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Chapter 1

INTRODUCTION The phenomenon of global aging (Armas, 2001) is occurring at a rate never seen before and the number of people age 65 and older more than tripled over the past half-century, to a record 420 million worldwide. The number of people in the U.S. over age 65 is projected to reach 55 million by the year 2020, with those over 85 expected to grow from 3 million to more than 13 million. These aged members of our society use the lion’s share of long-term care services with diversity of needs ranging from differing personal values and considerable disagreement about what constitutes an optimum quality of life. The diverse needs of the long-term care consumers can no longer be cared for in a “one size fits all” (Pratt, 1999) healthcare service delivery system for their needs are as diverse as where they are coming from. There has to be new ways to accommodate and address their diverse healthcare needs in the long-term care setting.

Filipinos were ranked as the 2nd highest in number among the Asian population (US Census, 2000) residing in the United States. They are also recognized as one of the five largest contributors to the nation’s Asian-born population and are expected to have one of the biggest percentage increases between now and 2030. As the rate of Filipino population increases, so does the aging population and yet no known non-profit medical model of geriatric healthcare setting imbedded with ethnic-specific, psycho-socio-emotional, religious and culturally-sensitive services is in place, especially in the Bay Area and San Francisco, to respond to their needs. Filipinos bound for institutionalized healthcare setting, just like their Asian counterparts, still carry with them a “cherished culture” despite their being acculturated and assimilated into the mainstream society. The following Table 1 (National Federation of Filipino-American Associations, 2004, p.1) suggests where most of the Filipinos live in the United States.

The table also indicates that California has the most Filipino population; hence, it is likely to be the first and best option to start establishing a Geriatric Healthcare Center for Filipinos followed by Hawaii, Illinois, New Jersey and New York.

Statement of the Problem

The current long-term care system seems to be a “one size fits all” healthcare model that is not culturally-sensitive to meet the healthcare needs of its culturally-diverse consumers (Ward et al, 1997). This brings about a lack of greater interest in formulating a healthcare model that provides culturally-sensitive services, more so, the establishment of a non-profit medical healthcare facility, to benefit in particular the Filipino aging population living in the United States.

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In response to this concern, the writer was prompted to study and seeks to

propose a business plan for the establishment of a Geriatric Healthcare Center for Filipinos. Specifically, this study will attempt to address the following key issues:

1. What is the proposed business plan model for a Geriatric Healthcare Center for Filipinos?

2. What kinds of services are required to meet and be responsive to the needs of Filipino Elders in the long-term care setting?

3. What are some of the Filipino cultural values that one needs to be aware of as service delivery is being provided?

4. How can an awareness of these cultural values be useful to provide quality of care among the Filipino Elders in the Center?

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Need for the Study

It has been a common belief that Filipinos belong to a group who could assimilate easily in the mainstream society because they are acculturated faster than their Asian counterparts. They are said to be resilient and blend well within their new ways of life that they have chosen to live with. However, the truth remains that although it is true they assimilate within the new culture, it is also equally true that they are within them “very much” Filipinos as manifested in their own way of thinking and feeling, and so their aspiration as a people remains to be ideal, a Filipino in America. This brings with them, the Filipino in America, deep in their heart and soul until their hair turns gray and become old unable to take care of themselves but expect their children and/or family to take care of them due to filial responsibility (Cole, Van Tassel and Kastenbaum, 1992) This expectation creates conflict within the family for it brings unnecessary difficulty in their new lifestyle of working hard to survive and meet the necessities of life dictated by their new ways of looking at things such as: materially meeting all the amenities needed for them to live life in a more comfortable manner. They turn to each other and seek a way to find an appropriate placement for their aging parents who need long-term care but feel very concern they wouldn’t be as comfortable as when they are “at home” in their own family. Since the current healthcare system does not provide culturally-sensitive services to respond and meet the ethnic-specific needs of its consumers, the researcher sees the need to design and establish a Geriatric Healthcare Center for Filipinos to address the issue of providing culturally-sensitive services in a homelike environment, thus making them feel “at home away from home”. Basic Assumption of the Study

It is the assumption of the field study that the Geriatric Healthcare Center for Filipinos shall, in addition to compliance with CCR Title 22, Div. 5, Chap. 3 and OBRA 87, to:

• be oriented towards meeting the quality of care per JCAHO’s standard and shall become a JCAHO accredited facility (Kern, 2004);

• be operated as a non-profit medical healthcare facility, under the corporate management of CYDF USA, Inc. (Mendoza, 2004) and that,

• Filipino elderly in the long-term care setting would require culturally-sensitive services to meet their healthcare needs.

Goal and Objective of the Study

The primary goal of this field study was to develop a business plan for the establishment of a non-profit medical healthcare facility, to be named as Geriatric

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Healthcare Center for Filipinos, that is imbedded with ethnic-specific psycho-socio-emotional, religious and culturally-sensitive services.

The study was to complete a comprehensive review of the current literature, deemed not only relevant to the business plan but related to ethnogerontology, with a specific focus on Filipino cultural values in order to address the assumption that Filipino elderly in the long-term care setting would require culturally-sensitive services to meet their healthcare needs. Limitation and Delimitation of the Study

The proposed Geriatric Healthcare Center for Filipinos seems to be a gigantic undertaking; it is, however, a doable and feasible plan because it is being undertaken in the spirit of a genuine effort to provide healthcare service in a non-profit environment. For purposes of this study, the Center to be established shall be a Long-Term Care Facility that is in compliance with CCR Title 22, Div. 5, Ch. 3, and OBRA 87. It shall provide culturally-sensitive services to effectively meet and respond to the healthcare needs of the Filipino elderly in the long-term care setting. The Center shall be oriented to respond beyond compliance when it becomes fully operational and doing business as (d.b.a.) of a nonprofit corporation CYDF USA, Inc. It shall eventually aim itself to pursue and become a JCAHO accredited facility, as it consistently provides culturally-sensitive services to its target population. Definition of Terms • Asian-American is a term that technically includes, to name a few: Chinese,

Filipino, Japanese, Asian Indian, Korean, Vietnamese, Laotian, Cambodian, Hmong and Thai people. (Holmes, 1995).

• Culture is a set of learned values, beliefs, customs, and behavior that is shared

by a group of interacting individuals (Mosby, 1998).

• CYDF USA, Inc. is the sister Foundation of Calantas Young Dreamers Foundation, Inc. (a Philippine-based nonprofit corporation; founded on August 21, 2000 and registered at the Securities and Exchange Commission (SEC) on August 16, 2002). CYDF USA, Inc. (California Registration In-Progress) was organized on August 7, 2004, in San Jose, California, to carry on its third objective as specified in its Articles of Incorporation that reads:

“To establish a non-profit social and medical model healthcare center for Filipinos, imbedded with ethnic-specific psycho-socio-emotional, religious and culturally-sensitive services.” (Mendoza, 2004)

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• Ethnicity refers to (1) group membership based on (b) the integration of (c) values and feelings and (d) practices and behavior that (e) arise through historical roots in the family of origin and (f) through common cultural, religious, national, and/or linguistic background and (g) culminate in a shared symbol system and (h) a sense of shared identity. This approach suggests that ethnicity is a living reality, a way of life. (Holmes, 1995).

• Geriatrics is the branch of medicine dealing with the physiologic characteristics

of aging and the diagnosis and treatment of diseases affecting the aged (Mosby, 1998).

• Gerontology is the study of all aspects of the aging process, including the

clinical, psychological, economic, and sociologic issues encountered by older persons and their consequences for both the individual and society (Mosby, 1998; Green, 1993).

• JCAHO is an acronym for Joint Commission on Accreditation of Healthcare

Organizations. It evaluates and accredits nearly 16,000 healthcare organization programs in the United States. It is an independent, not-for-profit organization and is the nation’s predominant standard-setting and accrediting body in healthcare. Since 1951, JCAHO has maintained state-of-the-art standards that focus on healthcare and its comprehensive accreditation process evaluates an organization’s compliance with these standards and other accreditation requirements. Recently, it has introduced a new concept that will change how accreditation is viewed for the long-term care organization: Shared Visions – New Pathways. Complete document is attached in Appendix E (JCAHO, 2004).

• Long-Term Care is best defined in terms of those people who require to use it

and who are functionally dependent on a long-term care basis due to physical and/or mental limitations, and those who require health care, personal care, social and supportive services over a sustained period of time (Pratt, 1999) and may be classified as non-skilled but requires a 24-hour nursing and medical care due to their chronically-ill health conditions.. Long-term Care is a term interchangeably used for “healthcare” in this study.

• Minority is a term used in this study to connote the size and number of

population of a group of people coming from different ethnic background against the dominant mainstream society.

• Title 22, Div. 5, Ch. 3, Art. 3 is a California Code of Regulations on Social

Security about Licensing and Certification of Health Facilities such as Skilled Nursing Facilities, Home Health Agencies and Referral Agencies which reads:

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“Skilled nursing facilities shall provide, but shall not be limited to the following required services: physician, skilled nursing, dietary, pharmaceutical and an activity program.”

• Taglish is a term coined for Tagalog and English languages put together. This is becoming very popular mode of communication in the Philippines and when Filipinos (i.e. Filipino elderly) migrate to the United States, they still use this Taglish form of conversation. Taglish words used for discussion in this study are demonstrated in the Glossary of Pilipino Terms. Example of Taglish conversation: “I went to see my Tatang (father). Did you mano (kiss his hand) to him? Mano is a Filipino value.

• Value is an ideal and principle by which man lives. It is related to the search for meaning in human life. It is a personal belief about the worth of a given idea or behavior (Mosby, 1998). Life is meaningful when a man has found something capable of arousing his commitment to it, something deserving of his best efforts, worth living for, and if need be, worth dying for (Andres, 1989). Values are things, persons, ideas, or goals which are important to life – anything which enables life to be understood, evaluated, and directed. It is whatever is actually liked, prized, esteemed, desired, approved, or enjoyed by anyone at any time. It is the actual experience of enjoying a desired object or activity. It is an existing realization of desire (Mayers, 1984).

Digital Photo taken by Nini in front of the Mendoza Residence at 936 Vienna Street, San Francisco, CA

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Chapter 2 REVIEW OF RELATED LITERATURE

This chapter presents a comprehensive review of the current literature related

to ethnogerontology with a specific focus on the Filipino elderly and some of the cultural values they cherish in their hearts when they come to settle in the United States of America. The Aging Process

There have been several attempts to understand why people age and why they live so long (Allen, 1997). Many theories are explored to discern the issue of why people age and yet, no one theory claims to explain the aging phenomenon without being subjected to criticism because the discussion tends to be more narrowed down on biogerontologic theory about why we age. The understanding of why we age being referenced to the limited functional capacity of the person due to age does not address the view of why we age but directs us to the field of geriatrics (Mosby, 1998), a branch of medicine dealing with the physiological characteristics of aging and the diagnosis and treatment of diseases affecting the aged. To say that there is a cure for old age is a fallacy because old age is not a disease. Age changes are not in themselves diseases but rather are natural losses of functions. And the professionals who specialize in treating the elderly with their natural losses of functions are called geriatricians and those who study the problems of the aging population in society are not usually physicians but gerontologists. As the understanding on the complexity of issues pertaining to the aging process (Anderson, 2002) is enhanced, the likelihood of improved healthcare service delivery among the aged is expected, especially to those who are bound and committed to institutionalized long-term healthcare setting due to their chronic healthcare condition requiring a 24-hour nursing/medical care.

Development of Nursing Homes

The history of the modern nursing homes (Cole et al, 1992) goes back to 16th Century England and the Elizabethan Poor Law. In America, nursing homes were quickly distinguished from hospitals. Long-term care facilities took the form of the poorhouses or almshouses. After the passage of the Social Security Act in 1935, public funding gave a subsidy to private, propriety homes for the aged, which have confirmed to be the overwhelming pattern in America, The passage of Medicaid/Medicare in 1965 created another major stream of public funding and stimulated a new spurt of growth. And, the growth of the elderly population over the next several decades as the baby boomers age will test the system’s ability to respond. The combination of increasing need and diminishing resources will require

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that new, more efficient delivery methods of services be found but not at the expense to compromise quality of care provided to the residents.

In the Philippines, 95.98% surveyed Filipinos (Medina, 2001) expressed that it is unthinkable for them to put their elderly parents in nursing homes due to filial responsibility. However, there is a growing trend, at the same time, that placement of the aged in nursing homes is an involuntary reaction to poverty and after children have exhausted all means to care for their elderly at home. Some are mendicants, misplaced, usually migrants who are very poor, without any family, or abandoned by relatives due to negative behavior, disease or disability. There are only 21 institutional homes for the aged in the country, most of which are sponsored by private, religious or interfaith groups, philanthropies, civic and other non-governmental organizations.

Strengths and Weaknesses of Long –Term Care System in the U.S.

The current long-term care system has its strengths and weaknesses. While it is true that it is less than perfect, it has provided essential care to a very large, very diverse population for a long time, by being responsive to the changing needs of its consumers (Allen, 1997). The long-term care system in the United States has evolved in ways that fit the attitudes of our society and are somewhat unique to this culture, such as strong reliance on personal responsibility, resistance to heavy government involvement and defense of individual rights to choice. Majority of people working in the long-term care are highly dedicated to the welfare of those for whom they care. It is this dedication that has allowed the long-term care system to survive and its increasing focus to serve its consumers.

