HomeMy WebLinkAboutOur Island Home Work group report March 2017 1
2016–17 FUTURE OUR ISLAND HOME WORK GROUP REPORT MARCH 7, 2017 This report is available on the website: nantucket-ma.gov Search: Our Island Home Work Group 2016 Go to: Our Island Home Work Group Final Report 3/7/17
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TABLE OF CONTENTS Abstract 3 1. Annual Town Meeting Warrant Article Recommendations 4 2. Background to the Present Proposal 9 3. Financing the Future Our Island Home 17 4. Proposed Relocation of Eldercare Services to Mid-island 19 5. Proposed Building Site 21 6. Model and Delivery of Care 24 7. Public Opinion/Public Relations 28 Appendix 1: History of Our Island Home 35 Appendix 2: Present Culture of Our Island Home 38 Appendix 3: Comparative Flooding Concerns 47 Relevant Literature 50
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ABSTRACT The voters at the November 17, 2016 Special Town Meeting passed Article 5, mandating the immediate formation of a workgroup “to resolve financial and otherwise unanswered questions or open issues related to the relocation, design, staffing, site control, and demographics of Our Island Home.” The work group has met weekly with representatives of the Board of Selectmen, SMRT Architects and Engineers, and members of the public. Work group members also made a site visit to a “small house” facility in western Massachusetts. At the work group meetings the history of Our Island Home and past changes of location and model of care have been reviewed, and concerns about the present proposal have been heard. Recommendations in 2007–2009 and 2012–2013 and the present proposal were made without participation of family members, staff who provide direct care, and long-time volunteers. Based on input to the present work group, the following issues have been identified as in need of further clarification: 1. Cost of operation of Our Island Home in the future 2. Potential for future privatization of Our Island Home 3. Concept of creating a mid-island eldercare “campus” 4. Multiple issues about the site located off Miacomet Road 5. Necessity of relocation 6. Future disposition of the East Creek Road site 7. Appropriateness of the proposed model of care for Nantucket elders The work group brought six questions to the January 11, 2017 meeting of the Board of Selectmen and made two recommendations concerning a warrant article seeking appropriation of funds for building a new Our Island Home facility. The work group was unsatisfied with the response to these questions received from the Town of Nantucket Administration. Further discussion within the work group has resulted in additional recommendations to the Board of Selectmen: 1. There should be an independent review of the East Creek Road site for potential renovation or a new facility. 2. Any warrant article that seeks appropriation for a new facility should address the Town of Nantucket’s commitment to continue to own and operate a skilled nursing facility, guarantee non-privatization of the facility, and guarantee that the operations of Our Island Home and Sherburne Commons will not be merged. Frances Karttunen, Chair Tim Soverino, Vice Chair Alison Forsgren, Recording Secretary Rachel Day, OIH Administrator Dawn Hill-Holdgate, Board of Selectmen Clifford Williams, Finance Committee Virginia Andrews, Member at large Stephen Welch, Member at large Georgia Ann Snell, Member at large
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1. ANNUAL TOWN MEETING WARRANT ARTICLE RECOMMENDATIONS At the 2017 Annual Town Meeting the Town of Nantucket Board of Selectmen intends to ask Nantucket voters to approve an appropriation for the construction of a new building for Our Island Home on town-owned property abutting Sherburne Commons and accessed from Miacomet Road (Article 14). The planned facility is to be designed according to the “small house” model current in eldercare philosophy.1 In the same warrant there will be articles seeking an appropriation to purchase private land adjacent to the town-owned property (Article 15), seeking approval for extending sewer to the site (Article 16) and changing zoning to permit the building of a care facility on the site (Article 17). There are factors that may lead to the less-than-required two-thirds vote in favor of the warrant article or its failure if it goes to a paper ballot after being approved at the 2017 Annual Town Meeting. 1. The Board of Selectmen may have misjudged the strength of attachment of Nantucket voters to the present location on East Creek Road.2 2. The Board of Selectmen may have underestimated the reluctance of Nantucket voters to connect Our Island Home in any way with Sherburne Commons. 3. The Board of Selectmen may not have taken into account the resistance of abutters, including residents of Sherburne Commons, to having a facility built in their neighborhood. 4. There is concern that the proposed model of care and size are not appropriate for Nantucket’s future needs. 5. Public relations efforts in favor of the present proposal have proven unconvincing to Nantucket voters. 6. There is insufficient evidence that the present planning for a new facility will address i) direct and complementary eldercare needs as they are likely to 1 See the list of relevant literature attached to this report. 2 See Appendix 1: History of Our Island Home.
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develop over the useful life of the facility; ii) staffing, including workforce development and overtime leveling; and iii) what if any services provided through Our Island Home might help goals within each of these areas. The Future OIH work group3 was tasked by the BOS4 to bring recommendations before the board at their January 11, 2017 meeting. Although it was not possible for the work group to prepare a full report by this deadline, the group brought to the meeting six questions and two recommendations:
The work group is of the opinion that in order to pass a warrant article seeking and an
appropriation for the construction of a new facility for Our Island Home, Nantucket
voters need answers to the following questions:
1) If Our Island Home were to be moved from its current location, what would
happen to the current land and building?
2) Upon building a new facility, will the town seek to privatize it, sell it, or merge it
with Sherburne Commons?
3) Will the town commit to funding for the continuing operation of a skilled
nursing facility?
4) With only 40 beds to begin with, will the new facility be able to expand to more
beds if needed? Will the new facility over its lifetime be adaptable to changes in
community needs?
5) With regard to the model, can we commit to a more home-like atmosphere
without necessarily committing to a small house/GreenHouse® model? Can we
go forward with a flexible hybrid design to be developed by the building
committee and then implement the operational plan? 3 Among the members of the work group are one current and two former members of the Board of Selectmen; one current and three former members of the Finance Committee, one of whom is a current member of the Capital Program Committee; and individuals representing families of present and former residents of Our Island Home. 4 Abbreviations used in this report are BOS Board of Selectmen; TON Town of Nantucket; OIH Our Island Home; FinCom Finance Committee; CNA Certified Nursing Assistant; DPH Department of Public Health; NCH Nantucket Cottage Hospital.
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6) Can we, in more depth, revisit with architects and engineers the possibilities of
the current location to see what could possibly be done with the current
building in place?
The work group is uncomfortable with the presentations to date concerning both the
current site and the site abutting Sherburne Commons and what could be placed on
either one. Moreover, dependable demographic information is needed in order to build
a facility that can adjust to potential changes in size and use over the next thirty years.
Just as Nantucket Cottage Hospital has adopted the motto ”Building the Right Hospital
for Nantucket,” we must build the right Our Island Home for Nantucket.
Therefore, we recommend that the BOS:
1. Defer action on an appropriation by removing the request as a warrant article at
the 2017 Annual Town Meeting pending explicit answers to the above questions and
bring it to Town Meeting in the fall of 2017 or the Annual Town Meeting in 2018.
2. Incorporate into planning a demographic survey to be carried out by the Nantucket
Center for Elder Affairs under a grant it has received for the purpose through the
Community Foundation for Nantucket, and/or specific demographic information
compiled by other means, and the final report of the OIH work group. At their January 11, 2017, meeting, the BOS, with chairman Jim Kelly absent, voted unanimously to defer placing a warrant article for an appropriation for construction of a new OIH facility on the 2017 Annual Town Meeting warrant until a later Town Meeting, although without deferring the warrant articles seeking sewer extension and zoning change. Following the January 11 meeting, Town Manager Libby Gibson sent to the work group written answers to the group’s six questions:
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To question 1 concerning the future of the East Creek Road site: In all likelihood
a group would be established to review reuse possibilities. The Board of Selectmen will
be discussing this at its meeting on February 1st. The current Board has no intention of
selling or transferring the property to any private entity.
To question 2 about whether the TON would seek in the future to privatize the
new facility, sell it, or merge it with Sherburne Commons: No.
To question 3 about whether the town is committed to future funding to
continue to operate a skilled nursing facility: The current Board has committed
to continue funding the operation of the current facility with endorsement of the FY 18
proposed budget which still requires town meeting approval. The current Board
intends to continue seeking town meeting approval of annual budgets for continued
operation of a skilled nursing facility at the Miacomet Road location; however, the
Board cannot commit future Boards to this. Ultimately, continued funding is up to the
voters.
To question 4 about expandability and flexibility of the proposed new facility:
One of the benefits of the small house model is that it can be flexible both with number
of beds and “type” of beds. All 45 beds at the current facility are generally not filled
100%, 100% of the time.
To question 5 about commitment to the small house/GreenHouse® model: The
home-like atmosphere is one of the guiding principles of the Small House model and it
can certainly be flexible within a range of possible designs.
