A New Model of Nursing Homes Badly Needed

The entire issue of the December 2020 AARP bulletin is dedicated to multiple articles and perspectives on the horrific loss of life to COVID in the U.S. nursing home industry. And believe me, it IS an industry. Seventy percent of all skilled care facilities (the licensing nomenclature of ‘nursing homes’) are for-profits. 


While many researchers, experts, and workers in long-term care long saw it as a disaster, not just waiting to happen, but actually happening throughout their history, it took massive loss of life to get the journalists, politicians, workers, to put nursing home fatalities on the front page.

“Fewer than 1% of Americans live in long-term care facilities. But 40% of COVID-19 deaths have occurred there” (AARP.org/bulletin 12/2020). Within four months of the first known infection, some 54,000 residents and workers in long-term care facilities died of causes related to COVID.  

There is finger-pointing every which way. Lack of personal protective equipment, lack of availability of timely testing, too many residents per staff, poor infection control, and lock downs that kept long-term care ombudsmen from seeing what was actually happening.

Blame goes back to the 50s with misguided laws that ultimately made nursing homes, “The bastard child of the poor house and the hospital,” the late Rosalie Kane, Ph.D., revered expert on long-term care.

According to the AARP special edition, we wound up with a medical model of a crowded hospital, as opposed to, for example, a college dorm or a modest hotel. Forcing frail folks into small multiple-occupancy rooms with beds four feet apart is a petri dish for disease. If it were not for the pandemic, many people would not have foreseen the disaster predicted by experts for decades. In addition, one expects to spend a few days or at most a few weeks in a hospital. To live a life lacking in privacy, autonomy, and choice for months or years is cruel.

Many facilities have long been understaffed and underfunded. “For-profit structure appears to have reduced quality at many nursing homes.” The funding structure, with three-fifths of residents paid for by Medicaid, doesn’t make for a balanced budget. “The relatively small number of well-paying (private pay) residents make up for the money they say they lose on the rest.”

As I have ranted elsewhere, we needed a total transformation of long-term care into one that is person-centered, affordable, homey, and respects individuals, caregivers, and families. 

Green is the new silver–and gold

The two foci of my life are: mitigating global warming and improving long-term care. These are related, because both are essential quality of life issues.

COVID itself is related to global warming because as habitat for bats and other wildlife decreases, human/wild creature interactions increase, to the detriment of both. Restoring native plant habitats all over the world will do a great deal to slow down warming and potentially decrease the chance of pandemics from interactions with and consumption of wild creatures. Plus, intact forests are one of the more gigantic carbon sinks on this planet. 

Greening long-term care also has the potential to minimize the risks of COVID for both workers and residents of nursing homes, which have suffered 40% of the incidence of COVID in this country and one of the highest rates of mortality so far (Winter 2020). By greening I refer specifically to “Green House” homes, the brilliant model created by Harvard-trained MD Bill Thomas. Who among us wants to live in a small double-occupancy room with a stranger and a shared bathroom? Not only is this a recipe for conflict (particularly if dementia is involved), it’s also a petri dish for COVID and any other infection you can think of.

For decades my fellow gerontologists and other experts in this field have worked for improvement of nursing homes by teaching and action to create smaller, more homelike settings where staff and residents have real relationships. The Providence Mount St. Vincent in Seattle created this, even with a huge facility, by creating ‘neighborhoods’ on each floor with a small group of residents in rooms around a central dining, living, and hanging out area. Dr Thomas’ model involves small groups of eight to 10 in group homes with private rooms around a central kitchen, dining, and relaxation area. Variations abound, but the key is intimacy, relationships, and a physical and emotional sense of home. Washington Post (11/3/2020) did an insightful article about this https://www.washingtonpost.com/local/green-house-nursing-homes-covid/2020/11/02/4e723b82-d114-11ea-8c55-61e7fa5e82ab_story.html. With the right reimbursement from Medicare and Medicaid, as well as increased respect for the elderly and the workers who help them, it can be cost-effective. Ageism and racism are part of the reason most people haven’t even heard of this model. Our society has disrespected the immigrants, the women, the people of color who dominate caregiving, and we’ve disenfranchised older people as a culture as well.

I think with our new administration coming in January we may be able to do more about this. Systemic racism is no longer acceptable and distain for older people and their caregivers is on the wane.

A book of compassion


Review of The Elderwise Way, Sandy Sabersky, available on Amazon

People with Alzheimer’s can live a life of anxiety, sadness, and pain. Or people with dementia can live a life of joy and beauty. You will increase people’s chances of the latter if you read this book.

