CCRCs represent one form of managed care for the elderly. Many CCRCs have managed both acute medical and long-term care services for the elderly for decades. CCRCs plan, administer, and often provide these services, in combination with housing and other services, frequently in a campus-like setting. The number of residents in a CCRC varies, but averages about 300, most of whom are elderly people leading active lifestyles and living in independent housing units. Some residents receive personal care, such as assistance in bathing and dressing, either in their own residential units or in special assisted living units, and some receive skilled nursing facility care. Residents may also receive physician, laboratory, and other care on site. Expenses for these and other medical services are reimbursable by Medicare on the same basis as for the elderly who do not live in CCRCs. CCRCs assess prospective residents’ health and financial status to ensure a fit with services offered and required fees. Residents commonly pay an entry fee to join the community and a monthly fee thereafter. These fees vary considerably depending on factors such as the level of CCRC financial risk for long-term care services, the size of the residential unit chosen, whether fees are for single individuals or couples, and the kinds of additional services and amenities provided. (See app. II for a description of the different financial risks CCRCs assume.) In the 11 CCRCs we visited—all of which assume residents’ risk for long-term care costs—entry fees ranged from a low of $34,000 for a studio apartment for one individual to a high of $439,600 for a two-bedroom home for a couple. Monthly fees in the 11 communities ranged from $1,383 for an individual to $4,267 for a couple. The CCRCs we visited use a variety of practices for health promotion, disease prevention, and early detection of health problems to help residents maintain their health and functioning. These practices are part of an approach to care that encourages CCRC residents to adopt or maintain a lifestyle that is believed to promote good health. Providing activities and services, usually on site, encourages residents to take advantage of them. Many of the CCRCs we visited promote good health for their residents by encouraging exercise, proper nutrition, and social involvement. Encouraging regular exercise is a common practice that CCRCs we visited use to maintain or improve residents’ health and functioning. CCRC efforts include having swimming pools and fitness equipment on site, providing staff for exercise programs, and sponsoring lectures and information on the value of exercise. Exercise classes and activities include aerobics, flexibility and strength exercises, swimming, yoga, lawn bowling, and square dancing. Residents may participate through a formal program or on an informal basis. Several CCRCs also strongly encourage walking. The campus-like designs of some CCRCs encourage walking by locating residential buildings within walking distance of commonly used services. Some campuses also incorporate nature trails or other attractive walks. Another common health promotion practice at CCRCs we visited is the encouragement of proper nutrition. Residents at many of these CCRCs are offered three meals a day in common dining rooms, which encourages adequate consumption of healthy foods. Some CCRCs require residents to have at least one of their meals each day in these settings. For other meals, residents may cook at home or eat elsewhere. The foods offered and nutrition information provided encourage residents to eat appropriately for weight and other health considerations. Special diets may be provided. At most of the CCRCs we visited dieticians are often available for consultation and can help residents develop individual diet plans. CCRC officials told us that on-site dietary counseling and nutritionally balanced meals in congregate, attractively decorated dining areas help encourage adequate nutrition and healthy eating habits. Encouraging residents to interact socially is also a common practice among the CCRCs we visited. CCRC officials told us that they encourage interaction because social isolation is associated with poorer health and functioning among the elderly. They also said that the physical layout of CCRCs fosters social interaction and is an integral part of the CCRC model. Residents live next door to each other and may see each other frequently through visits or while eating in congregate settings, checking mail, and engaging in a wide range of CCRC activities. Recreational, educational, cultural, and volunteer activities are frequently initiated, planned, and organized by residents. Officials said that arranging and participating in these kinds of activities are an important part of residents’ social interaction in the community. Activities may include on-campus lectures, movies, musical performances, woodworking, flower arranging, photography, and civic and charitable activities. Many of the CCRCs we visited attempt to maintain their residents’ health and functioning through disease prevention and early detection of health problems. These activities are carried out by nurses, social workers and physicians who may be either affiliated with or independent of the CCRC. Most CCRCs we visited encourage immunizations against common preventable diseases, such as flu and pneumonia, to reduce illness and possible fatalities. They may encourage immunization in a number of ways, including inoculation clinics, seminars, distribution of printed