To question 6 about further consideration of the East Creek Road site: The
Board of Selectmen is not inclined to spend additional funds revisiting the current site.
While it is within the realm of possibility to construct the new facility at the current
facility are significant, not realistic and advice from industry professionals indicates
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site, the operational and logistical challenges of doing so while operating the current
that DPH approval would be unlikely. At the January 18 meeting, without notifying the work group members, chairman Kelly called for a re-vote, and this time, by a three-to-two vote, the appropriation article was placed back in the warrant without any wording of the article to provide assurances to the voters on the concerns the work group had identified. Understandably, work group members, who were charged by the fall 2016 Special Town Meeting “to resolve financial and otherwise unanswered questions or open issues related to the relocation, design, staffing, site control, and demographics of Our Island Home” prior to the voters making decisions at the 2017 Annual Town Meeting, felt that their charge had been ignored and overturned by the BOS. Under the circumstances, the work group has resolved to continue its work to complete this report of its work and make it available to the public prior to the 2017 Annual Town Meeting. We have no intention of advocating for or against passage of any of the relevant warrant articles, but we do intend to make public the substance of our weekly meetings, complete with public input.
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2. BACKGROUND TO THE PRESENT PROPOSAL 2a. 2007 and 2009 BruJan/DeMarco proposals: The roots of the present proposal go back to 2007, when then-OIH administrator Pam Meriam presented to the BOS three concepts for a future OIH facility that she had developed with Janet and Bruce Glass of BruJan Consulting of Campton, New Hampshire, and Charles DeMarco, an architect from DeMarco and Associates of Rockford, Illinois. The consultants and the architect are both experienced in designing mainland eldercare facilities. The first concept was a “cottage-style” facility to be built on five or six acres of land in an unspecified location. Each separate cottage would house 12 to 15 residents. Also included in this concept were a family medical clinic, an adult daycare center, a childcare center, and staff housing. Exclusive of land acquisition, the estimated cost of this concept was between twenty-two and twenty-seven million dollars. The alternative concepts were either to build five cottages on the present OIH site without accommodations for adult daycare or childcare or to renovate/expand the existing facility. The renovation/expansion concept would add an administrative wing, an additional twenty-one rooms, “revamped nursing stations,” and common space. It would also create space for adult daycare, childcare, and staff housing. The estimated cost of the renovation/expansion concept was between twelve and a half and fourteen and a half million dollars. It was acknowledged that building on-site would cause “some disruption to resident daily life during construction” and add demolition costs to the total price of the project. Part of the motivation for this study by Meriam, the consultants, and the architect was a 1998 study that had found OIH to have “insufficient beds.” At the time, the facility’s 45 beds were filled, and there were 20 people on a waiting list for admission.
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The 1998 study had also criticized the facility’s “long. gloomy corridors.” Meriam’s presentation stated that there had been a “fundamental shift” in eldercare philosophy from a “medical institutional model” to a “quality of life model.” Meriam acknowledged that care at OIH received some of the highest customer
satisfaction ratings in the Commonwealth of Massachusetts. Nonetheless, she was quoted as stating that “Nobody wants to come here, nobody says I want to come to a nursing home, so we’re trying to make it the best possible.” Then-selectman Patty Roggeveen was quoted by the Inquirer and Mirror on March 26, 2007, as expressing the opinion that the “philosophical setting” (the model of care) needed to be decided on first, followed by the site, and then the cost. BruJan Management and DeMarco and Associates submitted a document to the BOS in 2009 updating their 2007 presentation and acknowledging the bankruptcy of Sherburne Commons as a complicating issue. They noted that the care delivered at OIH was excellent, but they described the building as obsolete and noted that the TON had to subsidize annual losses “due to institutional factors beyond the control of management.” They presented four options: 1. Continuing the status quo with increasing annual losses and “reduced desirability” 2. Closing OIH and moving the residents to mainland care facilities 3. Finding an “outside provider” to operate OIH
4. Making the investment to upgrade OIH to make it less costly to operate
and also to make it “more attractive” The document dismisses the first three options and focuses on the fourth, which they state relates to Sherburne Commons, which at the time was in Chapter 11
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bankruptcy and being put out to market. They consider the option that OIH could be moved to the existing Sherburne Commons buildings but state that the Sherburne
Commons buildings could not be made to conform to nursing home
construction standards.
They propose, however, that the TON construct a new nursing home on the
Sherburne Commons site “while converting certain of the buildings to usage
for other services.” They describe this repurposing as creating a “campus
setting” and to “provide economies of scale for both operations—particularly
if other services were included.” They go on to report on having made inquiries to potential providers about operating the combined OIH and Sherburne Commons facilities and to have found
interest in such operation but not in the cost of construction of the new OIH
facility or in paying for acquisition. Hence they conclude that the TON would
need to do the building of a new OIH and then lease “it “ (presumably the
combined operation) to an outside operator. They state that while the cost of construction would be large, the subsequent benefits to the TON would be the following: 1. OIH would have a new, energy-efficient building which residents “would be proud to live in.” 2. The independent and assisted living (at Sherburne Commons) would continue. 3. The TON could provide on-site “an array and quality of senior services that would be unique in Massachusetts.”
4. The TON would no longer operate OIH and thereby get out of its
operational costs. 5. Capital costs could be recovered through Medicaid (MassHealth) “and/or the operational lease.”
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6. The “attractive” site on East Creek Road could be sold or repurposed by
the TON. 7. Some of the Sherburne Commons buildings could be used for staff housing or low-income housing. The report ends with the statement that this course of action, essentially combining OIH and Sherburne Commons and turning them over to an outside operator, “would represent a monumental commitment by the Town of Nantucket—but one that
would pay dividends for years to come.” 2b. 2013 Work Group report: In September 2012 a local work group was appointed by the BOS to investigate in depth the issues surrounding the future of Our Island Home. A little under a year later they presented their report to the BOS. This report emphasized that because of Nantucket’s remote location, islanders could not make use of facilities in neighboring localities, so “a significant burden will be placed on families if
skilled nursing care is not available on-island.” Moreover, based on information from demographer Peter Morrison, the group acknowledged that Nantucket’s
demand for skilled nursing care “is likely to grow over the next 20+ years.” The work group recommended to the BOS that a new OIH facility should be built elsewhere than on its present site on East Creek Road, and, to subsidize the construction, the TON should “sell the land where the OIH currently exists to
the Land Bank at fair market value. Use the land sale proceeds to pay for or
offset the costs of a new facility and to fund startup costs for community-based
care delivery.” The 2013 work group report is explicit about operating costs of OIH, stating that the deficit, which the TON had to cover ranged from half a million dollars in 1996 to
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nearly four million dollars in 2009. The assumption of the report is that the deficit
would continue to rise each year going forward, this deficit being driven by
increasing personnel costs and decreasing Medicare and Medicaid
(MassHealth) reimbursements. According to the report, eighty per cent of the OIH operating costs are for salaries and benefits. The report states that as a percentage, 80% is not appreciably higher than reported in 2010 for other such facilities. However, actual labor costs for
every category of employee of OIH are higher than at mainland facilities, with
the highest differential being in the salaries for the CNAs who provide direct
care for the OIH residents. Some staff members at OIH are unionized TON employees. Their pay rates and benefits are negotiated through agreement of the TON with the Service Employees International Union and the Laborers International Union of North America, and these rates and benefits had been increasing at around 5% per year. The report notes that if an outside entity were to take over managing OIH, that entity
would have to abide by these same collective bargaining terms currently in
place unless OIH were to be closed and all current employees laid off for two
years. (By comparison, the union’s agreement with Nantucket Cottage Hospital provides less for hospital employees in the same classes, while Sherburne Commons is non-union.) The work group reports: “When 80% of your operating costs are increasing by
5% per annum and your revenue base is flat to slightly declining, this business
model becomes increasingly unsustainable without increasingly generous
taxpayer support.”
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Examining the state of the current facility, the work group repeats verbatim the 2007 criticism of “long, gloomy corridors” and states that the building is out of
date in terms of energy efficiency and conformity with newer models of care. Borrowing from the literature of the current philosophy of skilled nursing care delivery, they criticize the existing building as “institutional,” concluding that,
“While the quality of care remains high, the physical facility has become
problematic.” Again borrowing from the current nursing care literature, the report states that in a modern skilled nursing facility, residents should have “expanded
choices of when, where, and what to eat, wider control over daily activities,
and a wider choice of meaningful activities.” The work group recommendations to the BOS included:
1. Developing community-based care to be delivered to people in their
homes rather than as residents of a skilled nursing facility, “a transition
that will have to come sooner or later.” 2. Bringing existing elder services together “via privately supported concepts such as The Village Model” originating in Boston. 3. Moving OIH, as a smaller facility, to abut Sherburne Commons.
