|Triangle J Council
Jack Magiera, former Director, Litchford Falls Health and Rehabilitation Center
Michael Boles, Director, Total Life Centers, Resources for Seniors, Inc.
Catherine Goldman, Human Services Senior Practitioner, Wake County Human Services
Barbara Ann Hughes, President, B.A. Hughes & Assoc., Aging Services Committee Chair
Betsy Sykes, Business Development Director, Magnolia Glen Senior Living Community
Linda Lang, Director of MR/MI Services, Wake County Human Services
Tom Ford, Executive Director, Woodland Terrace Senior Living Community
Clarice Faulkner, owner, Serenity Homes
Vanessa Funderburk, Wake County Human Services
Many older adults will face the need for assistance with activities of daily living at some point in the aging process. In
some cases, physical disability will necessitate help with tasks such as meal preparation and housekeeping, or
personal care such as dressing. For others, memory loss or other cognitive disability may require that they have
constant supervision and structure to ensure safety. When these disabilities occur, seniors are faced with difficult
When possible, most seniors prefer to remain in their own homes and take care of their own needs. Their next
preference is for family caregivers to provide assistance, and in fact the majority of care is still provided by family. While
families may be willing, it has become increasingly difficult for family caregivers to meet the needs, as more women
are working outside the home, and more families are dependent on having two incomes. Also, families are
increasingly split geographically, so that caregiving must take place at a distance. When family members are not
available or not able to provide the necessary care, individuals may seek out paid assistance in the home.
The least-favored and most-feared option, for most people, is institutional care in assisted living (adult care home) or
nursing home settings. A relatively new option, which provides a middle ground between independent living and
institutional settings, is the adult day care center where seniors and other disabled adults may receive daytime care in
a group setting.
Existing Resources and Challenges
Wake County has a variety of services available to people who need personal care beyond what can be provided by
family caregivers. Forty-eight agencies offer in-home services ranging from skilled therapies to personal care aides
and homemakers. Ten adult day programs serve those who need care during the day in a group setting. Twenty-nine
assisted living facilities, 27 family care homes, and 16 nursing homes accommodate those who need care in an
institutional setting. As usual, the greatest variety, choice, and quality of care is available to those who have the
financial resources to purchase care privately. This is a situation where the services are present in the community, but
are not accessible to many people because of cost.
In Home Care
There are two broad levels of in-home care needs among seniors. First in the continuum of care is the level at which
the senior begins to have difficulty with tasks such as housecleaning, meal preparation, and grocery shopping,
whether due to physical or mental limitations. Such “homemaker” or “companion” services are available from private
agencies or individual workers at a cost of approximately $10 -15 per hour. There is no public funding currently
available to subsidize these specific services in the absence of higher-level care needs – because of limited
resources, public funding for in-home care is currently prioritized for clients who also have personal care needs.
Clients who cannot afford private duty services can seek volunteer assistance from the Center for Volunteer Caregiving,
but there are not enough volunteers available to meet the need.
At the next level of care, the senior is having difficulty not only with the home-maintenance tasks described above, but
also with personal care needs such as bathing and dressing. There are some publicly-subsidized programs to
provide such care, but they are desperately inadequate.
If the senior qualifies for Medicaid, they are eligible for Personal Care Services (PCS) or the Community Alternatives
Program for Disabled Adults (CAP/DA), depending on their level of care needs. These services allow seniors whose
income is below the poverty level to receive the care they need.
However, if the senior's income is slightly higher, so that they do not qualify for Medicaid, their options are much more
limited. Medicare provides very limited, short-term in-home care under very specific circumstances, but offers virtually
no long-term in-home care. Funding from the Home and Community Care Block Grant (HCCBG) and from Wake
County (Wake Independence at Home) provides services to a limited number of seniors on a voluntary cost-share
basis. However, waiting lists for these services currently exceed two years, due to limited funding.
In practical terms, this means that many seniors have no option but to consider institutional placement, since their
income, while too high for Medicaid, is not even close to sufficient to pay for services out of pocket. Current rates for
private-duty in-home care from home care agencies are averaging $15-17 per hour. For a senior with an income of
$1000 a month, purchasing care equivalent to that offered by the Medicaid PCS program (60 hours per month) would
cost at least $900 a month -- 90% of their total monthly income!
Adult Day Services
Adult day care was identified through the scan and critical issue analysis as a cost-effective component of the
continuum of care, serving as an alternative to institutional care for a growing number of both older adults and adults
with disabilities. Adult day services are able to accommodate adults age 18 and over, accommodate both cognitive
and physical disabilities, offer a required staff to participant ratio of 1:6 for Day Health services, offer complete
personalized care, including assistance with Activities of Daily Living such as toileting, ambulation, eating, etc., offer
skilled nursing level care with an LPN or RN on staff, and offer respite and support to the family caregivers of their
Day services are able to provide both social and health care options to participants and their families and are more
cost-efficient than many other community-based programs and services. Private fees for service range from $35-$55
per day depending upon the level of care, and a variety of public funding sources can also be accepted.
Wake County’s aging population (age 55 and older) is projected to grow by 135% by the year 2020. From October
2002 until October 2003, the Total Life Centers, six certified adult day services sponsored by Resources For Seniors,
Inc., have experienced an increase of 13% in average daily attendance. This was in addition to an 8.5% increase from
FY 2001-2002. At the current rate of growth, the Total Life Centers will be at certified capacity by October of 2006. In
order to continue serving the same percentage of Wake County residents, at least four additional adult day services
must be built, each with a certified capacity of 50, to accommodate the expected growth of seniors in Wake County by
The recent changes in fire, building, and sanitation codes for Adult Day Services, which went into effect in 2002 and
2003, severely restrict opportunities for growth in the adult day service industry. Historically, adult day services in North
Carolina were able to open a new service by sharing space in an existing local church or community building. With the
new codes for fire and sanitation, an adult day service certified with the capacity to maintain growth percentages equal
to Wake County’s need (50) requires a sprinkler system and a commercial grade kitchen. Due to these two
requirements, opening an adult day service in a local church is no longer feasible. The best option to serve the
growing needs in Wake County would be a state-of-the-art purpose-built adult day center.
Long Term Care Facilities
Although many long-term care facilities provide high-quality care, concern about conditions in long-term care facilities
underlies much of seniors’ fear regarding placement. There is a need for greater public involvement and awareness
of long-term care issues, and improvements in communication between facilities and residents and their families.
Funding for long-term care is another major problem. In the institutional setting, the state/county Special Assistance
program helps low-income individuals pay for assisted living care. For those who do not qualify for Special
Assistance, there is no financial help whatsoever available to pay for assisted living care. Since the income cut-off for
Special Assistance (currently $1127.50) is significantly lower than the private-pay cost of care in even the most modest
facilities ($1500-2000), there is a group of people whose only choices are to remain in community settings where they
have insufficient care, or to try to qualify for a higher, nursing home level of care where they can receive Medicaid
benefits. Unnecessary placements in nursing homes not only deprive seniors of the least-restrictive level of care, but
are also an avoidable strain on public finances.
Personal Care Workforce
Quality of care is another serious concern. Much of the direct care in either home or institutional settings is provided by
Certified Nursing Assistants (CNAs). These workers do the physically-demanding and often unpleasant work that is
essential to providing direct care. Though critical to the quality of life of our seniors, their wages are low and they
receive little recognition for the importance of their work. Not surprisingly, there is a high rate of turnover (greater than
100% per year in some settings) in these positions and a constant need for new workers. This turnover is a problem
for both employers and care recipients.