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No Room For The Aging

As The Number Of Senior Citizens In Puerto Rico Grows, The Number Of Housing And Care Options Is Shrinking. Nearly 20% Of Our Population Will Soon Be 65 Or Older. How Will We Care For Them?


July 3, 2003
Copyright © 2003 CARIBBEAN BUSINESS. All Rights Reserved.

Twilight of the boomer: The graying of Puerto Rico will strain facilities and services for the elderly

The U.S. Census Bureau estimates that by 2025, more than 20% of the population in Puerto Rico, or 852,244 people, will be 65 years of age or older.

Is the island prepared to attend to this population? Are there enough housing options for the elderly? Opinions differ, but one thing is certain: There aren’t enough independent- or assisted-living housing developments on the island.

"Our society continues to get older as life expectancy increases," said Tomasa Crispin, owner of nursing home Crispin Country Home Care Inc. in Carolina. "The way things are going now, though, we won’t have the resources to face these challenges. The elderly population isn’t being taken into account, and it doesn’t look as if there’s any interest in finding solutions."

A former secretary of the Puerto Rico Health Department who wished to remain anonymous echoed Crispin’s concerns. "I’ll tell you one thing, we don’t have the necessary [nursing home] facilities to take care of the elderly," he said. In fact, some nursing homes have extensive waiting lists of more than 30 people.

Other local government officials and managers of nursing homes, however, said there are enough nursing homes, with many more receiving permission to operate.

No one argues that there are enough independent- and assisted-living housing projects, though the government seems to be addressing the deficiency. "The government is working to develop more independent- and assisted-living projects, especially outside of the metropolitan area," said Rossana Lopez Leon, director of the Governor’s Office of Elderly Affairs (Ogave by its Spanish acronym).

Health Secretary Johnny Rullan told CARIBBEAN BUSINESS his department will open elderly affairs centers around the island. The centers will provide health and housing assistance and coordinate leisure activities for the elderly.

Types of housing for the elderly

Puerto Rico has various housing options for its 425,137 seniors, and each is different. Ogave says there are 9,573 seniors in 631 nursing homes and some 7,875 in 83 independent-living facilities. More than 400,000, however, live alone or with their family.

The first housing for the elderly is often the independent-living facility, known in Spanish as egida. It is designed for seniors who can still take care of themselves. Next is assisted-living housing, which is meant for those who need help to perform some chores and require moderate supervision. This is a new concept in Puerto Rico. Then there are nursing homes, which are for those who depend on others to take a bath, eat, take medicine, and other tasks.

There is a new trend in elderly care. Many families in Puerto Rico are opting for home care, whereby a nurse spends about 20 hours each week rendering assistance in a senior’s own home.

Having these options is all well and good, but paying for them is difficult for many seniors and their families. In 1990, 56% of the elderly in Puerto Rico lived below the poverty level, with an average annual income of only $5,477. The percentage dropped to 44% in 2000, said Ogave’s Lopez Leon.

Their families weren’t much better off. The U.S. Census Bureau reported that in 2000, the median household annual income in Puerto Rico was $14,412. It estimated that in 1999, more than 44% of local households lived below the poverty level.

Not enough independent- and assisted-living projects

Ogave says there are currently 83 independent-living facilities in Puerto Rico. That might seem a lot, until one considers that 29 of the island’s 78 municipalities didn’t have any sort of independent-living facility in 2000.

Assisted-living housing projects, for seniors who need help performing daily tasks, are new on the island. Some local hospitals, such Ryder Memorial Hospital in Humacao, are pioneering this area of elderly care.

Naida Alvarez, public relations director at Ryder, said that seniors from all over the island come to the hospital’s independent- and assisted-living facilities because their own municipalities lack such housing. "There really aren’t enough independent- and assisted-living projects on the island, particularly in rural areas," she said. "Here, we have people from Morovis, the San Juan metro area, Aibonito, Coamo, and Arecibo."

To address this paucity, Ogave and the Family Department are working with the U.S. Department of Housing & Urban Development (HUD) to help local developers obtain federal funding for independent-living housing projects. "So far this year, the Family Department has inaugurated four independent-living facilities in the western part of the island, in municipalities such as San German, Aguadilla, and Rincon, thanks to these efforts," said Lopez Leon.

