Friends have made a substantial impact on the availability and quality of senior care in the United States. Friends senior service providers have been pioneers in the field, especially in the Philadelphia area, since Anna T. Jeanes donated substantial funds in the late 1800s for the creation of boarding homes for seniors in each of Philadelphia Yearly Meeting’s quarterly meetings. Many of those programs continue today as quarterly meeting homes in Pennsylvania and New Jersey, sometimes under new names.
Others were predecessors of current-day continuing care retirement communities (CCRCs), including Foulkeways and Medford Leas. These, followed quickly by Kendal, were the CCRC pioneers in this region, playing a major role in setting the standards for those that followed, Quaker and non-Quaker alike. Quaker senior services have emerged, as well, in Maryland, Ohio, California, Oregon, and elsewhere, although nowhere with the density in the Northeast. And serving seniors has long been a specialty of Friends Hospital and Jeanes Hospital, the two Quaker hospitals in the United States.
In the nonprofit world of senior services, Friends have long been known for their contributions to restraint-free care—an early and continuing commitment of the Kendal Corporation, in particular, and now a hallmark of most Quaker organizations. Friends have also pioneered with life care at home programs—a concept invented by Friends Life Care at Home in the Philadelphia area. Our continuing care retirement communities were central to the creation of the Continuing Care Accreditation Commission, an accrediting body for not-for-profit CCRCs and a major force for assuring quality in these complex organizations. Overall, we are recognized for the excellence of our care—highlighted in a major national consumer magazine some years ago as the best in the business.
Despite Friends’ long history and prominence in the field, concern for the plight of seniors is not an historic testimony of Friends. Serving seniors doesn’t ignite the passions of most Friends. Unlike Quaker schools, which have a far longer history and which are the subjects of Quaker queries, scrutiny, and concern at least within Philadelphia Yearly Meeting (with which I am most familiar), Quaker senior services are rarely mentioned in business meetings, in yearly meeting sessions, or elsewhere in Quaker circles. There is little dialogue among Friends about the tremendous societal challenges of aging in the United States and the joys and difficulties of meeting seniors’ needs. And finally, Friends involvement in aging services is unevenly scattered across the United States, with (arguably) more than half of the Quaker-sponsored organizations devoted to serving seniors in the world located within a few miles of Philadelphia.
The organization for which I work, Friends Services for the Aging (FSA), is an association of Quaker organizations that provide services to older adults in California, Maryland, New Jersey, Ohio, Oregon, and Pennsylvania. It was founded by Delaware Valley provider organizations in 1991 to facilitate cooperation among these independent programs and to enhance the quality of their services. FSA accomplishes this through collaboration in staff training and development, support to boards of directors, purchasing, marketing, referrals, and other joint efforts. As its head, I’ve had the opportunity to work intimately with most of the Quaker organizations serving seniors throughout the country. I have had the honor of participating with their board and staff leadership and with their frontline staff in trying to give meaning to their distinctive Quaker identity.
Where is Quakerism evident? On one level, some of the Friends organizations are Quaker due to their connection with quarterly or yearly meetings. But these are in the minority. Most are Quaker because they say they are! They have bylaws that stipulate that they operate with boards that are more than 50 percent Quaker in composition, and they use Friends decision-making processes. The organizations also have missions that are framed in terms of Quaker beliefs and testimonies. Some have substantial Quaker resident populations or membership; others have few or no Friends among those they serve. Some have chaplains and most have regular Quaker as well as other forms of worship. The question of manifestation of Quaker identity has become more interesting, as FSA has recently been enriched by inclusion of two retirement communities that have grown out of the evangelical tradition.
How do these diverse organizations sustain their Quaker identity in meaningful ways in a secular world that is marked by competition, severe governmental regulation, and overwhelmingly non-Quaker staffs?
As I have come to know these organizations and the people whom they serve, I have been impressed by the degree to which Quaker identity carries with it profound expectations. Even in settings where there is little formal discussion of Quakerism, staff quickly get a sense that Friends organizations are different. They say they feel more respected than in other settings. They know that their respect for residents or members or patients is the bottom line. They value the participatory approach to decision making.
For residents, their selection of Friends services often draws on their positive predisposition toward Quakers and Quaker organizations. They are drawn to distinctive features including Friends’ respect for differences, our emphasis on the bonds of community and the culture of participation and service, our concern for the spiritual as well as the physical care of those we serve, our emphasis on wellness and on residents’ and members’ involvement in decisions that affect them, and Friends’ reputation for running financially sound organizations.
In a number of our settings, residents, staff, and board members have sought to articulate the relevance of Friends testimonies to their work and life together. In one, for example, the staff leadership team held a retreat to identify the core values that they shared, and the ways in which they can exemplify these core values in their work. Most of our member organizations regularly send staff members to orientations to Quakerism that are sponsored at least twice a year by FSA. These have become settings in which staff can bring their experiential knowledge of Friends through their work in a Quaker setting and learn something of the history, beliefs, practices, and worship of Friends.
