BY: SUSAN MCDONOUGH and NANCY MULVIHILL, MA
Ms. McDonough is vice president, elder services, and Ms. Mulvihill is vice president, corporate communications, Covenant Health Systems, Lexington, MA.
Congregations Have Choices in Deciding How and Where to Provide Care for Aging Members
Today many communities of women and men religious (and dioceses as well) face a major problem: On one hand, an increasing percentage of sisters, brothers, and priests are elderly. On the other hand, the number of members able to provide care for older colleagues is dwindling. In some instances, the caregivers are themselves elderly and, in most cases, conducting the congregation's active ministry.
Over the last five years, a wide range of religious communities have turned to Covenant Health Systems, Lexington, MA, for help in developing eldercare plans for their members. Covenant has created plans for both large and small congregations. Such planning frequently occurs when new leaders take office. Unfortunately, it is also sometimes brought on by a crisis.
Religious communities considering the development of eldercare resources have multiple needs. The needs of women and men religious vary, like those of other elderly people. They include supported housing, assistance with personal care, case management, assistance with medication, and nursing home care, depending on the independence of the individual and the care she or he requires.
It is nearly impossible for even large congregations to add the full array of eldercare services to their existing services, although a few have done so. At some point, members of most religious communities will need to receive care from lay staff, outside agencies (such as the Visiting Nurses Association), or facilities sponsored by other groups. Some congregations with financial resources have transformed their own primary facilities into eldercare institutions, either for aging members or (after some conversion) for religious and lay people alike.
Seven Important Questions
In deciding whether to create eldercare services or to affiliate with a group already possessing such services, a congregation should conduct a thorough planning process. If it chooses the former, it will likely need to make structural changes. Such changes will require familiarity with the eldercare business. Before deciding to develop assisted living or other formalized eldercare setting, the community should answer seven important questions.
Should Local Religious Communities Undertake Eldercare?
Most religious eldercare services will require financial support from their congregations, even when public funds are used to pay for care. Covenant, when approached by representatives of a religious community, generally asks them, "How long can you continue to provide your aging members with care without changing the current process?" If the answer is "only a few years," then we advise the community to begin exploring alternatives now. We also suggest that the community cast its financial projections over a period of at least five years, no matter which option it chooses.
Does the Congregation Itself Have the Necessary Financial Resources? To establish eldercare for its members, a congregation must have a very clear picture of its financial resources and the current cost of care provided. To do this, it should estimate the cost per person per month for each of its members. Some congregations calculate their housing and administration costs on a global basis, rather than according to particular houses, floors, or other units. However, figuring costs globally makes it difficult to determine the expenses the congregation currently incurs in operating an infirmary or in caring for elderly members in other ways. To determine the costs of operation, it may be necessary to itemize expenses or, at a minimum, fully allocate costs.
Where Should the Eldercare Facility Be Located? Many congregations, having spent many years in a particular geographic area, plan, appropriately, to centralize their eldercare in that area. Other congregations, whose members have been scattered throughout the diocese (or the nation) and have ties to many different areas, may need to organize their eldercare in multiple sites. And congregations devoted to missionary work overseas may need to create eldercare facilities in other countries.
Should a Congregation Create Eldercare Services for Its Own Members Alone? If the congregation is planning to establish such services, it should first determine the regulatory requirements involved and the availability of religious exemptions for:
- Zoning
- Certificate of need
- Participation in Medicaid
But if one of the congregation's reasons for developing formally licensed care is to gain access to the additional financial resources afforded by public benefits programs, it should not pursue this option until it first determines whether participation in such programs is possible.
Some states that make such exemptions available (including many in New England) are likely to grant the congregation fewer beds than they allow other organizations.
It should be recognized that a 40-bed nursing home for religious will have operational inefficiencies not found in a 123-bed home that welcomes both religious and nonreligious residents. It is nearly impossible for smaller facilities to pay their own way; most must be subsidized by their congregations. If, for instance, the cost of care per person per day is $110, yet public reimbursement is only $100 per day, then the congregation must make up the difference. Over the course of a year, that $10-per-person-per-day subsidy will cost the congregation $3,650.
On the other hand, public reimbursement can frequently help a congregation stretch its financial resources. Suppose, for example, that a congregation currently paying $100 per day for each elderly member in its infirmary seeks licensure as a nursing home. The licensure requirements may add expense, raising the total in the example above to $110 per member per day. But, assuming that a $100 per day subsidy is available through Medicaid, the cost of care to the congregation will drop to $10. A real benefit thus results from developing a licensed resource and securing public reimbursement. This option does require an ongoing subsidy from the congregations, which must be factored into the decision.
