by Edwin Quinabo
Senior advocacy groups have been warning of a silver tsunami for decades and a need to prepare for the rising demand in health care and assisted senior living facilities that the massive Baby Boomer and late Baby Boomer generations will require.
That time has come.
According to the U.S. Census Bureau, more than 56 million adults ages 65 and older live in the United States, accounting for about 16.9% of the nation’s population.
In Hawaii, those 65 and over make up about 20% of the state’s population. From 2020 to 2030, the state Department of Business and Economic Development and Tourism estimates this demographic will grow from 19.1% to 22.5%. About 37% of Hawaii’s residents are 50 and older, or just over a half-million people.
Statista 2023 further breaks down Hawaii’s senior demographic as 65 to 74, 11.3%; 75 to 84, 5.9%; and 85 and over, 2.5%. The general rule of thumb is the older a senior is, the need increases for assisted senior care. Statista also provides a near retirement age breakdown: 55 to 59, 6.1%; and 60 to 64, 6.4%.
Statistics suggest that demand for assisted living facilities will only rise especially since Hawaii has the highest life expectancy age in the nation at 81.3. But health care experts say the ratio of potential caregivers to the elderly needing care is projected to decline.
Estrella Avelino, 82, and her husband Rico, 85, live in an assisted living facility (ALF). They have two children who live in California, have a house in Foster Village, Oahu, but rent it out. Their children convinced them to move into an ALF after Rico’s Alzheimer worsened and Estrella couldn’t fully care for Rico.
While Rico requires more attention (what some in the senior care industry refer to as having “self-care difficulty”), Estrella is healthy and is fairly independent as much as a woman of her age can be.
Because they share a private room (often called apartment unit) together and Estrella is able to help look over her husband, this has saved the couple some money because a typical Alzheimer patient alone would require additional care from ALF staff. But a private room is much costlier.
Estrella describes the room as spacious. They have their own bathroom, sitting area with TV, mini kitchen and a large bed they share. They have 24-hour assistance if needed and staff help could be accessed by a call system. They have three meals a day that are available in the cafeteria.
“It’s like living in a hotel. I love it,” Estrella said. “It reminds me of when we used to go to Las Vegas when we were younger. It would be nice if they had slot machines, even if it were only for fun,” she said jokingly.
“But the atmosphere is good because we see lots of other people. It’s not as lonely here than just being alone in the house. You know people our age, we hardly have visitors. Because all of the people our age have either passed away or are too old to drive and get around,” Estrella explained.
Rico doesn’t have much to say. “Sometimes he forgets that he already ate or that he was bathed, I feel secure that we are here because I used to worry when we were alone at the house that Rico would walk away and not remember how to get back home,” Estrella said.
The Avelinos are typical of ALF residents. They enjoy the social environment and feel safe. But people in the business of senior care also say residents typically express a positive attitude, but often find it difficult to accept that they are not healthy enough to be on their own and be fully independent.
But these are the residents who are mentally healthy enough to process their situation. There are others who express or say very little, senior care workers say.
Cultural stigma of ALF
When it was explained to Rico of their new living arrangement in an ALF, Estrella said he understood what that meant and did not want to cooperate with their children’s suggestion. “He was upset, angry. He felt ashamed. Because in our Filipino culture, when old folks are not able to care for themselves, there is this expectation that they would be cared for and live with their children.
“For our generation, going to an assisted care home, there is judgement that your kids don’t love you enough or have enough respect to care for you. That is what Rico was thinking but couldn’t express himself too well. This is how it has always been done in the Philippines. So, we expected the same for us” Estrella said. “There is shame. And for our children, there is guilt, too. But we are here, and we want to make the best of it.” She said there are still people who do not know that they are in an ALF. And that they’d like to keep it that way.
Estrella said the social part of having people around is good for now. “But I’m not sure if my husband were to pass away before me, I would have the same outlook. I think even though there are more people, I would probably feel lonely. I’m not sure.” (Editor’s note: only their real names are withheld from this article.)