materials, and reminders from medical staff when a resident makes an outpatient visit or has a medical examination. Most of the CCRCs we visited encourage early detection of health problems through periodic medical exams and other health assessments. CCRC officials told us that these exams and assessments help staff and residents to be more proactive in using effective medical treatments and changing lifestyles to slow or reverse the loss of good health and function. A combination of physicians, nurse practitioners, and social workers may conduct elements of these exams and assessments, which may include periodic inventories of prescription drugs used by a resident to assess potential unwanted side effects from drug interactions, examination of an individual’s ease in walking or getting out of a chair, and observation of changes in an individual’s mental state. CCRC medical exams may include testing blood pressure for hypertension and blood glucose levels for diabetes. They may also include tests for colon, breast, and prostate cancer as well as vision and hearing impairments. Residents’ medical records and staff are usually on site, making the periodic exams and assessments convenient for residents. The CCRCs we visited typically encourage periodic medical exams through seminars, written materials, and reminders such as notices sent to residents on their birthdays asking them to schedule an exam. Some CCRCs follow up by telephone or other means when residents do not schedule or appear for medical exams. If a resident does not come for an exam after follow-up, some CCRC officials told us that this information is tracked and an exam conducted when the resident next comes in for outpatient care because of illness. CCRCs we visited use a multidisciplinary, coordinated approach to manage care for their residents with chronic conditions such as hypertension and heart disease. Essential elements of this approach include a wide range of on-site services, coordination of services to ensure residents receive them in an appropriate and timely manner, and active monitoring of residents with chronic conditions. The prevalence of chronic conditions increases substantially with age, and CCRC officials told us that properly managing these conditions helps maintain residents’ functioning while delaying or reducing use of costly services such as hospital care. CCRCs we visited offer a wide range of services on site to manage care for residents with chronic conditions. These services may include primary health care, care by specialists, skilled nursing care, and laboratory testing. Other services may include physical therapy, social work, personal care, dietary counseling, home chore service, and transportation. Various combinations of services may be provided across a range of settings, including an outpatient clinic, a skilled nursing facility, or a resident’s own home. In addition, some of the CCRCs we visited adapt their health promotion and wellness programs to help meet the needs of residents with chronic conditions. For example, they may modify a regular exercise program to help people with arthritis retain the ability to walk. Similarly, these CCRCs may encourage and help those with chronic conditions to continue regular social interaction through special arrangements. For example, a resident who can no longer walk to recreational events and congregate eating areas may be provided with an electric cart so that he or she can remain independent. CCRC officials told us that having a wide range of services on site makes it possible to manage most of the care of residents with chronic conditions within the community even when the needs are intense. CCRC officials said that residents less frequently need care at hospital emergency rooms or as many days of hospital care when admitted because they have access to physicians, nursing care, and other services at the CCRC. The availability of a skilled nursing facility where residents can easily be admitted from the hospital or from home for short stays may also help return residents more quickly to their homes, according to these officials. CCRCs we visited typically coordinate services to enhance their benefit for residents. CCRC staff coordinate various services provided by both CCRC staff and other providers whether on site or off. For example, a CCRC may coordinate an arthritic resident’s pain relief medication, specialized exercise program, home modifications, the availability of walkers or other ambulatory aides, and periodic assistance with dressing or bathing to help the resident stay as functional as possible and to reduce or delay the use of more intensive services. Multidisciplinary teams may facilitate coordination through joint team assessments and the development of a plan of care. Teams meet regularly to reassess needs and services. CCRC officials told us that nursing staff generally serve as the focal point for convening teams and providing ongoing coordination of services between team meetings. Some CCRC officials said that nursing and social work staff usually have day-to-day responsibility for coordinating services and troubleshooting when problems arise. CCRC officials told us that they actively monitor residents with chronic conditions. Staff oversees the plan of care developed for each resident with chronic conditions to ensure that the resident is receiving needed services. Monitoring can include simply verifying that a resident has visited the clinic as prescribed or kept a scheduled appointment with the physical therapist.