By BARBARA DURR, Asheville Watchdog
The second of two parts
As Buncombe County contends with a rapid increase in residents over 65 that shows no sign of abating, an already acute need for services will likely worsen, placing more of the burden of caregiving on families.
One in four Buncombe residents will be 65 or older by 2036, according to the North Carolina Office of State Budget & Management. Experts and advocates say the area is ill-prepared for the demographic shift. As the number of people over 65 has risen, the area’s aging services agencies, which lack sufficient staffing and funding to serve them adequately, haven’t kept pace.
Annual funding for aging services has remained at about $2 million for the last seven years, and per capita funding is less today than it was in 2017. Meanwhile, just in the pandemic years of 2020-2022, adults over 65 made up 96.1 percent of Buncombe’s population increase, according to the North Carolina Office of State Budget and Management.
Asheville resident Debra Walker has experienced the challenge firsthand with her now-deceased parents. After the elderly couple had a car accident, Walker moved them in 2019 from Greensboro to Asheville. Her mother needed memory care because she had dementia, and her father needed skilled nursing.
“I thought I would be able to provide them with a high quality of life for their last years,” she said. “And I was not able to do that despite my best efforts. Until I had them here, I didn’t realize how much help they needed.
“You think if I just get the right doctor or follow the right protocol or learn the right way to do this, I can make their lives nice. But you can’t. They’re in pain and they’re miserable.”
She found multiple facilities for each but discovered few provided the care she had hoped for.
“Even though we were actually paying like $10,000 a month for my mother’s care, they had staffing problems,” she said. “Just throwing money at it isn’t going to fix it. When you face these situations, people really don’t know what to do.”
While Buncombe’s aging services are supported by federal community block grants and the county’s own funding, the money is limited and, consequently, agencies that provide aging services are understaffed, said Alison Banzhoff, the county’s Adult and Aging Services Program manager.
Staffing is “one of the biggest challenges,” she said, because with limited funding the agencies “don’t pay adequately, so you can make more working at Chick-fil-A. That’s something we’re seeing across the board…for adult and family care homes, nursing homes, and those kind of things.”
LeeAnne Tucker, the director of Land of Sky Area Agency on Aging, which covers Buncombe, Henderson, Madison, and Transylvania counties, echoed Banzhoff. “We’re seeing funding as an issue, but right now the overarching issue is we don’t have enough folks to do the work, so there’s a three- or four-year wait list (for services and housing),” she said.
“There’s not enough in-home aides and CNAs (certified nursing assistants) to do the work because other jobs pay more,” she said.
North Carolina’s median hourly wage for direct care workers (DCWs) was just $13.62 an hour in 2022, according to the Paraprofessional Healthcare Institute (PHI). Its report for North Carolina said 92 percent of the 119,000 direct care workers in North Carolina are women, and 61 percent are people of color.
PHI’S research shows that between 2018 and 2028, the state will have had more than 186,000 job openings in direct caregiving, including 21,000 new jobs to meet rising demand and 165,000 jobs that will have been vacated as workers transition careers or exit the workforce.
“These statistics emphasize the essential role of DCWs in delivering essential care services and underline the necessity of addressing workforce shortages in this sector,” according to a report from the North Carolina Department of Health and Human Services in January. Among its recommendations: Recruit and retain DCWs, create a living wage for them, and expand apprenticeship programs.
“It’s not just that the population is growing older and the needs are increasing, the funding is not there, the labor is not there, and the infrastructure is not there,” said Elizabeth Williams, executive director for both MountainCare and the Council on Aging of Henderson County. She leads both organizations so they could share staff.
April Warren, client case manager at home care agency A New Hope, said clients who can pay privately, have long-term care insurance or are veterans are able to pay more and more readily get help.
Needs vs. services
Because most older adults want to age in place, experts say, the responsibility for care falls mainly on family members, who can find themselves suddenly scrambling to find services and support for their loved ones and for themselves.
Other family members discover their loved ones are not able to age in place, and they face a different set of challenges and discover aging services are underfunded and understaffed.
The challenge hit home for a retired health worker in Asheville when her once healthy, vibrant wife was diagnosed with Alzheimer’s in 2021. She spoke to Asheville Watchdog on condition of anonymity to protect her spouse’s privacy.
She relies on MountainCare’s adult day care services a few days a week for respite from caregiving, which includes housekeeping, managing finances, cooking, shopping, driving to doctors’ appointments and managing medications.
She pays hundreds of dollars a month for the service, and because she and her spouse have fixed incomes from a pension and Social Security, she worries how she will pay for it in the long term. Yet, she said, “My mental health is worth it.”
“The caregiving burden might seem light,” she said. “It’s not. There’s an emotional toll. I’m losing or have lost my spouse. We don’t talk about how hard this is emotionally for both of us.”
Given the constraints on labor in the area, the challenge is finding the right care and support.
