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A guest blog post by Brian Mailliard, CFO of St. Paul’s Senior Living Community

What does a community do with a prospective resident that is nursing home-eligible, does not need 24-hour care and yet can’t live independently? Up until now, the answer in western Pennsylvania has primarily been “personal care.” Unfortunately, Pennsylvania has many older adults who primarily live off of social security. These seniors do not have the assets to pay for personal care.

The problem is especially severe in rural western Pennsylvania. Here, the main industries of farming and manufacturing have taken a hard hit over the last 20 years. To make matters worse, affordable housing options for older adults are few and far between.

The good news is that, in the last five years, an alternative housing model has appeared. Share Care houses have been opening up in western Pennsylvania. This new housing bridges the gap for those with a low asset base who need assistance with activities of daily living.

A Neighborhood Solution

For-profit and nonprofit companies have been purchasing three-bedroom ranch homes in the community outside of their traditional campuses. The companies make small renovations, such as wheelchair ramps, wider doors and accessible bathrooms, to accommodate three residents. The residents utilize the Medicaid Home and Community-based Services waiver program,  plus their social security, to cover the cost of care. Once the home has three residents, the community can typically recoup the cost of the real estate purchase, plus renovations, in a 4–5-year time frame. At this point, the model becomes profitable. Since there are not more than three residents receiving services under the same roof, this model does not fall under personal care regulations.

The waiver will pay for an individual to get up to eight hours of assistance per day in a home in the community. Housing three residents, each optioned for eight hours of care per day, under one roof allows a company to have a care partner in the home 24 hours per day, seven days per week. Staffing is provided though a company’s home and community-based service providers, which now have the ability to offer staff the set schedules that are typically offered in home care. What I have found is that, in these small homes in the community, the staff and residents become their own little family. They grow close by doing activities together, such as shopping and cooking.

New Share Care Homes Opening

St. Paul’s Senior Living Community has opened two of these Share Care houses in the last six months. Wesbury United Methodist Community in Meadville, Pennsylvania, is also involved in Share Care. In addition to providing care at its campus, Wesbury owns and operates eight Share Care homes in the Meadville area. I have toured two of these homes. I’ve also met with Wesbury’s chief financial officer to discuss the community’s successes and struggles with Share Care.

Wesbury identified the need for a level of care for lower-income individuals that are not nursing home-appropriate. It first heard about the Share Care model from a local home care agency that operated a home. The Share Care homes are contributing to the entity’s bottom line and are operating at a profit. The impact on the outside community has also been very positive for Wesbury, with residents and staff getting involved in the greater communities in which the houses are located. That community involvement is something I plan to take back to promote at the Share Care homes within my organization.

Lessons Learned About Share Care 

Wesbury learned early on that, when making renovations, it is best to keep the house looking just like any other in the neighborhood. This way, neighbors do not get a sense that an outside organization is coming in and changing their neighborhood. One of the ways in which Wesbury combats this stigma is by putting the wheelchair access ramp inside the garage. That means the ramp is out of sight when people are driving through the neighborhood.

We have opened two of these homes in the last six months, and we are filling our second one with residents now. During this process, it has become obvious that, with any fewer than three residents, the costs outweigh the revenue. Because of this, filling the home has become a priority. When I asked Wesbury how it combats the cost of census turnover in its homes, I received a simple answer. Currently, they said, the only way to absorb the cost is by scale. The more houses you have to spread the costs of census turnover across, the better the model performs financially.

The Top Challenge Communities Face

What’s the number one struggle that Wesbury — and now St. Paul’s — has with this care model? It’s getting people approved for the waiver. Individuals who apply for the waiver wait, on average, six months for approval to be finalized. And, unlike the Medicaid benefit for the nursing home, there is no presumption of eligibility with the Home and Community-based Services Waiver. This means that someone in need of services cannot start receiving them until final approval is given.