Is the Congregation Willing to Take Lay People into Its Eldercare Facilities?
This is a vital question. Eighty- and 90-year-old religious may not be comfortable sharing space with lay people, especially with those of the opposite sex. The issue should be openly discussed and any concerns addressed. Otherwise, the eldercare facility will be an unpleasant environment for both its religious and lay residents.
If the congregation does decide to share space with lay people, its members must clearly understand that lay people need an environment that incorporates their lifestyle — including extended family visits, activities, a varied food service, and an overall lively atmosphere. Many older adults, feeling isolated at home, move into eldercare facilities because they are looking for company. Elderly religious, hoping to continue to live in a setting that permits peaceful contemplation, may want a quieter atmosphere. Conflicts between these two lifestyles are likely to arise.
Congregation leaders must address several specific questions:
- Where will the religious live: On separate floors? In separate wings? Or integrated with lay people throughout the building?
- Where will community meetings take place? Will a separate space be reserved for the congregation?
- Will liturgy be available to all?
- How many personal items will be accommodated for each resident?
- What types of activities will be provided?
How Much Renovation Will Be Necessary? The congregation will probably have to renovate the planned eldercare building, even if it intends to limit residency to members. Extensive renovation will be necessary if the congregation plans to seek licensure and attract lay people. (The congregation must also determine whether residents can live in the building while renovations are under way.)
If the congregation's leaders plan to develop unlicensed services or care settings without strict physical plant or fire safety requirements, they must, keeping the frailty of older people in mind, address several practical issues:
Staircases If the only route to sleeping quarters is a staircase, planners should consider reconfiguring the building to place bedrooms on the ground level. Failing that, they may want to add a chair lift or a small elevator.
Bathrooms Falls in bathrooms are major problems for older adults, so these facilities must be made safe and easy to use. Raised toilet seats, grab bars, good lighting, seats in the showers, and hand-held showerheads are all vital.
Corridors All corridors should have handrails. Because traveling down a long dark corridor to use the bathroom can be hazardous for older people, planners may want to shorten distances between bedrooms and bathrooms.
General Accessibility To ensure residents' safety in case of fires or other emergencies, accessibility throughout the building is important. Mobility-impaired residents should be able to enter or exit the building without assistance. The chapel and common spaces should be easily accessible and usable for those using a cane, walker, or wheelchair. Outside the building, there should be an accessible space for residents to sit or easily walk around in.
After considering all the factors involved, a congregation may decide that adapting a building for appropriate elder care is too costly. One group was told it would cost about $300,000 to renovate its motherhouse as a licensed eldercare setting for women religious. (Most of the estimated cost involved fire safety issues.) Renovating the building to meet lay market standards would have cost more than $1 million. In some instances, it may be more economical to construct a new building than to renovate an old one. Whether the congregation decides to build or renovate, it should first make sure it understands the financial ramifications involved.
What Kind of Services Will Be Provided? Once it decides to establish eldercare, the congregation must determine how various services will be provided. Congregations seeking a formal license — for assisted living or nursing home care, for instance — can expect strict standards. For congregations choosing to enhance their own services without seeking formal licensure, we offer the following points as a guide:
Personal Care This form of care — especially assistance with bathing and dressing — is a key component of eldercare. Unfortunately, because they are themselves elderly, many religious have difficulty providing such assistance to others. Safety is a concern in such cases. One 80-year-old sister trying to help another with a shower is an accident waiting to happen. Realizing this, many religious communities hire outside lay people or agencies to perform the services.
Activities The congregation should consider hiring a trained recreational therapist to design and provide stimulating activities.
Nutrition The congregation should establish a high-quality, nutritious food service program that, with the assistance of a registered dietitian, recognizes the unique dietary needs of older adults, offers low-fat and low-sodium options, and provides such essential elements as calcium.
Health Care The congregation is likely to face challenges in trying to provide residents with high-quality health care, even if it decides to preserve its infirmary. It should assign a member (or committee of members) responsibility for monitoring scientific and technological developments in eldercare and incorporating new care methods in the group's facility.
For example, most health care providers long ago abolished the use of physical restraints and replaced them with methods that keep the patient safe while preserving his or her dignity. Some religious infirmaries still routinely use restraints, however. Congregations planning eldercare facilities should work hard at developing relationships with organizations that provide this type of knowledge, expertise, and support, thereby ensuring that the facility's residents receive the best, most modern care.
Architecture and Management Similarly, a congregation planning formal eldercare services must ensure that the laws and regulations pertinent to such services are met, if necessary by hiring lay people to do so. This is particularly important if licensure is being pursued. To meet regulatory requirements, the congregation may need to hire a professional architect (especially if it hopes to serve a lay market) and administrators.