The system has also created innovative ways to meet the needs of its consumers such as: (1) Aging In Place/Community-based Long-Term Care– designed to bring services to consumers rather than moving them to where services are available (Pelham et al, 1986). The problem in this model lies in the difficulty of implementation of the logistics in requiring all necessary services available at a reasonable cost. (2) Multilevel Facilities are long-term care facilities that provide several different levels of care in the same location such as skilled and non-skilled nursing, assisted living/residential care and various types of supported independent living arrangements. (3) Adult Day Care programs are designed to provide relief for family members who provide long-term care for relatives in their homes.

The current system has its flaws, too. Its weakness lies in the need to find solutions fast to the rapid growth in the number of people needing long-term care services. Some of the weaknesses of the long-term care systems are attributed to the following: (1) It is a reimbursement-driven system wherein providers have come forward to meet needs for which there is reimbursement, but have been understandably reluctant to create services for which they will not be paid, or for which reimbursement is extremely limited. The type and amount of service

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available to individual consumers is more often than not dependent on the type and amount of financial coverage they have. (2) It is fragmented and uncoordinated system. Nursing facilities are subjected to different rules and regulations than are home care agencies. By Federal Law, for example, all states must license nursing home (nursing facility) administrators. Yet, there are no overall standards governing how they do so, and there is a great variation from one state to another. (3) Poor Public Image – Nursing Homes are seen by a generation as places where one goes to die, or places where family members can “get rid of” a burdensome relative, or a long stay in a nursing home can consign a resident’s family to financial hardship, even poverty. But choose the wrong nursing home, and you may also consign your loved one to physical and emotional hardship, including premature dependency and incontinence, even premature death. This poor image translates into tougher regulations and/or opposition to funding of long-term care. Being cognizant to the vast geographic, ethnic, economic, and social differences in this large country indicates a difficulty to find any monolithic system that meets all of those needs equally to its consumers.

Towards an Ideal System

Accordingly, an ideal system that although it cannot be achieved, Pratt (1999) asserts that we can come a lot closer to it if we have to survive and prosper by considering the following criteria: (a) it should be based on recognition of the needs, rights and responsibilities of individuals, (b) it should be easily accessible, (c) it should coordinate professional, consumer, family and other informed caregiver resources, (d) it should be an integral part of the health and social system, to promote integration, efficiency and cost effectiveness, (e) it should be adequately and fairly financed, and (f) it should include an education component to create informed consumers, providers, reimbursers and regulators.

In addition, the writer also believes that an ideal long-term care system should be operated as a “non-profit model” (Mendoza, 2004) to address the respective multi-ethnic needs of the population that is imbedded with ethnic-specific, psycho-socio-emotional, religious and culturally-sensitive services.” It should be a system (Lesnoff-Caravaglia, 1985) that is not concerned about gaining material wealth over the needs of the elderly bound for the long-term healthcare setting.

When a long-term care facility is for profit, one can’t help but to raise concern about the quality of care being compromised due to increasing demand of care and diminishing resources; and operators would be tempted to place profit over the needs of their consumers because they exist for that reason.

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Culturally-Sensitive Long-Term Healthcare Model

n a society as diverse as the United States, a “one size fits all model” may not be as effective service delivery of healthcare services to its multi-ethnic elderly long-term care users. The needs of the individuals are as diverse (Sokolovsky, 1997) as where they are coming from. In the long haul, it may be cost effective to consider being culturally-sensitive in the provision of long-term care services to meet the needs of the elderly as reflected in the diversity of their ethnicity.

In a study conducted on Ethnic Diversity Issues in Long-Term Care: Administrator-In-Training Observations (Antonelli, 1997), the researcher observed that the population in the United States is becoming increasingly ethnically diverse and so with the staff and resident population in long-term care facilities and found that the staff were observed to have the strongest perception of ethnic diversity as being an important facility issue (65%), followed by administration (42%) and residents (26%). She suggested that further research be conducted to help LTC administrators and staff develop interventions to effectively meet the needs of an increasingly diverse target population.

The Stanford Geriatric Education Center at Stanford University School of Medicine has developed a variety of twelve (12) ethnogeriatric programs and curriculum resource materials to educate healthcare professionals on the cultural issues associated with aging and health and promotes cultural sensitivity and competence to improve the quality of healthcare delivered to the rapidly growing population of ethnic minority elders such as the Filipinos (McBride, 2004) in the Unites States. The programs appear to prepare healthcare professionals to become culturally-sensitive and competent to address the ethnic diversity issues of their clients.

It was, however, noted that caregivers/staff should not only be educated to become culturally-sensitive and competent but ethnicity plays an important consideration in nursing home operation and in the interaction between residents and staff where positive interaction (Holmes, 1995) could take place because they share common class and/or ethnic background. The sharing of a common ethnic background of residents and caregivers seems to be a critical component in the operation of a long-term care institution that would bring about and effect culturally-sensitive-service environment in the facility. As such is the design of the proposed Geriatric Healthcare Center for Filipinos where sharing of common ethnic background is not only the main factor but an in-depth knowledge of one’s own cultural values of people served coming from the different regions of the home country, i.e. Philippines, plays a significant consideration.

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The Filipino Community and Its Aging Population

The growth rate of Filipino population in the United States could be attributed to the increase in number of immigrants, new birth rate and longer life expectancy of the elderly for which cultural values are treasured in their hearts as they grow old.

a. Filipino Immigration to the U.S., A Historical Perspective The Spanish-American War brought the Treaty of Paris in 1898 of which

Spain gave Philippine control to the U.S, after 300 years of occupation. This era proclaimed the Philippines, a colony of the United States. The initial relationship between the Filipinos and Americans was rough. After the Treaty of Paris, Gen. Emilio Aguinaldo declared Philippine Independence on June 12, 1898, and the Filipino-American War began that lasted for three years. Despite turbulent beginnings, the United States brought democracy in the Philippines (Aquino, 2001).

In the early 1900, other Filipinos (a.k.a. Pinoys) came to Hawaii and other parts of the country to work and seek a better life in America. These Filipino pioneers were known as “Manong generation.” Americans blamed them for taking their women and their jobs. As a result, Filipinos were discriminated against by not being allowed in restaurants, hotels and other public places. These led to the Tydings-McDuffie Act of 1934 which limited Filipino immigrants to 50 persons per year.

WWll, Americans viewed Filipino immigrants with less hostility as the third wave of immigrants arrived. Many Filipinos joined the U.S. Navy to fight against the enemy and were labeled “stewardsmen.”

After the Immigration Act of 1965, the fourth wave of Filipino immigration started and continues today. As many as 20 thousand immigrants are allowed annually. This wave of immigration brings many lawyers, doctors and nurses. This era is named the “brain drain.”

Most recently, from 1990 to the present, the 1990 amendment to the Immigration and Naturalization Act brought an influx of aging 4,000 WWll veterans who were given instant US citizenship because of the unfulfilled promise made to them for US citizenship when they fought for the Allies in WWll.

In 2000, the US Census reported that there are more than 1.8 million Filipinos and ranks as the 2nd highest among Asian population residing in the United States. McBride (2004) noted that Filipinos in the US aged 65 and over are 95% born outside the U.S.; 57% were naturalized; 89% spoke a language other than English; 56% said they do not speak English very well; 17% are classified as linguistically isolated. There are eight (8) major regional languages spoken in the Philippines, namely: Pilipino/Tagalog (29.6%), Cebuano (24.2%), Ilocano (10.3%), Ilonggo (9.2%), Bicolano (3.5%), Waray (4%), Kapampangan (2.8%), and Pangasinanes (<1%).

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b. The Filipino Elderly There was no practically social research conducted in the Philippines about

the Filipino Elderly until the United Nations designated the year of 1982 as the Year of the Elderly (Medina, 2001). According to the UN, the Philippines has the highest growth rate of elderly population in the whole of Asia and the Pacific. The elderly constituted only 4.6 percent of the population in 1970, increased to 5.3 percent in 1980, and 5.4 percent in 1995. Life expectancy rate at birth has increased from 60.9 years in 1975 to an estimated 66.0 for males and 70.0 years for females in 1996. People on the average live longer today due to the improvement of health and medical science. And, the proportion of aged people in the population is increasing due to the decline of fertility and increased life expectancy.

From the cultural point of view, Medina (2001) asserts that the aged member of the family is not considered a burden. One is seen as an asset both to the family and to the community in terms of wisdom, high status and influence, skills in interpersonal relations, and accumulated experience in social, political, and economic affairs. It is assumed that the family is to take care of the welfare of the aged. Thus, the aged are not perceived as posing any critical problem to society.

As Filipino elderly enjoys being reunited with family and children, it is expected that one should be accorded the same treatment and respect due to being as an older person. He/she cherishes deeply in one’s heart what every Filipino knows about how an elderly person should be treated, and that is:

Respect for Age – Traditional Filipino society is organized on the basis of generation and concept of seniority which involves deference and respect for older persons regardless of gender. This great esteem and high respect accorded the elderly dates back to the ancient times when age was equated with wisdom (Jocano, 1988). A traditional and polite way to speak to the elderly person is to use “po” or “ho” and the use of plural form of the second person, “kayo”, instead of the singular form “ikaw” or “ka” for “you”. Another sign of respect is to address an elderly person who belongs to one’s grandparents’ generation as “Lolo” (Grandfather) or “Lola” (Grandmother), without regard for real or direct consanguinal or affinal connections. If the elderly person belongs to one’s parents’ generations, then he or she is addressed as “Tiyo” or “Tata” (Uncle) for the male, or “Tiya” or “Nana” (Aunt) for the female, again irrespective of actual blood ties. Within the same generation, the older person among the Tagalogs is addressed as “Kaka” or “Ka” followed by the first name such as “Ka Pedro”. Among the Ilocanos, it is “Manong” for the male and “Manang” for the female. A young person may not address an older one, much less an aged person, by his first name only. The “Mano” tradition in which the young person kisses the hand of an elderly person is also another way of showing respect.

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c. Needs and Problems of the Filipino Elderly In addition to economic security, Medina (2001) further contends that social

interaction is a problem when the aged develops difficulty in relating with family members, or other people, especially with the young moderns. Either they are misunderstood or they have actually become intolerant, rigid, and touchy. Sometimes conflict may be traced to simple miscommunication. This may be due to the decline of sensory functions, like in the case of a grandmother who can no longer see well, or a grandfather who is hard of hearing.

Another cause for emotional anxiety and insecurity among the aged is the loss of health and vigor. One, who used to be very active and solicitous over the children and grandchildren, by cooking their favorite meals, taking them to the mall, and catering to all their desires, now feels helpless and useless, due to physical restraint. The realization that one can no longer contribute any activity to the family can be psychologically depressing.

Another problem of the elderly is the loneliness, the grief and mourning upon the loss of a spouse which can be intensely painful and may take some time to overcome. The loss of a close friend can also bring deep psychological trauma. The aged person notices her diminishing number of peers as they pass away one by one which means the loss of daily companionship, of shared memories and psychological support.

One major concern of the elderly is how best to spend the remaining years of their lives. There are many new roles and activities to which they usually redirect their energy. They enjoy reminiscing the past by relating their experiences to the young. Many get involved in service-oriented activities in the church, in civic organizations, and in the community as a whole. Others engage in business or in a variety of leisure activities like gardening, mahjong and visiting friends.

“The future belongs to the youth and the youth holds the light of the future with ardent passion to make a difference and to effect change in her life and those around her as she learns to become socially responsible.”

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Chapter 3 METHODOLOGY

Research Methodology

The purpose of this study was to complete a comprehensive review of the current literature pertaining to ethnogerontology with a specific focus on the Filipino-American elders by using computerized and traditional search processes to address the hypothesis that Filipino-American elders will require culturally-sensitive services to meet their healthcare needs in the long-term care setting.

Provision of culturally-sensitive services necessitates an understanding of what psycho-socio-emotional and religious services are, in addition to the awareness of some of the significant cultural values that the Filipino-American elders cherish in their hearts. These ethnic-specific services imbedded in the healthcare service delivery are important integral segment of the holistic healing process of the resident at the facility. And, this sense of awareness and understanding shall be the basis for designing a nonprofit medical model healthcare center, to be named as proposed: “Geriatric Healthcare Center for Filipinos.”

The proposal is prompted by the recognition of the lack of or even the non-existence of a nonprofit social-medical model healthcare center to benefit the Filipino community in San Francisco and the Bay Area, in general, especially those older persons bound for and/or who are already in the long-term care setting. There shall be three phases of development of the actual proposed business plan. And for purposes of this field study, it shall address only the Phase 1 of the Business Plan Development. Phase 1: Long-Term Care (Non-Skilled): A Medical Model

Phase 1 addresses the formulation of a proposed nonprofit medical model business plan, to be called as “Geriatric Healthcare Center for Filipinos” that shall provide long-term care services to its residents with non-skilled nursing/rehab needs. A non-skilled resident is one who has reached the plateau of one’s skilled nursing/rehab needs but would rather, otherwise, require a 24-hour medical and nursing care, in addition to the provision of pharmaceutical, social and activity program services, because one could not be discharged back to one’s previous place of residence. Skilled resident is one who requires rehabilitation (OT/PT/ST) and usually stays in the Center for at least 3 months and/or 100 days of Medicare Health Coverage, and after which, the resident may be discharged back to a lower level of care or be sent home, when appropriate. But, if a resident needs more long-term care services; he/she may be discharged to long-term care facility because his/her health condition requires a 24-hour medical/nursing care without the benefit of rehabilitation.

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Phase 2: Short-Term Care (Skilled Nursing): A Medical Model This is a stage where the Center shall provide skilled nursing/rehab services. This

shall take place as when resources are made available. The Center shall then and in due time have both non-skilled and skilled nursing/rehab services to be provided to the Filipino-American elders under its care. Therefore, Phase 2 shall not be addressed in this study but be part of the on-going process of development for the CYDF USA, Inc., the Sister Foundation of Calantas Young Dreamers Foundation, Inc. (based and registered at Securities and Exchange Commission in the Philippines). The CYDF USA, Inc. has one of its mission objectives, “to establish a nonprofit medical model healthcare center for the Filipino elders that is imbedded with ethnic-specific psycho-socio-emotional, religious and culturally-sensitive services.”