As leaders in our communities, we have the ability to effect change. Organizations like ours and LeadingAge PA can advocate for change to the approval process for the waiver. Additionally, organizations such as mine that are just starting to offer Share Care can work with experienced organizations, like Wesbury, to learn how to navigate the current approval process. Share Care has proven that it can be an effective care model for low-income individuals who need help to live on their own. We just need to work together to make it easier to implement.

At the 2019 LeadingAge Tennessee Conference and EXPO, an entire audience of people sat together quietly, eyes closed, remembering how they felt on the first day of school.

After several minutes, the presenter had them open their eyes and share their feelings. Emotions ranged from fear and excitement to nervousness and anxiety.

Why did presenter Melissa Ward, PT, MS, RAC-CT, Vice President of Clinical and Regulatory Affairs at Functional Pathways, have the audience do this exercise? She wanted to evoke the emotions students and parents feel on the first day of school, which is very similar to the way residents and their loved ones may feel on their first day in a retirement community.

Trying to find your way around an unfamiliar place can be a tremendous adjustment, and the move can be just as stressful for families leaving their loved ones. But there are ways to help the transition go more smoothly, like the techniques described in this recent article in McKnight’s Senior Living. And now, new residents and their families have another powerful resource to draw on: a unique program developed by the Functional Pathways team.

According to Ward, the Transition Concierge Program began as a “what-if” idea about two years ago. “A client community was  struggling with having residents successfully age in place,” Ward said. “New residents came in and weren’t engaged in community life. They weren’t taking advantage of everything available on the campus. This issue was leading to increased risk for falls and residents requiring higher levels of care.”

That’s when the Functional Pathways Team, led by Beth Reigart, Clinical Outcomes Specialist, decided to create the new Transition Concierge Program. This collaborative approach brings together a powerful arsenal of tools, including social services, nursing, therapy, activities, wellness, resident programming, resident support groups, resources for the family, on-campus physician services and more. By making the transition smoother, the program helps residents successfully age in place.

How the Transition Concierge Program Works

When the resident moves in, a Navigation Team conducts in-depth standardized assessments. Then, an Interdisciplinary Team creates a plan of individualized support. Every element is geared toward giving the individual input into his or her own life.

Here are a couple of examples: If a resident has breathing problems, he or she may need a plan that addresses limitations in endurance to make it possible to get to the bistro. If a resident has low vision, apartment modifications or a plan to get and read mail may be needed. Every resident adjusts to resident living at a different rate, according to Ward. The program was designed to provide services and support that fit each individual’s unique needs.

More Than Just a Real Estate Transaction

The Functional Pathways team believes that moving into an independent living community should be “more than just a real estate transaction.” It’s fostering a true continuum of care through this innovative service.

New residents may still face those first-day-of-school jitters. Fortunately, this innovative collaboration helps ease the transition so they can find passion and purpose in their new environment.

How is your community helping resident transitions go more smoothly? Let me know at . I’d love to feature your strategies in an upcoming blog post.



Eaton Senior Communities is home to 164 residents and, occasionally, a socially assistive robot called Ryan, now being developed at the University of Denver. In a series of posts, I’m talking to people involved in this fascinating project and getting their perspectives on how this lifelike “companionbot” could benefit seniors living with depression and dementia.

Today, Sarah Schoeder, wellness director at Eaton Senior Communities, shares some of her favorite stories about resident interactions with Ryan.

DW’s Story: Reengaging in the Community

DW struggled with depression after the loss of his wife earlier this year. We no longer saw him smile, and he had begun to isolate, no longer taking meals in our dining room or attending holiday parties. At 93, he had limited access to technology in his lifetime — and certainly not to a robot! What transpired was the old DW returning to us. He smiled and laughed again and was always on time, never missing a session. His daughter was thrilled that her dad was once again engaging in the community, and it lessened the stress she felt when she was away on business. DW will tell you that it “was fun” and that “Ryan helped take my mind off the constant thoughts of my wife. It gave my mind a new direction, you might say,” he said. He felt valued, helping the interns achieve their goals and receiving the opportunity to engage with younger adults.