She added that the government’s goal is to have as many assisted-care facilities as there are independent-living facilities. "This way we can ensure a continuation of services to the elderly who can no longer live independently," she said.

Lopez Leon said more assisted-care facilities are also needed to keep semi-independent seniors from nursing homes, where they "can become depressed and end up bedridden," she said. "We have to make sure we place the elderly in their ideal environment."

Approximately 270 people currently live in Ryder’s five housing projects, which include assisted-care and independent-living quarters. Of those, 238 are over age 62 and the rest are disabled people over 18, said Maria de Angel Bartolome, who oversees all of Ryder’s housing projects.

She noted that two more projects will be inaugurated soon, one for assisted care and the other for independent living. Ryder received a HUD grant of $20 million to construct the housing.

"The first one will have 20 living units and is currently known as Ryder Assisted Care III, but we are trying to change the name to Colina Ryder," said Bartolome. The second will have 41 living units and is known as Ryder Village II, though the hospital wants to rename it Alturas Ryder.

Bartolome said Ryder Village II will be exclusively for seniors who are still independent and don’t require constant monitoring. "Still, if they should need medical help, they will benefit from living right on the hospital’s premises."

The elderly living in the new projects will pay rent according to their income. "Normally they would pay only 30% of their income, after medical expenses are deducted," said Bartolome. Although Medicare doesn’t directly pay development or operating costs or rents for senior housing, it often covers health-related services such as transportation and home healthcare.

Nursing homes getting a bad rap

Lopez Leon said only 2% or 3% of the 425,137 elderly in Puerto Rico live in nursing homes, compared with 7% or 8% stateside. She attributed the disparity to cultural differences and a negative image of nursing homes that is partly deserved.

Negative stereotypes about nursing homes, particularly that seniors are often mistreated or abused, are part of the reason many families decide to keep their elderly at home.

"Abuse does exist, but the truth is that the biggest perpetrators are the children and grandchildren of the victims [not the staff of a nursing home]," said Lopez Leon. "They don’t necessarily do it on purpose. It’s a result of not knowing how to care for the elderly."

She noted, however, that cases of elderly abuse in Puerto Rico have decreased. "In 2001, there were 3,139 cases of abuse reported; last year there were 2,446," she said.

Of the complaints lodged against nursing homes, most are related to security or hygiene. The next most frequent complaint is improper supervision, followed by inappropriate diets. Sources in local nursing homes point out that many of the complaints are made against unlicensed facilities, of which the Family Department says there were 102 in May 2003.

Lopez Leon said Ogave hopes to continue reducing the instances of abuse through new education and mediation programs. "We have a program through which we teach family members how to care for the elderly at home in a way that doesn’t burn them out," she said. "Burnout is what often leads to abuse."

Ogave offers conferences and clinics on these techniques in communities throughout the island. Its mediation system, meanwhile, aims to get the elderly and their family members to communicate and the family to assume responsibility for the elderly, given that many cases of elderly abuse are the result of negligence on the part of family members.

Some owners of local nursing homes told CARIBBEAN BUSINESS their institutions have helped many seniors stave off loneliness, which can turn into depression. "I have received elderly patients who were on the brink of death, but we began talking to them and keeping them company and they quickly got well," said Nancy Castro, owner of Gardenville Nursing Home in Guaynabo. "Many families are so busy that they don’t have time to spend with their elderly."

Another way the government intends to improve the quality of care at local nursing homes is by establishing stricter regulations. Pablo Ortiz, the Family Department’s licensing director, said the agency is considering amending Rule 4701 of 1992, known as the Elderly Care Establishment Rule.

Rule 4701 requires nursing homes with more than 10 patients to hire a nutritionist and those with more than 50 patients to hire a social worker as well. The new rule under consideration would require nursing homes with seven to 20 patients to hire a nutritionist and those with 21 to 49 patients also to hire a recreation officer and a social worker. Homes with more than 50 patients would also need to have a kitchen assistant.

Lopez Leon said that the government is keeping pace with the number of nursing homes required by the elderly population. Cecilio Cabrera, president of the Nursing Home Association of Puerto Rico, said, "The Family Department is constantly licensing new nursing homes as the demand increases. There are nursing homes opening every month." He added that the Family Department encourages the development of nursing homes by offering counseling to interested parties.