Research Procedures a. The writer has explored different venues to generate comprehensive literature and

information by using computerized and traditional search processes such as ERIC, Psychinfo, Info Trac and visits to public and academic libraries;

b. securing government and nonprofit website information on the legal requirements on how to establish a nonprofit corporation; and, for defining a framework to direct the Center into providing a quality of care per JCAHO standard of care, in addition to the compliance issue with the State Law (Title 22);

c. attending workshops at the Foundation Center in San Francisco for information on how to establish a nonprofit corporation and subscribing to their Newsletter for updates on issues affecting the operation of a nonprofit corporation;

d. getting consultation directly from some authors and publishers in the Philippines on Filipino cultural values via long-distance communication;

e. securing access to the Stanford Ethnogeriatric and Ethnic-Specific Modules on the Healthcare of Filipino-American Elders, and

f. getting some useful information on the nonprofit status of some healthcare facilities in the Bay Area, to provide some insights on how to address the following concerns relevant to the establishment of a nonprofit medical model of the proposed Geriatric Healthcare Center for Filipinos:

1. What is the proposed business plan model for the Geriatric Healthcare Center for Filipinos?

2. What kinds of services are required to meet and be responsive to the needs of the Filipino elders in the long-term care setting?

3. What are some of the Filipino cultural values that one needs to be aware of as service delivery is being provided?

4. How can an awareness of these cultural values be useful to provide quality of care among the Filipino elders in the center?

g. Chapter 4 addresses the aforementioned questions to shed light on what the proposed Geriatric Healthcare Center for Filipinos could be.

h. Chapter 5 focuses on the actual proposed business plan. The chapter is a complete business plan document “ready to be pulled-out” for use in fundraising activity to target potential supporters and benefactors in the establishment of the Center.

i. Chapter 6 summarizes the findings, provides conclusions and recommendations.

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Chapter 4 DISCUSSION OF THE BUSINESS PLAN

It has already been noted that the long-term care system in the U.S. tends to be a “one size fits all” model and, apparently, is not designed to be culturally-sensitive to meet the healthcare needs of its culturally-diverse consumers such as the Filipinos. Although it is unthinkable and a disgrace for most Filipinos to put their elderly parents in nursing homes because of filial responsibility and obligation to parents due to their love and care for the aged parents, family members/children resort only to institutionalization after exhausting all means to care for their elderly at home. However, due to modernization, urbanization, industrialization and now, immigration to a new land where they have difficulty making adjustment to a new environment, can have a negative impact on the position of the elderly in the family. The aged is getting more and more isolated as young people become too busy with their own life and creates a generation gap, coupled with the economic crisis which has placed tremendous pressure on the family’s ability to sustain its members, has driven some families to leave their aged members to the care of the institution. With the 95% aged 65 and over born in the Philippines now residing in the United States (McBride, 2004) due to the influx of immigrants and increase of life expectancy of the Filipino elderly, we have in our midst in the long-term care setting who may feel trapped because of the lack of ethnic-specific psycho-socio-emotional, religious and culturally-sensitive services. Being aware of the dynamics of “who” the Filipino elderly is, the writer shall discuss the proceeding issues to be able to articulate and define of what makes the proposed “Geriatric Healthcare Center for Filipinos” responsive and be able to provide culturally-sensitive services to its consumers:

l. The Business Plan Proposal

Phase 1 of the proposed business plan for “Geriatric Healthcare Center for Filipinos” is a medical model long-term healthcare facility with residents being classified as having non-skilled needs; and shall be operated as a d.b.a. of CYDF USA, Inc., a nonprofit corporation, with an assumption that the Center shall, in addition to Title 22 compliance, have to orient itself in aiming to achieve the JCAHO standard of quality care services and eventually, become a JCAHO accredited facility. The nonprofit corporation in-charge of the overall supervision of the Center shall be identified as “CYDF USA, Inc.” CYDF USA, Inc. (California Registration In-Progress, as of this writing) is a nonprofit public benefit corporation and is a sister Foundation of the Calantas Young Dreamers Foundation, Inc. (based and registered as a nonprofit corporation at the Securities and Exchange

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Commission in the Philippines in August 2002). CYDF USA, Inc. clearly articulates its 3rd mission objective written in its Article of Incorporation (Mendoza,2004), to wit: “To establish a chain of medical model healthcare services center (Long-Term Care/ Skilled Nursing Facility) imbedded with ethnic-specific psycho-socio-emotional, religious and culturally-sensitive services for the Filipino-American aging population in the Bay Area and across the USA.” The photo below are the initial members of the Board of Directors and their children, taken during the second meeting on the formation of the Foundation on August 7, 2004, in which the Articles of Incorporation and By-Laws of CYDF USA, Inc. were deliberated and finalized. All members came from the same community in the Philippines called “Calantas” and those who responded were residing in the Bay Area and as far as Southern California. The first two organizational meetings were conducted at the Hellyer Park in San Jose, California. The meetings were informal but achieved what the agenda called for, which is the “formation” of the CYDF USA, Inc. The group adopted to meet annually during the First Saturday of May in the Bay Area.

Figure 1: Calantas Children and the Formation of the CYDF USA, Inc.

Source: Photo taken on August 7, 2004, during the formal adoption of the Articles of Incorporation and By-Laws of the CYDF USA, Inc. at Cottonwood Lake, 985 Hellyer Ave., San Jose, CA

The first annual Board Meeting of the Foundation is scheduled on May 7, 2005 at the Coyote Point Park in San Mateo County for which the final reading and signing of the By-Laws of the Foundation would be formally signed by the officers and members.

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The following documents are appended to set-up the Geriatric Healthcare Center for Filipinos: (1) Articles of Incorporation of CYDF USA, Inc., (2) Title 22, Div. 5, Ch. 3, (3) OBRA’87: Summary, (4) JCAHO Shared Visions-New Pathways. Once the Center is established, it is also appropriate to address its own growth and development by instituting a “built-in mechanism” to ascertain a successful business operation with a credible and equitable “Net-Profit Distribution Process,” a.k.a. NPDP. The following Table 2 demonstrates just as how NPDP is designed to positively impact growth and development of the Center so that its existence becomes more viable and sustainable to consistently provide culturally-sensitive services to its long-term care consumers. The NPDP is equitably addressed to ascertain that the Center continues to have a sound financial capacity and function at best in providing a maximum quality of care to Filipino elderly without necessarily overlooking one development over the other. The NPDP will situate the Center against putting unrealistic expectations on the growth and development of the Center which could prove financially difficult to accomplish. It will realistically respond and address the healthcare growing needs of the residents per Title 22 compliance and JCAHO Shared Visions-New Pathways standard of care, as the Center measurably ventures into program and physical developments.

Table 2: Net-Profit Distribution Process (NPDP) To Program/Physical Developments Number of Years

of Operation NPDP Percentage

to Program Development NPDP Percentage

to Physical Development 1st Year 95% 5% 2nd Year 90% 10% 3rd Year 85% 15% 4th Year 80% 20% 5th Year 75% 25% 6th Year 70% 30% 7th Year 65% 35% 8th Year 60% 40% 9th Year 55% 45% 10th Year 50% 50%

The Net Profit Distribution Process (NPDP) shall take effect as soon as the Center becomes operational and on its 10th year of operation and beyond, it shall have a full equitable implementation to effect its own growth and development. The Center shall be oriented towards self-sustainability by recognizing its ability to manage and maximize equitably its own limited resources for growth and development without necessarily compromising quality of care as reflected in its provision of culturally-sensitive services. For better articulation, program development includes the design of, among other things: (a) any program activity, services and resources that could positively affect quality of care being provided to residents at the Center, and

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(b) the benefits and compensation package of licensed and unlicensed staff. Whereas, physical development includes any physical improvement, renovation or acquisition of property for the operational expansion of the Center to address growing demand of program development.

II. Required Services at the Center The kinds of services required to make the Center responsive to the needs of

the Filipino-American aging population in the long-term care setting shall be those that are imbedded with ethnic-specific psycho-socio-emotional, religious and culturally-sensitive. All services provided shall be integrated, if and when appropriate, to the different programs and activities of the residents to effect a holistic approach of healing process, while yet the resident is in the Center. This means, that in addition to the mandate of the State Law per Title 22, Div. 5, Ch.3, Art. 3 compliance of providing medical, skilled nursing, dietary, pharmaceutical and activity program activities, the Center shall address the peripheral issues which are, otherwise, not in themselves and per se, reimbursible services because they are non-clinical in nature but are important part of the holistic approach of healing process of the resident in the facility. This holistic approach may suffer financial setback in terms of non-clinical services being provided but would, in the long term, become beneficial because the Center will provide services that would eventually make residents feel at home away from home, thus minimizing anxiety and restlessness of residents who, otherwise, would create psycho-socio-emotional instability and uncertainties of complaints and unsatisfactory stay in the facility.

Geriatric Healthcare Center for Filipinos will provide the required services by hiring a Filipino gero-psychologist to be able to meet the demands of this defined responsibility. Residents shall be referred and encouraged to participate based on the level of their cognitive functions as indicated in the initial assessment during their admission to the Center, and such assessment shall be used to classify residents, to wit, as having: (1) LT (long-term) and ST (short-term) Memory Intact, (2) LT Memory Intact but ST Memory_Deficit, (3) ST Memory Intact but LT Memory Deficit, and (4) LT and ST Memory Deficit. Recommended activity sessions under each classification from initial assessment are designed to enhance mood and behavior of residents positively affecting their general psychosocial well-being that would make them feel comfortable and at ease in their new environment. A. On Psycho-Socio-Emotional Services

(1) for Residents with LT and ST Memory Intact, the following are recommended: • Support Group. The residents could ventilate in a non-threatening environment

one’s personal issues or problems without necessarily being labeled or misunderstood as having, “mental health issues.” Residents could articulate and share their pain and agony, probably caused by personal issues and impact of

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one’s own health condition to self and suffering. Residents will have the opportunity to express and share their thoughts and feelings where they will feel heard and listened to by those who are in similar health situation. The Support Group is a social interaction where they could express their emotion which would make them psychologically at ease and supported. Thus, the group participants will psycho-socio-emotionally feel being supported, making them feel at ease and comfortable. This will provide a healing effect on the health condition of the resident by being less anxious, feeling accepted and feeling at home, thus: feeling at home, away from home.

• Individual Contact/Session. This will be provided to individuals who are at bed-side, alert, oriented and who, otherwise, are also hesitant to talk and share in the group setting. This is also the time when a resident might be able express oneself much better and find peace and strength in confronting one’s own health condition causing him/her pain and suffering.

• Group Counseling. The setting is similar to support group but with a different intent to provide direct or indirect guidance from the facilitators. Groups will be classified depending on the issues/concerns needed to be addressed or what kind of issues/concerns residents would like to be addressed.

• Individual Counseling. As appropriate, if residents feel more comfortable seeking counseling in an individual setting to be able to articulate and express much better one’s own thoughts and feelings.

• Print Media published by Filipinos; a collection of Filipino books for the Mini-Library; quarterly publication of in-house newsletter to encourage residents and staff for an interactive communication about thoughts, feelings and simple pleasantries and share in writing about poetry, brief stories, drawings/art works, family news, and anything worthwhile talking and sharing about to others.

(2) for Residents with LT Memory Intact but ST Memory Deficit: • Reminiscent Group Activity. This is a group activity for the residents to

articulate and share the sweet memories of good old days so as to evoke good feelings and emotions and would be just as happy to talk about them.

(3) for Residents with ST Memory Intact but LT Memory Deficit: • Pilipino Poetry Reading. This will give residents a venue to evoke into

expressing their feelings and emotions as they enjoy listening on the beauty of literature. Poetry Reading will include reading all available literature written in local dialects appropriate to the language of the residents.

• Living at the Moment Group Activity. Residents with LT deficit but ST memory intact will benefit most to be exposed with the current events of their life. Any simple activity that could stimulate sensual perception and arouse reaction (emotional, psychological, etc) could enhance their mood and behavior affecting their general psychosocial well-being.

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(4). For Residents with LT and ST Memory Deficit • Tactile Stimulation Activities such as (1) task-oriented talk (talking to

resident while care is given even if response is not indicated, (2) access to ethnic-specific multi-media venues like TV ( Filipino TV Channel direct from the Philippines); Audio/Music available in different Philippine dialects; Tagalog Movies (DVD-VHS format), to name a few.

B. Religious Services. As noted by Holmes (1995), the religious tradition observed in the United

States has little effect on attitudes towards the aged. The Biblical teaching to “Honor thy father and thy mother” states an ideal but does not represent a guarantee of respect and responsibility. American religion is youth oriented and very few maintain special organizations for the elderly. Some denominations operate retirement or nursing facilities for the aged, like the Sisters of the Poor of the Catholics. Similarly, in the Philippines there are hardly 21 nursing homes established throughout the country which are mostly operated by non-governmental efforts and kind-hearted individuals who believe in the cause to care for the elderly. The Geriatric Healthcare Center for Filipinos, therefore, shall address the religious life of its residents, as part of the holistic efforts of the healing process while at the facility. Religious Service is not inclusive or exclusive practice of the Christian Faith but any resident wanting to express one’s faith in communion with the Ultimate Being, he/she worships. Therefore, the atmosphere of religious services should depend on what kind of faith the individual and/or group of people would like to come and worship together in a place provided for the purpose of worship in private or in seclusion.

