It's no secret that the fastest-growing segment of our population is over the age of 65 -- and the greatest increase is occurring in those 85 and above. At the same time, there is growing awareness of the benefits of massage for people who are affected by debilitating illness, injury or cognitive impairment. There is clearly a burgeoning market for massage therapists who want to work in eldercare or hospice. But the people whom massage may benefit the most -- and who make up a big portion of this market -- are often embedded in a system that is full of intimidating obstacles for the therapist. They are behind the doors of long-term care and hospice organizations. You may discover that the door into these organizations seems closed -- closed not because you lack skill or passion for the work, but because you don't know the system and its jargon or how to get past the gatekeepers to the potential client. This article offers a key to open that door: knowledge of the system and how to navigate through it to help you succeed in expanding your practice to eldercare or hospice settings.

Types of Eldercare and Hospice

First, you must become familiar with the various types of eldercare or hospice organizations: assisted living, skilled nursing (nursing home), continuing care retirement and hospice.

Assisted Living The emphasis in assisted living settings is to support mentally or physically limited persons who need help with activities of daily living, but do not need the skilled medical care provided in a nursing home. Facilities consist of private rooms or apartments as well as common areas. These facilities provide 24-hour staffing, meals, housekeeping, social activities and limited nursing services such as management of medications. Some assisted living facilities provide specialized care for elders with Alzheimer's disease.

Skilled Nursing (Nursing Home) People enter a nursing facility usually as a result of illness, injury or mental or physical debility that requires 24-hour nursing care and continuous assistance with activities of daily living. Some require this level of care temporarily, and then return home. Others require permanent care. Facilities consist of semi-private or private rooms, a common dining room and social areas. Services include 24-hour nursing and personal care, meals, psychological and spiritual support, and planned social and recreational activities. Physical, occupational and speech therapy, as well as specialized care for those with Alzheimer's disease, may be available.

Continuing Care Retirement Community This is typically a campus setting with multiple levels of care including independent living, assisted living and skilled nursing. Residents can remain in the same community even if their needs change. Communities provide an array of services and amenities including dining, housekeeping, recreational activities, health care services, personal care assistance and nursing care.

Hospice is not a place but a concept of care. Eighty percent of hospice care is provided in the patient's home, family member's home and in nursing homes. Inpatient hospice facilities are sometimes available to assist with caregiving.

Most of these organizations will not have considered massage as an ancillary service. The following questions will be on the mind of a potential employer--be proactive in answering them.

How does massage help our residents or patients?

Not all administrators share your awareness of the benefits of massage. Remember that YOU are the expert on how massage therapy impacts the body, mind and spirit. These points will make a convincing case.

1. Massage alleviates aches and pains, resulting in:

• A possible reduction in need for pain medication
  
• The ability to perform activities of daily living with greater comfort

2. Massage increases circulation, contributing to:

• Improved skin condition
  
• Decreased risk of pressure ulcers

3. Massage provides tactile stimulation, which:

• Alerts the senses
• Increases body awareness

4. Massage induces a relaxation response, leading to:

• Improved quality of sleep
• Greater ease of breathing
• Calmed agitation

5. Compassionate and caring touch supports emotional well-being by:

• Providing a pleasing way to interact with others
• Offering a means for non-verbal communication

6. Focused touch enhances spiritual well-being, resulting in:

• Being grounded in the present moment
• Greater sense of self-worth

"It is the position of the American Massage Therapy Association (AMTA) that massage therapy can improve the quality of life for those in hospice and palliative care." AMTA evidenced-based position statement 2009

How do massage services benefit our profession?

Eldercare and hospice organizations are in business, too. They will want to know how massage services will improve their bottom line. Tell them that an organization that offers massage:

• Is in step with consumers' increased use of massage therapy. According to a consumer survey by the AMTA, the use of massage among those 65 and older has tripled since 1997.
  
• Will be recognized as raising their standard of care. This may give the organization an edge in a competitive marketplace. Barbara Clayton, a Missouri nursing home administrator, says, "Providing massage for our residents puts us a cut above other facilities--going above and beyond what's required."
  
• Enhances resident (or patient), family and staff satisfaction. This is a win-win-win situation. The resident or patient wins by directly reaping the benefits of massage. Family members enjoy the positive response of their loved one. Staff members win in two ways: indirectly, when the elders they care for have fewer complaints of discomfort and are more content, and directly if they, too, receive an occasional massage!
• Augments the special care of residents with Alzheimer's disease or other forms of dementia. The Alzheimer's Association states, "Residents who are not ambulatory can be meaningfully engaged and stimulated by such activities as massages ..."