4. Selling the land on East Creek Road to the Land Bank at fair market
value and using the income to offset the cost of building the new facility
at Sherburne Commons. So far as the present work group is aware, the current proposal only addresses recommendation 3. The report concludes: “While the Work group has proposed recommendations,
none of these solutions can advance without a community dialogue; this is,
after all, a community decision on how to spend our resources and care for
our elders.”
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2c. SMRT Architects and Engineers presentations: In June 2015 a request for qualifications (RFQ) was issued for a feasibility study for a new OIH facility, and from among five respondents, SMRT Architects and Engineers was chosen by Rachel Day, OIH Administrator; Heidi Bauer, TON Chief Procurement Officer; Libby Gibson, Town Manager; and Greg Tivnan, Assistant Town Manager, to do a feasibility study of sites and comparison of the options of renovation of the existing building versus new construction. Their choice was based on how they perceived the applicants to have responded to the criteria of the original request for qualifications. Although the firm was given several sites to consider, only one model, according to SMRT representative Dick Webb, was specified, namely the small house model. SMRT gave considerable attention to the present site and concluded that the site on
East Creek Road was too small for the construction of a small house facility for
45 residents. They concluded that the Wyer’s Valley/Wannacomet site that had been considered for the new Nantucket Cottage Hospital was not feasible, citing the possibility of threat to Nantucket’s sole-source aquifer (a concern that Wannacomet Water Company had dismissed when the hospital was considering the site). According to information provided to the work group, another factor inhibiting this choice of site is a conservation restriction that limits the Wyer’s Valley site to parkland if and when Wannacomet Water Company moves away. Town-owned land adjacent to the TON’s public safety building was also deemed unusable because of existing plans for other building on the site. SMRT concluded that the town-owned land adjacent to Sherburne Commons was the only feasible site. They generated plans of how a new OIH facility would be sited
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on that land and presented a slide show to the BOS in September 2015. Subsequently they gave the same presentation to a public forum held at the Dreamland Theatre in October 2015 and at Sherburne Commons in January 2016, and they have made periodic presentations with conceptual drawings to the BOS since, most recently on January 11, 2017.
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3. FINANCING THE FUTURE OUR ISLAND HOME Members of various TON bodies such as the Board of Selectmen and the Capital Committee have consistently stated that the TON must face up to how the operation of OIH will be funded in the future. According to the report of the 2013 work group, the continually rising cost of operation coupled with decreasing reimbursements render the operation of OIH unsustainable. If the voters vote to spend many million dollars on building a new facility, will operation of that facility be any less expensive than it currently is? If so, how will reduction of cost be accomplished? Apparently the fact that a new building will be more energy-efficient than the current building will not even begin to offset the rising cost of operation. One means of cost reduction is to have fewer residents. The current plan for the new facility reduces the total number of beds from forty-five to forty and removes ten of those forty beds from the expensive skilled nursing level. This might reduce costs initially, but some demographic projections for Nantucket point to rising, not falling need for skilled nursing beds in the future. SMRT’s design for the site off Miacomet Road abutting Sherburne Commons allows for building a fifth living unit of ten more beds between two of the four small house living units in the current plan. An alternative to future expansion is not to admit more residents in the future, whatever their needs, relying instead on “community-based” delivery of more home care to keep potential residents at home. Another means of reducing costs is elimination of positions for cooks, dietary aides, and housekeepers by transferring food preparation, personal laundry, and some cleaning to the CNAs who provide direct care to the residents.
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As recently as February 1, 2017, a Selectman returned to the notion of selling
the TON’s East Creek Road property to raise money for construction of the
new OIH facility and also to fund future services. Yet another notion about bringing in more revenue to support OIH is to create more OIH services beyond skilled nursing care. In the past All OIH beds were consistently filled, and there was a waiting list. Currently there are two or three beds available for admissions. The change from having a waiting list to having available beds has been attributed to the creation of Nantucket Cottage Hospital’s swing-bed program that is perceived to have siphoned off short-term admissions to OIH of patients leaving hospital care for rehabilitation. It has been pointed out that Sherburne Commons also is investigating offering services to Nantucket’s elders who are not resident at Sherburne Commons. It has been suggested that without needing any extra space, OIH could develop competing home services that would successfully bring in more revenue. That success could be dependent upon location and access to the facility. Ultimately, operational costs will be borne by the taxpayers of Nantucket. It should be noted that on the exit questionnaire at the March 2017 public meeting, the majority of respondents said they would be willing to vote for a tax increase to pay for a new facility, but the questionnaire did not address a tax increase for ongoing operational costs once building was complete. Concern has been voiced that the TON will invest millions of dollars in a facility it cannot afford to operate, ultimately resulting in a forced sale of the expensive new facility for pennies on the dollar. If the TON cannot find a way to support a new OIH going forward, the issue of its location is moot.
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4. PROPOSED RELOCATION OF ELDERCARE SERVICES TO MID-ISLAND Whatever the BOS states it has decided about the future location of OIH, it is up to the Nantucket voters to decide what they want and where they want it. Assuming that the taxpayers choose to invest in building a new OIH facility and commit to operating it at whatever the cost, location does become an issue. There has been mention of creating an eldercare campus at the mid-island site, bringing together Sherburne Commons, OIH, and additional services in one contiguous area. Evaluation of location should include examination of possible competition from other organizations or institutions. The term “campus” first came up in the 2009 proposal. Recently it was echoed by Selectman Atherton in a December 9, 2016, interview on Geno TV. Atherton expressed the notion that it would be a “better package” if not only OIH but also the Saltmarsh Senior Center were to be relocated to mid-island next to Sherburne Commons. On December 29, 2016, Kevin Cormick, the new executive director of Sherburne Commons, coming to the island from managing operations of mainland Massachusetts and New Hampshire eldercare facilities, described Sherburne Commons as “a beautiful campus” and spoke enthusiastically of expanding some of the services of Sherburne Commons “to elderly residents across the island.” The expressed ideal of gathering all Nantucket seniors to a mid-island eldercare “campus” evokes suspicion that the subtext is to create a large enough amalgam of senior activities that an off-island entity might invest in purchasing/leasing and operating it. The notion of “campus” is hardly a Nantucket concept, and there is skepticism about the practical utility of the concept. By mainland standards no place on the island is at a great distance from any other place, so the difference between an aggregation and the present dispersed location of OIH, the Saltmarsh Senior Center, the
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Landmark House, and Sherburne Commons does not seem to be of great significance. On the other hand, OIH and the Landmark House have stood adjacent to each other for decades without any appreciable interaction or mutual support.
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5. PROPOSED BUILDING SITE The initial 2007 recommendation was for detached cottages for ten to fifteen residents each. Since then, the proposal has evolved to a “small house” model, a collection of connected living units for ten residents each sharing some common spaces, but each having its own kitchen and dining area, a common area known in the eldercare literature as a “hearth,” single rooms, and a bathroom for each resident. The notion of “small house” is a spin-off of the GreenHouse® model, which is tightly regulated. By adopting a small house rather than a GreenHouse® model, there is latitude for some adaption to local needs and desires. Nonetheless, building multiple individual housing units, even if not as wholly separate cottages, requires a great deal of land. SMRT Architects and Engineers have provided several conceptual drawings of how three or four of these units, each housing ten to fifteen residents, could be made to fit on the TON-owned site off Miacomet Road. Since SMRT’s initial conceptual drawings were made public, it has been determined that adjacent Land Bank property is not available to the TON, and those first designs will not fit on the TON-owned site In fact, the TON-owned site off Miacomet Road is not large enough to accommodate a small house complex for forty residents (much less the present forty-five), and the TON is presently seeking to purchase additional property to the west of the present site in order to have enough land to go forward. Such a purchase will add another 2.5 million dollars to the cost of the project. Even with the additional land, the living units will be closely packed and inward-looking, ringed by parking spaces. The proposed new OIH building complex will also be larger than any of the nearby Sherburne Commons buildings.