However, it is good to note that for several centuries since the introduction of Christianity in the 16th century with the coming of Ferdinand Magellan in 1521, the Philippines has remained predominantly a Catholic country, 85% (Aguado, 1999) of Filipinos are Catholic Christians. Other religions were also introduced in the Philippines like Protestantism with several denominations such as Presbyterian, Methodists, Baptists, Episcopelians, to name a few. Local churches were also organized like Iglesia ni Cristo and Philippine Independent Church. Islam has been embraced mostly in the southern part of the country like Mindanao. C. Culturally-Sensitive Services to Filipino Elderly in a LTC Setting

While it is true that healthcare workers and residents may come from the same ethnicity, it is equally true that they may come from the different parts of the country where there are eight major languages (McBride, 2004) and about 111 cultural groups (Andres, 1987) within the main Filipino culture to be aware of. It is important to recognize where and which part of the country the Filipino elderly is coming from. The region from where the residents come from in the Philippines

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will indicate their cultural idiosyncrasies, a cultural value practice that may differ from one region to another neighboring region. Thus, the presentation of the following cultural values reflect their origin from different regions in the country but would collectively comprise some of the “Filipino Cultural Values” and staff should be aware of them as service delivery is being provided to the residents: Provision of culturally-sensitive services connote an understanding of the cultural idiosyncrasies of the residents where one needs to be aware of their meaning and how important that value to a person is. It simply means also that “what may be valuable to you may not be for the other.” So, to be culturally-sensitive is to understand and accept the meaning of the value assigned to it per other person’s perspective and value orientation and never to insist that’s how I understand it. Whatever meaning the other person sees it, although at times you may use the same word, try to understand and accept the meaning on how the other person means it. Look at it from the other’s perspective and not yours. This sense of perspective is very critical in providing culturally-sensitive services, especially among Filipino elderly who may happen to come from the different parts or regions of the country where cultural idiosyncrasy is obvious and evident.

Philippines is composed of three main islands: Luzon, Visayas and Mindanao. The map on Figure 2 (Mendoza, 2004) helps the reader to visualize where Luzon is at, being the main island where most of the different subcultural values subject for discussion in this study originated from. Thus, it is the intent of this study to present an understanding the Filipino cultural values from two perspectives: (1) understanding the Filipino cultural values, in general, and (2) understanding the different cultural values in Luzon, Philippines, differentiated by environment, history, dialect, values and physical boundaries separating the regions from each other.

lll. Presentation and Understanding of Filipino Cultural Values: Basis for Providing Culturally-Sensitive Services to Filipino Elderly in LTC Setting

In order to provide culturally-sensitive services in the long-term care setting, a staff has to recognize the meaning of the “cultural values” that the Filipino elderly cherish in their hearts. For purposes of this study, the understanding of Filipino cultural values was used as a basis to provide culturally-sensitive services and it has to be viewed from two perspectives:

(a) general understanding of the Filipino cultural values, and (b) understanding the different cultural values of Filipinos, especially those Who live in the northern part of the Philippines, Luzon.

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Figure 2: Map of the Philippines

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A. Understanding the Filipino Cultural Values: A General Perspective Filipino culture is an integrated system of learned behavior patterns that are

characteristics of the members of the Philippine society. It refers to the total way of life of the Filipinos. It includes everything that the Filipinos think, say, do or make. It includes Philippine customs, traditions, language, values, beliefs, attitudes, concepts of self, morals, rituals and manners.

The Filipino culture, like any other culture, grew differently because of its need to respond to Filipino problems. One has to remember two considerations when looking at Filipino culture: (a) it is important to note that there is no intrinsically “right’ or “wrong” solutions, no objectively “better” or “worse” ways of meeting basic needs, and (b) every culture is and has always been ethnocentric, that is, it thinks its own solutions as superior and would be recognized as superior by any “right-thinking,” intelligent, logical human being (Andres,1987).

There are regional differences among Filipinos as they are influenced by different economic conditions and geographical locations. The Filipino is known to be a spendthrift if one comes from the Tagalog region, the Visayas or Pampanga, but an incorrigible tightward if he/she comes from the Northern provinces. Filipinos from the sugar area enjoy better credit facilities and are loose with their money, whereas the Ilocanos are generally industrious and thrifty with their hard earned money. The Visayan Filipinos live in rich lands, with very fertile soil that does not require much tilling to make it productive. The Filipinos from the Visayas, therefore, do not have to work too hard to enjoy a bountiful harvest.

There are 111 linguistic, cultural and racial groups in the Philippines. While the Philippines has a national language called Pilipino, English remains the language of instructions in most colleges and universities.

Filipinos have embraced two of the great religions of the world: Islam and Christianity. Islam was introduced in the Philippines during the 14th century, while Christianity, during the 16th century with the coming of Ferdinand Magellan in 1521. Other religions were also introduced as early as the 18th century. While most Filipinos practice Christianity, they can also be superstitious. This is what they call “split-level Christianity.” Staff in the Center need to be aware of these superstitious beliefs for they might encounter a resident who may be resistive to care, without knowing that it has something to do with what a person believes. Superstitious beliefs are presented and discussed later in this chapter. Filipinos are known for their hospitality, their generosity is boundless. A Filipino will welcome you openly into his house, and will even offer you his/her bed. The line “My home is your home” is often uttered in welcome (Aguado, 1999). If you happen to arrive at the Filipino’s doorstep during mealtime, he/she will give you a special place at the table. A Filipino will readily share one’s food with others even if there is little left for him/her.

There is a strong family ties. There is a saying that if you marry a Filipino, you marry the entire family. In a sense, this is true because one never severs his/her

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ties with the family. Strong ties transcend the family. If you come from the same province, there is a tacit pact to support each other because you also consider yourselves, in a way, brothers.

Filipino’s respect for one’s old folks is exemplary. In the Philippines, we take care of our aging parents at home. This is also evident in the United States. Sending them to a home for the aged is unthinkable. It is small wonder why few such homes thrive in the Philippines. Most Filipinos feel it is inhuman to “send away” their old folks when they can no longer take care of themselves. Filipino parents caring for their children have no time frame, even if their “kids” are already full-grown adults or even married. So, when they advance in age, their children take care of them in return.

B. Understanding the different Cultural Values in Luzon, Philippines

The writer confines himself to the discussion of nine (9) subcultural values in Luzon out of the 111 cultural groups in the entire Philippines, namely: (1) Values of the Metro Manilans/Tagalogs, (2) Values of the Malabon People, (3) Values of the Bulakenos, (4) Caviteno Values, (5) Values of the Tarlakenos, (6) Pampango Values. (7) Values of Nueva Ecijanos, (8) Values of the People of Bataan, and (9) Ilocano Values.

The writer is also using as a reference, the work of a Filipino scholar and author, Dr. Tomas Andres, who has written extensively on the aforementioned topics on cultural values coming from the different regions in the Philippines, thus: 1. Values of the Metro Manilans/Tagalogs

The name Manila is derived from the Tagalog word, “manilad,” or a place overgrown with “nilad” – a small tree bearing white flowers. Metro Manila is the commercialized, political and cultural capital of the Philippines consisted of 5 cities and 12 municipalities. The influx of people from the provinces resulted in about 40% of the residents being either transients or non-Tagalogs and the remaining 60% are Tagalogs. Its population, as a whole, has kinship with the rest of the country by reason of blood, marriage, language or culture.

The Tagalog people consist of the following provinces (Andres, 2003): Bulacan, Batangas, Cavite, Laguna, Rizal, Marinduque, Mindoro Occidental, Mindoro Oriental, Quezon, Bataan, Palawan, and part of Tarlac, Nueva Ecija, Zambales and Metro Manila.

Understanding some of the following values (Andres, 2002) of the Manilan/Tagalog person would help establish rapport to make him/her feel at home, away from home to eventually lessen one’s own anxiety of stay in the Center:

• Courtesy and Respect for Elders. This is one Filipino value that has remained in the book of unwritten laws. Filipino parents exercise almost absolute power over the children. It is unthinkable for a Filipino to do an

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important thing without consulting one’s own parents. The latter do not condone children talking back not only to them but to anyone else older than they are. The word “po” may look innocent, but that little words shows respect for another. The elders believe and demand that they be obeyed – right or wrong. Their advice must, therefore, be sought on all important matters that affect the whole family, for what happens to one of the members affects the rest.

• Close Kinship and Clannishness. Filipinos in the Tagalog provinces enjoy close kinship and look to the family as a source of happiness, security and inspiration. They would do anything to provide for the needs of the family and to protect the family name and honor. The Tagalogs always look forward to clan reunions, especially during the Christmas season, fiestas, All Saints Day, weddings, birthdays. They find these reunions as a way of finding out how they can get help for advancement in life or to provide help for others who are in need.

• Pride and Honor. Tagalogs place so much value in family and personal honor. They try to be true to their friends, neighbors and buddies, and expect recognition and praise for good acts done or contributions given to other organizations. They are most unhappy when a family or a clan member is disgraced or has done something wrong to society. They are proud of their beginnings, their place of origin, and of their heroes and do not hesitate to tell their children and other friends of their feats, good achievements and success.

• Bayanihan. The people in the Tagalog regions can easily be called upon to help a neighbor/member of the community if an influential person will initiate such a cooperative endeavor. It is through effective leadership that people from these regions will give their leadership help.

2. Values of the Malabon People

Malabon is 13 kilometers from downtown Manila and at the other end of EDSA, if en route from Caloocan City. Its first settlers (Tagalogs) named the town “Malabong” (young bamboo shoots) because of the abundance of bamboo trees in the place. The place is famous for its “pansit Malabon” cuisine prepared by using seafoods such as shrimps, oysters and other small fishes as ingredients together with a variety of noodles.

In his second book, the author (Andres, 2003) explains and describes some of the values of the people of Malabon. Among these are:

• Pakikisama. The ability to get along well with other people is one trait that Malabon folks have. They are typically enterprising and hard-working but the pressure to keep the family business successful and stable could put them under stress and tensions.

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• Simplicity. Despite the success in life, the Malabon folks generally remain simple in their manner of living, manifested by their manner of dressing; houses are not extravagant but comfortable and are offended by people who brag about their wealth.

• Religiosity. They believe that an individual’s destiny lies in one’s own doings and God. Being religious people, they still celebrate and honor the patron saints of the different barrios in the town which could be attributed to their morally upright and ethical behavior.

• Clannishness. The welfare of their own families always comes first which could be a motivation for a member of the family to work hard so that he/she will have enough savings for one’s own family’s needs. Their high regard for the family has brought about the strong attachment among the family members. Hence, even if children are already of legal age, still stay with their parents.

• Ugaling Malabon. Being easily annoyed is typical of Ugaling Malabon. When things don’t go their way, they easily get irritated, annoyed and hot-tempered that could lead to fights but could easily get settled because they are mostly petty.

3. Values of the Bulakenos The ancient name of Bulacan is “Ma-yi” and is one of the earliest provinces

founded by the Spaniards in 1572. The present name is derived from the Tagalog word “bulao” (meaning cotton). Bulacan is a small province located north of Manila with 25 towns under its jurisdiction. Once a backward province surrounded by rice fields, now it has towns which have become busy and progressive and fast becoming an alternative venue for first class residential subdivisions.

In the third book (Andres, 2003) on Understanding the Values of Bulakenos, the author asserts that one needs to be aware of the following values while in conversation with a Bulakeno person:

• Family and Kinship. Bulakenos are taught from childhood that the primary loyalties of children belong to the nuclear family and by extension to their other kinsfolk. In any celebration, the guests are usually relatives. They are taught to revere the elders and to care for the aged. Elder brothers and sisters are called “Ate, Kuya, Ditche, Diko, Sanse or Sangkong,” depending on the order of birth. There are three types of kinship operative in Bulacan: (1) Consanguinity refers to blood kinship which is generated by the sharing of a common ancestor. It links the individual to the family into which he/she is born and reared. Since the Filipino inherits a network of kin from each of his/her parents, he/she has a vast number of relatives. And so the number of consanguinal kin is further augmented by the acquisition of the (2) Affinal Kin, or in-laws upon marriage. His/her spouse’s relatives become his/hers as

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well. While the relationship to the latter is affinal, the children’s relationship to them will be consanguinal. (3) Ritual kinship is the 3rd type of kinship found among Christian Filipinos. Ritual kinship or compadre system was intended by the Catholic Church authorities to ensure the child’s education in the faith. The godparents of the child during confirmation and baptism are to be additional spiritual guardians, in case the parents are unable to discharge their duties.

• Religion. Bulakenos are religious. They pray for nine days for the rain to come, especially when the planting season is near as the “palay/rice” needs more water to survive. People from different places go to Obando Church to make a devotion to dance for nine consecutive Sundays to be blessed with a child.

• Respect for the Aged. Among the Bulakenos, this is strictly adhered to, especially in the rural areas. Respect for elders, such as acknowledging their presence in a gathering and pagmamano (kissing of the hand) is among the oldest practices in the province.

• Paglilingkod. This is an act of service to others. Service is not confined to members of the family but also extended to members of the community.

• Pagtutulong-tulong. This is about providing education to members of the family. Family members, who acquired college degrees and are gainfully employed, are under obligation to assist the other members of the family in pursuing their education.

4. Values of the Cavitenos

The province of Cavite derived its name from the Tagalog word “kawit,” meaning a hook, referring to the shape of the narrow neck of land extending to the waters of Manila Bay which is Cavite City. Cavite is composed of 19 municipalities and three cities (Cavite, Tagaytay, Trece Martires).

