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BY: GORDON BURNSIDE

System's Long-Term Care Continuum Anticipates Future Needs

Fragmentation is the big problem David Lincoln sees with most current care programs for older people. "I'm not just talking about the fact that elder care providers compete against each other," he says. "I mean that most providers are themselves fragmented, forcing the frail elderly to look to a variety of sources for their healthcare, their preventive care, and their spiritual care."

But Lincoln, who is president and CEO of Lexington, MA-based Covenant Health Systems, Inc. (CHS), says his organization is working to break down these barriers.

"We're building what we call neighborhoods of care,'" he says, "campuses that provide the elderly with acute care, recuperative care, long-term care, preventive care, spiritual care—and all from the same source. We're accomplishing this through sponsorship, partnerships, and management contracts. To do it, we partner with CHS members, with other Catholic providers, and with other not-for-profit, values-based providers. We think we're creating a model for the elder care of the future."

Expanding into Elder Care
CHS was formed in 1983 by the U.S. St. Joseph Province of the Sisters of Charity of Montreal (Grey Nuns). In 1996 CHS became a public juridic person of pontifical right, assuming sponsorship of the Grey Nuns' healthcare organizations in this country. CHS currently sponsors, manages, or has an affiliation with 19 healthcare facilities in New England (see "CHS-Related Healthcare Facilities" at the end of this article).

In 1995 CHS, which had been primarily an acute care provider, decided to expand into elder care. There were three factors in this decision.

Experience The Grey Nuns had traditionally offered services to older people in their acute care facilities, Lincoln points out. "And compared to other regions, New England has a high proportion of senior citizens," adds Susan McDonough, CHS's vice president of elder services. "So our system's acute care institutions were providing a continuum of care' many years before people actually began to use that phrase."

Managed Care "The coming of the managed care revolution was a big factor in our thinking," says McDonough. "We saw that acute care stays were going to get shorter, forcing providers to develop subacute care and postacute care options. We knew that, to compete successfully with other providers, we would have to develop the region's lowest-cost, high-quality settings. That's when we begin to think in terms of neighborhoods of care.'"

Congregations' Changing Needs The Grey Nuns' membership was itself aging, says McDonough. CHS helped the congregation convert its Lexington, MA, provincial house into Youville Place, a 90-unit assisted living facility whose residents include both retired women religious and other elderly members of the community. CHS also aided other New England congregations and dioceses in their efforts to set up care for their aging priests and sisters.

"At first, those were congregations that tended to be active in social service work or teaching, but not in healthcare," says Lincoln. "Sisters in New England now have an average age of 70, but their congregations frequently have little in the way of healthcare or elder care supports. So they ask us to help them create elder care plans for their members. In some of these plans, the congregation develops its own resources; in others, it focuses on strengthening its bonds with other Catholic providers."

CHS also began to get appeals for help from congregations that were healthcare providers, because their members were also aging. Such organizations were preparing for the day when they could no longer operate their institutions. "In some cases, these congregations have delegated governance and operational responsibility to CHS, through the terms of a membership agreement," says McDonough. "In other cases, we sign a contract to manage the facilities."

CHS's Continuum of Care
CHS currently offers a wide range of subacute services in its continuum of elder care.

Subacute Care Patients are typically admitted to subacute facilities following a stay in an acute care hospital. The average length of stay is 15 to 20 days. CHS has subacute care units at Youville Lifecare in Cambridge, MA, and St. Marguerite D'Youville Pavilion in Lewiston, ME.

Long-Term Care CHS offers two types of long-term care:

• Nursing home care. These facilities offer both short-term recuperative care and long-term care for patients who, because they have a chronic disease or are extremely frail, require skilled nursing. These services are provided at Mary Immaculate Nursing/Restorative Center, Inc., Lawrence, MA; St. Joseph Manor, Brockton, MA; Maristhill Nursing Home, Waltham, MA; Sancta Maria Nursing Facility, Cambridge, MA; St. Marguerite D'Youville Pavilion; and Youville Lifecare.
• Residential care. Residential facilities, for frail elderly people who primarily need support and supervision, offer bed and board along with personal assistance and limited nursing care. St. Joseph Residence and Loretto Home, both in Rutland, VT; St. Joseph's Home, Burlington, VT; and Michaud Manor, Derby Line, VT, provide such services. All are managed by CHS.

Assisted Living Residents of assisted living facilities are typically in their eighties. Although capable of independent living, they need certain supportive services. CHS provides them with studio apartments or one-bedroom units and such services as personal assistance, meals and transportation, and limited nursing care. CHS has assisted-living facilities at Youville Place, Youville Lifecare, and Mary Immaculate Residential Communities in Lawrence, MA.

