration of the placement. If the elder has natural family members, the staff encourages them to stay involved and visit often in the new setting, respecting the privacy and schedule of the host family. Family members have access to 24-hour back-up assistance if a medical emergency or other situation arises that requires professional advice.

Less Isolated Lives

For many older people, participation in Family Care brings new social contacts and opportunities for recreation. Florence Alber, a 74-year-old single woman with severe arthritis, had spent her life caring for aging relatives, leaving little time for socializing or getting out to community events.

About a year ago, Miss Alber moved to the home of a couple with the remarkably appropriate name of Dennis and Beverly Welcome in the town of West Deerfield, close to her hometown. Several weeks later, Miss Alber attended the Franklin County Fair for the first time since 1948 where she renewed old acquaintances and surprised herself by winning a stuffed kitty on the midway.

Since then, she has also developed friends at the Elder Day Center which she attends twice a week. The rest of the time, Florence Alber likes to stay busy around the house, folding laundry and drying dishes, as her health permits. Beverly Welcome appreciates Florence's help and, in turn, assists Florence with her personal care.

"She's a member of the family," says Beverly Welcome. "My kids are grown and gone and the house seemed so empty before Florence came--I had no one to do things for. I love being home, so this has worked out great."

As for Miss Alber, she can't imagine living anywhere else. "I guess I've got myself a real family now."

In another town, Emma Elovirta has two 83-year-old women living with her, her husband, and their 6-year-old daughter. "I worked in a nursing home and have always been interested in the elderly," explains Emma. "I feel good about helping people. I want to make sure when I get old that there's a program like this to care for me."

To Betty Sweeley, who was in a nursing home before coming to live with the Elovirta's, "Family Care is wonderful. Beats a nursing home! Here, I'm more independent and can schedule my time the way I choose."

The other new member of the Elovirta household is Edna Bassett, a diabetic with Parkinson's disease who had been hospitalized with a compression fracture of the spine before she came into Family Care. "I had a fear of going into a nursing home," Edna admits. "So I felt 100 percent better knowing that I could go into Family Care... My new family gives me attention and is helping me to get stronger."

Family Care is getting stronger as a community care option in Massachusetts. Still a relatively small program compared to the state's 12-year-old "Home Care" system which provides in-home services to 44,000 elders each month, the Family Care concept enjoys the full support of the Executive Office of Elder Affairs and the Medicaid Division within the state's Department of Public Welfare.

"We're pleased that Family Care has gone so far," comments Richard H. Rowland, Secretary of the Executive Office of Elder Affairs. "We want to see Family Care cover 100 percent of the state. It's part of the continuum of long-term care in Massachusetts."

For further information on the Family Care Program in Massachusetts, write to: Jeanne Dionne, Executive Office of Elder Affairs, 38 Chauncy Street, Boston, Mass. 02111, or to Hazel Croy, Medicaid Division, Department of Public Welfare, 600 Washington St., Boston, Mass. 02111.

Pat Bradford is the Program Manager of Franklin County Home Care Corporation's Family Care project, and Albert Norman is the Executive Director of the Massachusetts Home Care Association.

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