Reflections — Humane Long-Term Care: A "Product" Always in Demand

January-February 2002


Fr. Place is president and chief executive officer, Catholic Health Association, St. Louis. This article is adapted from his November 6, 2001, address to the annual meeting of the American Association of Homes and Services for the Aging in San Diego.

November 2001 marked the 40th anniversary of the founding of the American Association of Homes and Services for the Aging (AAHSA). During a four-day meeting in 1961, 99 far-sighted women and men joined together to create a national organization that would be guided by the highest ideals of care for the oldest members of our society. What a foundation they laid! From a charter membership of 250, AAHSA has grown to comprise more than 5,600 not-for-profit nursing homes, continuing care facilities, retirement communities, assisted living and senior housing facilities, and community service organizations. Each day AAHSA members serve more than 1,000,000 older persons.

As I reflected recently on these 40 years of evolution, I was reminded of my own experiences with institutions that serve the older members of our society. I was raised in Evanston, IL, and have vivid memories of riding my bicycle around the campuses of the Mather Home and the Presbyterian Home there. Both were imposing structures surrounded by sweeping lawns. They conveyed such a strong sense of tranquility that when one later heard adults whispering that Grandma Jones, say, had "gone to the home," it did not seem such a bad thing.

In 1968, when my own grandmother was no longer able to care for my grandfather, my mother and I began looking for a care facility for him. For the first time, I experienced the smells and sounds of poor senior care. Thankfully, we found a quite different place for my grandfather–that same Presbyterian Home of my youth. Later, after I was ordained and began visiting parishioners in various senior facilities, I often left them wondering: Why don't these homes provide the kind of care my grandfather was fortunate enough to receive?

Although that question unfortunately remains appropriate for some long-term care (LTC) institutions, this nation has been blessed to have AAHSA and its members. AAHSA members remain committed to serving those whom many in society would prefer to forget.

Rabbi Abraham Heschel, addressing the White House conference on aging in 1961, remarked that old age should be regarded

not as the age of stagnation but as the age of opportunities for inner growth. The years of old age may enable us to attain the high values we failed to sense, the insights we have missed, and the wisdom we ignored. They are indeed formative years, rich in possibilities to unlearn the follies of a lifetime, to see through inbred self-deceptions, to deepen understanding and compassion, to widen the horizon of honesty, to refine the sense of fairness. 1

Pope John Paul II has noted that "in all cultures old age is synonymous with wisdom and common sense. By their very presence, older people remind everyone . . . that life on earth is a 'parable' with its own beginning and end: to find fulfillment, life must be based on values that are not transient and superficial, but solid and profound."2

AAHSA members share the belief that old age is "an age of opportunity." As I think about the organization, four of its qualities come to mind. I want to say something about each of these qualities here.

AAHSA Has a Values-Based Tradition
The organization's founders spoke in terms of "the social components of care," by which they meant that care cannot be limited to health care alone; it must address the whole person: body, mind, and spirit. Forty years later, this remains a cornerstone AAHSA value, a tradition affirming that:

  • Each person is unique and has inherent dignity.
  • All, as members of society, have rights and responsibilities vis-à-vis each other.
  • Those with means have a responsibility to meet the needs of the poor.
  • The helping process involves an exchange in which all participants benefit — because in helping others, the helper is also served.
  • Each of us has an obligation to be careful stewards of the resources entrusted to us.

These affirmations, along with the other values and beliefs constituting AAHSA's tradition, ring a universal chord in humankind and provide us with a foundation and framework for the good work we do.

AAHSA Has a People-Attentive Perspective

As fee-for-service payment and cost-based reimbursement have been replaced by arrangements that put providers at financial risk, the patient-first/people- attentive ethic is increasingly challenged. This trend has recently been evident in the transition to a prospective payment system for Medicare nursing home patients. When the provider is at risk for a resident's care decisions, who will be the advocate for the person in need? How, in circumstances sure to generate pressure to minimize services or undertreat, can such pressures be balanced?

The best counterweight is a set of people-attentive values, such as those of AASHA and its members. Indeed, AASHA institutions represent the "gold standard" for person-centeredness, beautifully expressed in AAHSA's statement of values: "We identify with the aspirations and concerns of those we serve and those with whom we serve." This is one of the most difficult tasks we face: not to impose our own ideas on those we serve, but to truly understand and help them realize their own desires.