High cost of Assisted Living Facility
While the Avelinos have mixed feelings about being in an ALF – happy to be in a social environment and feel safe, but also feeling ashamed to be there because of cultural stigma – they are considered by many to be among the lucky ones their age who can afford quality senior care.
According to AssistedLiving.org that conducted extensive research on 22 ALFs in Hawaii, while long-term care costs in the state vary significantly among the islands, Hawaii’s monthly assisted cost is $5,500, which is $1,500 more than the national average.
That cost does not include personal items such as clothing, prescription drugs, doctor visits and personal hygiene items.
Estrella was shy about saying how much they are paying monthly. Her two children are professionals, she said, “they can afford it.”
The Avelinos’ private room to themselves costs extra, beyond the average $5,500.
The median price of a private room in an ALF exceeds $160,000 a year in Hawaii, according to GensWorth, a long-term care insurance company.
Each nonprivate room in an ALF must be shared with no more than four residents.
The Hawaii couple uses some of their rental money from their house mostly for personal items not provided by the ALF.
Medicare/Medicaid. To supplement seniors’ retirement savings and benefits, financial experts recommend that seniors purchase long-term insurance because Medicare generally will assist with short-term stays in nursing facilities or require that seniors be homebound (unable to physically leave one’s home due to poor health) before providing extra financial assistance.
Medicaid will pay for long-term care at ALFs, but seniors must meet income requirements to qualify. Hawaii’s entitlement program for seniors is called Med Quest Integration. It is funded jointly by the state of Hawaii and federal governments.
What is an Assisted Living Facility?
There are 42 ALFs in Hawaii. The State of Hawaii defines an Assisted Living Facility as a combination of housing, healthcare services and personalized supportive services.
An ALF is different from the other popular senior care assisted living that many Filipinos have their business in, the adult residential care home.
ALFs usually are in a building complex with multiple dwelling units. Many ALF residents have independent lifestyles even as they receive assisted living services. Meals are provided and there is multiple staff.
Adult residential care homes are as the name states, privately owned homes in residential districts with typically one to three staff staggered within a 24-hour period. Residents typically are no more than five in a home.
AssistedLiving.org lists typical services at ALFs:
*Three meals a day served in a common dining area
*Assistance with the activities of daily living
*Access to medical services
*24-hour staffing and security
*Personal laundry service
*Exercise, social and recreational activities
ALFs’ Requirements and Service Plans
A service plan is a contract between the ALF resident and facility that outlines assistance needs, medication schedules, evacuation plans, costs, residents’ rights and responsibilities, and services offered such as housekeeping, personal hygiene care, and health monitoring.
Before a service plan can be drawn up, a new resident must undergo a comprehensive medical examination that will determine the resident’s medical needs.
ALFs have different admission requirements. Some will accept residents requiring complete assistance, but these facilities usually admit fewer residents. Some will only accept residents that need minor assistance. These ALFs tend to have more residents.
ALFs admission requirements are usually dependent on the number of staff and special equipment they have to assist seniors. Grounds for dismissal of a resident could include deteriorating health that the facility’s staff or equipment cannot accommodate.
Residents and their families must comb through the service plan carefully because there are often wide differences among eligibility, requirements and costs. Senior advocacy groups recommend seniors and their families do research to find the most suitable ALF based on services needed and cost that matches their budget.
Lower price doesn’t necessarily mean better care, experts say, which is why going over reviews and ratings should be included in their research.
Nursing homes fall into a different category from ALFs and Adult residential care homes. Nursing homes are generally for seniors that require specialized care with mostly registered nursing staff. Hospice care (for terminally ill patients) falls under the nursing home category.
Teresita Bernales, a senior, lives at home with her husband in Kailua. Like many seniors, she and her husband prefer to stay home as long as possible. “At the moment, I want to age in place as long as I can. I will try to make a realistic decision as I advance in age, that there is a point in one’s life when I have to admit that I am having difficulty living independently. I will try to be objective in making the right choice, by deciding on what I need, finding a location that matches my needs and evaluating the locations using multiple resources. Throughout the journey for my new home that will keep me and my loved ones happy and healthy in the present and years to come. I will seek assisted living arrangements for my husband and I when needed,” she said.