Placing Members in Other Settings
Congregations that decide against creating their own eldercare will benefit from a review of religiously sponsored and secular facilities, including both existing facilities and those under development.
One group (for which Covenant provided support) chose to rent an entire floor in a planned assisted-living residence being developed by a private company. The congregation selected a facility that intended to participate in the Medicaid program and would permit qualified women religious to participate as well. The facility's developer, who knew that nearly half of his units would be rented to sisters, was more than willing to create a multipurpose space in which liturgies could be conducted. This space, the developer agreed, would be used for religious services, education programs, and major meetings, but not for activities such as bingo. As it happened, many older Catholic lay women, realizing that they would have the sisters as neighbors, were attracted to the residence as well.
Other congregations may prefer to investigate existing Catholic or other faith-based nursing homes and assisted-living residences, many of which welcome religious in need of care. In their search for these homes, congregations may want to draw up "preferred provider" lists based on information gleaned from Catholic directories, local agencies on aging, and conversations with members of other religious groups.
The congregation should send representatives to visit any such facilities before placing members in them, however. These representatives should inspect the facility's rooms (assessing the value of private rooms versus semiprivate ones, for example), research its regulatory compliance history, and begin to develop a relationship between the facility and the congregation. The congregation should also determine:
- Whether a local or visiting congregational superior will be available to the facility's religious residents
- What type of spiritual support will be available to them
Some elderly religious may fear that the congregation, in placing fellow sisters (or brothers or priests) in an eldercare facility, is abandoning them. To prevent such sentiments from arising the congregation's leaders should:
- Explain why the congregation must seek outside eldercare services
- Explain the circumstances in which a member would be placed in a "preferred provider" eldercare facility
- Review the accommodations and services this facility will provide
- Describe the efforts the congregation will make to maintain its link to the member
The first few placements will likely be very difficult. But once the congregation has identified the facility, and has shown older members that in moving there they will be joining a new religious community, it will begin to receive a positive response.
IMPROVING CARE FOR RETIRED RELIGIOUS AND CLERGY
The transition from independent living to an assisted-living or long-term care facility can be fraught with emotional difficulties. People making this transition often feel a sense of loss — of autonomy, privacy, and a familiar routine.
This transition is no less difficult for elderly religious and clergy than for other people. (Indeed, retired congregation members may feel additional stress if they find themselves in a facility not established solely for the members of their own community.) Trying to adjust to new surroundings and people, adhering to new rules and routines, and experiencing a sense of loss — all this can have a powerful emotional impact.
If, however, the facility's staff members are aware of religious' unique set of needs and concerns, they will be able to address them with understanding and compassion.
Recognize that Spiritual Activities Are Essential
"Spiritual activities are perhaps the most important consideration for elderly religious and clergy who enter an eldercare facility," says Sr. June Ketterer, SGM, provincial superior of the Grey Nuns. "Religious are accustomed to living in community and celebrating certain rituals, including daily prayer. Maintaining a daily spiritual connection is absolutely essential to us."
"Among the activities that can help to maintain that connection are liturgy, planned retreats, and special holiday prayer services," adds Sr. Elizabeth Sullivan, SSJ, administrator of Mont Marie Health/Care Center in Holyoke, MA. "Celebration of congregational events such as the member's anniversary or the congregation's major feast day can also be observed. This information can be obtained from the resident at the time of admission, or from the congregation itself."
Administrators might also consider holding special religious or clergy-only events, such as designated days of prayer, retreats, or meetings to discuss religious life. At Mont Marie, "everything offered is offered to everyone, so that it truly becomes a widespread celebration," says Sr. Sullivan. "This introduces our 'nonreligious' residents to various congregations' missions and helps everyone feel a sense of belonging."
With the help of the Covenant Health Systems management team, the Grey Nuns converted their provincial house in Lexington into an assisted-living residence. Thirty-seven Grey Nuns currently live in the 91-resident facility. "What we may have lost in the singleness of a Grey Nun retirement community, we have made up for by creating a new ministry in which our older sisters can participate," Sr. Ketterer says. "Their mission continues as they befriend new residents. Having experienced a transition themselves, they can knowledgeably say, 'Be patient with yourself — it takes time to adjust.' They have established a 'buddy system' to orient new residents to the routine of assisted living and keep a watchful eye over them. In fact, our sisters won a volunteer-of-the-year award from the Massachusetts Assisted Living Foundation for the implementation of this concept."