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On several occasions Nantucketers have viewed SMRT’s conceptual drawings. At first, the living units were designated “pods,” and Nantucketers viewing these designs were not universally favorably impressed. One compared the concept to prison construction, while to others the word “pod” brought to mind storage containers. When the term “pod” proved unpopular, the proponents of a new OIH facility abandoned that term in favor of small house. Unfavorable reaction to the SMRT conceptual illustrations of a future OIH centered on the impression that the illustrations looked very much like Sherburne Commons. Quite a few Nantucketers have negative or distrustful attitudes toward Sherburne Commons not only because of its past financial failures, but because to them the main building looks and feels like a pricy but soulless mainland suites hotel. SMRT’s drawings showed furnishings inappropriate to OIH residents, and the stock photographs representing residents did not begin to approach the level of disability of many OIH residents. Most ironic was that SMRT’s original opening slide was of a harbor view, exactly what OIH residents would be giving up. After a protest about that, the opening slide was changed to a photo of Lower Main Street, an equally irrelevant image for OIH residents. There is continuing push-back from the residents of Sherburne Commons and from abutting land-owners to the relocation of OIH to the site adjacent to Sherburne Commons. Residents of Sherburne Commons have made it known that they do not want vehicle access to an abutting facility via their property. In response, the TON has assured them that there will be a gate and a buffer area separating Sherburne Commons from the proposed new OIH facility and that all visitor, staff, and emergency access to the OIH facility will be from Miacomet Road. Residents who live along Miacomet Road oppose siting the new OIH in their neighborhood on the grounds of scale, increased traffic, necessity of an upgrade of Miacomet Road to accommodate emergency vehicles, promises made when
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Sherburne Commons was built that the neighborhood would be protected with buffer zones, and general inappropriateness. There are also archaeological concerns. In the 1700s Nantucket Wampanoags were displaced from their original settlements around the island and congregated in the Miacomet area where they had dwelling houses and a meetinghouse. On February 8, 2017, the State Archaeologist wrote to the Nantucket Town Manager requesting submission of draft plans for archaeological site avoidance and protection in compliance with the National Historic Preservation Act.
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6. MODEL AND DELIVERY OF CARE There is universal consensus that residents of Our Island Home need and deserve to live in a “homelike” milieu. What constitutes “home” for Nantucket elders, however, may be different from what it means to elders in other places. Small house architecture and model of care are inextricably bound to each other. The planners of the proposed new OIH facility have framed their argument in terms of “institutional” (bad) versus small house (homelike, good) although many ills of large facilities on the mainland do not pertain to OIH. There is no point to fixing what is not broken. In their focus since 2007 on building a village/pod/small house facility and on creating a mid-island eldercare campus, those involved in planning for the future of OIH have disregarded the demonstrated desire of residents, their family members, the staff who care for the residents, and those who anticipate one day becoming residents of OIH to remain in direct contact with Nantucket Harbor and the core town. Bill Thomas, the founder of the GreenHouse® movement, would himself likely rate the dynamic and unique environment of saltmarsh, harbor, and town as priceless in its power to keep residents oriented. It is unlikely that can be replaced with enclosed gardens, artificial fireplaces, and open kitchens. No matter how crucial it may be to the respondents to the several petitions and questionnaires, however, public concerns have to do with more than preservation of OIH’s present harbor view. The model of care itself is in question for Nantucket. Since, for the most part, OIH residents, their families, and the staff all know each other well, dividing up the forty to forty-five residents into small, separated groups may be inappropriate.
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OIH is currently a vibrant community. A visitor unaccustomed to life at OIH might come at a time when residents are sitting about unengaged, but anyone who comes regularly to OIH throughout the day is aware that these down times are interim periods. OIH residents have a great many opportunities for group engagement morning and afternoon The large number of daily and weekly visitors is remarkable, as is the fact that visitors overwhelmingly know not only their particular “loved one,” but other residents as well.5 Published studies consistently show that satisfaction with care in nursing facilities is proportional to how long the direct caregivers have been employed at a particular facility. The longevity of the OIH staff is unprecedented in geriatric health care, a field generally bedeviled by high turnover.6 There are seventy people employed by OIH.7 Thirty-three employees have worked at OIH for over ten years and twelve more than twenty years. Despite imminent retirements, the number of long-time employees is exemplary, and one reason for this lies in the fact that OIH employees earn a wage that makes it possible to survive Nantucket’s high cost of living. There is concern that the small house model will not only unnecessarily segregate residents into small groups, but it will not provide an adequate number of CNAs at times when they are needed. If CNAs are also segregated two to each house, what is to be done when a transfer is needed that requires more than two? Can CNAs realistically be expected to do all they currently do to provide care for fragile elders and also be responsible for meal preparation, residents’ personal laundry, and housekeeping? If nurses are not located among the resident population but are somewhere outside the houses and “visiting” from house to house, will a nurse be on hand when needed? 5 See Appendix 2: Present Culture of OIH. 6 Consult the Relevant Literature at the end of this report. 7 Nurses and CNAs at OIH work around the clock in three shifts. The OIH administrator, director of nursing, social worker, employees in the finance office, and activities director work regular daytime hours, Kitchen, housekeeping, and maintenance staff have different hours.
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It is a matter of concern that the present OIH nurses and CNAs have hardly had a voice in the discussion of future model of care. Dismissive remarks that nurses are set in in their ways and resistant to change and that CNAs who deliver direct care to the residents are in need of a “culture change” miss the point that these are the people with a valuable fund of knowledge of the day-to-day challenges of the present OIH. They need to be heard. Another issue is the resident population itself. On visits to the Leonard Florence Center for Living in Chelsea and to Mary’s Meadow in Holyoke, OIH work group members asked about how disruptive behaviors are managed. At the Leonard Florence Center the answer was that there were no disruptive behaviors, and at Mary’s Meadow, we were told that a little more food and a little more attention would redirect disruptive behavior. There is, however, an unspoken factor; the two facilities we visited (and in private care facilities in general) admission can be denied to potentially problematical applicants. Although OIH has the option of not admitting any applicant for a variety of reasons, OIH is expected to admit anyone from the Nantucket community who cannot live safely at home. This includes individuals with challenging behaviors. Such a resident in a house of ten would be harder for the other residents to tolerate than in a general population of forty-five. The 2013 work group remarked on a national trend to keep people needing skilled nursing care “in the community as long as possible” by providing in-home services. Included in the report are the statements, “Alternative care models such as
community-based care are arising nationwide to combat the increasing costs of skilled
nursing facilities and the fiscal demand it is placing on Medicare and Medicaid.” However, “Nantucket does not have a well-formed and coordinated community-based
care.” “While many individual support services exist, they are not coordinated in a way
that optimizes senior care for all. As reimbursement methods change and the care
model shifts to more community-based care, increasing coordination among and
optimizing all senior services will rise in importance.”
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If “community-based” care means care that is funded by some other entity than the TON, this would appear to be an abdication of our island community’s unique responsibility for our elderly and disabled members who can no longer live safely at home. Moreover, in the face of demographic predictions of a growing population in need of skilled nursing care, the planners of the future OIH intend to reduce the number of beds in the new facility and to rely on currently nonexistent and unfunded community-based delivery to individuals in their homes. The funded demographic study to be carried out by the Nantucket Center for Elder Affairs/Nantucket Council on Aging should be part of the planning process for the future OIH.
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7. PUBLIC OPINION/PUBLIC RELATIONS Although the 2013 OIH Work Group report concluded that a public dialogue about the future of OIH was critical, that dialogue has come late and has been fraught with mistrust. Plans for moving OIH to a site adjacent to Sherburne Commons had been on the boards since 2007, but the general public for the most part only became aware of these plans when the Inquirer and Mirror began reporting on SMRT’s presentation in September 2015. In particular, residents of OIH and their immediate family members remarked that they only knew what they “read in the newspapers.” Individuals were distressed by the notion of moving OIH to mid-island from its current site overlooking Nantucket Harbor. To test how strong this sentiment might be Frances Karttunen posted an on-line
petition on Change.org in support of the therapeutic value to the residents of the current site. By early November 2015, 415 people had signed the petition. Some of the signers of this petition are not Nantucket residents/tax-payers, but most of the off-island signers are relatives of OIH residents or former employees of OIH. Many left messages about why they signed. Eighty-one Nantucket residents who
signed this petition left written comments in support of the notion that being
in sight of Nantucket Harbor and the town was of great importance to current
and past residents of OIH. In response to a request for a paper petition for Nantucket residents without access to the on-line petition (because they did not use computers), a TON citizen’s
petition was circulated. Unlike the on-online petition, the citizen’s petition was open only to current Nantucket registered voters. This petition was signed by 326
certified Nantucket voters.
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Allowing for potential overlap of the two petitions and the fact that some signers of the on-line petition were not resident voters of the TON, at least 500 Nantucket
voters expressed their opinion that it is important to residents of OIH to
remain at the East Creek Road location. In response to this reaction, Town Manager Libby Gibson arranged an immediate meeting with a group of supporters of the two petitions followed by a public forum on November 4, 2015, at the Dreamland Theatre. Both these meetings were held during working hours on weekdays. A list of Frequently Asked Questions about the plans for a new OIH facility was distributed and posted on the TON website. To accommodate people who had been unable to attend the TON forums, a meeting
about the future of OIH was arranged by family members of OIH residents,
with sponsorship of the Friends of Our Island Home, on Saturday, March 5,
2016. In order to facilitate parking, the meeting was held at the Veterans of Foreign Wars facility. Charles Walters, president of the Nantucket Town Association, moderated the meeting. Poster exhibits were placed on the walls showing SMRT’s conceptual plans for a new OIH facility, and there was a brief presentation about the history of OIH. The meeting was open to public questions, and representatives from the TON, the 2013 OIH work group, and the Land Bank were on hand to address some of those questions. There was also an exit questionnaire. Fifty-eight people attended, and thirty-
nine returned exit questionnaires. An additional six responses had been submitted before the meeting. One letter was read at the meeting.