In his 4th book on Understanding the Values of the Cavitenos (Andres, 2003), the author describes their values as follows:

• Customs and Traditions. Cavitenos are a people, having not only a deep love for freedom but also, for their hospitality, respectfulness and strong sense of family unity. Wherever you go in Cavite, you are greeted with overwhelming cordiality and warm hospitality. Their being well-mannered is often shown not only through words, but also through actions. They take off their hats when greeting people, they call out “Tao po” whenever they visit friends in their homes and usually leave their slippers at the foot of the stairs before entering the house. Oftentimes they use “sila” and “kami,” instead of “ikaw” or “ako.” The younger ones usually use “opo” and “po” when talking with their elders, and kiss the hands of the old folks.

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• Innate Courage and Strength. The province of Cavite played a pivotal role in the country’s fight for independence. It was in this province where the seeds of the revolutionary government took root due to the Cavitenos’ innate courage and strength. It is known as the “cradle of freedom,” like the cockpit of the Philippine revolution that gave birth to the Filipino nation. On June 12, 1898, General Emilio Aguinaldo raised the Philippine flag for the first time, accompanied by the country’s national anthem.

• Music Lovers. As they work in the fields, they sing to the accompaniment of a guitar. They do not mind the long hours of work under the heat of the sun when they plant rice as long as they are able to sing as they put their children to sleep, when cleaning the house, cooking the meals, or even when selling goods in the market.

• Devotion to Family. Cavitenos have deep devotion to their family and would go, to some extent, sacrificing their personal needs just to be able to send their children to school. Education is utmost importance to them. In fact, their ultimate dream is to see their children become professionals to spare them from a life of hardship previously experienced by their parents.

• Love for Fiesta. From the Spanish influences, Cavitenos inherited their zest for sumptuous banquets during fiestas. They are big eaters and would not normally settle for one-dish meals, especially during fiesta time. Some would go to the extent of borrowing money just to be able to treat their guests to a banquet.

• Love for Games. Cavitenos consider Sunday sacred – the day they engaged in cockfighting.

5. Values of the Tarlakenos

Tarlac is situated in the central plain of Luzon with 17 towns under its jurisdiction. Almost all of these 17 towns were patiently developed by the Ilocanos and Pangasinanes, except for the three towns of Capas, Bamban and Concepcion which were developed by the Pampangos. Four dialects are widely spoken in Tarlac: Ilocano, Pangasinanes, Kapampagan and Tagalog. As for values, since Tarlac is composed of different inhabitants and immigrants, practices of norms, beliefs, customs and traditions vary according to their origin.

In his 5th book on Understanding the Values of Tarlakenos (Andres, 2003), the author describes the different cultures affecting their values:

• Pampango Influence. One third of the province of Tarlac is occupied by the Pampangos; some are recognized by the Spaniards among the wealthiest and most influential men in Asia who have cultural ties with the Malays and Indonesians. Their cultural ties are evident with the following common words, such as: “nasi” (rice), numerals such as “isa, adua, atlu” (one, two, three), “minum” (drink), and “payung” (umbrella), to mention a few. The

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Pampango word “tulak” (to push) is “torak” in Malay. “Babi” is pig in both Pampango and Bahasa.

• Ilocano Influence. The greater number among the population in Tarlac are Ilocanos and their influence is very pronounced, such as the marriage practices of “sabit-sabit” (pinning of money), the “sab-ong” (dowry), and the “tupak-tupak” (cash on the table). An Ilocano is trained from childhood to work hard, to love manual labor, and to hail the dignity of agricultural work. Having undergone difficulty and hardship in life, the Ilocano values every single centavo and spends his/er money usefully and wisely. For this reason, he/she never spends money for the sake of “pakikisama.” Parents teach their children that money is meant for important and necessary purposes, not for extravagance. They should not be considered “kuripot” (stingy) but “matipid” (thrifty); and only through a knowledge of this culture that an Ilocano should be understood and accepted.

• Tagalog Inluence. The Tagalogs contributed some of their customs, beliefs, traditions and values to other Tarlakenos. The Tagalogs are closely interwoven with their culture and traditions such as doing household tasks, planting and harvesting, traveling and hunting, war and love, with a network of prescription of taboos. The women had better morals; they were docile, affable and modest in their action and conversation. Cleanliness is an outstanding character trait among the residents.

• Family. The family plays the center and greatest influence among its members. It sets the rules, values and credo for the new member of the family to follow. An exhibit of independence is unwelcome and almost everything is prescribed: from the spiritual to the material possessions. All these should be revered as they are “manna” (inheritance/heritage) from the family.

• Duties and Responsibilities. Duties and responsibilities start and end in the family. Any endeavor taken is always for the family. If one is sent to school in a big city, it is primarily for the family and secondly for the individual’s self-interest. One’s ambition in life is encouraged, but is limited by the family means, although in some cases, the family will do anything, even to the extent of borrowing or selling some property for the realization of a dream. The reason behind this dream is the ultimate economic upliftment of the family.

6. Values of the Pampanguenos

Pampangueno is one of several ethnolinguistic groups inhabiting Region III in Luzon. Figure 3 Map (Andres, 2003) constitutes several provinces, each of which has its own dialect and cultural idiosyncrasies distinct from each other. Pampangueno, as a dialect, cannot be understood by someone who lives in a neighboring province with another distinct dialect. To be understood, they have to

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communicate in Pilipino, the national language, or in English, a second language of the country.

In his 6th book on Understanding Pampango Values (Andres, 2003), the author noted that a Pampangueno shares much in common with his neighbors in Region III of Luzon and other lowland people in the Philippines but the Spanish regime homogenized Philippine culture, blurring many differences that had existed before the conquest of the archipelago when groups had been more isolated. But a separate dialect continued to distinguish the Pampangueno from the others, even to the present time from which the writer himself is a native of Pampanga and bears credence to this reality. Some of the traits and values discussed by Dr. Andres are as follows:

Figure 3: Map of Region III in Luzon, Philippines

N

S

• Highly Cultured. Pampanguenos are intelligent and highly cultured. They preserve, maintain and hand down to posterity the beauty and richness of Pampanga culture and heritage, as well as its arts and literature.

• Pride in their Hearts. Pampanguenos take pride in their courageous past that earned them a ray of the sun adorning the Philippine Flag, for being one of the first provinces revolting against the Spanish regime. They are proud of their tongue that speak of a distinguished culture handed down by their forebears as tradition, art and literature. .They are opulent in their talents: (1) they cook well, (2) they carve life into a piece of wood, (3) they make Christmas exotic with their giant San Fernando lantern, (4) they delight in their music and strive to excel in the use of their famous Lumanog guitar.

• Religiosity. The religiosity of some Pampanguenos is evident in their celebration of the Holy Week and Easter. Although, these are Catholic religious

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practices, people tend to literally translate them into action in a manner not encouraged by the Church such as “some penitents being nailed to a cross at about the same time that Jesus Christ was crucified in Golgotha nearly 2000 years ago.” The penitents make this vow to undergo the same of crucifixion as a gesture of thanks to Christ for all the good things that have happened to them. This is what they call “Folk Christianity.”

• Family Ties. They have strong family ties reared and educated with Christian values that cannot be broken by mere intrigue. If a Pampangueno loves you, it will be for life. But if you hurt his/her feelings, he/she would not show you his/her resentment but would remember it until he/she dies (maramdamin).

1. As a People. Pampanguenos are warm and gentle not only to fellow townmates, but also to other people who come from other provinces and who have different upbringing. They can be easily distinguished. Pampanguenos love to dress up in the latest fashion and would spend their last centavo to buy clothes and accessories to show off to their friends. They like to stand out in everything. They love festivities and parties and are good cooks. They are also hardworking people, most of whom work in the farm. They give foremost priority to send their children get education. Pampanga has a very good secondary private educational system.

7. Values of the Nueva Ecijanos

Nueva Ecija was originally part of Pampanga and was formally organized and recognized as a province in 1801. It was one of the first eight provinces to revolt against the Spanish regime in 1896. In modest recognition of the heroic deeds of the revolutionaries of the province, the Filipino flag was designed to include eight rays around the sun to symbolize the eight provinces, one of which is Nueva Ecija.

The geographical proximity of the province to several provinces whose inhabitants have uniquely different qualities from each other has made Nueva Ecijano’s personality a mixture of diverse traits.

The individuals are as resilient as their migrating forebears. They do not easily give up and the promise of a financial reward is not the major consideration that motivates them. They see themselves as part of a whole having a singular goal. As such, they realize the importance of excelling in their assigned tasks in order to help in the attainment of the group objective. It is not surprising therefore that they make decision as a group. In his 7th book on Understanding Values of Nueva Ecijanos (Andres, 2003), the author noted their values as follows: • Smooth Interpersonal Relationship (SIR). Parents expect their children to

support them in their old age in return for the support extended to their children far into their adult years. This interdependence stems from the value placed in

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smooth interpersonal relations and the eventual support to their parents stems from their belief in “utang-na-loob.”

• Paggalang. The children have a status subordinate to that of the adults. They are expected to yield to adult authority. Although “paggalang” is a value, this does not mean blind obedience or inability to think for oneself. Paggalang emphasizes respect due to the elders.

• Marriage. Marriage is stressed but consensual marriages outside of the legal framework are also acceptable. Priests occasionally have ceremonies for couples who have been living together for months or even years. Legal documents may not be considered essential, but community pressure is strong and a consensual union is quite stable.

• The Family. Obligation to the family is the highest order among the people of Nueva Ecija. The assignment of economic tasks, provisions for old age, assistance during times of misfortune, vocational training, religious instruction, maintenance of social order, and many other functions take place within the family.

• Amor-propio. Amor-propio means self-esteem. The desire for social acceptance is accompanied by a fear of personal rejection, a sensitive amor-propio, a keen sense of personal dignity, and a high sensitivity to personal affront, insult and criticism. The amor-propio is enhanced by signs of acceptance and it is the amor-propio and “hiya” (shame) that act as social sanctions guarding against the loss of social acceptance and harmonious relationships. The Nueva Ecija person is reserved.

8. Understanding the Values of the People of Bataan

The province of Bataan is situated on the western coast of the island of Luzon. To the north lies the province of Zambales and to the northeast the province of Pampanga. All other parts of Bataan are surrounded by the waters of Manila Bay and the China Sea.

Bataan is a historical place which has a surface of sun, sea and beaches. The people remember the Filipino forces who fought during WWII in Bataan in Mt. Samat, where now stands the Damabana ng Kagitingan in honor of all soldiers who died for freedom. Mt. Samat symbolizes the bravery and love of freedom of Filipino and American soldiers, fighting side by side against the invading Japanese Imperial Forces. This is the historical significance of the recent arrivals of the WWII 4,000 Filipino elderly veterans to the United States that in addition to the fulfillment of the promise made to them to become US citizens; they first fought for their love of freedom.

In his 8th book on Understanding the Values of the People of Bataan, Dr. Andres (2003) noted the following values of the people of Bataan:

• They are innately industrious, peace-loving and simple in their ways of life. They are humble and cooperative. The “kapitbahayan” and “bayanihan” values

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are very operative among them. Whenever a relative or a neighbor is in distress or in need, they are always ready to help by giving money, service, or their time.

• They are not showy even those who are rich and can afford luxuries. They live a simple life and dress moderately. They are hospitable, too, so parties and feasting are common in Bataan. They are fond of the “kumpadre” and the “tayo-tayo” system.

• They are sociable and communicative. They prefer personal vis-à-vis communication. There are times, however, when a “third party” acts as an intermediator when someone would like to request something. One of their most cherished values is “utang-na-loob.”

• They are strongly influenced by when other people might say (“baka may masabi”). Thus, they usually conform to the social norms and the laws of the land. They know how to control their temper and their emotions. If they feel hurt deeply by something, they have the courage to tell this only after they have drunk and gathered enough courage.

• Social reciprocity is very strong among them. It is their firm belief that one who sows goodness will reap goodness and one who sows evil will reap evil. They are excellent people to those who do well to them.

• They treasure their work and consider it as a means to attain stability. They are hardworking people.

• While the man is considered the head of the family, the woman is given much respect. The children are well taken care of and educated. Women are always consulted before the men make decisions. The husband governs his home with love and goodness and the wife/children give him respect and honor him.

9. Understanding Ilocano Values

Ilocano refers to the people and the dialect of the Ilocos region. It is also called “Samtoy” which translates “the language (or dialect) we use here.” The Ilocanos are known to be the third largest linguistic group in the country, next to Tagalogs and Cebuanos. Ilocandia is the alternative name of Ilocos, a region that occupies the northern portion of the Philippines. The Ilocano lives in a region where no great plains are found, where the hilly, rocky and barren soil yield no rich harvests, For this reason, the Ilocano has managed to survive through thrift, sheer industry, and ingenuity, and has also found it expedient to migrate to other places.

When reference is made to Ilocanos the first thing that comes to one’s mind is the word “kuripot,” or being tightfisted in money matters. This label has become a stigma that has stuck to Ilocanos. However, many may not realize it that this term has positive connotation that is “frugal.” Frugality is virtue that Ilocanos are proud of. Frugality or thriftiness is a virtue that enables one to spend his resources properly, efficiently and with purpose.

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Administratively known as Region l, Ilocandia’s provinces include Ilocos Norte, Ilocos Sur, La Union, Abra, Pangasinan, and the Mountain Provinces (Benguet, Ifugao, Bontoc, and Kalinga Apayao), Isabela, Cagayan, Nueva Vizcaya.

In the 9th book of Dr. Andres (2003) on Understanding Ilocano Values, he summarized the prominent values in the Ilocos Region, namely: • Sipag at Tiyaga. This is a value to the Ilocanos who are mostly farmers. Many

families in this region sacrifice a lot to send at least one member of the family to college; when this person finishes with a degree, he/she returns to take care of the younger members.

