—With additional reporting by Kiesa Kay
Pat Boone struggled to the podium during public comment at the Yancey County Board of Commissioner’s regular meeting on June 11. She had come to advocate on behalf of her husband, Ray Bud Boone, but she first apologized for her own difficulties. “I’m sorry, I had chemo today.”
When Pat first saw the signs of her cancer, she was afraid to tell anyone — she is the primary caregiver for Ray Bud, who has dementia and requires 24/7 supervision, and worried what would happen to him if she fell ill herself. “I was bleeding for six weeks before I told anyone about the cancer,” she explained. “The doctor said if my daughter hadn’t made me come in to see him, I would have been gone in two months.”
Together with a handful of other Yancey County residents, Pat pleaded for the commissioners to sustain a lifeline she’d found in her husband’s need for constant care: the Heritage Adult Day Retreat. The service gives Ray Bud a sense of purpose during the day while giving his family members much-needed respite from their caregiving responsibilities.
The nonprofit organization that operated Heritage, the Yancey County Committee on Aging, had become financially insolvent, and the adult day care center was slated to close on July 1. “We’re exhausted,” Pat said, in a voice barely above a whisper. “We just need that center to stay open. He has served his country in the military! It wouldn’t be right to put him in a nursing home.”
Pat and Ray Bud’s daughter, Lisa Boone, added that the center allows her to maintain a job at Lil’ Smokey’s restaurant in Burnsville while contributing to her father’s care. “I don’t know what I’d do without Heritage,” she said. “I can’t quit my job, but someone has to watch my dad every minute.”
For families like the Boones, adult day care services can function as the only line of defense against the transformation of a difficult scenario into an impossible one. As illustrated by the Heritage situation, however, these services are often balanced on fragile footing. And as Western North Carolina’s baby boomers age into retirement and beyond, the need for caregiver support can only continue to grow.
Heritage’s importance is amplified by being the only adult day care in Yancey County. That singularity isn’t unusual, especially for rural areas: Of North Carolina’s 100 counties, 50 lack any adult day care, and of the 85 facilities certified by the state, the bulk are located in major metropolitan areas. The next-closest center for residents of Burnsville, Yancey County’s largest city, is over 40 minutes away in Asheville.
The center was part of a collection of services offered by the Yancey County Commission on Aging, which also operated the county’s senior center and Meals on Wheels. For over 40 years, Yancey County government designated the nonprofit to receive Home and Community Care Block Grant funding from the state Division of Aging and Adult Services, as well as direct funding from the county itself. In fiscal year 2015, the latest for which documents are available, the CoA took in $193,971 in state funding and $118,799 from the county.
But early this year, says Yancey County Commission Chairman Johnny Riddle, the county learned that the nonprofit was running out of money. Between increasing expenses and flat or decreasing grants from state and federal governments, the Committee on Aging said it would be unable to sustain itself without additional county funds.
That wasn’t a path the commission was willing to take. “If we give one nonprofit more money than is usually allocated to them, what’s going to keep another nonprofit from wanting more money?” Riddle says. “We decided we were going to have to take this operation over because there’s got to be some internal problems going on.”
While the county could run the Committee on Aging’s other services, it was unable to directly take over the adult day care. “The Department of Social Services and Health Department are required to inspect different operations of the Heritage Adult Day Retreat. We can’t inspect and oversee an operation that we operate,” explains Jaime McMahan, planning and economic development director for the county. “It’s not a matter of the county cutting funding to it or choosing to let it close — we couldn’t operate it even if we wanted to.”
Follow the money
McMahan, who also serves on the Committee on Aging board of directors, notes that Heritage contributed to the nonprofit’s monetary difficulties. “The adult day care center has operated at a deficit for every year since I’ve been on the board,” he says. “They can handle up to 20 patients, but they really only average six or seven on a daily basis. Without increasing the number of patients they serve, there would be no way to make it financially viable.”
Unlike the other services funded by Home and Community Care Block Grant money, adult day care centers have maximum reimbursement rates set by the General Assembly. These rates — $33.07 or $40 per client per day, depending on the presence of a registered nurse — haven’t been adjusted for over a decade. The N.C. Adult Day Services Association has been advocating to repeal this reimbursement cap since 2014 but has made little progress.