The facility's sister residents hold weekly meetings, which help them maintain their sense of community. They also continue to conduct daily liturgies, to which all other residents are invited, and an annual, weeklong retreat.
Recognize the Difference between Solitude and Isolation
"All staff must understand that, for religious and clergy, a quiet, solitary time set aside for prayer and reflection is as essential as breathing," says Sr. Sullivan. "This may be perceived by staff as withdrawal or isolation when, in reality, it is an integral part of the religious person's life."
Staff must be trained to recognize the difference. Solitude — characterized by privacy, silence, and a sense of retreat and quiet — aids contemplation, meditation, reflection, and reading, all of which enhance and enrich spiritual life. Isolation, on the other hand, is characterized by alienation, withdrawal, and loneliness, all of which may result in physical symptoms and depression.
Pain Management and Religious Beliefs
Many religious and clergy have a lifelong pattern of sacrificing themselves for God, for others, and for their communities. Some believe they should suffer silently and offer up suffering and pain to God. In addition, some fear that narcotics used for pain relief can lead to an addiction.
"It can be helpful to talk about the church's position on pain and suffering and about how Jesus does not want people to be in pain," says Sr. Ketterer. "God wants us to be as pain free as possible, especially during the dying process. The standards of the Joint Commission on Accreditation of Healthcare Organizations standards say that pain management is essential in the life of the suffering individual."
Recognize the Need to Continue Ministry Functions
"Some of our resident retired priests have found a new ministry within our assisted-living residence," Says Joanne Parsons, executive director at Youville House Assisted Living Residence, Cambridge, MA. "In a most natural way, they have reached out to our lay residents, offering them the sacraments and spiritual support. Our lay residents, comforted by the knowledge that this type of support is available to them, have in turn been very respectful of our priest residents' need for privacy and time to themselves."
"Depending on their physical well-being and mental acuity, religious and clergy in a nursing home can often extend the capacity of the home's pastoral care department," Sr. Sullivan says. "Many of our sister residents will sit with a dying person (whether lay or religious) and pray the rosary, say the prayers for the dying, or simply be present at this sacred time. Some also serve as greeters to visiting family members, often becoming friends with them as a result. If her health allows it, a sister resident can continue her ministry of caring in many ways. She can be one more person at Mont Marie who can reach out to others while remaining connected herself. Our sisters who are very infirm continue to participate in our ministry of prayer, and some continue to write or sign letters on social justice issues."
Handling Behavioral Issues
Because religious and clergy have enjoyed a great deal of solitude in their lives, noisy, active situations can at times cause them to become agitated or engage in inappropriate behavior. If such should occur, caregivers should first determine whether the behavior is indeed the result of environmental factors, and, if it is, take steps to remedy the situation. This may simply mean allowing the resident to stay in his or her room alone at certain times of the day or to visit the chapel instead of attending a group event.
It is important to remember that religious and clergy are human and may exhibit behavioral problems as the result of chronic illness or dementia. Caregivers should use with them the same approaches they would with any other resident, trying to protect the individual's dignity while also addressing his or her human condition.
"Above all, remember that each of us is a human being with a unique history," adds Sr. Ketterer. "It is not helpful to generalize about the religious. Human nature is the same for all people. Men and women religious experience different choices and changes in their lifetime, and these choices and changes create the persons we meet in their senior years. Because we are religious does not mean we are saints."
Rev. James O'Donohoe, Covenant's ethicist, talks about some of the characteristics he has noted in older priests. "Decreased independence and increased reliance on others is difficult for anybody, but they may be even more of a trial for religious and clergy whose role in life has been to care for others," he says. "Now we find ourselves in need of care and assistance: The roles have been reversed. Perhaps we will need a little preaching — to be told that the value of a person is based not on our potential for productivity but on our status as a person beloved of the Lord.
"When we religious and clergy retire, we can, like many other people, become depressed because we wonder if we still count," Fr. O'Donohoe continues. "We may suffer what some call the 'old priest in the back room' syndrome. For many of us, our sense of self-worth was based entirely on our formal pastoral role. When this role is diminished, our self-respect and sense of identity are also diminished. Caretakers should know these things about us. But they should also realize that, although the aging process is inevitable, we all age as individuals."
Sponsor In-Service Programs
Sr. Ketterer recommends educating nonreligious staff members about residents' congregational backgrounds. "Knowledge of the unique charisms and histories of residents' congregations can only serve to facilitate a better understanding of the resident," she says. "It can be helpful to know, for instance, whether a resident comes from a contemplative order or perhaps one active in education or health care. The more staff learn about the religious life these men and women have led, the better the care they will provide them."
— Susan McDonough and Nancy Mulvihill