A moving example of this value involved a terminally ill resident at the Community Parkview Care Center in Elwood, IN. The resident's wife visited him daily during the eight months he was at the center. One evening, the resident became extremely ill; he was clearly dying. But it was late in the evening and his wife could not drive after dark. Recognizing the urgency of the situation, an employee of the facility voluntarily drove to their home, picked up the resident's wife, and brought her to the center so that she could be with her husband during his last hours.

This recognition, that our own fulfillment and well being are inextricably bound up in that of those we serve, is an extension of our not-for-profit character. Our AAHSA institutions all have a mission central to their identity. Though they may differ somewhat in the wording of their mission statements, all share the understanding that service is their source, cause, and goal — that service is both means and end.

This commitment to service involves service to the whole person, including his or her spiritual needs — such as that provided at St. Anne Home in Greensburg, PA. Every day St. Anne's women religious and resident chaplain welcome new residents, conduct group and individual spiritual programs, and minister to all residents and their families. They sit holding the hands of terminally ill residents. They attend wake and funeral services, offering their support to family members. Through religious services, group prayer and share gatherings, special holiday programs, personal visits — and in countless other ways — St. Anne's pastoral care staff are present for each resident's spiritual needs.

AAHSA Members Are Community-Grounded
AAHSA's person-centered ethic is complemented by its members' grounding in their communities. We recognize that residents are part of a community and that our institutions are a part as well. We recognize that every community has a host of needs that are unlikely to be addressed by for-profit institutions. We recognize that communities need stability and continuity of services, for example; we know that we must be there for them, in good times and bad.

Doing so requires listening to the community. In Newton, KS, for example, Friendly Acres conducted a utilization assessment and convened community focus groups to determine whether to extensively renovate a number of nursing-home beds and convert them to assisted living. When Friendly Acres told focus group participants how much more the facility would have to charge to cover the renovations, the groups urged it to go ahead with the assisted-living conversions but to hold off on the renovations, so that the new units would be more affordable. Friendly Acres took the groups' advice. The new service, now completed, is one that local seniors both want and can afford.

Another example can be found at Elyria United Methodist Village in Elyria, OH. When that organization found that it needed to move 12 cottages in order to construct a new apartment building, it adopted two strategies aimed at improving housing opportunities in its community. First, Methodist Village donated four of the cottages to the Community Housing Cooperative, a local not-for-profit organization that provides housing to low-income families. Methodist Village then sold the remaining eight cottages for $1 each to anyone wanting the opportunity to be a homeowner. Purchasers had only to provide their own lots and the cost of moving a cottage. As a result, some Elyria families acquired homes that they might not otherwise have been able to afford, the cooperative was able to serve more community members in need, and Methodist Village saved the cost of demolishing the cottages.

The participation of volunteers is another critical aspect of the community-based ethic. As the management expert Peter Drucker has noted, volunteerism in not-for-profit organizations can provide an important counterbalance to family dispersal and dissolution and the fraying of community ties. Volunteers, whether board members or bedside aides, can change lives — and in doing so, as Drucker says, "forge new bonds to community, a new commitment to active citizenship, to social responsibility, to values."3

In AAHSA facilities, volunteerism is a two-way street. For example, Jan Ostraner originally came to the Brandel Care Center at Covenant Village of Northbrook, in Northbrook, IL, to visit her mother, a resident there. After awhile, Ostraner decided to become a volunteer at the facility; today she spends two or three hours a day helping to lead residents' activities. Many other facilities are involved in cooperative programs with local schools. Residents of John Knox Village in Lee's Summit, MO, act as "adopted grandparents" and "lunch buddies" for local schoolchildren who need good friends and good listeners.

AAHSA Facilities Have a Transformational Role
Because it is hard to put into words, we talk less often about an organization's transformational role. But it is vital, in a time of challenge such we are experiencing now, to emphasize that role. It has three aspects.

Transformation of the People Served The defining feature of a not-for-profit organization, Peter Drucker says, is not that it is non-profit but rather that it has a role in society different from that of either the for-profit or the government organization. The product of a not-for-profit institution, in Drucker's words, is "a changed human being. The non-profit institutions are human change agents. Their 'product' is a cured patient, a child that learns, a young man or woman grown into a self-respecting adult; a changed human life altogether."4

As AAHSA's values statement puts it, the organization's members "contribute to people's ability to realize their full potential." AAHSA members recognize that "a changed human life" is possible at every age, in every stage of life. One such change occurred at the Boulevard Temple Retirement Community in Detroit, where residents volunteer their time at the Great Grandchildren's Place, an intergenerational day care program. Retirement community residents read to the children and help them understand the world they live in. The retirement community's director likes to talk about a resident named Dr. Wolfe, who did not do well when he first came to Boulevard Temple. But Dr. Wolfe's spirit "blossomed" once he became involved in helping children, the director says.