Two of the realities of senior services and long-term care are complexity and expense. Those Friends organizations that include nursing homes are subject to regulations reinforced by the threat of harsh penalties, most are subject to the federal law mandating privacy, and all are challenged by the changing tastes and demands of the marketplace. They are also subject to the massive increases in insurance costs related to anything medical, to similarly increasing costs of prescription drugs (some of the Friends communities provide coverage for residents’ medications), and to the pressures of a tight healthcare labor market. And, for those that seek to serve people with little in the way of resources, they are also struggling with Medicaid reimbursements that fall far short of covering the costs of care or with the growing complexity of federal funding for low-income senior housing. Furthermore, our values lead these organizations to provide staffing at levels that exceed state requirements, and they tend to see state and federal regulations as providing the floor for quality of care, not the ceiling. In other words, our Friends organizations are attempting to provide high-quality services in a society that has no rational healthcare or housing policies for seniors.
In at least some of these areas, Friends organizations have found innovative solutions that flow from our values. One such area is in response to regulations and the federal government’s pressure to develop corporate compliance programs that are designed to assure adherence to the ever-changing, often ambiguous, and always complex regulations governing nursing homes. The government’s target is "fraud and abuse" in healthcare, and its vastly increased investigatory force does not recognize innocent mistakes; any errors can be considered criminal.
The government has strongly recommended that all healthcare providers institute corporate compliance programs, designed to meet federal guidelines that are published in—of all places—the Federal Sentencing Guidelines! They urge the creation of programs that meet specific criteria, including a new, high-level staff position of corporate compliance officer in each organization. The presence of such a role can be a mitigating circumstance in the penalty phase of a trial if an organization is found guilty of "fraud and abuse."
A number of heads of Friends organizations came together five years ago to consider how to respond to this federal initiative. The group recognized that, however scrupulous they are, even Friends organizations were subject to mistakes. They quickly came to a sense that it would be better to respond collaboratively rather than individually. And they came to unity on a program that would do more than keep them out of jail; it would base the program in their shared values and ethics and be used as a new tool for enhancing the quality of the care our organizations provide. Finally, they developed the insight that our program would go beyond the federal requirements; it would become a means for monitoring our performance in relation to our own values and expectations. This value-based and quality-oriented approach represents a radical departure from the inherently defensive, legalistic approach in other settings. The Friends program was the first, nationally, to be structured as a collaborative venture among independent organizations—providing a model that has since been recommended by the federal government. It continues to be unique in its orientation. The program is thriving, now also becoming the vehicle for compliance with the new federal privacy laws. The program has attracted the interest of Mennonite and Brethren providers of long-term care, and it became a point of early connection between the Historic Peace Churches in senior care, with more than a dozen Anabaptist organizations now served by the Friends Compliance and Privacy Program of FSA.
Sometimes this program has to find solutions to apparent clashes between the unique cultures of our Quaker (and Mennonite and Brethren) organizations and federal regulations. When privacy regulations were first made public, they appeared to ban any communication with nearly anyone about the health of an individual. One of our CEOs raised the question: "How can we protect privacy in an environment in which our residents care so much for one another?" Flexibility, pragmatism, and creative approaches to the regulations have allowed our organizations both to comply with the law and preserve their values and cultures.
Another arena in which Friends (again, in concert with our Anabaptist neighbors) have responded to an external challenge is liability insurance. Nursing homes have experienced massive increases in premiums, even as the number of companies willing to insure them has dwindled to a handful. Friends responded quickly and enthusiastically to an initiative by Mennonite and Brethren senior service providers to explore a self-insurance program. What has evolved, based on each group’s commitment to cooperation and on a strong Anabaptist tradition of mutual aid, is a new insurance company: Peace Church Risk Retention Group. We have used federal law to create our own insurance company, in which the owners are also the policy holders. The new venture, launched this past January after two years of exploratory work, holds the potential for sustaining our combined, excellent record of low losses as a result of litigation. It also assures our programs of continuing access to insurance at a time when such access is far from certain in the commercial insurance market. Our user-owned insurance company holds the potential for significant long-term savings and for addressing those factors that can lead to accidents affecting those we serve.
During a recent FSA planning process, a fresh insight emerged. It is becoming increasingly clear that Quakers with the inclination and needed skills for board membership are in heavy demand. In recognition of this and our deeper ties to the Religious Society, FSA and the Quaker service providers committed ourselves to investing as we can in the future of the Religious Society of Friends, and not simply drawing upon its human resources. Our hope is for more dynamic relationships in which we are able to be attentive to the concerns and movements of the Spirit within the Religious Society, and we are able to share with Friends our challenges and the ways in which Friends testimonies are lived out in our organizations.
In the context of our strong Quaker history of advocacy for social, racial, and economic justice, FSA has come to realize that Friends and our Quaker senior service providers have not been engaged very vigorously as advocates for seniors and for humane, accessible, high-quality senior health and long-term care. Our preoccupation with delivery of services has led us to focus on the needs of those we serve directly. As Friends organizations, we need to engage in the broader social, political, and economic debates about the needs of all seniors—and especially those who cannot afford most of the services currently provided by Friends. My hope is that a more engaged relationship between our providers, Friends, and Friends meetings and churches will help us find our voices and refine our skills for such needed advocacy.