Equal numbers of respondents stated that location and model of care were
their primary concerns for the future of OIH, followed by affordability and
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availability. The overwhelming majority of respondents said they would be
willing to vote for a tax increase to pay for a new facility. Slightly less than half said their willingness would be conditional on the facility remaining on East Creek Road, while slightly more than half stated that their support of a tax increase
would be unconditional with respect to location. An overwhelming majority stated that OIH should continue to be operated by the TON. Slightly under half felt that the small house model would be appropriate for OIH. Nine felt that it would not, with others unsure about the model of care. Well over half the respondents anticipated needing OIH for themselves or for a family member in the future. About the same number were familiar with OIH because a family member of friend is or has been a resident there. Most of the respondents were over 50, with more than half that group over 65. The final tabulation of the exit questionnaire is available. A further questionnaire has been circulated. This one was offered to visitors to OIH
during the month of December 2016. Fifty-two visitors returned responses. The eleven questions seek to determine who visited OIH during the month, their pattern of visiting, their acquaintance with the general population of OIH and with the staff, whether they bring children and pets to visit, whether they combine visits with errands to nearby businesses, and to what extent they believe the present location is important to the people they visit and to themselves.8 Somewhat over half the visitors stated that they combine visits to OIH with visits to nearby businesses. Slightly under half of the visitors state that the frequency of their visits would be affected by relocation of OIH. More than half of those who say the frequency of their visits would be affected are those who visit daily or several times a week. 8 Responses to the questions about visits with children and pets and about mutual acquaintance of residents, visitors, and staff are incorporated in Appendix 2: Present Culture of Our Island Home
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Eighty percent of the visitors were of the opinion that the present location is
important to the resident(s) they visit, and eighty-two percent of the
respondents said the present location is important to themselves. The final tabulation of this questionnaire is available. Toby Shea of SK Advisors, Boston, and Jude Rabig of Rabig Consulting, Easthampton, MA, were recommended by SMRT in 2016 and subsequently hired by the TON. Shea and Rabig scheduled meetings at OIH with family members of current OIH residents, with the nurses at OIH, and with the CNAs (the individuals who provide direct care to the residents at OIH). The meeting for family members was well-attended, although it took place in the afternoon on a workday. Attendees were less than happy that the meeting was not recorded and that Shea and Rabig took no notes.
When asked for a show of hands about preference for site, with the exception
of members of the family of one resident, attendees raised their hands in favor
of remaining at the East Creek Road site. There is mixed information about the other scheduled meetings. According to hearsay, Shea and Rabig said they had heard all they needed to, and they did not hold meetings with the nurses and CNAs. Some CNAs say they did not attend any meeting with Shea and Rabig. It is difficult to determine to what extent the
voices of residents’ families or the people involved in direct care of residents
was taken into account by these consultants. Adding to discontent is the fact that Jude Rabig is an acknowledged promoter of the GreenHouse® model of care from which the small house model derives. Despite their protestations of complete
independence and their assurances that they were present to listen, Shea and
Rabig failed to inspire confidence in people they spoke with.
Some concerned Nantucketers have also been put off by the tone in which members of TON government have advanced arguments for relocation of OIH to mid-island, this tone being perceived as patronizing and bullying.
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Skepticism about the validity of some of the arguments persists. It has not been convincing to everyone that over the next thirty to forty years there is a flooding or sea-level rise issue at the present site. The work group has heard considerable opinion that the flooding issue for East Creek Road has been grossly overstated and that, on the other hand, to date the site off Miacomet Road has not been investigated for flooding issues.9 The argument that one of the consultants is “ninety-nine percent sure” that the Massachusetts Department of Public Health would not permit building at the East Creek Road site is not sufficient for all critics. A direct statement from the DPH would settle that matter. If it were true that the DPH actually would not permit a new facility on the site of the present one, the question of relocation would be moot. Short of such a definitive statement from the DPH, the controversy will continue. A salient question for concerned Nantucketers is whether construction of a new facility at the East Creek Road site is possible with the current residents of OIH continuing to reside in the present building during construction. Scenarios of closure for two years with current staff laid off and residents dispersed to mainland facilities or, alternatively, residents being universally drugged to make it possible for them to bear the noise of construction in their immediate vicinity strike some as scare tactics. Some Nantucketers experienced in the building trades believe that the present building can be incorporated into a new, expanded facility while the residents remain in place, and others are convinced that a new adjacent facility can be constructed in stages with the residents remaining in place. Individuals holding these beliefs cite instances of care facilities elsewhere being expanded without displacement of residents. They are of the opinion that the stated impossibility of such construction is not truly a matter of fact but a failure of imagination or failure of will on the part of TON government. 9 See Appendix 3: Comparative Flooding Concerns
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A suggestion has come from at least two sources that the TON construct an interim OIH building that meets Massachusetts nursing home code on TON-owned land where residents would be housed in double-occupancy rooms for the period of construction of the new permanent OIH facility. Upon their move into the new facility, the interim building would be repurposed by the TON for non-residential use. It has been stated repeatedly that everything presented to the public so far is “conceptual” and open to negotiation, but at the same time the BOS insists that location and model of care have been decided and are non-negotiable. A core principle of the GreenHouse®/small house movement is choice (“expanded choices of when, where, and what to eat, wider control over daily activities, and a wider choice of meaningful activities”), but in the matter of site and model of care, the choice has been made by a small group of individuals apparently contrary to the concerns articulated by a large number of Nantucketers (not a “small but vocal minority” as reported in the Inquirer and Mirror). Suspicion has been expressed that someone is bound to profit by disposition of the current harbor-side site (described back in 2009 as “attractive”) and potential merger and privatization of OIH and Sherburne Commons. Had planners back in 2007 sought public input and commissioned a design for a new 45-bed facility on East Creek Road with temporary on-island accommodation of OIH residents during expedited demolition and construction of a new facility, the current residents might already be living in a new energy-efficient and comfortable OIH. The work group recommends that another firm be engaged through the required Commonwealth of Massachusetts procurement process to review the current site
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and what options exist for renovating the current facility at East Creek Road, this to be done independently of the Board of Selectmen. Second, for a requested appropriation to pass at the Annual Town Meeting and then on a subsequent paper ballot, the warrant article needs to include some clear, unequivocal language that at this point can only be achieved by amendment from the floor of the Annual Town Meeting. In the work group’s consensus opinion such language must state what the disposition of the current land on East Creek Road will be if the new OIH is built at the land abutting Sherburne Commons. It is insufficient to hope that the Land Bank might purchase it for fair market value or to leave any question about its actual (versus intended) use. The TON must commit to repurposing and funding the site for community use such as the Saltmarsh Senior Center and/or the currently proposed funeral home for Nantucket. It must commit in irrevocable language that the land will not be sold off as private property. The TON must also commit unequivocally to: 1. Continuing to own and operate a skilled nursing facility of adequate size for the future needs of Nantucketers. 2. Guaranteeing non-privatization of OIH if not in perpetuity, then at least for the next fifty years, to be followed by renewal of that commitment. 3. Incorporating language that unambiguously states that the operation of OIH and Sherburne Commons will not, now or in the future, be merged. With these provisions written into the warrant article, there is a chance that the appropriation will pass. Otherwise, in our opinion, it will be back to the drawing board by all of us older and wiser than when the present proposal developed its momentum. We must find Nantucket solutions to Nantucket issues, and we have to get it right the first time.