How does massage therapy help meet federal guidelines?

Massage services can be integrated into the resident or patient's plan of care. Documentation of your service contributes evidence of:

• A non-pharmacological complementary approach for relieving pain, calming agitation, and aiding sleep.
  
• An innovative one-to-one bedside activity for low-functioning residents.
  
• A program that contributes to reducing the need for restraints.

Who pays for massage therapy services?

The answer to this question lies in the structure of the agreement you have with the organization. You may be hired as a staff member, in which case you would be paid a salary to provide massage with or without employee benefits. More likely, however, you would be brought on as an independent contractor. In this case, there are two possible options for payment.

Option #1: The organization pays you an hourly rate for a set number of hours per month.

This offers them two advantages: any resident or patient may receive massage, and they can offer your services as a "value added" amenity, something that may be attractive to their potential customers. The advantage to you is reliable hours of work. The organization may also agree to pay you for staff massages or educational presentations.

Option #2: The organization permits you to offer massage on a fee for service basis. In this case, the resident or patient or his responsible party hires you directly; therefore you would work only with those individuals who have contracted your services. With this arrangement, there is no cost to the organization, which may appeal to the management. The challenge is that you have to attract and retain clients Ask the administrator or director to distribute information about your services. One suggestion is to place

your service brochure in the materials that all new residents or patients receive upon admission. Offer to give a short presentation about massage at family meetings or create a display for the lobby to announce the new service.

Other funding sources may include:

• Medicaid personal needs allowance
  
• Individual trust accounts.
  
• Private insurance. Some policies cover therapeutic massage for specific conditions with a physician's order.
  
• For not-for-profit organizations funding for a massage program may be available through grants.

Is a physician's order required for massage therapy?

No. There are instances where you should consult with the physician to insure safety--for example, if the resident or patient has had recent surgery, acute illness, or chemo-therapy.

Can our staff members receive massage?

Care professionals can benefit from on-site seated massage to reduce the effects of job-related stress and prevent burnout. Massage is perfect for incentive programs to reward employees for a job well done! Offer to provide this service on a regular basis.

What qualifications should the massage therapist have?

Provide your license or certification credentials and proof of professional liability insurance. Highlight any specialized training in meeting the needs people in later life stages.

Including this special population in your practice can be professionally and personally rewarding. It requires specialized skills, sensitivity, and compassion--as well as a bit of a pioneering spirit. You can succeed in opening the door to eldercare or hospice organizations and in doing so reach out to those who need your touch.

Resources

1. American Massage Therapy Association, 500 Davis Street, Suite 900 Evanston, IL 60201 www.amtamassage.org
   
2. National Hospice and Palliative Care Organization, 1731 King Street, Suite 100 Alexandria, VA 22314 www.nhpco.org
   
3. Dementia Care Practice Recommendations for Assisted Living and Nursing Homes (2005), Alzheimer's Association, 225 N. Michigan Ave., Chicago, IL  60601 www.alz.org
   
4. Touch Research Institute, University of Miami School of Medicine, P.O. Box 016820, Miami, FL 33101 www.miami.edu/touch.research
   
5. Hospice Foundation of America, 1710 Rhode Island Ave, NW, Suite 400, Washington, DC 20036 www.hospicefoundation.org
   
6. American Health Care Association, 1201 L Street, N.W Washington, DC 20005 ww.ahca.org

Helpful Terminology

Eldercare and hospice has its own jargon. Knowing how to communicate with the professionals who serve as gatekeepers in these settings will help you establish credibility and build relationships. Here are some terms that will help you "speak the language:"

• Activities of daily living: Functional tasks including bathing, dressing, eating, toileting, walking, household chores, leisure activities.
• Ancillary service: A service, like massage, offered as a supplement to the standard care in a facility.
• Eldercare: The broad spectrum of support services for frail older adults that can consist of care in the home, assisted living or skilled nursing facility. Also referred to as long-term care.
• Fee for service: Method of charging whereby a practitioner bills for each session or service rendered.
• Hospice is a special concept of care--rather than a place--designed to provide comfort and support to patients and their families when a life-limiting illness no longer responds to cure-oriented treatments.
• Independent contractor: A person or agency that provides a service but is not an employee of the facility.
• Patient: commonly used term to describe the person receiving hospice services.
• Personal needs funds: When Medicaid (the state-operated public assistance program that pays for health care for people with low income) is paying for long term care, the person may receive a set amount of money each month for personal use.
• Resident: A person living in a long-term care facility.
• Responsible party: A person who is designated to oversee the financial and health care needs of a resident or patient--most often a family member.