• Malakas. This value does not necessarily mean being strong physically, but strong in connections, that is, having acquaintances with prominent people or political figures. People tend to look up to such people for favor; although such an attitude is negative, it can be balanced by the positive effects as it can benefit a lot of poor people.

• Kuripot. Ilocanos are known to possess this value which other regions regard as a negative value. On the contrary, this is a very positive value if the intention of the individual is to save or earn money, thinking of the future of his family.

• “Mahirap lang kasi kami.” Definitely, this is a negative value. However, if the individual concerned will take this value as a challenge, it will become positive, as this can motivate a person to work harder, to strive harder and enable one to get out of his/her predicament.

• Bayanihan. This is the pooling of people’s efforts in order to accomplish a task better and faster. Those involved in this endeavor do not expect any remuneration.

• Kusang loob. This is a person’s voluntary act (e.g., the contribution for a poor neighbor or relative, without solicitation, an amount or anything of value to help).

• Mano. Kissing the hand of the parents or older people as a sign of respect; in return a blessing is received from the elders.

• Tiwala. This means having positive beliefs, faith or confidence in others. It is also means having strong will power towards anything negative.

• Pagkakaisa. Act of unity, solidarity, and cohesiveness in work, or cooperation in any endeavor or purpose.

• Pakikisama. The ability to get along with others; this is a value that is expected from fellow Ilocanos.

• Hospitality. Ilocanos feel bad if they cannot offer anything to a friend or visitors. They always want to show their affection to guests by inviting them to their home for a meal, or anything.

• Religious Beliefs. Before Ilocanos learned the Christian concept of religion, they had ideas of a Supreme Being whom they call “Kabunian.” They believe in spirits. They believe that their ancestors’ spirits dwelt in objects or places near

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them, to look after them, to protect and help them in their survival. The early Ilocanos believed that “anitos” are the spirits that help and serve God and “anitos” had a special task to perform and each is given a special name.

C. Superstitious Belief: A Counterproductive Value

Superstition is present in the lives of most Filipinos. A Filipino will not admit to being superstitious since it goes against the grain of Christianity. Instead, he/she will counter that there is no harm in taking precautions, which is practically admitting his/her belief in superstition. Christianity is Spain’s legacy to the Philippines, which is the only Christian country in Asia and 82 percent of Filipinos are Catholic Christians (Aguado, 1999). There exists among Filipino Catholics the phenomenon called “split-level Christianity” (Andres,1987). This consists of the co-existence within the same person of two or more thought and behavior systems which are inconsistent with each other. This split-leveling involves the absence of a sense of guilt, or the presence of only a very minimal amount. One who practices a split-level religiosity is convinced that two objectively inconsistent thought-and-behavior systems really fit each other. This inconsistency is either not perceived at all, or is pushed into the rear portions of consciousness. Hence, the feeling of inconsistency and hypocrisy does not arise. This inconsistency remains in the unconsciousness or in the semi-consciousness until an authority figure discovers the existence of the split. Split-leveling is the practical way one learns to handle the opposing pressures of two distinct groups holding different value systems. Desirous to please of two distinct groups possessing opposing value systems, one solves the dilemma of both pressures by keeping them apart and by simply ignoring the inconsistencies. A Filipino is very religious but at the same time, very superstitious. The following are some of the superstitious beliefs of Filipinos: 1. Related to Death.

• If a black butterfly lingers around a person, it means that one of his/her relatives has just died.

• No one should go out before the utensils used in eating have been washed

and put away; otherwise a member of the family will die.

• One must not organize teams of 3 or 13, otherwise one member will die.

• Eating sour fruits at night will cause the early death of one’s parents.

• If a sick person on his way to the hospital meets a black cat, he will die.

• If someone smells the odor of a candle when there is no candle burning, one of his/her relatives will die.

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• If one dreams that one of his/her teeth is being uprooted or pulled out, a

member of his/her family will die.

• If a person eats “malunggay” (leaves of a Philippine tree used as a vegetable) when one member of his/her family has just died, all the other members of the family will die.

• If one cuts his/her fingernails at night, a member of the family will die.

• When a group of three has their picture taken; the one in the middle will

die first.

• If a cock crows in the afternoon, it means somebody will die.

• If an owl is seen near the house of a sick person that sick person is sure to die.

• If a person’s shadow appears to be without a head, that person will soon

die.

• If you place a dead person with his/her feet pointing toward the rising sun, a relative will die.

2. Related to Illness

• Sleeping with wet hair causes blindness.

• A person will get sick if he/she takes a bath on Friday.

• If one removes ear wax at night, he/she will become deaf the following week.

• A person who cuts his/her fingernails at night will become sick.

• A person who cuts his/her fingernails on Friday will have a serious

illness.

• Before throwing hot water on the ground, give a warning to the elves, otherwise you will become sick.

• Playing with one’s shadow will make one crazy.

• Warts are caused by the urine of frogs.

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• Bathing during menstruation period causes insanity.

• Eating sour food during menstruation causes stomach trouble.

• Drinking dog’s blood is a cure for tuberculosis.

• Eating “bugok” egg (partially incubated eggs without the embryo) will make a person dull.

3. Related to Sickness, being the Work of some Evil Spirits.

• When some painful and red spots appear suddenly on the body of a person who came from the field, an invisible hand is suspected to have mischievously touched the person.

• When a person has a stroke of paralysis, an evil wind is believed to have

hit him.

• When a tumor grows in a part of the body, a displeased witch or a person who has contact with an evil spirit is thought to have planted it.

• To scare the spirits away and to cure those afflicted by the evil spirits, the

curative practices are: to flog the patient, put signs of the cross on his forehead or at every post of his house, and make all kinds of noises, sacrifice some live animals or offer some food, and oil to appease the offended spirits, and wear amulets (anting-anting) to neutralize the machinations of the devil.

• When a person is seriously or is pronounced by reputable physicians as

hopeless or incurable, he/she and his/her family have that instinctive urge to resort to the cure of the magicians, wizards, sorcerers, voodoos, mystics, conjurers, manghihilot (sprain curer), herbolarios (faith healer), be it of dubious value. Remorse comes if they do not resort to such a practice because as a result of breaking away from old beliefs and practices, someone in the family might keep saying ever afterward, “If only we had done this, the patient might have pulled through.”

• Many people leave their skin diseases untreated because of the belief that

those ailments serve as outlets for noxious substances produced in the body.

• A red patch of skin is the result of the mischievous “touch” of an invisible

hand of an “anito.”

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• Amulets (anting-anting) protect the wearer from illnesses and help counteract witchery. They also promote good health.

• Eating too much fish causes intestinal worms.

• An evil spirit usually goes with the fragrance of flowers at night. Anyone

who smells it would also suck in the evil spirit who will eat the bridge of the nose until it crumbles down.

• Recurrences of an illness, vernacularly called “binat, begnat or belnat,” is

caused by eating certain kinds of food or by cutting the hair too soon after illness. This relapse is best treated by fumigating the patient with smoke produced by burning the offending food or the patient’s hair.

• Friday the 13th is an unlucky day – doubly unlucky – for anyone who does

any business, work or operation.

IV. Significance of Filipino Cultural Value Awareness It has been noted (Andres, 1987) that there are 111 linguistics, cultural and

racial groups in the Philippines and there are eight (8) major regional languages spoken (McBride, 2004). The writer recognizes the extent of information needed to make a comprehensive study of the different subcultural values of Filipinos. He, therefore, confines his discussion on the significance of Filipino cultural value awareness from two perspectives: (a) a general understanding of Filipino cultural values where a commonality of values is shared by all Filipinos, and (b) an understanding of cultural values of nine (9) groups of people reflected in the available writings of some Filipino scholars which are the initial basis for providing culturally-sensitive services to Filipino elderly in the proposed long-term care facility called: “Geriatric Healthcare Center for Filipinos.”

It is also noted that the United States is a country with multi-ethnic and culturally diverse population that provides a “one size fits all” model (Pratt, 1999) of healthcare delivery system. This model is, apparently, not responsive and sensitive to the diverse cultural needs of its long-term care consumers. The writer believes that it is up to the individual community, like the Filipinos, to formulate a service delivery model that is culturally-sensitive and responsive to the long-term healthcare needs of its consumers. The Filipino community, being the 2nd largest of Asian population in the country today, may need to formulate a healthcare service delivery model reflective of the cultural values of its elderly population in the long-term care setting.

While it is true that the current healthcare system seems to be a “one size fits all” model in providing long-term care service to its culturally diverse consumers, it is also true that it is a reimbursement-driven system wherein providers have come

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forward to meet needs for which there is reimbursement and have been understandably reluctant to create services for which they will not be paid, or for which reimbursement is extremely limited; and the type and amount of service available to individual consumers are more often than not dependent on the type and amount of financial coverage they have. It can also be said to be true that even if some required culturally-sensitive services in the proposed Geriatric Healthcare Center for Filipinos are not reimbursable, they could be created to provide a holistic healing process which could not only positively impact the mood and behavior but also improve the general psychosocial well-being of the resident in a long-term care setting. This could be addressed by creating a position and hiring a Filipino gero-psychologist to implement this type of peripheral services which is a significant part of the resident’s holistic healing process while at the Center. The salary could be absorbed by the whole financial structure of the Center.

A. Cultural Relevance and Sensitivity across all Filipino Subgroups It appears overwhelming and mind-boggling to even consider of providing

culturally-sensitive healthcare services to a target population coming from a country of 111 linguistic, cultural and racial groups spread out in the 7,100 island people of the Philippines.

1. How can then the proposed Geriatric Healthcare Center for Filipinos insure to address cultural relevance and sensitivity as it provides healthcare services across all subgroups of Filipino elderly in the long-term care facility as residents?

In response to this inquiry, the writer offers the following discussion to articulate cultural relevance and sensitivity to the residents:

The Geriatric Healthcare Center for Filipinos is designed to operate as a non-profit medical healthcare facility that is imbedded with ethnic-specific psycho-socio-emotional, religious and culturally-sensitive services to insure that Filipino elderly in a long-term care setting will have a “homelike environment”. Homelike environment may be defined as a new environment created to promote “real life situation” while resident is in the facility, with the intent to reduce one’s own anxiety and address adjustment issue in the facility. This can be achieved by promoting culturally-sensitive services as when the entire manpower and/or staffing of the facility is made aware and situate itself to understand the cultural idiosyncrasies of the residents coming from the different regions of the Philippines. The staff should have the capacity to respond with cultural sensitivity. Their capacity to be culturally-sensitive may be materialized if they and the residents share (1) common cultural value experiences such as arts, music, dances, food, language, lifestyle and heritage, (2) historical significance and (3) cultural idiosyncrasies which could bridge better communication and understanding; thus, making residents feel more comfortable and at home in the Center.

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Being culturally-sensitive also connotes of trying to understand the “meaning” of the word and the value given per person’s perspective and orientation. This sense of perspective is very critical in providing culturally-sensitive services, especially among Filipino elderly who happen to come from the different parts of the country where cultural idiosyncrasy is sometimes obvious and evident.

The following are some interactive activities for which cultural relevance and sensitivity can be articulated and observed by the staff:

a. Task-oriented Talk: This is an interaction between staff and resident while healthcare service is provided in the facility. Per Chapter 5, Part IV, Section 2 discussion, nursing staff like CNAs are given ample time to be able to do the “task-oriented talk”. The ratio of patient load will give CNAs comfortable time to engage resident in a casual conversation, as residents’ ADLs are being taken care of. This “task-oriented talk” is concentrated in the day shift with a ratio of 6.25 residents per CNA. Atmosphere created in this “ratio of CNA staff to resident load” is one that makes residents feel “not being rushed” to get things done by their CNAs on duty and would encourage them to communicate their thoughts and feelings. If at some point, the resident has an issue or concern that can’t be handled in a casual conversation with the CNA, the resident may be referred to the Filipino gero-psychologist for follow-up to be engaged more in an in-depth talk and assessment.

b. Use of Language/Dialect. During the “task-oriented talk,” both resident and staff can talk in the language or dialect they understand each other. Their topic of conversation can be anything under the sun, as they say, with an objective to make the resident feel at home, away from home.

c. Arts, Music, Dances, TV Shows/News/Sports/Movies, Books, Literature, and Newspapers. The activity staff may acquire relevant materials through local Philippine stores and use them as activity tools to empower residents to feel good about something “dear and close” to their hearts so as to enhance their general psychosocial well-being. Direct TV Filipino satellite disc can be installed in the facility for a continuous 24-hour coverage of newscast, sports, movies and variety shows directly fed from the Philippines. This could bring “updates” direct from the Philippines, like being close to home environment.

d. Food and Fiesta Celebration. Create festive mood by celebrating important dates as they reminisce the historical and/or religious significance of an event through Filipino food delights, music and dances.

e. Birthday Celebrations. Celebrate their birthdays on a monthly-basis so as to make them feel that they are never forgotten on their birthdays and that they are important.

f. Respect for Age. It is important to indicate that a sense of respect is never forgotten by the way how the staff address or greet them. See discussion on Respect for Age on the Filipino Elderly in Ch. 2.

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g. Understand the Cultural Idiosyncrasies of Filipinos. An extensive presentation of the cultural values of Filipinos are presented in Ch. 4. This chapter will help the staff to learn more about some cultural idiosyncrasies of Filipinos coming from different regions of the country.

h. Decorate the facility and the rooms of the residents with objects that reflect Filipino culture, value and mood.

