An Analysis of the Demand for an Assisted Living Facility in the Wagoner, Oklahoma, Medical Service Area

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1 An Analysis of the Demand for an Assisted Living Facility in the Wagoner, Oklahoma, Medical Service Area Oklahoma Cooperative Extension Service Rural Development Oklahoma State University Oklahoma Office of Rural Health Rural Health Policy & Research Center Oklahoma State University March 2010

2 AE An Analysis of the Demand for an Assisted Living Facility in the Wagoner, Oklahoma, Medical Service Area Lara Brooks- Assistant State Extension Specialist, OSU, Stillwater ; FAX Brian Whitacre - Extension Economist, OSU, Stillwater Jack Frye - District Rural Development Specialist, OSU, Ada Alan Parnell - Wagoner County Extension Director, OSU, Coweta Val Schott - Director, Oklahoma Office of Rural Health, Oklahoma City Oklahoma Cooperative Extension Service Rural Development Oklahoma State University Oklahoma Office of Rural Health Rural Health Policy & Research Center Oklahoma State University March 2010

3 An Analysis of the Demand for an Assisted Living Facility in the Wagoner, Oklahoma, Medical Service Area This report will examine the need for an assisted living facility in the Wagoner County, Oklahoma medical service area. This report briefly describes the process decision makers can utilize to help determine the demand for an assisted living facility. Specifically, the study will: 1. Determine the service area and population; and 2. Estimate the number of potential participants in the service area. No recommendations will be made. The information included in this report is designed to assist local decision-makers in assessing the need and potential for an assisted living facility. Introduction The population of the United States continues to age. Those ages 65 and over are making up a larger percentage of the total population. In 2000, the age group of 65 and over accounted for 12.4 percent of the total U.S population and 13.2 percent of the state of Oklahoma s population. This percentage had increased to 12.6 percent and 13.3 percent respectively, according to 2008 estimates by the U.S. Census Bureau. This increasing trend is extremely evident in rural Oklahoma. Rural areas also tend to have higher percentages of populations aged 65 and over. The U.S. Census Bureau estimates for 2008 indicate that those aged 65 and over account for 9.8 percent of the total population in Wagoner County. This is a slight decrease from 2000 when Wagoner County reported that the 65 and over population accounted for 10.2 percent of the total population. These numbers are expected to continue to increase as the Baby Boomers reach closer to retirement. 1

4 With a growing aging population many questions are raised about long-term care options. In particular, there are many concerns about long-term care options in rural areas. Traditionally, there have been fewer options for the rural elderly population needing assistance with activities of daily living (ADLs) such as bathing and dressing. Nursing home care or living with a family member, when available, were the only options. In more recent years, assisted living facilities have begun to spread out into rural areas. There are significant differences between assisted living and nursing home care. The U.S. Department of Health and Human Services describes an assisted living facility as an alternative housing option for older adults who may need assistance with dressing, bathing, eating, and toileting, but do not require the intensive medical and nursing care provided in nursing homes. Therefore, those who need assistance with a few ADLs have the option of an assisted living facility instead of nursing home care. Services provided in assisted living facilities may include: Three meals a day served in a common dining area; Housekeeping services; Transportation; Assistance with eating, bathing, dressing, toileting, and walking; Access to health and medical services 24-hour security and staff availability Emergency call systems for each resident s unit; Health promotion and exercise programs; Medication management; Personal laundry services; and Social and recreational activities The percentage of residents needing help with ADLs varies per activity. The National Center for Assisted Living estimated that 64 percent of residents needed help bathing, 39 2