Compassion is at the core of all the world’s major belief systems: Buddhism, Islam, Judaism, and Christianity. “Do unto others as you would have them do unto you.”  Compassion is also the heart and core of her brilliant new book, The Elderwise Way, and the Elderwise programs.

The author describes the Elderwise day: where one is warmly welcomed with delight; seated comfortably with a warm beverage in a mug and toast at a table with fresh flowers or natural items such as shells or lovely stones. Then you are invited by a facilitator to talk or be quiet. Toward the end of the social hour the participants transition to paint or work with clay or poetry; then there are moments of meditation and guided movement with music; then a delicious freshly-cooked healthy lunch.

Heck! I wish all of our mornings started and ended this way! While the author mentions that all people should be treated as of equal value, much like Mr. Neighbors, “you are perfect just as you are,” we should all be reminded that this holds true for all people of all ages, not just ‘elders’.

You need not be a location-based entity to honor people the Elderwise way. Nor do you even need to be an elder or caregiver. Read this book and learn the how and why of better treatment of people of all ages and cognitive states. Buy this book or request it from your local library. As a writer myself, I know the agonizing suffering of birthing a book. It should not go unread!

Jeannette Franks, PhD

Why We Need a War on Weeds

I wear two hats. One hat is that of a PhD gerontologist specializing in long-term care, alternatives to nursing homes, and aging well. The other hat is as an award-winning expert on native plants and habitat restoration. They are related in an intricate web on our suffering planet. Nursing homes in the US and Europe have been particularly hard hit by COVID-19.

“Weed Warriors are not ornamental gardeners. Noxious weeds are not about dandelions. Read on!

What does a healthy native plant environment have to do with global warming? It has everything to do with global warming, not to mention COVID-19, and quality of life for humans of all ages and all living things.

As I write this in August of 2020, the U.S., ostensibly the richest country in the world, has one of the 3 highest rates of COVID-19 per capita in the world.  In addition, the virus has killed Black Americans at twice the rate of others in the country. Older people are at greater risk of contracting the virus, dying from COVID-19, or being left with lasting disabilities. The issue of global warming is connected to the corona virus in multiple ways. As habitat shrinks from rising seas and encroachment of human habitation and farming, wild creatures, such as bats, lions, rats, and the viruses, bacteria, and dangers they spread, will increasingly invade human habitations.

How can we green the planet to insure a decent world for our grandchildren and our species?

We can restore the environment around us to a more natural state. When we clear-cut forests for farms, or cities, or timber, the first plants that appear are non-native noxious weeds. These invaders can smother the more productive and desirable plants with aggressive growth, stifling the trees that help combat global warming.

Weed Warriors struggle on Bainbridge Island to return parks, forests, road ends, schools, tree farms and the like to a more natural, healthy, sustainable environment. Trees are a priority, and trees are on the front lines of global warming. I could go on about the healing qualities of green and nature, but this is a start on understanding why removing ivy, Scotch broom, tansy ragwort and other noxious weeds is important, gratifying, and fits into a larger context.

Deaths rise in nursing homes precipitously

As I write this in spring of 2020, we are seeing deaths and diagnoses of coronavirus climb. This may be the worst health disaster since the plague in the middle ages. It is yet another reason to stay out of a nursing home. A Seattle area skilled care facility was the epicenter for Washington state, which was one of the three hardest-hit states in the country early in the disease. The CDC found that a staff member in that nursing home worked two different days with symptoms, which then promptly spread to 82 residents. While the death toll continues, the first facility infected had 160 people sickened and 35 who died of COVID-19 as of February 2020. Two of the same hands-on staff there also worked at two different facilities, spreading the virus among staff and residents quickly. Nursing home caregivers often work more than one job in order to support themselves and their families. The CDC investigation also found seven people at the facility who were infected but showed no symptoms at the time. Cited from Seattle Times March 26, 2020.

According to the April 15, 2020 New York Times, “Virus deaths at U.S. nursing homes top 3,800, with 45 at one site in Virginia.” The Times included in its count nursing homes, assisted living facilities, memory care institutions, retirement communities, and long-term rehabilitation facilities. While these are all defined and regulated somewhat differently, the deaths and illnesses present one of the negative factors of congregate living of older people close together.  Perhaps these people would have lived longer lives at a higher quality of life in a different setting. Now, by April 18, 3 days later, the total is 6,900. “Over all, about a fifth of death from the virus in the United States have been tied to nursing homes or other long-term care facilities, The Times review of cases shows.” Today, April 23, 2020, deaths climb to over 10,000.