2. How will the Center know that cultural relevance and sensitivity are achieved as pointed out in the prior discussion?

The management of the Geriatric Healthcare Center for Filipinos will have to design a “Satisfaction Survey measured by the following scales: 1 is Extremely Satisfied; 2 is Very Satisfied; 3 is Satisfied; 4 is Not Satisfied; and 5 is Undecided”. The Form will be filled out quarterly by residents and/or with help from family members to determine whether the facility has achieved cultural relevance and sensitivity for its services to the target population. Suggestions from residents and/or family members will also be encouraged to enhance cultural relevance and sensitivity in the facility.

The writer acknowledges, for the purpose of this field study, that he has limited himself to the discussion of nine (9) Filipino cultural values found in Luzon, a northern part of the Philippines but intends to continue his research on cultural values of Filipinos living in other regions of the country with the following strategies: • by interviewing family members of residents staying in the Center and realign to

integrate their responses with the current format of the field study; and/or by going to the Filipino community in the San Francisco Bay Area;

• conduct research to universities and public libraries in the Philippines through computerized search;

• continue to make contacts with some Filipino authors and scholars here and in the Philippines.

In principle, cultural relevance and sensitivity across all subgroups can be addressed within the structural management of the Center and could prove useful to (a) top level management (Allen, 1997) like the Administrator with input from the different department heads to formulate and define some policies and procedures so as to improve culturally-sensitive healthcare service delivery that will positively impact the general psychosocial well-being of the residents, (b) Mid-level Management (DON and Department Heads) to coordinate implementing policies and procedures with (c) Lower-level Management (Charge Nurses and Nurse Supervisors/Other Department Supervisors) to have direct line implementation of policies and procedures by the (d) direct line staff (licensed and non-licensed staff/all employees having contact with residents).

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B. Improved Communication with Institutionalized Elderly. Communication with an institutionalized elderly is an important factor of the

person’s institutional life and institutional care. When a staff tends to normalize communication with a resident, insensitivity to the healthcare needs of the person is compromised, more so, being unable to provide culturally-sensitive services. The growing demand of services and diminishing resources due to increasing number of long-term care consumers put a stress on the delivery of healthcare system, complicated by the resident’s inability to communicate because of one’s health condition. This is tantamount to saying as “the absence of talk” (Nussbaum et al, 1995). There is a noticeable absence of talk between carers and elderly residents, or among the residents only. The lack of interest or the absence of talk could be attributed to either a lack of common interest of topic to talk about, or simply the resident could not communicate well to the staff because she/he speaks differently. So, if both staff and resident share a common interest like having the same ethnicity and at some point, sharing some cultural values, this could trigger some efforts on either part to engage each other, especially the resident to communicate with interest among the staff in the facility. Due to cultural awareness, a staff becomes culturally-sensitive as service delivery is provided and communication is effectively executed by using a “task-oriented talk.” Interaction between staff and resident is centered on particular care tasks. C. Sensitivity to Individual and Collateral Needs of Residents

Being aware of the cultural values of a person in a long-term care setting is indicative that one is sensitive to the needs of the individual. If there is a lack of or even the absence of cultural sensitivity when one provides services to the resident, it will put the resident at-risk of being inappropriately misunderstood and labeled in a box of having a “psych issue” for the simple reason that he manifests a mood and behavior pattern (MDS 2.0, 2000) affecting adversely his general psychosocial well-being. Consequently, he may be referred to for a “psych eval” and the psychiatrist may do further evaluation and treatment. At this point, the resident may be treated with psych medication to restrain him (with consent from responsible party) from the manifested mood and behavior pattern. When a person is given medication to restrain his behavior, he is on a chemical restraint. Just like physical restraint, chemical restraint is not an ideal treatment for someone who may happen to be suffering from psycho-socio-emotional stress and syndrome. So, prior to making a psych eval referral, it would be helpful to consider the following non-pharmacological approaches in dealing with a resident with apparent mood and behavior pattern affecting his general psychosocial well-being such as those identified in this chapter as “required services” to be provided at the Center: (1) Psycho-socio-emotional services, i.e. support group, reminiscent group activity, individual contact/session, group counseling, individual counseling, Pilipino poetry

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reading. (2) Religious services, and (3) being culturally-sensitive to understand the person’s values and beliefs.

1. “A Home, Away from Home” Environment

Staff will become more aware and sensitive to the needs of the resident in the Center as the former becomes more aware of the latter’s cultural idiosyncrasies, thus making him/her feel more at “Home, Away from Home” which is very crucial to their holistic healing process. When a resident feels having a “homelike environment” in a land away from his/her own native land while at the Center, that would lessen his/her anxiety and restlessness for he/she would feel the best quality care is being provided (psycho-socio-emotional), coupled with being attended to his/her spiritual needs. 2. Filipino Community’s Acceptance to Long-Term Care Services

Providing culturally-sensitive services would positively affect the Filipino community’s perception that it is unthinkable and a disgrace for most Filipinos to put their elderly parents in nursing homes because of filial responsibility and obligations to parents due to their love and care for the aged parents. They would see the Center, however, augmenting their love and care for their aged parents in a Center designed to make the stay of any Filipino elderly “feel at home, away from home.” 3. Enhanced Emotional Life

Providing culturally-sensitive services could lessen the emotional anxiety, insecurity and loneliness that could lead to depression among the aged. Filipino elderly who could still experience their life’s worth and meaning by being engaged in activities familiar to them, in terms of their cultural values.

4. Adjustment to New Environment

Providing culturally-sensitive services could help the Filipino elderly adjust to a new environment, making him feel less isolated as their children become too busy with their own life. 5. Feeling Assured of Meeting Residents’ Healthcare Needs

Being aware that the Center is a nonprofit medical healthcare facility and operated by Filipino professionals, is a good welcome sign for them to feel assured that the Center is established to meet their healthcare needs with cultural sensitivity, at this time in point of their life. 6. Feeling Welcome, “New Home”

The recognition of where the Filipino elderly may come from the Philippines and considering their distinct cultural values creates an atmosphere of being “welcome” and has entered a place called “my new home.”

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7. Respect for Dignity and Rights as Residents Recognizing the distinct cultural and subcultural value idiosyncrasies of the

Filipino elderly residing in the Center is tantamount to saying, “respecting their dignity as human beings and their rights as residents” for they are not summarily labeled as the but a Filipino elderly at the Center. This would imply providing services to consider their distinct subcultural values, religious beliefs and at some point, their superstitious beliefs affecting their mood, behavior and general psychosocial well-being. 8. Enhancement of General Psychosocial Well-being

A resident may be resistive to care (MDS, Sec. E.4.e) like resisting taking medications, injections, ADL assistance, or eating. An understanding of Filipino cultural values, religious and/or superstitious beliefs might be influencing their mood and behavior, thus affecting their general psychosocial well-being. A staff should, then, respond appropriately by connecting the resident to a Filipino gero-psychologist. To dramatize this issue, the writer would like to share of an incident that he encountered while working as a Social Worker in a healthcare facility:

Scenario: A 76 year old female, Caucasian, independently living by herself, unmarried,

no relative or children, was admitted from the hospital due to a fall from her bed at home while attempting to get up in the morning. After a couple of weeks for rehab, she would be discharged back to her previous place of residence, as part of her discharge plan.

Meanwhile, after few days of stay in the facility, the resident started getting agitated, restless, and anxious and refused to eat. She resisted any form of care attempted by staff and since they could not get through her and had a difficult time assessing her, they thought that she had some psych issues for which a psych eval referral might be appropriate. A Social Worker on duty was called to assist assess on the psych eval referral…until, one of the Filipino Certified Nurse Assistants overheard her saying, “I will eat only if you give me rice.” Staff would not give her rice since she was on a strict diet. She started shouting and became more uncooperative and hostile. Very discretely, one nurse aide on night duty gave resident a few spoonful of rice and had the rice pureed. Resident ate and expressed gratitude, became calm and subdued and had been, since then, cooperative for she was given rice as part of her menu. When asked about her clamor for rice, she responded saying “I grew up with rice and fish in the Philippines till I became a young adult.”

This scene creates a need to address cultural issues of non-Filipinos that had

established bonding with the cultural values of Filipinos and had them cherished in their hearts. It is then appropriate to consider this reality to include non-Filipinos

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with bonding to Filipino cultural values to benefit from the culturally-sensitive services provided by the Geriatric Healthcare Center for Filipinos. 9. Lack of Cultural Sensitivity leads to Internal Failure System

Recognizing unnecessary nursing time spent in the narrated scenario due to lack of cultural sensitivity and awareness on what the resident was really trying to communicate situates the Facility in lost nursing service time. Time spent put together until a nurse aide decided to discretely respond on the “clamor” of the resident was about four (4) hours from the 2-3 days of being unable to respond appropriately. Translate these 4 hours of nursing time spent at a rate of $30/hr., the Facility has lost $120.00 for this particular incident. The quantification of the incident demonstrates that the lack of culturally-sensitive services can be equated not only to a financial loss but nursing care time that could have been more used efficiently and effectively in the provision of direct nursing care to other residents. Pratt (1999) identifies this as an “internal failure system.” For management purposes, then, the way to maximize limited resources is to understand this principle of internal failure system so as to reduce cost and minimize financial loss without necessarily compromising quality of care by being culturally-sensitive to the needs of residents and, nurse could have spent more nursing time to other residents. Therefore, internal failure system is defined as a “staff time used ineffectively creating an equivalent COST related to financial loss for the facility, precipitated by lack of culturally-sensitive services due to staff’s lack of cultural awareness.

Dr. Darlene Yee, Gerontology Professor and Academic Adviser, who empowered me to walk incessantly to reach the finish line of my study in gerontology. Thanks to Dr. Rita Takahashi,

(Dep’t. of Social Work) for being my 2nd reader and reviewer of the final draft of my Field Study.

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Chapter 5 THE BUSINESS PLAN DOCUMENT PROPOSAL FOR

THE GERIATRIC HEALTHCARE CENTER FOR FILIPINOS

A. Preliminary Discussion on the Need for Business Plan Writing a business plan is like drawing a map to indicate where you are

headed to. A business plan is a tool to help you understand the need to take time to evaluate the potential and map a plan for the future. One of the main reasons for business failure is the lack of an adequate business plan. “You can run your business by the seat of your pants but you will probably end up with torn pants,” said Pinson (2001) in her book on Anatomy of a Business Plan. She further stated, saying “The business that fails to plan, plans to fail.”

The Geriatric Healthcare Center for Filipinos is a new business to be operated as a nonprofit medical model healthcare facility providing culturally-sensitive long-term healthcare services to Filipino elderly living in the San Francisco-Bay Area. As a facility providing healthcare services, it does not have any cost of goods to sell which is a very important variable to consider in the financial statement preparation of the Center. Therefore, the Geriatric Healthcare Center for Filipinos shall only have to project, at this stage, its financial statement in the business plan.

The business plan of the Geriatric Healthcare Center for Filipinos shall serve two purposes, (1) to serve as guide and (2) as documentation for financing. And since the Center is a new business, it shall present only projections for its financial statement and the proceeding discussion will further articulate and clarify the methods for which it shall embark on its business operation and management and shall be divided into 2 phases of business plan development: • Phase 1: A business plan to serve as Guide addressed to key supporters,

benefactors, philanthropists, private and public funding institutions and/or foundations; to jump start the implementation of establishing the Geriatric Healthcare Center for Filipinos in the provision of culturally-sensitive long-term (non-skilled) healthcare services to Filipino elderly;

• Phase 2: A business plan to provide short-term care services (skilled) addressed to similar group on Phase 1 and possible inclusion, if feasible, of private funding institutions plus the implementation of NPDP principle for physical development of the Center.

1. Use as Guide for Phase 1: Long-Term Care Planning

Without a guide, the Geriatric Healthcare Center for Filipinos will have no focus direction and its operation will be ineffective that would compromise quality of healthcare service delivery to its residents. At this juncture, however, the Center has already defined its mission and direction, that is to provide ethnic-specific psycho-

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socio-emotional, religious and culturally-sensitive services to meet the healthcare needs of its residents in a long-term healthcare setting requiring a 24-hour medical/nursing care; operating as d.b.a. of CYDF USA, Inc., a nonprofit public benefit corporation which registration in the Office of the Secretary of State in California and other government agencies (please, see Appendix B) is in progress, pending completion of all necessary legal paperworks (Mendoza, 2004). The most important reason for writing a business plan for the Center is to develop a guide for members of the Board of Trustees of the CYDF USA, Inc. and/or through its representative, the CYDF Founder and writer will follow throughout the lifetime of the business. The plan is a blueprint that will provide the management of the Center with the tools to analyze and implement changes that will make the business more profitable. The net revenue, also known as profit, of the business is designed to implement the NPDP (Net-Profit Distribution Process as reflected in Table 2 on page 30) for a sustainable growth and development of the Center so that it can continuously provide maximum quality of healthcare service delivery to its residents. The business plan will provide detailed information on all aspects of the Center’s past and current operations, as well as its projections for the next few years. It is, however, understandable that new owner, the CYDF USA, Inc. represented by its Founder, has no history and will base the information in his plans on projections developed through current research of the industry. To be of value, the plan must be kept up-to-date. Plans presented to lenders must be bound; the Founder-representative of CYDF USA, Inc. may choose to keep a working copy in a loose-leaf binder. Then he adds current financial statements, updated rate sheets, recent marketing information, and other data as they become available. The Geriatric Healthcare Center for Filipinos, as a nonprofit facility, shall not address Phase 2 of the Business Plan for it is, at this time in point, not timely to present as yet its business plan to lenders to seek financing. This will be further discussed in Phase 2 of the Business Plan and a separate business plan needs to be prepared and written. At this point, the writer addresses Phase 1 that serves as Guide to the business plan of the Geriatric Healthcare Center for Filipinos to have the Filipino-American community, supporters, benefactors and other interested members of the mainstream society, get involved and be guided accordingly to comply with the following steps and assumptions prior to effective implementation of the Phase 1 Business Plan: 1. On the assumptions that the writer has successfully made it through the Board

Exam as a licensed Nursing Home Administrator; that CYDF USA, Inc. has been granted a 501.c3, a tax-exempt status from the IRS; that all other legal requirements from different government agencies affecting the operation of the Foundation shall have been complied with, including but not limited to the registration of the Foundation as a nonprofit public benefit corporation with the Office of the Secretary of State in California has been legally secured; the writer can then safely make a statement that all funds coming through to financially help to implement the

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business plan of the Geriatric Healthcare Center for Filipinos shall be credited as tax-deductible in favor of the donor. This is a win-to-win situation between the Center and the donors/supporters.