5 percent needed assistance dressing, 26 percent needed help toileting, 19 percent needed help transferring, and 12 percent of residents needed assistance eating. They also concluded that 87 percent of the current residents need assistance with meal preparation, and 81 percent needed help managing their medications (National Center for Assisted Living, 2009). Another major difference in assisted living care versus nursing home care is the cost. Since intensive medical and nursing care is not required for assisted living facilities, there is often a substantial difference in cost. A survey in 2009 completed by MetLife Mature Market Institute found that the national average overall cost for a one-bedroom assisted living facility room was $3,131 per month. This is compared to the national overall average cost of a one bedroom private room in a nursing facility is $6,661 per month. The average monthly rate per patient for a private one bedroom assisted living facility room was $2,503 in Oklahoma. This compares to the average of $3, per month for nursing home care in Oklahoma. Much of the funding for one s stay in an assisted living center largely comes from personal funds. According to the National Center for Assisted Living, 66.7 percent of the total funds for assisted living are from personal funds. Medicaid accounted for 9.1 percent of funding for residents of an assisted living facility. These statistics are represented in Figure 1, along with other funding sources for assisted living. This heavy reliance on personal funds implies that lower-income individuals may have a hard time paying for assisted living services. 3

6 Figure 1. Funding Sources for Residents of Assisted Living Centers 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 66.7% 13.5% 9.1% 8.4% 1.8% 1.5% Long Term Care Personal Funds Medicaid Supplemental Insurance Security Income Family Assistance Managed Care Source: National Center for Assisted Living, Survey 2001 The total number of assisted living facilities in Oklahoma for 2009 reached 121 with 80 located in metropolitan areas, and 41 located in nonmetropolitan areas (Oklahoma State Department of Health, 2009). There are a total number of 7,312 assisted living facility beds/rooms statewide. The facility size ranges from 5 beds/rooms up to 166 across the state. The average number of beds/rooms for assisted living facilities in a nonmetropolitan area is 49, which is lower than the metropolitan average of 67. This compares to the state average of 60 beds/rooms. Table 1 depicts these results. Table 1 Number of Assisted Living Facility Beds/Rooms for Oklahoma, Metropolitan Areas, and Nonmetropolitan Areas Total Average High Low State 7, Metropolitan 4, Nonmetropolitan 2, Oklahoma State Department of Health, Directory of Oklahoma Licensed Long Term Care Facilities, 2009, website: 4

7 Medical Service Area Estimating potential participation for an assisted living center requires defining the service area for the facility, identifying the population of the service area and calculating the different age groups within the service area. Figure 2 shows the proposed medical service area with the surrounding assisted living and nursing facilities according to the latest Oklahoma Medical Facilities Directory (April, 2009) obtained from the Oklahoma State Department of Health website. The proposed service area for the Wagoner assisted living facility is derived by considering the relative travel distances to the alternative facilities. The proposed medical service area includes all of the zip codes shown in Table 2. Table 2 presents the 2000 census estimates and 2000 estimates from ESRI (a different data source) for comparison purposes. Zip code delineations are arbitrary and change frequently resulting in slight differences between the two estimates. Zip Code data is not available from the U.S. Census for Therefore, population from the 2009 ESRI estimates will be utilized in estimating number of participants. The 2009 ESRI estimated population of the medical service area is 60,462. As is common in this part of the state, all towns included in the analysis have experienced an increase in population since the 2000 ESRI estimates. The largest zip code population in the medical service area is Wagoner with an estimated population of 18,259 for The population for Coweta is second with a total count of 14,132. Locust Grove and Inola follow with populations of 6,787 and 6,662, respectively. 5

8 Figure 2. Wagoner Proposed Service Area for Assisted Living Facility SOURCE: Oklahoma State Department of Health Denotes Existing Assisted Living Facility Denotes Existing Nursing Home Facility Proposed Service Area County City Facility Type Beds Cherokee Tahlequah, OK Cherokee County Nursing Care Nursing Home 100 Cherokee Tahlequah, OK Go Ye Village Med-Center Nursing Home 42 Cherokee Tahlequah, OK Grace Living Center- Tahlequah East Nursing Home 125 Cherokee Tahlequah, OK Grave Living Center- Tahlequah Univ. Nursing Home 158 Cherokee Tahlequah, OK Heritage Place Assisted Living Assisted Living 55 Mayes Chouteau, OK Meadowbrook Nursing Center Nursing Home 65 Muskogee Fort Gibson, OK Fort Gibson Nursing Home Nursing Home 66 Muskogee Haskell, OK Haskell Care Center Nursing Home 58 Rogers Inola, OK Inola Health Care Center Nursing Home 65 Wagoner Coweta, OK Coweta Manor Nursing Home Nursing Home 100 Wagoner Wagoner, OK Wagoner Care Center Nursing Home 147 6