These deaths demonstrate one of the many reasons to take steps early in your maturity to avoid spending the last year of your life in a nursing home. Now, I’d best get back to writing that book!

Dementia in the Time of Coronavirus

Each day I nag myself to work on the book I’m writing, 7 Actions to Take to Stay OUT of a Nursing Home. The coronavirus has pulled a plague on us, and staying out of a nursing home seems even more relevant and yet less relevant than ever in my life and in your life.

Nursing homes are one of the epicenters of the virus. In Kirkland, 20 miles away, the Life Care Center of Kirkland had some of the first diagnoses and many of the first deaths in the state of Washington. Nursing homes are a perfect petri dish for disease. You have closely packed residents with compromised immune systems. You have staff who are often poorly compensated, sometimes minimally trained, and everyone is in close contact providing the most intimate of services.

So, for the time being I am going to focus my writing on aspects of the virus that others are not highlighting and about which I have some expertise.

Dementia in the Time of Coronavirus

Are you shut in with a beloved family member with Alzheimer’s? Are you trying to support a cognitively-impaired neighbor living alone? Is your mom in an institution and you are now forbidden to visit?

Here are some important tips, suggestions, and facts

Don’t correct; only connect

One of the hardest issues for me with my difficult demented dad was not pointing out how wrong he was. When he tried to give away my mother’s pearls to a caregiver, she properly refused and told me. (Not all caregivers would be so ethical, I know). Rather than preaching that family heirlooms were not an appropriate gift, or that he should not be sexually attracted to his caregiver (which he was), I asked, “Tell me about when you and mom picked out this gorgeous necklace.” He happily complied and we agreed to safeguard it in the box at the bank.

When a person with impaired judgement wants to drive, don’t say, “You are no longer a safe driver.” This is an insult to almost every American, especially a man. Ask instead, “Dad, tell me about your first car.” Or when you learned to drive. Or how you got your first driver’s license. Long-term memory stays intact long after short-term memory is shot. Most individuals with dementia can tell you about their wedding in the 40s but are clueless about what he or she did yesterday.

When mom asks, “Where’s Dad?” never say “Don’t you remember, he died last year?” This is cruel indeed. Ask instead, “Tell me about when you met dad.” Or ask about the wedding or point to the ring and ask when they bought it.

Give choices but not too many

We are accustomed to asking, “What do you want to wear?” or “What do you want to eat?” While choices are honoring preferences are enormously important, simplify. “Do you want to wear the blue shirt or the plaid shirt”, and hold them up. Ask, “Do you want fish or chicken?” This honors control, choice and preferences but doesn’t make it an ordeal of dithering.

Contact with no contact

Supporting an institutionalized elder is going to be much more difficult during the coronavirus. Since you can’t visit, ponder the other possibilities. I’ve been exchanging postcards with a family member. As long as we still have the sacred postal system, a letter or card can brighten the day for the receiver. It also shows staff that the person they care for is valued.  It also is a meaningful activity for you.

If the tools and skills are available, video chatting with Facetime or Zoom are great. Staff are usually willing to help, especially if it is as simple as handing over a cell phone. A phone call, even without the visuals, is communication but of course not every person with dementia can handle it.

Sending flowers may be an option, depending on where you live. Talking with staff will also help you learn what’s going on with the person living there, and it’s an opportunity to thank them for their invaluable service. At the present time, many of the people working in nursing homes, or any health care facility, are risking their lives. Let’s hope they don’t make the ultimate sacrifice and die, as many providers already have.

Please let me know if this has been useful. What changes would you add or suggest? What topic would you like to know about? As long as it relates to dementia, aging in place, long-term care, and similar issues, I’ll work on it. WordPress makes it easy to contact me. Follow me please!





Introduction to 7 Actions to Take to Stay OUT of a Nursing Home

Introduction: Reasons to read this book

Do not spend the last year of your life in a nursing home. Too often people assume that nursing homes are inevitable. No! Too often people assume that paid and family caregivers will help you stay at home. Really?

I don’t want to spend the last year of my life in a nursing home. You don’t want to spend the last year of your life in a nursing home, and I don’t want you to either. Reading this book will decrease your risk significantly.