LW’s Story: Overcoming Depression

LW was another unexpected success. As a younger resident with a higher level of education, I was not sure what to expect. She surprised me when she said that “Ryan understands me; she knows what I am going to say before I do.” LW struggled with depression that was intensified by her recent move to the community. Over the course of the trials, she began to report that moving here had improved her mood, and she looked forward to her sessions with Ryan. She is anxious to further participate in clinical trials and recognizes that Ryan helped her overcome the deep depression she felt earlier this year. I am happy to say that she is now an active community member, participating in many social events and helping her neighbor regain her love of art.

PN’s Story: Making a Friend

PN was thrilled when invited to participate with Ryan. He frequently commented on how beautiful her smile and facial features were. He recalls how he asked her out to dinner, but she declined, saying she was not hungry! PN commented on the variations in facial expressions and quality of speech. He was aware of these features and how it affected his relationship with her. PN looked forward to his interaction with Ryan, and the excitement that followed after his sessions was priceless!

BC’s Story: Seeing His Dream Come True

This resident had studied psychology in the 1950s and had particularly enjoyed the area of artificial intelligence. In his 90s, and highly educated, BC enjoyed seeing the “future” that, years earlier, he could only dream of. After his sessions, he would smile and talk at length about the interactions. It was great to see his mind stimulated and the smile he was well known for return when his health was failing him.

See Ryan from her inventor’s perspective in another blog.



This article is the second in a three-part series, offering a fresh perspective on a topic that aging services providers often overlook older adults experiencing homelessness. For this series, we are interviewing Brother Damien Joseph of the Society of St. Francis. Damien works with people experiencing homelessness in California and offers some incredible insights.  

You can read the first article here.

There will be one more post in this series, so make sure to stop back next week as we complete the interview.

Many people think of the homeless as younger, or even middle-aged. From your experience, how many people experiencing homelessness are age 55+? What struggles might they face that the younger homeless population doesn’t?

Your point is well made. In most reports I’ve looked at, “young” is defined as under 25 or thereabouts. HUD reports to congress seem to use this division. The category of homeless seniors is often left out, but the older homeless population is growing alarmingly fast.

In my personal contact with individuals living directly on the streets, I am alarmed both by how many very young homeless there are and by how many older homeless there are. Increasing income disparity, cultural changes, individual social and moral attitudes and a deeply flawed social safety net are among many factors contributing to the fact that no age group is safe from homelessness.

The unique struggles for older homeless individuals are many. Many do use an age well below 55 or 65 to define “older” among individuals who experience homelessness, because the toll it takes on a person physically and emotionally is devastating and certainly reduces life expectancy. I’m often surprised when a person who has been unhoused for an extended period tells me his or her age. That “little old homeless man” you see wandering around your town may turn out to be 50, not 70!

I know that, even in middle age, I find that a night away with a lousy mattress is taxing. Imagine, as a senior, how uncomfortable it is, sleeping on hard surfaces like the ground, concrete, cots or metal shelter bunks! Plus, many are sleeping exposed to the elements. Even in shelters, temperature controls can be unpredictable, and leaks and dampness abound.

The “street” population explodes in numbers every day around 7 or 8 a.m. That’s the time that many, if not most shelters require most of their residents to leave for the day, returning again in the evening. During those daylight hours, folks will have to deal with whatever temperature, weather and air quality issues there are. Escape from the sun, heat, rain and so on may be possible, or individuals may be continually “moved along” by business owners and police who don’t want to see them hanging around. Many cities have been actively removing public seating areas, or at least designing them to make lying down impossible. In some cities, including in San Francisco, it is illegal to sit down or set down your property on a public sidewalk. In order to comply with this law, an individual would literally have to remain on the move, carrying all of his or her possessions all day long. Businesses increasingly install what activists call “violent architecture” or “anti-homeless measures,” placing raised or jagged structures on flat surfaces to prevent them from being used to rest.