Uncertainty, fear of unknown
Not only is it stressful for family caretakers, but seniors also express deep reservations just thinking about the possibility of moving to an assisted care facility in the future. “Moving comes with both physical and emotional stress because you leave behind a family home full of memories and the comfort and safety of your neighborhood environment. The fear of the unknown is another factor to be considered,” Bernales said.
She mentions the benefits of aging in place like the comfort of home, family, pets, social engagement in the community, cost-effectiveness, and the ability to maintain dignity and independence.
Bernales advocates for preparation. “It is better to prepare early and be ready for a change of lifestyle when the time comes with the help of your loved ones. Fortunately, experienced in-home caregivers are available to optimize the benefits of aging in place.”
Hawaii’s culture of caring for seniors at home
Studies show that seniors who age at home tend to have better health. Asian and Pacific Islander acceptance of multi-generational households alleviates some of the demand for ALFs.
But the financial burdens of senior care don’t escape these households that often require a working adult to give up work to care for a kupuna.
AARP Hawaii estimates there are 157,000 unpaid family caregivers providing about 131 million hours of care a year in Hawaii at a value of $2.1 billion.
For two-income households (not multi-generational), the financial burden is more acute, which has led the state in 2018 to pass the Kupuna Caregivers Program (KCGP) that offers employed Hawaii residents an opportunity to continue working and receive financial assistance from the state to go toward hiring senior care.
Employed women 55 and older is the demographic that commonly takes on the role of home caregiver to a parent(s) or relative, according to AARP Hawaii.
Besides feeling financially strained, home caregivers report high levels of stress over their responsibilities that most received no training for.
ALF is not right for some even if they could afford it
Lita Pulanco, 57, Moanalua, fits AARP’s demographic as those who most frequently take on the role of caregiver. Lita cares for her mother Reyna, 74, who needs help with hygiene care from bathing to brushing her teeth. Lita must cook for her mother as well.
“It’s been getting increasingly difficult,” Lita says, “because my mom’s liver disease is worsening. She suffers from dehydration often and her muscles cramp up. I’ve been spending a lot of time lately massaging the parts of her body where cramping occurs.
“We are also going to the doctors more frequently and preparation to leave the house is additional stress. I need to change her. Load and unload the wheelchair. Just helping my mom go from the passenger’s seat to the wheelchair is nerve-wracking because I’m afraid she might slip from my arms and fall.”
Lita said her family has talked about getting outside help or if ALF is a possibility in the future. But right now, her family decided that an ALF or adult residential care home for Reyna is not best for her.
“We probably will not take that route because my mom is aware of what’s going on, her surrounding, and only trusts me to take care of her. I know my mom would be frightened to be alone and away from me or my family given her health condition.
“I have to endure the stress, but I can do it, because I see in her eyes how much she needs me. Some people can handle an ALF or care home, that is a win-win situation for both the senior and family. But it’s not for everyone like my mom is an example,” Lita said.
Lita used to work in accounting at a top advertising firm in downtown Honolulu. She’s had no experience as a caregiver. Senior advocates say this is typical. When a parent suddenly is diagnosed with a terminal illness, the family member turned caregiver almost overnight is not prepared.
The caregiver needs to handle a dying parent’s finances, pay the bills, do all the errands, grocery shopping, cleaning, driving to doctors appointments, cooking, be a positive health cheerleader, be a spiritual and psychological counselor, be a nurse’s aide, be a pain management expert, administer medicine, and more.
On top of that, the family caregiver has to cope with the emotional stress of losing a loved one.
Lita’s son and daughter have seen firsthand how their mother has cared for their grandmother Reyna. “If there is a silver lining in all the hardship I’m going through, at least I am setting an example for my children. I don’t have the fear of being in a care home like my mom. But if my children would want to care for me at home when that time comes when I’m practically disabled, I’d rather be at home,” Lita said.
She makes a final point that what seniors ultimately want in their golden years is the ability to have options. She said, “we all have different priorities and levels of comfort. What having options does is empower us when we are most powerless.”
by Edwin Quinabo