Getting old sneaks up on you. Even as a Ph.D. gerontologist writing and teaching about aging and having done research on long-term care, I am surprised at what is happening to me in my 70s. The people I love the most die. Even with two new hips I am not nearly as fast, as flexible, and as active as I was even just ten years ago. “Just”—did I ever think I would call ten years ago, “just” ten years ago?

This is not a book that is anti-aging or ageist. You cannot, nor should you want to prevent aging. You want to be healthy, attractive, and smart at whatever age you are.

You don’t want people to be ageist. If that word does not provoke dismay in you, think of how odious are the clichés, negative stereotypes and bigotry of people who are sexist or racist. Those are despicable.  Just like sexism and racism, ageism is awful. It’s inspires self-loathing, limits potential and opportunities, and is just plain wrong. Ageism may itself play into the existence of nursing homes and the unlovely lives that people live in them.

There often is a societal culture of discounting old people. Believe me, it’s much more difficult for a single gray-haired woman to promptly get a nice table at a restaurant than it is for an attractive 25-year-old. If a 20-somehing person has a severe disability and cannot care for him or herself, it is much less likely he or she will be placed in a nursing home than an eighty-year-old. The first is a minor lament; the second is grossly discriminatory. The 87-year-old wants to stay out of a nuring home just as much as the 27-year-old.


So this book is about factors that promote staying out of nursing homes.


How to read this book

You need not read these chapters in the order they are written. You may already be an expert on end-of-life planning, estates, and finances. (However, even as an expert, you still may learn something new—or tell me about important facts omitted or update information in this fast-changing world.)

Some factors that contribute to staying out of a nursing home, such as exercise and a healthy lifestyle, are well established. However, are you really practicing a healthy lifestyle?  There are tricks you may not know for acquiring healthier habits. This is more important than ever because we continue to learn more about dementia and how a healthy lifestyle, particularly exercise, can lower your risk of Alzheimer’s disease. Other topics, such as in Chapter One, rarely occur to people until it is too late.


I’m not asserting that all nursing homes are bad. After spending hundreds of hours interviewing hundreds of people in dozens of nursing homes, I know there are fine skilled-care facilities with kind and well-trained staff. But even in these well-run and well-designed places, most people don’t want to live there, especially for over a year.

So read this book in any order you please but please learn what you can in order to lessen the risk of spending the last year of your life in a nursing home.


Chapter One: How can UD keep you out of a nursing home?

How to Hire Help

If you decide to make your home or apartment friendlier for aging in place, how much will it cost and who will help you do to do the work? Additionally, if you choose to move, there are typically a large number of major and minor upgrades required to prepare a house for the market.

Even the most capable do-it-yourselfer slows down with age. Protect your back by not doing it all yourself, and protect your budget by being extremely selective.  Happily there are many resources via your keyboard. If you are not a fan of computers, your local library can help you conduct an electronic search.

I recommend trying to find an “Aging in Place Specialist”.  In my small community, when I went to the Certified Aging in Place Specialistsite of the National Association of Homebuilders, more then 30 popped up, mostly architects and contractors.

Of course some were not what I was looking for, such as a reverse mortgage advocate. At the present time, reverse mortgages need to be considered very carefully. Also listed were some individuals with a poor reputation in my community. Others listed had no information at all.

Select three contractors and obtain at least three references for each. This means a minimum of 9 phone calls, but that’s cheaper than a botched job or an overpriced remodel.

I would also look up the Northwest Universal Design Council website for ideas https://www.environmentsforall.org/home-checklist/. Their home checklist is particularly useful. Other urban centers probably also have similar organizations.

I suggest that any person you hire be licensed, insured, and bonded. While we have had some luck with sub rosa (under the table) handypersons, those who operate without credentials, we have also had some bad luck. Caveat emptor—buyer beware!

The same goes for plumbers and electricians, although you may not have the leisure in a time of need to get numerous referrals and recommendations. Learn a bit about plumbing yourself. Anyone can plunge a toilet if he or she knows how.


I recommend having a housecleaner well in advance of when it becomes a necessity if you can possibly afford it. When I had unexpected hip replacement, I was so relieved to have a trusted, competent, and even beloved person to do the essential cleaning. Many women think it self-indulgent to have a cleaner or are convinced that someone else wouldn’t do nearly as good a job as they do themselves.  First of all, I consider it an equity issue. Some men, it appears to me, have never scrubbed a bathroom. Why should I be the only one cleans the commode? But more important, as we age, there will be certain tasks that are too difficult or too risky for a frail older person. Hiring a helper in advance of necessity precludes hiring a person you don’t know in a time of great stress and great need, such as when you are in the hospital about to be discharged. It also precludes dusting that top shelf, falling, and ending up in the hospital. Admit it in advance that there willbe a time when you will be hospitalized and then discharged and will need help at home.