9 Table 2 Population of Wagoner Service Area Medical Service Area Population by Zip Code City Populations 2000 Census 2000 ESRI 2009 ESRI Wagoner 13,780 15,653 18, Inola 6,145 5,601 6, Chouteau 4,841 4,513 4, Locust Grove 6,763 6,682 6, Coweta 10,445 11,046 14, Hulbert 4,589 5,578 6, Porter 2,906 3,079 3,652 Total 49,469 52,152 60,462 % Change from 2000 ESRI 15.6% SOURCE: U.S. Census Bureau, 2000 Census Data, ESRI 2009 Community Sourcebook of Zip Code Demographics, 23rd ed., ESRI Business Solutions. Tables 3 and 4 divide the total service area population by age groups. Table 2 displays all age groups from 0-19 years of age to 65+. The age group of 65 and over makes up about 12.5 percent of the total population for the service area with a population of 7,557 for The largest age group is the year range. This group makes up around 33 percent of the total population. 7

10 Table 3 Population by Age for Proposed Service Area Age Census 2000 ESRI 2000 % of Total ESRI 2009 SOURCE: U.S. Census Bureau, 2000 Census Data, ESRI 2009 Community Sourcebook of Zip Code Demographics, 23rd ed., ESRI Business Solutions. % of Total ,023 15, , ,236 17, , ,014 12, , ,196 6, , Total 49,469 52,152 60,462 Since potential participation will come from those 65 and above, Table 4 further describes this population group. The largest percentages of residents 65 and over are aged years of age (58 percent). Individuals in this age group may not currently be looking for assisted living or nursing home care, but may find themselves in need of these services within the next few years. Table 4 Population 65 and Over for Proposed Service Area Age Census 2000 ESRI 2000 % of Total ESRI 2009 % of Total ,591 3, , ,018 2, , Total 6,196 6,532 7,557 SOURCE: U.S. Census Bureau, 2000 Census Data, ESRI 2009 Community Sourcebook of Zip Code Demographics, 23rd ed., ESRI Business Solutions. Table 5 offers insight into some basic economic indicators for Wagoner County. According to the Bureau of Economic Analysis for 2007, Wagoner County s per capita income 8

11 of $29,237 was lower than the state average of, $34,997. From the U. S. Census Bureau, the percent of people in poverty in Wagoner County was 11.0 percent in 2008, as compared to 15.7 percent for the state and 13.2 percent nationally. Therefore, the percentage of total people in poverty in Wagoner County was lower than the state and the nation. The percentage of people under age 18 in poverty in 2008 followed similar trends, with Wagoner County being lower than both the state and the nation. Another economic indicator for Wagoner County is the total dollar amount of transfer payments. Transfer payments represent that portion of total personal income whose source is state and federal funds. These typically include social security, Medicare, and retirement / disability payments. Total transfer payments for Wagoner County equal $324,693,000. Medical payments (such as Medicare or Medicaid) alone total $19,307,000 or 36.7 percent of total transfer payments. This percentage is less than the state percentage (42.4 percent) and the national percentage (44.8 percent). Transfer payments as a percentage of total personal income is another economic indicator for Wagoner County. In 2007, transfer payments accounted for a total of 16.5 percent of the total personal income. This percentage is lower than the state (16.8 percent) but higher than the national percentage of