Rents at local nursing homes fluctuate between $800 and $1,500 per month, but they can go even higher at the best facilities. Yet the only government assistance comes from the Family Department, and it is only for indigent patients.

"The financial assistance from the Family Department in many cases is complementary, and may not cover all the monthly fees for a nursing home," said Ortiz. Other sources said the monthly assistance is between $500 and $700. To make matters worse, Medicare doesn’t pay for nursing-home services in Puerto Rico or stateside.

Families prefer long-term home care

According to a study conducted in May and June by Caregivers of Puerto Rico, which provides long-term home care, 82% of the 100 respondents said they would prefer that elderly family members receive home care than be sent to a nursing home.

The problem is that long-term home care is even more expensive than a nursing home. "We offer our services 20 hours a week, instead of the 24 hours a day nursing homes do, and we charge an average of $198 a week," said Caregivers President Glenn Patron. "It may seem cheaper, but do the math and you realize this service is much more expensive than a nursing home. However, it does allow families to keep their elderly with them."

Heartbeat Group, owned by Jose Rodriguez, offers "service 24 hours a day if the client should need it." Patron also noted that there are only four companies on the island providing long-term home care, an almost negligible number compared with the number of nursing homes.

Medicare sources said the plan does cover homecare services in Puerto Rico if ordered by a physician and if the elderly patient is homebound and needs part-time skilled nursing, physical therapy, speech pathology services, or continued occupational therapy.

Patron and Rodriguez said that while Medicare does pay for some medical services, it doesn’t pay for a nurse’s visit. "For example, if the elderly person only needs someone to help him take his medicine and cook his meals, Medicare won’t cover that," said Rodriguez.

There are other resources, however. Sandra Perez, president of Good Care, said the local Family Department helps indigent seniors pay for home care. Also, the U.S. Department of Veterans Affairs assists elderly veterans in the same manner.

Will be able to afford elderly care?

The Family Department and other government agencies may provide financial assistance to the indigent, but what about middle-class families?

The answer could lie with the insurance industry, said Patron. There are currently only two local companies offering insurance for long-term care, which covers stays at nursing homes and long-term home care (though the insurance isn’t only for seniors). These are Mutual of Omaha and Mass Mutual Financial Group.

Mutual of Omaha has seen sales of this policy jump 35% in one year, according to District Manager Jaime Estrada. Mass Mutual agent Iraida Davila said her company is offering seminars and workshops to inform locals about the insurance product and how it can help them cope with the financial burdens that come with aging and living on their own.

"We are evaluating offering this type of policy, but it is an expensive product," said Medical Card Systems President Carlos Muñoz.

Meanwhile, countries such as The Netherlands require adult citizens to put 10% of their yearly wages (up to approximately $3,200) toward their future care needs, according to a report by the BBC.

Research for this story was excerpted from an Eli Lilly Health Fellowship study sponsored by the Overseas Press Club of Puerto Rico.

Nursing homes getting a bad rap

Lopez Leon said only 2% or 3% of the 425,137

Puerto Rico’s Projected Elderly Population

2003 to 2050

Year: Age 0-59 / Age 60+

2003: 3,242,587 / 636,092 (16.4%)

2004: 3,243,479 / 654,481 (16.8%)

2005: 3,242,210 / 674,422 (17.2%)

2010: 3,210,634 / 790,143 (19.7%)

2020: 3,100,174 / 1,008,876 (24.6%)

2030: 2,908,183 / 1,205,575 (29.3%)

2040: 2,659,567 / 1,349,727 (33.7%)

2050: 2,396,934 / 1,419,837 (37.2%)

Source: U.S. Census Bureau, International Database, and the P.R. Elderly Affairs Office

Profile of P.R.’s Elderly Population

Percentage of elderly living below poverty level as of 2000: 44%*

Unemployment rate as of 2001: 88.7%**

*Population age 65+

**Population age 60+

Source: P.R. Elderly Affairs Office

Average annual income of population

Age 65+ as of 2000

$6,334 Men

$5,581 Women

Source: P.R. Elderly Affairs Office

This Caribbean Business article appears courtesy of Casiano Communications.
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