Prilosec Killed My Husband

Prilosec killed my husband  (not taking it can also be perilous)

Jeannette Franks, PHD January 2019

Recent studies suggest that if my beloved husband had not taken Prilosec, a PPI, he would be alive today. PPIs are a class of drugs called proton-pump inhibitors. These medicines block production of stomach acid. Long-time use of PPIs also interferes with the body’s ability to absorb calcium, which can lead to osteopenia, especially in women and older people. Osteopenia is a precursor of osteoporosis, devastating thinning of bones.

Osteoporosis is difficult to treat and irreversible. Although there are medications that slow the process, those medications have negative side effects and do not produce the quality of bone one would want.

Thinning of the bones after age 70 is a risk factor for fractures, hospitalization, and premature death. Yet if you read the precautions on a Prilosec label,  it says nothing about thinning of the bones. And how many people actually read the fine print? It does admonish users to take only one a day for 14 days, and not to repeat until 40 days have passed, but it does not even hint why. I think it should say DANGER BONE THINNING in huge red letters.

When my late husband learned about the serious negative side effects and his low bone density, he tried to quit the PPI. However, the rebound effect was very painful, so he upped his weight-bearing exercise, calcium and vitamin D. Yet when he had what for many of us would have been a minor fall, so many bones broke that he was in ICU at Harborview for 10 days before he died. The pain was enormous and with the addition of pain medications, intubation, dialysis, and feeding tube, his condition consistently worsened.

While this is by no means a scientific treatise, I just want more people to know the risks of PPIs. Perhaps you or someone you love can avoid a painful and premature death. But you may also need to take a PPI for certain forms of cancer and other diseases. There are always tradeoffs for taking or not taking drugs.


Notes from a new widow

You will never be prepared enough. Although I taught a continuing education course on Grief and Loss for over 15 years for the UW School of Social Work, there were unexpected issues after the devastating loss of my beloved husband.

When I called my lawyer, a respected colleague, I was surprised when she said, “Don’t tell the bank yet.” Indeed she was correct. My husband and I always had three expenditure accounts: his, hers, and ours. One of the credit cards was in his name only. It had been used for an expensive trip that had to be cancelled. It will now be more complicated to receive the numerous refunds from hotels, airlines, and rental car. Put everything in both your names.

You must of course promptly notify Social Security, 800-772-1213. You can speak to a Social Security representative between 7 a.m. and 7 p.m. Monday through Friday. Generally, you’ll have a shorter wait time if you call during the week after Tuesday. They notify Medicare.

Keep in mind that you must then also notify any other health care programs such as the Medicare supplement and drug insurance. I called the prescription provider promptly. Nevertheless they mailed out a $500 prescription after they had been notified of his death. They were kind enough to refund the money but it was an added pain.

Make absolutely certain that the hospital understands your documented end-of-life preferences. These are obviously painful and complicated issues. For example, my husband had a pacemaker/defibrillator. Therefore he was DNR. That literally means do not use cardiopulmonary resuscitation. CPR would not work with a pacemaker. It does not mean comfort care only.

We still wanted broken bones to be mended, fluids and medications maintained, and more. However, when his situation slowly worsened over 10 days, the hospital kept adding interventions such as dialysis, intubation on a ventilator, a feeding tube. His potential for recovery became dimmer and dimmer. Even though I had durable power of attorney for health care and wanted to involve hospice, they refused. “We don’t do hospice here.”

I finally had to bring in a “Values Worksheet” our lawyer had given us. It clearly stated that he did not want extraordinary interventions such as permanent intubation, continuing dialysis, tube feeding.

My heart is breaking writing all this. My last piece of advice in this article is sign up for People’s Memorial. The web site for Washington State is https://peoplesmemorial.org. They can refer you other organizations in your area. They were wonderful. It is a non-profit co-operative, providing education and affordable cremations, burials, and green funerals. There is a one-time $50 fee and we were long-time members. One of the most difficult aspects of saying goodbye was made smooth and easy and cost less than $1000. My husband was always thrifty, and I respect that. Death is not cheap. Or easy.IMG_2861