“The workers that take care of us when we’re young, and the workers that take care of us when we’re old are the least paid in our society,” said Nathan Ramsey, director of the Mountain Area Workforce Development Board at the Land of Sky Regional Council. “It’s bad, and it’s going to get worse.”
“We are about 20 years ahead on aging compared to the nation and the state in western North Carolina,” said Ramsey. “We’re older, sicker, and poorer than the nation and the state.”
Older workers confront ageism
Even before older adults face a need for aging services, financial security is among their top concerns, experts say, because most mainly rely on Social Security and savings. Many must seek some form of work to supplement those resources.
“Most people haven’t saved enough to have retirement security, so they’re going to have to be working at some level at an older age,” said Ramsey.
Ramsey and his colleagues at the Land of Sky Regional Council have created an Experienced Workforce Initiative to encourage employers to hire older workers, an effort that partners with the American Association of Retired People (AARP) and NCWorks, an employment services agency for employers and job seekers.
Irene Canivet, a career advisor at NCWorks, said newcomers often don’t realize the resources needed to live in the area.
“I’d say 90 percent of the time the people I see are people who come to Asheville as retirees feeling they want a lifestyle, but they underestimate the amount of money they will need,” said Canivet. “Earnings are an issue.”
The NC Department of Commerce calculated in 2022 that 26.6 percent of Buncombe residents age 65-74 work as do 7.8 percent over age 75, said Barbara Darby, assistant director at the Mountain Area Workforce Development Board.
More broadly, Ramsey said, having such a high proportion of older adults in the population means “our retirement risk is higher than the state or national average, and that’s a concern for employers. So we need to encourage older workers to continue working.”
Yet, “older workers struggle much more than younger workers at finding new opportunities,” he said. “Basically, ageism is the last acceptable form of discrimination in our world.”
While the tourism and hospitality sectors receive a lot of criticism for paying low wages and driving up the price of housing, Ramsey said, “They are the most willing to try to accommodate workers,” and they also accept workers who want to work only part-time.
“Our long-term workforce challenge is due to demographics. We are aging and our birth rate is below replacement level,” he said.
Lack of planning
“People just don’t understand what’s needed in order to grow older,” said Williams of MountainCare. “We’re all going to age and we’re all going to die. We don’t want to talk about it. But it’s better to start planning it now.”
Tucker at the Land of Sky Regional Council, said people delay taking care of essential tasks related to aging. “We can barely get them to do a will or those end of life documents,” she said.
Susan Schiemer, who has spent her career in long-term care and heads the advisory committee for Buncombe’s aging services funding, said seniors often are in denial. “I think the whole denial thing is like people my age say, ‘I’m not old,’ and I say, “Yeah, I’m old. I’m over 65 and I got my Medicare card.’”
Others are caught off-guard because they hadn’t planned on being a caregiver. People who suddenly face being caregivers are rarely ready and are often older themselves, Williams said.
“That’s not what you thought retirement was going to be,” Williams said. “That’s not what you planned for retirement. But here you are.”
People “moved here healthy, thinking that they were always going to be active, hiking, going to OLLI (Osher Lifelong Learning Institute at the University of North Carolina Asheville), living the good life, going to the symphony, and that’s great,” said Barbara St. Hilaire, a caregiver for her wife. “But all of us are at some point going to not be able to do those things, and then who’s going to care for us? You just don’t know what’s coming.”
Housing challenges
Older residents often face a big challenge finding affordable housing, given the paucity of options in the Asheville area, Tucker said.
For those with financial resources, retirement communities such as Givens and Deerfield can be a solution. Both are continuing care retirement communities, starting with independent living, then assisted living, and finally full nursing care. But they have long waiting lists.
Givens Communities is the largest retirement organization in Buncombe and has expanded or is planning to do so into nearby counties. In Buncombe, Givens Estates and Givens Gerber Park are in Asheville, and Givens Highland Farms is in Black Mountain.
Givens Great Laurels is in Haywood County. With support from the Dogwood Health Trust, Givens acquired a site in Marion in McDowell County, where it plans to create affordable senior housing. According to Givens’ annual 2023 report, a partnership with Dogwood will help fund exploration of other possible sites in nearby counties, including Madison.
Givens Communities has 779 independent living residences, another 362 affordable residences, and 186 licensed health services beds, including 130 for skilled nursing and 56 for assisted living, said Givens’ Public Relations and Communications Director Geoffrey Cantrell via email. Givens offers rental housing, such as Gerber Park, but most require a significant financial commitment.
The average one-time entrance fee at Givens Estates is $353,572, and monthly fees range from $1,994 to $7,175, depending on the unit size, Cantrell said via email.
It has 315 people on what Cantrell called the “ready lists,” and the typical wait for a unit is close to four years.
“It’s not like booking a hotel room. You’ve got to plan ahead,” said Schiemer of the advisory committee for Buncombe’s aging services funding.