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APPENDIX 1: HISTORY OF OUR ISLAND HOME This is not the first time location and model of care for Nantucket’s fragile citizens have changed. The history of OIH, originally Nantucket’s asylum for the indigent, goes back to 1822 when the Town of Nantucket purchased a farm in Quaise for the purpose of relocating the town’s poor, aged, and disabled, whose support had become an increasing drain on TON finances. On this farm it was expected that the “inmates” would raise their own food. Despite criticism that the location was too remote, the farm too large, and the residents too debilitated to do farm work, the plan went ahead. When fire broke out in 1844, ten of the fifty-nine residents perished before help could arrive. The TON subsequently invested in a new asylum building in Quaise. Ten years later, the Quaise farm experiment was abandoned, and the building (now Landmark House) was moved to its present location on Orange Street in front of the present OIH site on East Creek Road. The asylum in its new location, complete with a chapel and a locked cell in the basement, continued to be a place “for the care of the needy, mentally ill, homeless, and diseased,” and they were still expected to grow their own food, which they did in the adjacent area known as Poverty Point. The Nantucket Historical Association preserves the records of the crops raised by and for the people who continued to be called inmates. In 1905 the Asylum was renamed “Our Island Home” with a mission to provide “tender loving care of the infirm aged,” a radical change from the judgmental and punitive model of the nineteenth century. In 1975 the Commonwealth of Massachusetts was closing all care facilities housed in wooden buildings. Inspectors cited twenty-six changes that would have to be made in the OIH building, changes that could not be accomplished without
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destroying the 1845 building. The Inquirer and Mirror published the required modifications for its readers to see. At the time, Nantucket Cottage Hospital expressed interest in building a wing onto its Prospect Street building to serve as a nursing facility, thereby relieving the town of operating OIH. When the Inquirer and Mirror interviewed the OIH residents about this plan, however, they expressed strong feelings against moving from their current location, citing the active harbor view and the refreshing air that came over the water to them. Tom and Marie Giffin, then publishers of the Inquirer and Mirror, editorialized about the proposal to move the residents of OIH to Prospect Street, where—as one OIH resident put it—the only thing they would have to look at would be a graveyard (the Historic Coloured Cemetery located adjacent to the hospital). On August 10, 1978, the Giffins wrote: ”If, for any unimaginable reason, we should cancel the new Home and add on to the Hospital instead, the location would no doubt be put up for sale to get it on the tax rolls. With its beautiful view it would command a handsome price, and before long, it would be built upon by one, or two, or several monied persons. (Certainly none of us could afford to build there.) Then, every time any of us drove by and looked at those expensive houses, and thought of the tax money we were receiving from them, we would feel a little sick to our stomachs. No one can steal from old folks, perhaps their own parents, without feeling a little sick … After all, it’s our own future, too, that we are defending.” A member of the Board of Selectmen pointed out that if the Department of Public Works were to move its facility on East Creek Road to Madaket Road, next to the landfill, the site it vacated could be utilized for a new Our Island Home building meeting all code requirements, and this is what was done. At the time, the Commonwealth of Massachusetts would only reimburse the town for double-occupancy rooms, whereas the residents in the old wooden building each
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had a single room. The TON built the new facility with twenty-one shared rooms paid for with state funds and three single-occupancy rooms that the TON paid for. When it opened in 1981, the residents of Our Island Home were delighted with their new building, even though they had to choose roommates. Nantucketers tend to have long memories, and thirty-five years later many still recall the scheme to transfer the operation of OIH to a private operator (in that case NCH) and the threat of the sale of the East Creek Road land, a plan averted at the time only to come up again beginning in 2009.
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APPENDIX 2: PRESENT CULTURE OF OUR ISLAND HOME At the 2016 annual meeting of the Nantucket Civic League, a question came from the floor about the nature of Our Island Home. The questioner asked what OIH is, whether it is a warehouse for the island’s elderly. The answer was that it is certainly not an elder-warehouse. But what is it? First and foremost, it is a community of residents, their families and friends, and the people who work there. Twenty-four hours a day, seven days a week, fifty-two weeks a year, these groups interact to provide Nantucket’s frail elders a safe home when they are no longer able live in their own homes. OIH is not a life-style choice. The 45-bed facility is not assisted living; it is a Medicare and Medicaid/MassHealth certified skilled nursing facility. At the Nantucket Civic League meeting it was mentioned that some people are resident short-term at OIH while undergoing rehabilitation after hospitalization, but these temporary residents are few. For most residents, OIH is their final home. Some live there for years, others only briefly, but while they do live at OIH, they are part of a community. Deaths are grieved by fellow residents and staff, along with family members and friends. There is an annual memorial service for those who have died during the year. Nantucket families typically care for their elders at home as long as they are able and often longer than that. People only become OIH residents when there is no longer any safe alternative. By the time this comes to pass, many have been cared for at home for considerable time with the aid of CNAs from one of only a couple of agencies that provide this service on-island. As a result, a large percentage of the OIH residents are substantially disabled in multiple ways. The majority of residents are wheelchair-bound.
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Often those who are ambulatory present disturbed thought processes that make it clear that they could not safely live alone at home or with family members, no matter what visiting support services might be available. How is OIH something other than a warehouse for people who must live there? A case has been made that they are living in an outmoded “institutional” setting which is one of only two municipally owned and operated nursing facilities in the Commonwealth of Massachusetts. The other is in Taunton. The Taunton Nursing Home is a 101-bed facility offering both rehabilitation and long-term residential care in a two-story 140-year-old building that is comparable to Nantucket’s Landmark House. Two privately owned care facilities with superior evaluations are located nearby. In recent years the Taunton Nursing Home has been a troubled institution, with operating violations and fines and a mass resignation from its board in December 2015. The city has been encouraged to sell the facility off to avoid financial losses. In terms of residency, Our Island Home is less than half the size of the Taunton Nursing Home and currently occupies a 35-year-old building that has suffered from deferred maintenance. It is generally acknowledged that as a stand-alone facility it is not an attractive property for any potential private purchaser. Moreover, since Nantucket is a remote island, there is no option of transferring patients to any accessible nearby facility. What is good about Our Island Home?
1. Location First and foremost, it locates its residents, the staff members who care for them, and the people who visit them in a dynamic environment that could and should give the Town of Nantucket bragging rights throughout Massachusetts and, indeed, in the nation.
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On town-owned high ground behind an extensive saltmarsh, OIH has a view across the harbor to the town’s waterfront, its roofs and church towers, and Brant Point Lighthouse. By comparison, many mainland nursing facilities are located next to busy highways, in crowded urban environments, or elsewhere on land that has been available at low price to developers. During their younger years, Nantucket’s elders may not have been able to live within sight of the open water that is our common heritage, but as Our Island Home residents, they wake each morning to the day’s tides and skies. The Creeks, the saltmarsh that separates them from the harbor, is full of activity that changes with the seasons. In spring migratory birds, especially big conspicuous egrets, arrive. In the summer the harbor fills with pleasure craft, and the Creeks are busy with day-campers, beach-goers, kayakers and paddle boarders. In autumn, the summer birds depart and others arrive; the humans on the beach are mostly dog-walkers; and with the thinning out of pleasure craft, the daily comings and goings of the scheduled passenger boats become more apparent. Soon the scallop fleet is out on the water. As the days shorten, some of the OIH residents wait each evening for the red light of Brant Point Lighthouse to come on. The winter saltmarsh is at times snow-covered or iced over, with storm clouds filling the sky above. Then spring brings the fresh green once more. Whatever the time of year, the residents, staff, and visitors are treated to sunsets. There is no need to employ landscape design and extensive maintenance. Nature provides this spectacular year-round show for free. It has been alleged that the residents of OIH are universally so impaired that they are unaware of their surroundings. This is patently false. In warm weather, the outdoor patio overlooking the Creeks and Nantucket Harbor is a favorite place for residents. On the Fourth of July and in August when the Boston Pops comes for its annual performance at Jetties Beach, residents, staff, and lots of children gather on the OIH patio to enjoy the fireworks. The Friends of Our Island Home hold staff-appreciation events and ice-cream socials there.
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Once cold weather sets in, the window at the end of the north corridor overlooking the harbor draws residents as well as staff doing their paperwork. The table and chairs at this window are popular for small family gatherings. Bible studies take place there. Recently a couple had their wedding there so the bride’s mother, an OIH resident, could attend without leaving the building. The visitors’ parking lot has the same sweeping view, and many family members find it helpful to sit and contemplate it for a few minutes before and after visits. None of this should be given up lightly.
2. Community Just as Nantucket’s geographical and cultural situation is unique, so is the cohesive OIH community of residents, staff, family members, friends, and volunteers. Nantucket is different. The arguments framing “institutional” (bad) versus the current small house model of architecture and organization (“good” or—at least—au courant) may be inappropriate when applied to Our Island Home. To begin with, many institutional ills have to do with scope. A facility with hundreds of residents is quite different from a community of forty-three to forty-five residents. The small house model of care may well be an improvement over eldercare institutions on the mainland with their hundreds of residents who typically enter such facilities without knowing any of the people (fellow residents and staff) they are joining. It may not be the best Nantucket solution. Nantucket is a maritime community. Over the course of the twentieth century, most of the dwelling houses in the core town, particularly those with a view of open
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water, have been acquired by wealthy seasonal residents, Consequently, year-round Nantucketers and their businesses have migrated to mid-island. So long as they remain healthy and mobile, Nantucketers drive to places with water views. Once age and illness put driving out of the question, they become dependent on others to get them out and about. The one thing they have been able to count on is that if they ultimately have to enter OIH, they will spend all their waking hours of their last years in contact with the water and their town. Residents at OIH are not shut away and forgotten. According to the December 2016 visitors questionnaire, nearly seventy percent of the visitors in December say they regularly visit anywhere from once a week to daily. Slightly over half visit for special events such as holidays and birthdays. About a third of the visitors bring children to OIH. Slightly less than a third bring pets to visit. About seventy percent of the visitors say they know several or most of the OIH residents, and eighty percent of the people who know current residents knew them from before they entered OIH. Nearly forty per cent of the visitors say they know most of the OIH staff members by name. Sixty percent of the people who claim to know most of the staff by name are daily or weekly visitors to OIH. Adding those who say they know most of the staff members by name and those who say they know several by name yields over 76 percent of the visitors. Would there be any benefit to separating OIH residents—many of whom have known each other before entering OIH—into residential groups of ten or twelve? Why is living with nine other residents, with bedrooms opening onto an interior central space with one table for dining and an artificial fireplace used to create a “hearth,” better than residents living all together and going for meals to a spacious dining room where people can sit at tables for four and look out the windows?