12 Table 5 Economic Indicators for Wagoner County, the State of Oklahoma and the Nation Indicator County State U.S. Total Personal Income (2007) $1,962,831,000 $126,272,950,000 $11,634,322,000,000 Per Capita Income (2007) $29,237 $34,997 $38,615 Percentage of People in Poverty (2008) 11.0% 15.7% 13.2% Percentage of Under 18 in Poverty (2008) 15.3% 22.0% 18.2% Transfer Dollars (2007) $324,693,000 $21,218,050,000 $1,712,794,000,000 Medical Benefits Included in Transfer Dollars (2007) $119,307,000 $8,991,021,000 $767,270,000,000 Medical Benefits as a Percentage 36.7% 42.4% 44.8% of Transfer Dollars (2007) Transfer Dollars as Percentage of Total Personal Income (2007) 16.5% 16.8% 14.7% SOURCES: 2009 Bureau of Economic Analysis; 2009 U.S. Census Bureau. Estimating Participation Tables 6 and 7 estimate possible participation for an assisted living facility in the Wagoner Service Area. One factor for estimating the need for assisted living services is the age of the population utilizing the majority of the services. According to the National Center for Assisted Living, the average age of residents living in assisted living facilities was 86.9 years. On average, only 24 percent of the residents are male, and the typical assisted living resident is an 86 year-old woman who needs assistance with 2 ADLs. For the purpose of this study, the 10

13 service area population are 65 and over will be utilized. This age group will be divided into two groups: those between and those over 75 years of age. Adams, Lucas, and Barnes (2008) found that 3.5 percent of individuals aged years have problems with ADLs. The age group of 75 and over had 9.0 percent facing limitations with ADLs. The rates of 3.5 percent for years of age and 9.0 percent for 75 years of age and over will be used in determining participation. Another criterion for estimating the need for assisted living is the ability to pay for the services. Utilization is determined not only by what people want but by what they can afford. As stated earlier, the average monthly cost for assisted living residents in Oklahoma is $2,503. As shown in Figure 1, private pay accounts for two-thirds (66.7%) of the total funding for assisted living those residing in assisted living facilities. For the purposes of this study, the assumption will be made that those age 65 and over that are also below the 250% poverty line will not be able to afford assisted living. Therefore, these individuals will be subtracted from the potential number of participants. The number of available beds/rooms in assisted living or nursing home facilities within the service area will also be subtracted from the number of possible participants. Those already residing in an assisted living or nursing home facility were included in the population estimates, and since they are already residing in one of these options, they can be eliminated from being a potential patient for the assisted living center currently being evaluated. Table 6 displays the results of the possible participation. After adjusting for the population years of age and 75 years of age and over needing assistance with ADLs, the percentage under the 250% poverty line, and existing long-term care options, there are an estimated 33 possible participants in the service area. 11

14 Since Wagoner is located near Tulsa and other larger communities that already provide nursing home care, four of the previous zip codes were removed. Most of the removed zip codes already had a nursing home present in their community. The smaller service area includes Wagoner, Porter, and Hulbert. Table 7 estimates possible participation with the smaller service area. After adjusting for the population years of age and 75 years of age and over needing assistance with ADLs, the percentage under the 250% poverty line, and existing long-term care options, there are an estimated 75 possible participants in the new service area. 12

15 Table 6 Estimating Potential Participation for an Assisted Living Facility, Wagoner, Oklahoma (Service area depicted in Figure 2) A. Population Age Years the Service Area 1 4,380 Population Age 75 Years and over for the Service Area 1 3,177 B. Percent of Population Age Years Having Problems with ADLs² 3.5% Percent of Population Age 75 Years and over Having Problems with ADLs² 9.0% C. Total Population Years having Problems 153 with ADLs A. x B. Total Population 75 Years and over having Problems 286 with ADLs A. x B. Total Service Population 65 and Over having Problems with ADLs 439 D. Poverty Rate for Over 65 Age Group 3 6.7% E. Estimated Number of Persons 65 Years and Over Having Problems with ADLs and in poverty 29 C. x D. F. Estimated Number of Persons 65 Years and Over having Problems with ADLs LESS those in poverty 410 C. - E. G. Current Occupancy of Assisted Living Facilities 4 0 H. Current Occupancy of Nursing Home Facilities I. ESTIMATED NUMBER OF POTENTIAL ASSISTED LIVING FACILITY RESIDENTS 33 F. - (G.+H.) 1 Population from U. S. Census Bureau 2 ADL Limitation percentages: Adams, PF, Lucas, JW, Barnes PM. Summary Health Statistics for the U.S. Population: National Health Interview Survey, National Center for Health Statistics. Vital Health Stat 10(236) Poverty Rate (250% poverty level) from U.S. Census Bureau, year average for 65 years and over 4 Data obtained at either state or community level 13