Something similar happened at Baptist Memorial Center in San Angelo, TX. When the center was given two computers, its leaders saw that they had an opportunity to try something new. They recruited a volunteer instructor from the community to teach residents how to do e-mail. After some practice, the first three students began showing their neighbors what they had learned. Today, two years and seven computers later, 22 residents are actively involved in the center's Computer Club and have published what they call a "Computer Manual for Senior Adults." Florence Rose, an 86-year-old resident, says, "The use of computers has really changed my life. I find myself eager to learn; feeling alive again!"

Transformation of the Institutions Themselves We AAHSA members are also the agents of our own self-transformation, reinventing what we do and how we do it.

A few years ago, I had an opportunity to observe at firsthand an AAHSA institution engaged in just such a transformation.

I visited Providence Mount Saint Vincent in Seattle and found it in the process of replacing a medical model of care with a resident-directed model. Over a period of many years of planning that involved staff, residents, families, and volunteers, the facility rewrote its vision and developed new set of goals. The new resident-directed model is designed to maintain residents' independence, privacy, sense of home, and dignity and to increase their interaction with staff and with each other. Under this approach, residents choose their daily routines and the services they wish to receive. In creating individual care plans for residents, the staff seeks to understand their backgrounds and personal preferences while, at the same time, educating them about concerns related to their well being.

To facilitate maximum independence, Providence Mount Saint Vincent created what it calls "neighborhoods," each of which has a large open kitchen/dining area where residents and staff can congregate and help themselves to food from steam tables any time of day. Each "neighborhood" has its own staff, cross-trained in doing both household chores and delivering resident care. The new resident-directed care model provides residents a home in which they have as much control and independence as possible. This self-transformational process, intended to promote individual transformations for those being cared for, is characteristic of AAHSA members.

Transformation of Social Attitudes A prime motivation in the formation of AAHSA was the fact that no national organization then existed to represent not-for-profit providers of LTC services to the elderly. In 1958, Sen. John Sparkman of Alabama sowed the seeds of AASHA when, during a hearing on nursing homes, he asked, "Who speaks for the nonprofit and church home?"5 We lacked a single voice then, but AAHSA has since filled the void and become the premier national representative for not-for-profit institutions and organizations dedicated to housing and caring for the elderly.

AAHSA's effectiveness in this role can be seen in its success, year after year, in preserving the Department of Housing and Urban Development's Section 202 senior housing program. Through AAHSA's efforts, this valuable program has been maintained even though other housing programs have been cut back or eliminated. Another feather in AAHSA's advocacy cap is the enactment of "return to home" legislation ensuring that if an elderly person needs nursing care after a hospital stay, the managed care company involved must make it available in the person's own community. AAHSA's voice in national policy debates is strong, vibrant, and effective.

A "Product" Always in Demand
What can we expect of AAHSA in the future?

First, we know we can feel confident about being not-for-profit in a for-profit world. Forty years of growth and success tell us that mission can more than hold its own in the marketplace. And, more important, we know that our "product" — a changed life — will always be in demand.

Second, we can feel confident about being person-centered in an age that is too often centered on material values. The process of improving the human condition characterizes our services and sets us apart from business organizations whose primary purpose is ensuring a reasonable return to stockholders. Instead of evaluating options and strategies in terms of their impact on stockholders, we ask what is best for residents, for the community, and for the continued availability of services in the community.


  1. Abraham J. Heschel, "The Older Person and the Family in the Perspective of Jewish Tradition," in C. LeFevre and P. LeFevre, eds., Aging and the Human Spirit: A Reader in Religion and Gerontology, Exploration Press, Chicago, 1985, pp. 35-44.
  2. John Paul II, "Understanding and Respect for the Elderly," July 25, 1999.
  3. Peter F. Drucker, Managing the Non-Profit Organization: Practices and Principles, HarperCollins Publishers, New York City, 1990, p. xiv.
  4. Peter F. Drucker.
  5. Evelyn L. Haught, The First 25 Years, American Association of Homes for the Aging, Washington, DC, 1986, p. 11.


Copyright © 2002 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Reflections - Humane Long-Term Care A Product Always in Demand

Copyright © 2002 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.