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Currently, the ambulatory residents at OIH are helpful to the residents in wheelchairs. They are often the ones to bring wheelchair-bound residents into the dining room. They retrieve things that drop on the floor. They fetch things. They create jobs for themselves such as keeping the glass on the paintings and photographs on the hall walls free of smudges, watering the container plants on the patio, and assisting with arranging and delivering the flowers donated weekly by a local florist. This mixture of abilities is a good feature of Our Island Home. At OIH there are no set visiting hours. Visitors come and go at whatever times best suit individual residents. Several current residents have family members who spend hours of every day joining them at meals and generally keeping them and other residents company. Visitors help bring residents into the dining room for meals and take part in group activities. One of the factors that makes visiting and volunteering easy at Our Island Home is its location close to businesses that Nantucket residents use on a daily or weekly basis: a large grocery store, post office, banks, pharmacies, home center, office products store, bakery, barber shops, etc. The current location facilitates combining errands with dropping in to visit OIH. The notion that times of rising, dining, and going to bed are rigid at OIH is untrue. There is flexibility in all these things. Alternative meals are always on offer, meals are held for residents, and warm food is available at all hours. Meals are served in the dining room, in other spaces at OIH, and by request in residents’ rooms. The dining room with its tables for four is popular to the point that residents congregate at the door ten or fifteen minutes before mealtimes and socialize before going in. The small house principle that residents should be involved in preparation of their meals or at the least should directly see and smell their meals being prepared is unconvincing. Resident weight loss is generally not a problem at OIH.
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An active OIH Resident Council is facilitated monthly by the activities director. The corresponding Family Council, facilitated by the OIH social worker, is currently not doing as well. Its monthly meeting takes place during the day on a weekday, precluding participation of family members with jobs. Currently there are plans to try different meeting times, including the possibility of evening meetings. OIH benefits from fund-raising carried out by the Friends of OIH to support activities and services that improve the quality of life of OIH residents. Friends of OIH also take an active part in putting on celebrations for the residents, staff members, families and children. OIH is also fortunate in the number of volunteers who serve in many capacities on a weekly basis. One of the characterizations of mainland eldercare is, nearly universally, of white elders are being cared for by immigrant women “of color.” By contrast, both the residents of Our Island Home and the staff members represent a rainbow of diversity. There is low staff turnover, especially as compared with mainland care facilities. According to a National Institutes of Health publication (Mukamel, et alia), turnover rates, especially for CNAs, has remained high nationally for decades despite persistent efforts to lower them.
3. Activities
Bill Thomas, founder of the GreenHouse® movement, started out by bringing dogs, cats, and birds into care facilities. At OIH dogs belonging to the staff are regular all-day visitors, and visitors’ dogs and cats are welcome. The occasional horse or bevy of miniature donkeys shows up. The schedule of weekly and monthly activities is busy. OIH’s passionate corps of daily Bingo and Trivia players has been in existence since at least the 1990s,
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facilitated by a number of veteran volunteers. Under the present activities director and assistant activities director, a great deal goes on every day at OIH, and there is something for almost everyone. Throughout the day and week there are many of the same activities that are described as part of the small house care model. The Friends of Our Island Home provides a budget for paid entertainment, both regular and occasional. This includes magic shows, visiting performers from off-island, musical performances by local artists, and the like. Many more activities are provided gratis. Among the scheduled weekly activities are floral arrangement; Bible study; art; Music for Memories; a weekly interactive slide show; a weekly “gam” that includes jokes, reading aloud, and conversation; a weekly newspaper discussion group; and interdenominational Sunday services. Seasonally, there are weekly bicycle outings with the Wheelers, a voluntary organization that takes residents out for rides on specially constructed bicycle-powered wheelchairs. Most weeks there are van rides around town for residents. Every holiday is celebrated, often with Nantucket pre-schoolers coming in to sing and dance. Every resident’s birthday is celebrated, both on the day and again at a group celebration once a month. What is wrong with OIH at present?
1. Obsolescent building First and foremost, the building is worn out. Old Nantucket houses were built (“overbuilt” according to one developer) to last. Many of us live in century-old houses, so it is difficult to believe that a building constructed less than forty years ago is unsalvageable, but apparently it is.
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The present OIH building was built to code for its time and to maximize state reimbursement. The double rooms are small, and it is difficult for the nursing staff to treat a sick patient in private. Moreover, the building was built in a manner that may have been considered economical at the time, but has proved far from that in the long run. Built on a slab, it is difficult or impossible to carry out repairs and maintenance on anything underneath. Eventual demolition will require jackhammer sectioning and removal of the slab. The building was, intentionally or otherwise, built for obsolescence, and routinely deferred maintenance has worsened the situation. There is insufficient storage space for everything from residents’ wheelchairs and walkers to hoist equipment to daily supplies. The bathtubs required by the state, which once provided relaxing hydrotherapy for residents, have long since worn out. The 24-hour kitchen that provides warm and cold beverages and food to residents 24/7 needs total renovation. The furniture is worn. The beautician who cut and curled hair and trimmed beards has retired, and the little salon stands empty. Besides the table and chairs at the ends of the corridors, there are no comfortable places for residents to gather in small groups.
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APPENDIX 3: COMPARATIVE FLOODING CONCERNS Much continues to be made about the potential hazard to the East Creek Road location from storm surge, catastrophic breach of the Haulover at the head of Nantucket Harbor, effects of a category 5 hurricane, and sea-level rise. The chair of the work group contacted Dr. Sarah Oktay about flooding potential in Nantucket Harbor. Dr. Oktay responded that while she advocates against waterfront construction in general, she does not see a likely threat to the East Creek Road site from sea-level rise in the next thirty to fifty years. She provided a number of references to publications about sea-level rise in our area. While considerable attention has been focused on potential flooding at the East Creek Road site, no attention was given by SMRT in its feasibility study to flooding potential at the site on Miacomet Road. An ocean storm surge up Miacomet Valley, which lies right against Miacomet Road, could potentially cut off the proposed new OIH site from access to/from both Nantucket Cottage Hospital and the Nantucket Fire Department in its present location. The potential for this merits further investigation. Work group member Virginia Andrews, a veteran of seven years on the TON Conservation Commission offers the following:
The Sherburne Commons site is closer to the South Shore, which faces the Atlantic
Ocean and suffers the highest erosion rate in Massachusetts. Sherburne Commons is
adjacent to Miacomet Pond, which is separated from the open ocean by a barrier
beach which breaches during seasonally high tides as well as storm events. Miacomet
Pond is also subject to rainwater accumulation over a large watershed, with
complaints of wet basements coming from as far away as First Way. If we are going to
evaluate East Creek Road based on the severity of a storm capable of possibly raising
water in the entire reach of Nantucket Sound to a height of more than 12 feet, similar
calculations should be provided for Sherburne Commons, figuring in shoreline retreat
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over the life of the facility, as well as rainfall for the Miacomet watershed. I
reference Nantucket Sound rather than the harbor because most of Coatue is
significantly lower than the current OIH site, unlike the New Orleans levee that broke
during Hurricane Katrina. Furthermore the present OIH site is protected by an
extensive saltmarsh, which is more erosion-resistant than the unconsolidated sand of
the South Shore.
FEMA Maps are valid planning documents. They predict locations where
problems may be reliably and repeatedly expected, and assist planning and zoning
officials in appropriate development. For example, they include the Washington Street
Town Building where the finance dept. is located, as a vulnerable site. It did indeed
flood during winter storm Juno, and likely will again. Because they impact
development and insurance costs, FEMA maps err on the side of caution.
In contrast, the NOAA “SLOSH” models are not planning documents, but rather
tools which can be calibrated to whatever setting the user wants to look at. The models
are designed to assist emergency mangers in reacting to specific weather predictions.