Independent/Congregate Housing In New England, independent living facilities are usually subsidized housing complexes for the elderly and disabled. Residents pay a third of their rent; the U.S. Department of Housing and Urban Development (HUD) pays the remainder. CHS has independent/congregate housing programs at Mary Immaculate Residential Communities and Marcotte Congregate Housing in Lewiston, ME. Although these programs are usually designed for people still capable of independent living, CHS sites also offer services (for example, meals, housekeeping, and supervision) that allow residents to "age in place."

Adult Day Care These programs offer supportive services to frail elderly people who continue to live in their own homes but need a supervised setting during the day. Adult day care programs have been established at Mary Immaculate Residential Communities; St. Joseph Manor; Youville Place; and St. Joseph's Hospital and Trauma Center in Nashua, NH. Several other CHS day care units are planned.

Home Care This has proved to be a relatively inexpensive way of providing care for patients who, without it, would have to be admitted to a hospital or nursing home. Services include skilled nursing, case management, personal assistance, housekeeping support, and therapy. St. Joseph Hospital and Trauma Center has recently merged with a certified home health agency. CHS is currently exploring the development of a systemwide home care and hospice capacity.

Other Services CHS has a geriatric acute care unit at Youville Lifecare and geriatric psychiatry units at St. Joseph's Hospital. The system has also identified compassionate end-of-life care as a high priority, consistent with CHS's mission and the Ethical and Religious Directives for Catholic Health Care Services.

Elder Care of the Future
CHS's twin facilities in Lawrence, MA—Mary Immaculate Nursing/Restorative Center, Inc., and Mary Immaculate Residential Communities—are an example of the "neighborhoods of care" concept, Lincoln and McDonough say.

Mary Immaculate, which is affiliated with Youville Lifecare in nearby Cambridge, MA, has 250 beds for elderly people requiring either recuperative or long-term care (a special unit is reserved for patients with Alzheimer's disease). It also has 304 assisted living units, built with HUD grants and Section 8 housing certificates, for seniors capable of relative independence. Finally, Mary Immaculate offers day care for the elderly, including medically intensive services for those who need them.

Each of CHS's member organizations has a continuum of services essentially like Mary Immaculate's, says McDonough. "In Nashua, NH, our St. Joseph's Hospital, an acute care facility, is affiliated with a non-CHS long-term care provider. Establishing the continuum is the main priority. In some markets there is no Catholic provider, so we look for partners among the local values-based, not-for-profit organizations."

Lincoln notes that CHS faces increasing competition in New England from for-profit care providers. "On one hand, we have to compete," he says. "We have to manage costs efficiently. We have to join purchasing groups so we can get volume discounts. On the other hand, though, we must provide high-quality, mission-based services."

CHS has several advantages over its competitors, Lincoln says. One is its emphasis on continuums of care. "In New England, 13 percent to 14 percent of the elderly—a higher percentage than in other regions—are in Medicare managed care programs. And New England states are now applying for federal waivers for dually eligible (Medicare/Medicaid) managed care. These trends will encourage the formation of programs like ours."

CHS's second advantage, according to Lincoln, is its religious heritage. "We've worked hard to help unaffiliated Catholic providers remain Catholic—through cosponsorships, membership, management contracts, or some other kind of affiliation," he says. "We've done that because we know people want care based in a spiritual tradition, one that recognizes the importance of caring for the whole person."

—Gordon Burnside

• St. Marguerite d'Youville Pavilion, Lewiston, ME (sponsored by CHS)
• St. Mary's Regional Medical Center, Lewiston, ME (sponsored by CHS)
• Marcotte Congregate Housing, Lewiston, ME (sponsored by CHS)
• Youville Lifecare, Inc., Cambridge, MA (sponsored by CHS)
• Mary Immaculate Nursing/Restorative Center, Lawrence, MA (sponsored by CHS)
• Mary Immaculate Residential Communities, Lawrence, MA (sponsored by CHS)
• St. Joseph's Hospital, Nashua, NH (sponsored by CHS)
• Maristhill Nursing Home, Waltham, MA (sponsored by CHS)
• St. Joseph Manor, Brockton, MA (member of CHS)
• St. Joseph Residence, Rutland, VT (managed by CHS)
• St. Joseph's Home, Burlington, VT (managed by CHS)
• Loretto Home, Rutland, VT (managed by CHS)
• Michaud Manor, Derby Line, VT (managed by CHS)
• Bethany Health Care Center, Framingham, MA (managed by CHS)
• Youville Place, Lexington, MA (managed by CHS)
• Youville House, Cambridge, MA (managed by CHS)
• Sancta Maria Nursing Facility, Cambridge, MA (affiliate of CHS)
• Berkeley Retirement Home, Lawrence, MA (managed by CHS on an interim basis)
• Optima Healthcare, Manchester, NH (affiliate of CHS)