The State Adult Day Care Fund, administered by the Division of Aging and Adult Services in the N.C. Department of Health and Human Services, provides another source of funding that county departments of social services can use to support adult day care centers. But its allocation of roughly $4.3 million, drawn from federal, state and county sources, has remained unchanged since fiscal year 2014. And according to North Carolina Health News, approximately 40 facilities throughout the state have closed since 2007.
Yet the Committee on Aging may also have failed to properly manage its operations in light of this funding reality. In 2015, the nonprofit acquired a new building to house its senior center and expanded its staff despite a decrease in program revenue from the previous year. “Nothing was done underhanded, nothing was done really wrong,” says Riddle. “It was just mismanagement, hiring too many people to do work out there that they really didn’t need.”
McMahan is more critical. “The management of the Committee on Aging did not keep the most accurate books, we have since discovered,” he says. While declining to go into detail about the accounting, he notes that the organization was subsisting on its fund balance; Riddle adds that the committee was unable to make the first payment on the new senior center facility earlier this year.
Harvey Sharpe, the chair of the Committee on Aging board, did not respond to multiple requests for comment, while Vivian Hollifield, the nonprofit’s most recent executive director, declined multiple interview requests. She did confirm that she is no longer associated with the organization, having moved to an administrative support role with Yancey County Cooperative Extension.
A path forward
On June 29, Yancey County Manager Nathan Bennett confirmed that the county had agreed to help the Committee on Aging cover its expenses over revenues for operating the adult day care through the end of September, with the goal of transferring operations to another entity. He added that the nonprofit’s state license for the center expires on Sept. 30 and will not be renewed.
While CarePartners, a Mission Health subsidiary that operates several adult day cares throughout the region, has declined to take over Heritage due to its own pending acquisition by HCA Healthcare, Bennett says that “the search for a new operator is ongoing, and I am encouraged that we will be able to have a positive solution.” He did not confirm reports from area residents that RHA Health Services has also been in talks with the county about the center.
Bennett was unable to give an exact figure for Yancey County’s support, citing changes to insurance policies and other operational aspects. For comparison, data from the Land of Sky Regional Council show that Buncombe County plans to provide $4,973 to DayStay Adult Services and $78,008 to CarePartners Adult Day Service in county funds above state block grant levels for the current fiscal year.
LeeAnne Tucker, director of aging and volunteer services for the Land of Sky Regional Council, sympathizes with the Heritage situation. She administers funding for aging programs over Buncombe, Henderson, Madison and Transylvania counties; “There’s just never enough funding to go around,” she says.
“The baby boomer demographic is growing, and as that grows, so does the demand for services,” Tucker explains. “Even though we have received a small increase over the past two years, it’s still not enough to meet the needs that are out there.”
Young and old
Ruth Price, lead long-term care regional ombudsman with the Land of Sky Regional Council, encourages those who fund adult day care centers to compare their cost to that of other options for care. A 2015 survey by insurance company Genworth Financial found that the median daily cost of a private nursing home room in North Carolina was $225, with a maximum cost of $630, versus $51 as the median daily cost for adult day care.
“I really think caregivers are the foundation of our health care system; we’d all be paying a whole lot more money for health care [without them],” Price says. “One of the biggest concerns is that caregivers end up neglecting their health, and sometimes they die sooner than the person they’re caring for. That has an impact on everybody, because then that person’s going to end up in a care facility, which is far more expensive.”
Communities also experience unexpected benefits from this caregiver support. Maria Kimble, for example, spoke during the Yancey County Commission meeting about how Heritage has given her the opportunity to serve area residents through her Spanish language skills. A native of Puerto Rico, Kimble provides translations for everything from doctor’s appointments to school meetings — as long as she can find a safe haven for her mother, for whom she is the primary caregiver.
“A lot of people’s lives will be affected if I don’t have this help with my mom,” Kimble said. “I’m here by myself from Puerto Rico, and when my mom can go to the center, I can help many people with translations. I get called at various times throughout the weekdays.”
Without additional support, Price warns, the impacts of an aging population will become increasingly apparent. “So many caregivers are running on empty,” she says. “People kind of look the other way while all of this is happening, so we’re always trying to just keep up with this growing population without a growing budget. It’s very worrisome.”