For example, a National Weather Service forecast may indicate a possible storm surge
at time of high tide. Typical winter storm model predictions that I can recall are
around .5 to 1.3 feet for Nantucket Harbor, and higher for east-facing shores. As “the
max of the maximum” they err on the side of alarmism.
It is up to Town officials, residents and individual property owners to decide
what is likely or prudent, or conversely, what level of risk is acceptable to them.
For the South Shore, even FEMA maps are somewhat lacking in details based on
actual measurements due to lack of data because of lack of buoys in the open ocean. (I
attended the meeting at which FEMA officials discussed the new maps.) I expect SLOSH
models suffer from the same lack of data. Depending on the surge level at which they
are set, they show flooding in areas of town that are already well-known as flood zones
or are former wetlands that have been filled in to varying degrees. On the South Shore
SLOSH appears to reflect primarily elevation, which is not entirely relevant to the top
of a dune on a retreating shoreline.
The fetch of wave action for the South Shore is approximately 2,000 miles. The
fetch of wave action at East Creek Road, which faces Nantucket Harbor, is less than a
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mile. Even if the Sound were to be included, the fetch is approximately 28 miles, still
significantly less than the Atlantic Ocean. The most likely release of storm water
accumulation in Nantucket Harbor is over Coatue, as happened during the 1991 No-
name Storm. Nantucket Sound is already open at the east and west, so it is not
comparable to the flooding suffered in Queens New York, during Superstorm Sandy.
The most likely release of excess water in the Sound is through natural re-opening of
the cut through Smith’s Point between Esther’s Island and Madaket, and across the
Galls on the way to Great Point, both phenomena that have been occurring periodically
since at least the 1960s and 70s, if not before.
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RELEVANT LITERATURE Cohen, Lauren W., et alia. 2016. “The Green House Model of Nursing Home Care in Design and Implementation.” In Health Services Research.
http://80.191.214.158/bitstream/Hannan/88662/1/2016%20Volume%2051%20Supplement%201%20February%20(8).pdf A comparative study of Green House facilities and “legacy” (traditional, institutional) nursing homes. Areas in which Green House principles are consistently observed and those in which they are not. Also areas in which outcomes are significantly better in one or the other. Gawande, Atul. 2014. “Chapter 5. A Better Life” in Being Mortal: Medicine and What
Matters in the End. Metropolitan Books. Grabowski, David C., Project Director, Robert Wood Johnson Foundation. ND. “Comparing the Green House model with traditional nursing homes on cost and quality of care.”
http://www.rwjf.org/en/library/grants/2011/06/comparing-the-green-house-model-
with-traditional-nursing-homes-o.html
Financing, marketing, and culture change. “The Foundation's Green House Initiative was
designed to: (1) increase the Green House adoption rates from 25 homes per year to 125
through intensive financing, marketing and policy activities; (2) develop a series of
program evaluations; and (3) use the Green House Initiative as the catalyst for
transforming institutional care at skilled-nursing homes.” “The ‘culture change’ movement
is transforming long-term care by promoting more home-like facilities and providing more
options for consumers to receive care how and where they want it, in their communities.
These models typically include new types of physical environments, organizational
practices, and workforce features that benefit consumers and direct care workers while
remaining cost-effective.” Moeller, Philip. April 4, 2013. “Green House Building New Senior Living Model” in U.S. News. http://money.usnews.com/money/blogs/the-best-life/2013/04/04/green-house-
building-new-senior-living-model
Saving on cost of staff and by charging more to private-pay residents: “Central to
making Green Houses work…is that nearly all of the care is provided by certified nursing assistants (CNAs). Traditionally at or near the bottom of the nursing-
home skills ladder, these CNAs receive special training to allow them to perform
nearly all of the staffing and management tasks needed inside a Green House.
This flat management structure can save a lot of money.” “While the houses are
often more expensive to build per unit than larger nursing homes… the staffing changes can make them economically competitive.”” Surveys have found that
people are willing to pay more for Green House living units than for other types of
assisted living… people would be willing to pay up to 20 percent more [for a
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Green House room] than they would pay in the market for a private room in a
nursing home." Mukamel, Dana B., et alia. 2010. “The Costs of Turnover in Nursing Homes” in Med Care, National Institutes of Health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2761533/
“As far back as the mid 1970s studies have documented average turnover rates
for registered nurses (RNs), licensed vocational nurses (LVNs) and certified
nurses aides (CNAs) ranging between 55% and 75%. Rates have remained high throughout the decades, often exceeding 100% for CNAs, the most common type
of caregiver in nursing homes. These high rates have persisted despite the large
number of studies documenting an association with poor quality of care, and an
ongoing concern among scholars and policy makers about the level of turnover in
nursing homes, as well as recent policy initiatives in many states that are aimed at lowering turnover rates.” Nelson, Gaius G., SMArchS, NCARB, ND. “Household Models for Nursing Home Environments,” a publication of Nelson-Tremain Partnership: Architecture and Design for Aging.
This 38-page report covers the history of nursing home design and the rise of “homelike” facilities plus a survey of regulatory challenges to the creation of care
facilities modeled on small-house/GreenHouse® principles.
Rabig, Jude. ND. “Small House Nursing Homes: Some are trademarked as Green Houses®” Livable New York Resource Manual
http://www.aging.ny.gov/LivableNY/ResourceManual/Index.cfm A concise description of the small house principles including the stipulation that such a facility provide “environmental cues that enable frail residents to
understand their surroundings, retain a feeling of familiarity, and perceive a
“sense of place”—which is particularly essential for residents with dementia.” Rabig, Judith and Donald. April 1, 2008. “From ‘nursing home” to ‘home’: The small house movement.” In iAdvance Senior Care.
http://www.ltlmagazine.com/article/nursing-home-home-small-house-movement#.WAESNr9V7Jg.gmail
Characterization of the small-house model of care by one of the consultants hired
by the TON: “A small house is an intentional community of 10 to 14 persons and
a staff of highly trained workers …When completely implemented, small house
…supplies sufficient staff and equipment to support personal care.” Rabig, Jude, William Thomas, et alia. 2006. “Radical Redesign of Nursing Homes: Applying the Green House Concept in Tupelo, MISS.” In The Gerontologist 46 (4): 533–39.
http://www.commonwealthfund.org/~/media/files/publications/in-the-literature/2006/dec/radical-redesign-of-nursing-homes--applying-the-green-house-concept-in-tupelo--
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miss/rabig_radicalredesignnursinghomesgreenhouse_tupelo_981_itl-pdf.pdf An early example of advocating for the GreenHouse® model of care by Jude
Rabig.
Semuels, Alana. April 21, 2015. “Building Better Nursing Homes: After plenty of isolated successes, the question isn’t what good nursing homes look like, but how to transform existing facilities into places that look like them.” In The Atlantic.
https://www.theatlantic.com/business/archive/2015/04/a-better-nursing-home-
exists/390936/
A history of the Leonard Florence Center for Living, Chelsea, MA, and Barry Berman’s plan to transform an existing facility into one that resembles the
Leonard Center. “He’s now embarking on what may be his most ambitious
project yet—an effort to transform the nursing home where he'd first put his
mother into a place that looks more like the Leonard Florence Center. It may not work. Nursing homes have been run the same way for decades, in part to meet
government regulations and to qualify for government payments such as
Medicare and Medicaid. And it's harder to turn an existing place around than it is
to build a better one from scratch.” Span, Paula. September 23, 2016. “Wages for Home Care Aides Lag as Demand Grows.” In The New York Times. https://www.nytimes.com/2016/09/27/health/home-care-aides-wages.html
“Home care aides, mostly women and mostly minorities, represent one of the
nation’s fastest-growing occupations, increasing from 700,000 to more than 1.4 million over the past decade.” Span, Paula. January 31, 2017. “Residents Gain New Rights in Nursing Homes: New federal rules strengthen protections but do not set staffing requirements.” In The New York Times. https://www.nytimes.com/2017/01/27/health/nursing-home-regulations.html
Staffing issues remain. “The government…declined to incorporate specific staff ratios or minimum hours of care in the new regulations, or to require nursing
homes to have registered nurses on site around the clock. (Current rules require
R.N.s only for eight hours.)” Wood, Debtra, RN. 2012. “Universal Workers Build Skills and Relationships to Enable Person-Centered Care” in Leading Age, May 14, 2012.
http://www.leadingage.org/magazine/mayjune-2012/universal-workers-build-
skills-and-relationships-enable-person-centered-care
Even though written in 2012, this article is relevant to the discussion about new roles for CNAs, and the possible use of home health aides who are not CNA's…
blurring between settings, roles, and responsibilities and also resistance, among
some workers, to changing their roles.