16 Table 7 Estimating Potential Participation for an Assisted Living Facility in, Wagoner, Oklahoma (Wagoner,74467; Hulbert, 74441; and Porter, 74454) A. Population Age Years the Service Area 1 2,372 Population Age 75 Years and over for the Service Area 1 1,721 B. Percent of Population Age Years Having Problems with ADLs² 3.5% Percent of Population Age 75 Years and over Having Problems with ADLs² 9.0% C. Total Population Years having Problems 83 with ADLs A. x B. Total Population 75 Years and over having Problems 155 with ADLs A. x B. Total Service Population 65 and Over having Problems with ADLs 238 D. Poverty Rate for Over 65 Age Group 3 6.7% E. Estimated Number of Persons 65 Years and Over Having Problems with ADLs and in poverty 16 C. x D. F. Estimated Number of Persons 65 Years and Over having Problems with ADLs LESS those in poverty 222 C. - E. G. Current Occupancy of Assisted Living Facilities 4 0 H. Current Occupancy of Nursing Home Facilities I. ESTIMATED NUMBER OF POTENTIAL ASSISTED LIVING FACILITY RESIDENTS 75 F. - (G.+H.) 1 Population from U. S. Census Bureau 2 ADL Limitation percentages: Adams, PF, Lucas, JW, Barnes PM. Summary Health Statistics for the U.S. Population: National Health Interview Survey, National Center for Health Statistics. Vital Health Stat 10(236) Poverty Rate (250% poverty level) from U.S. Census Bureau, year average for 65 years and over 4 Data obtained at either state or community level 14

17 Summary Many assumptions have been made in the preceding analysis. These include items that may change such as the population of the service area or service area delineation. For example, the service area depicted here may change due to the exit or entry of assisted living centers or nursing homes. Should this occur, revised estimates of potential participants and service area should be made. An assisted living center can be very costly to start up and staff. Therefore, all assumptions should be closely examined by local decision-makers to verify that they reflect local conditions. Local data should be included when available. The next step in this analysis should be to consider the costs associated with setting up and running an assisted living center. Decision makers can then determine whether the potential demand and associated revenue outweigh the costs of setting up and maintaining the facility. If further analysis is needed, please contact the authors on the cover page or your county extension office listed on the cover page of this document. 15

18 References Adams, PF, Lucas, JW, Barnes, PM. Summary of Health Statistics for the U.S. Population: National Health Interview Survey, 2006 National Center for Health Statistics. Vital Health Stat 10(236) American Association of Retired Persons, Assisted Living in the United States, Fact Sheet #62R, June ESRI 2008 Community Sourcebook of Zip Code Demographics, 22nd ed., ESRI Business Solutions. MetLife Mature Market Institute Market Survey of Long-Term Care Costs: The 2009 MetLife Market Survey of Nursing Home, Assisted Living, Adult Day Services and Home Care Costs. Accessed: January National Center for Assisted Living, Assisted Living Resident Profile, 2009, website: Accessed: January National Center for Assisted Living, Survey of Assisted Living Facilities, 2001, website: Accessed: January Oklahoma State Department of Health, Directory of Oklahoma Licensed Long Term Care Facilities, 2009, website: Accessed: January 2010 Shelton, R.D., St. Clair, C., Doeksen, G.A., and V. Schott A Systems Development Guide for Rural Assisted Living Facilities. Stillwater, OK: Oklahoma State University. U.S. Bureau of the Census, 2010, website: Accessed: January U.S. Bureau of Economic Analysis, 2010 website: Accessed: January U.S. Department of Health and Human Services, Administration on Aging, Fact Sheet: Assisted Living. 2009, website: Accessed: March

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