Finally, we must address the lack of access to appropriate health care and medical treatment. While this affects all people experiencing homelessness, the older population is clearly hit hardest. Most are uninsured or underinsured. State/federal program coverage generally gives them access to care, but certainly not the best available care. Elderly individuals without stable housing may find great difficulty in receiving any medical care requiring privacy, storing medications in need of refrigeration or other special conditions, keeping track of times for dosages and so on. Add to this continual exposure to infection, trash, body fluids, vehicle exhaust, smog and so on, and it’s remarkable that older people in this context can ever be healthy.

Clinics that specially serve this population exist, of course, but the one where I volunteered in San Francisco was continually swamped with demand, had few providers (with high turnover) and lacked access to easy referrals, specialty equipment and procedures that would be readily accessible in a private practice. I performed routine record reviews for patients due for follow-up but often found that they had no phone or address at which to be contacted, or that, in the frequent instability of temporary housing, they had moved, and their Medicare now required them to start over with a new clinic. Consistent care is rare. Many, even the very ill, never seek medical treatment until they end up in an ER. I met an elderly unsheltered man last year who asked for help filling his prescription for an infection on his leg. He pulled up his pant leg to reveal his entire lower leg blackened and necrotic. Had he been a properly insured, or able to pay consumer rate, he would have been instantly hospitalized for so serious an infection. But somewhere, some provider gave him a prescription for some cream and told him to figure out how to pay to fill it. This really drove home the issues with health care for me.

Health care is such an important example of what aging services providers offer. It’s hard to imagine how anyone could survive for long without appropriate care from trained professionals. Assuredly, this is a problem for our whole society one without an easy solution.

We hope you’ll join us next week when we conclude our interview with Damien Joseph and wrap up our discussion on the challenges faced by older adults experiencing homelessness.

Your elderly widower neighbor, Mr. Johnson, has always been a jovial and social member of the community. About a year ago, he had a stroke that took its toll, but after a couple of months, he seemed to bounce back and was living in his home as usual again.

Last month, you noticed a pink slip taped to his door that was warning of his electric being shut off for nonpayment. Come to think of it, you haven’t seen him in a couple of weeks. That’s when you realize that his mailbox is stuffed to the gills and overflowing. You knock on his door, and he comes to greet you, smiling as always.

When you inquire about the slip and the mail, he tells you that his children are handling all of those items for him now, so he’s just leaving them in place until his daughter comes to visit next week. When you ask him if he needs any help around the house, he politely rejects your offer, saying that he has it under control. He points to his cat and remarks how chubby he is getting from being well-fed. He assures you that everything is fine and seems to genuinely appreciate your visit. You walk away from the house, feeling confident that Mr. Johnson is okay. Little do you know, he’s in an abusive situation because of self-neglect.

Elder abuse is a serious topic that aging services organizations have invested millions of dollars in preventing. They’ve trained their staff and volunteers to look for signs of abuse and actively report any issues that may arise. The culture around abuse has changed for the better, and older adults are living longer, happier lives because of it. Yet, there is still one area of elder abuse that we can’t seem to get our hands around: self-neglect.

A 2014 survey conducted by the National Association of Professional Geriatric Care Managers found that self-neglect among seniors was the most common form of non-financial elder abuse/neglect. Everyone knows to look out for signs of physical, sexual and even financial abuse among those they care for, but self-neglect can be a bit harder to spot and is easily written off as a personal or lifestyle choice rather than a form of abuse.

So, when does self-neglect rise to the level of truly being abuse that should be reported by a caregiver? Here are six signs to watch out for, as reported in the study:

  1. A decline in personal hygiene, such as unkempt hair, failure to bathe regularly and inability to keep up with basic grooming habits
  2. Failure to take medication on time and on schedule
  3. Malnutrition or dehydration
  4. Unsanitary living conditions
  5. Inability to meet financial deadlines, such as unpaid bills, shut-off utilities, etc.
  6. Weight loss, especially in light of food insecurity in the home

These signs all seem like they’d be very obvious to an outsider providing care, yet in practice, the signs can be much harder to spot, as the opening story illustrates.

We encourage everyone who is working in the aging services space to always remember to be on the lookout for signs of self-neglect, as they can occur both in the home and in retirement communities.


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