Avoiding nursing homes
While some older adults may seek retirement communities that offer a continuum of care, most wish to avoid going to a nursing home or having to send family members to one.
“We all know that if we can avoid nursing home placement, we want to avoid it,” said St. Hilaire, who worked for 30 years as an aging specialist in the Asheville VA Medical Center, which offers primary health care to veteran seniors in their homes. “It financially breaks people.”
Schiemer said there are 20 nursing homes in Buncombe County. They may soon become even more expensive because the Centers for Medicare & Medicaid Services (CMS) has established new higher staffing ratios in skilled nursing – 3.5 nursing staff per patient — that must be implemented over the next few years.
“Because of COVID, droves of health professionals left care in general,” said Dr. Karen Dedman, a longtime family physician in Asheville, who currently works part-time in area nursing homes. “So now the nursing ratio (in nursing homes) is high 2’s, and travel nurses compose 95 percent of the night shift,” she said. “Care has really suffered in terms of nursing since COVID.”
To enter nursing home care, people must first be hospitalized. “Three nights in the hospital is the magic to get a bed in a nursing facility on Medicare,” Dedman said.
But Medicare will pay only for 21 days in a nursing home, and if someone must stay longer, they face a co-pay of about $175 a day, “which adds up,” Dedman explained. But Medicare can cut off those who don’t improve, and they become what is called “Medicaid pending,” Dedman said. A person must then “spend down all of your resources until you’re empty and then Medicaid comes in to help you,” she said.
Lack of awareness of aging resources
In Buncombe County, which is considered “Age Friendly” by AARP, a variety of aging services organizations receive funding, yet the public is generally unaware of those resources, advocates say.
“There’s no awareness of what the resources are, or even the limit of what the resources are,” said Walker, the Asheville resident who had to care for her parents after they moved to the area.
Buncombe County Commissioner Terri Wells said she regularly hears from residents that they do not know what aging services are available.
“We’ve got to do a better job of connecting people and making them aware of the resources,” she said.
Rachel Miller, the director of the Council on Aging of Buncombe County, a non-governmental organization, said it’s a challenge for “letting people know what resources are out there.”
Her organization offers guidance on Medicare and Medicaid as well as the Affordable Care Act and support services such as home repair, transportation, and food delivery and dining. It also has an aging services directory.
The Land of Sky Area Agency on Aging offers services, such as its caregiver support program, and has directories of services, such as its Caregiver Resource Directory, for Buncombe, Henderson, Madison, and Transylvania counties.
While Miller says her organization regularly gets calls from seniors who must wait months to see a doctor, AdventHealth, based in Hendersonville, has an age-friendly initiative that includes geriatricians, specially trained internal and family medicine providers, and mental health providers.
It has created the first “Age-Friendly Center” at AdventHealth Medical Group Multispecialty at Laurel Park, close to Hendersonville, where older adults can have their care appointments and therapies, said Victoria Dunkle Noyes, director of AdventHealth’s communications and public relations. She said Advent partners with the Councils on Aging in both Henderson and Buncombe counties to connect patients to services.
Mountain Area Health Education Center (MAHEC), known widely for its physician and nurse training, has a Center for Healthy Aging that provides care to MAHEC’s older adult patient population and has contracts for medical services at both the Givens and Deerfield retirement communities. It is also supported by Buncombe County to provide home-based care for older adults referred by the county’s aging services staff.
Dr. William McLean, co-director of the center and a faculty physician, said there’s a shortage of geriatricians and not enough can be trained to meet demand. MAHEC’s response is “to geriatricize primary care” to serve the burgeoning older adult population, he said.
CarePartners, run by Mission Health in Asheville, offers a local version of a federal program called PACE (Programs of All-Inclusive Care for the Elderly). It provides medical care and social services to older adults, who might otherwise require a nursing home level of care, to allow them to remain at home. All CarePartners PACE services are paid for by Medicare, Medicaid, and/or private insurance. If clients are fully eligible for Medicaid, there is no cost.
Federal and state agencies monitor PACE programs to ensure they comply with state and federal regulations and provide quality care and services, an important condition given the concerns about the quality of care at Mission.
Walker said, “We are lucky here with MountainCare (where she is now a board member) and MemoryCare.” MemoryCare is a non-profit that provides specialized care to older adults with cognitive impairment and supports caregivers. She attended and praised MemoryCare’s program called “Caregivers College,” which educates caregivers on dementia.
OLLI offers educational programs to help people plan for care, explore retirement communities, and convey life wishes to family. It even has a “Death Café,” that facilitates discussion about death and end of life issues.
Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and surrounding communities. Barbara Durr is a former correspondent for The Financial Times of London. Contact her at [email protected]. To show your support for this vital public service go to avlwatchdog.org/donate.
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Previously Published on avlwatchdog.org
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MAHEC’s efforts to “geriatricide primary care” is a crucial step in addressing the growing demand for elder care, especially with the shortage of geriatricians. Their comprehensive approach is commendable and much needed.