2. Upon completion of all legal requirements (see Appendix B), the writer will be able to commence implementing the business plan and by then, there is a strong likelihood of credible support that can be generated from among the healthcare professionals in the Filipino-American community, i.e., medical doctors, registered nurses, dietitian, pharmacists, certified nursing assistants, social workers, psychologists, psychiatrists and other healthcare professionals.

3. Raise the level of awareness of the Filipino healthcare professionals, Fil-Am community and mainstream society, in general, on the need to establish and implement a culturally-sensitive healthcare service delivery system model to benefit the Filipino/non-Filipino elderly living in the San Francisco-Bay Area, through a series of multi-media saturation campaign such as the Filipino TV Cable, TV Ch. 9 and Filipino print media, that will lead to a series of conferences (SFSU, UC Berkeley, SGEC and/or SJSU) with a main purpose of presenting to the community the proposed business plan for the Geriatric Healthcare Center for Filipinos. It shall be noted prior to conclusion of the event, a determination of participants’ willingness to get involved by providing support in the common effort of raising needed funding or resources to implement the proposed plan shall be assessed through a questionnaire. The amount generated through pledges from among participants and others could be used as seed money to seek for matching fund from private and public funding institutions, in the next level of generating and fundraising activity. Another venue to raise fund is by holding a series of live musical concerts performed by artists from the Philippines.

4. Once the seed money is generated, matching fund grant proposals (Carlson, 1995) shall be prepared and written to private and public funding institutions so as to complete the initial phase of fundraising and start implementing the business plan of the Geriatric Healthcare Center for Filipinos.

5. Once the needed fund is raised and there are enough funds to start implementing the business plan, the Center can be made to function.

6. If everything turns out to be as planned, growth and development of the Center can slowly move on to execute Phase 2 in seeking financing from private lenders. At this juncture, the business plan of the Center needs to be rewritten and adjusted to include significant information that would support the business plan, in terms of raising fund to address its needs for growth and development to better provide and maximize quality of healthcare service delivery to the target population, as consumers.

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2. Use as Financing Documentation for Phase 2: Short-Term Care Planning This is a stage of the business plan for Geriatric Healthcare Center for Filipinos

ready to move on to provide short-term care to Filipino residents with skilled needs. It has to be noted that another business plan is required for planning to seek financing. If you are seeking capital, the business plan details how the desired investment or loan will further the company’s goals and increase its profits. Every lender wants to know how you will maintain your CASH FLOW and repay the loan (with interest) on a timely basis. Every investor wants to know how his or her investment will improve the overall net worth of the company and help him/her to achieve the desired return on investment. You will have to detail how the money will be used and back-up your figures with solid information, such as estimates, industry norms, rate sheets, and others.

Geriatric Healthcare Center for Filipinos: Phase 1 Business Plan

The presentation in the proceeding pages is ready for use and is, per se, a complete business plan document that includes, among other things, the following:

Cover Sheet Agreement of Responsible Use of the Information Table of Contents (integrated in the main body)

Executive Summary 1. Organizational Plan 2. Marketing Plan 3. Financial Documents 4. Supporting Documents

Dr. Anabel Pelham, whom I originally met in the Gerontology Office at SFSU, had been very helpful in advising me on how to proceed with a new career in Gerontology. I think I am one of the luckiest heirs, as her student, to put into practice the principle of SELF-SUSTAINABITY guiding the direction of the Calantas Young Dreamers Foundation, Inc. and CYDF USA, Inc.

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GERIATRIC HEALTHCARE CENTER FOR FILIPINOS1

Contact Information

Antonio M. Mendoza, CYDF Founder 936 Vienna Street, San Francisco, CA. 94112

PCS: (415) 713-4448 * Telefax: (415) 452-2636 *Email: CYDF821@sbcglobal.net

CYDF USA, Inc. Corporate Officers FY: June 2004 – May 2005

Amado Serrano, President

3805 Polton Place Way, San Jose, CA 95121 (408) 238-7231

Corazon P. Melendez, Executive Vice President

287 Station Avenue, Daly City, CA 94014 (650) 997-3373

Lucila Cooley

Vice President for Operations (Southern California) 6260 San Ramon Way, Buena Park, California 90620

(714) 826-5294

Easther Marie M. Serrano, Secretary 256 Lafayette Avenue, Hayward, CA 94544

(510) 429-1782

Cecille S. Mendoza, Treasurer 44 3rd Avenue, Apt. #1, Daly City, CA 94014

(650) 992-3194

1This document contains information that is not considered strictly confidential. It is disclosed to you for informational

purposes and its content shall remain the property of Antonio M. Mendoza, Founder of CYDF USA, Inc. (California registration in-progress as a nonprofit public benefit corporation). This document shall be returned to Antonio M. Mendoza when needed. This is a business plan for Geriatric Healthcare Center for Filipinos, d.b.a. of CYDF USA, Inc. and does not imply an offering of securities.

CYDF USA, Inc. has a threefold mission, to wit: (a) to help address poverty in the Philippines through a scholarship program, (b) to design community youth empowerment programs to benefit Fil-Am youths and their immediate families, and (c) to establish a culturally-sensitive medical model healthcare service center for the Filipino elderly in the San Francisco-Bay Area.

CYDF USA, Inc. is adopted as a sister Foundation of the Calantas Young Dreamers Foundation, Inc. (based and SEC-registered as a nonprofit corporation in the Philippines) with a mission to help youth help himself through a CYDF Scholarship Program Model with SWREM Theory In Action, as its methodology.

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2 GHCF Business Plan: Phase 1

Agreement of Responsible Use of the Information

The undersigned (“Recipient”) hereby agrees that all figures and other information (“Information”) that it has and will receive concerning Geriatric Healthcare Center for Filipinos may only be used for educational and learning purposes and/or for the advancement on the cause of the Foundation, the CYDF USA, Inc., in the service of the Filipino elderly in a long-term healthcare setting living in the United States. It shall not be used for personal motive to gain material wealth.

The Information shall remain the property of the CYDF Founder/Writer and shall be returned to him promptly at his request together with all copies made thereof, especially if said information is being used contrary to what has been indicated above.

Recipient acknowledges that CYDF Founder/Writer reserves the right to legally intervene if information therein is not being responsibly treated such as by using it other than what it was intended for.

_____________________________________ ____________________ Print/Sign Name Date

_____________________________________ _____________________ Antonio M. Mendoza, CYDF Founder/Writer Date

Having to dream that someday I shall be awakened to see the dawn of day shining with the clatters of newsclippins, gleefully announcing the fulfillment of the dream, the opening of the Geriatric Healthcare Center for Filipinos!

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CYDF USA, INC

EXECUTIVE SUMMARY

CYDF USA, Inc., founded in May 2004, is to be registered in California as a Foundation under a Nonprofit Public Benefit Corporation (Title 1, Div. 2, Part 2, Sec. 5110 et Seq.) with a mission to establish a medical model “Geriatric Healthcare Center for Filipinos (GHCF)” imbedded with ethnic-specific psycho-socio-emotional, religious and culturally-sensitive services to benefit Filipino elderly in a long-term care setting. It is administratively located at the home address of its Founder at 936 Vienna Street, San Francisco, CA. 94112. Upon being awarded a 501.c3 tax-exempt status from the IRS, the Foundation will seek and explore to raise funds (seed money) from the following possible sources and jump start the establishment of the Center.

1. Cash Donation from CYDF USA, Inc. Membership...................

2. Cash from Fundraising Activities a. community supporters and benefactors................................... b. philanthropists......................................................................... c. Filipino Healthcare/Medical Professionals.............................

(Imputed Cost of Services Rendered with IRS approval) d. grants from private foundations.............................................. e. grants from public funding institutions...................................

f. live concerts revenue f1. sponsorship from the Filipino business community.....

f2. ticket sales to Filipino Social Organizations/Membership...

$ 50,000.00

$200,000.00 $500,000.00 $500,000.00

$1,000,000.00 $1,000,000.00

$100,000.00 $600,000.00

Total $3,950,000.00 .

Once the Geriatric Healthcare Center for Filipinos is operational, the Foundation will implement the built-in “Net Profit Distribution Process (NPDP) mechanism” it developed as indicated in Table 2.1 to equitably address the Center’s program growth and physical development, especially from beyond its 10th year of business operation. With NPDP mechanism in place, the Center should be guided towards self-sustainability as it employs an efficient use of its limited resources for a productive business operation without necessarily compromising quality and culturally-sensitive service care delivery to Filipino elderly residents in the long-term care setting.

Management. Geriatric Healthcare Center for Filipinos is managed as d.b.a. by CYDF USA, Inc., with its own board of directors, trustees and officers, to ascertain that quality of care is not compromised but provided at best to Filipino elderly by being compliant with Title 22, Div. 5, Ch. 3, Art. 3 of the California Code of Regulations and that it shall be oriented to provide services

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4 GHCF Business Plan: Phase 1

towards the standard of care per JCAHO’s document of Shared Visions - New Pathways (Kern, 2004), and to eventually become a JCAHO accredited facility

Table 2.1: Net-Profit Distribution Process (NPDP) To Program/Physical Developments

Number of Years of Operation

NPDP Percentage to Program Development

NPDP Percentage to Physical Development

1st Year 95% 5% 2nd Year 90% 10% 3rd Year 85% 15% 4th Year 80% 20% 5th Year 75% 25% 6th Year 70% 30% 7th Year 65% 35% 8th Year 60% 40% 9th Year 55% 45%

10th Year & Beyond 50% 50%

Current Market. Filipinos cannot continually take care of their aging parents at home due to changes in their healthcare needs that require a 24-hour long-term medical and nursing service care. The lack of or even the absence of a facility like the one being proposed leaves the market open and without competition with a promising future and success in operation.

Projected Market. With the number of Filipino population increasing as evidenced in the recent US Census2000 with a rank being the 2nd highest among Asian population and conversely of an increasing number of older persons requiring long-term care services, the market is like a “virgin land” that needs to be tapped and cultivated. When Filipinos begin to see and understand that the Center is a nonprofit medical model that provides culturally-sensitive long-term care services to meet the healthcare needs of their aging parents, there can be no reason why they will resist its use to benefit their aging parents, “making them feel at home, away from home,” at the Geriatric Healthcare Center for Filipinos, as residents.

Towards Institutionalization. With the seed money to jump start the establishment of the Geriatric Healthcare Center for Filipinos, the Center can smoothly sail to carry on its mission of providing culturally-sensitive services and, in time, become a self-sustainable nonprofit medical model healthcare facility to serve the Filipino aging population in need of long-term care services.

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Part I ORGANIZATIONAL PLAN

A. Summary Description of the Business

As a “d.b.a.” (doing business as) of CYDF USA, Inc., Geriatric Healthcare Center for Filipinos is being established in response to a lack of or even the absence of a nonprofit medical model long-term healthcare facility that is imbedded with ethnic-specific psycho-socio-emotional, religious and culturally-sensitive services to benefit the Filipino elderly requiring a 24-hour medical/nursing services.

Mission CYDF USA, Inc. has a threefold mission: (1) do fundraising to help address poverty in the Philippines through a Scholarship Program spearheaded by its sister Foundation called “Calantas Young Dreamers Foundation, Inc.” (based and SEC registered as a nonprofit corporation in the Philippines); and in the San Francisco-Bay Area, (2) to design community youth empowerment programs to benefit Fil-Am youths and their immediate families, and (3) to establish a culturally-sensitive medical model Geriatric Healthcare Center for Filipinos to benefit Filipino elderly in the San Francisco-Bay Area.

A Culturally-Sensitive Nonprofit Medical Business Model (CSNPMBM) The Geriatric Healthcare Center for Filipinos will primarily provide culturally-sensitive, as well as psycho-socio-emotional and religious services, to reflect what Filipino elderly cherish as “cultural values” in their hearts. This sensitivity of what is most dear and closer to their hearts plays a significant role in the holistic healing process while at the Geriatric Healthcare Center for Filipinos, thus providing them quality of care in tune with their cultural values. This model is demonstrated at the Jewish Home in San Francisco, being sensitive to the cultural values of their people.

Strategies2

Phase 1: Long-Term Care (Non-Skilled) as a Medical Model 1. The Foundation (CYDF USA, Inc.) will use the donated seed money ($4,000,000.00) to jump

start the Phase 1 implementation of the Geriatric Healthcare Center for Filipinos in the San Francisco-Bay Area by leasing, with an option to buy, an existing long-term care facility and gradually would phase in the admission of Filipino elderly while in the process to simultaneously address and appropriately discharge long-term non-Filipino residents to different levels of care facilities due to changes in their medical/healthcare conditions.

2. Phase 1 Phase 1 will primarily provide non-skilled nursing services and also, when appropriate, some restorative nursing services to the residents while in the long-term care setting due to their poor health conditions complicated by the significant loss of their ADL (activities of daily living) functions requiring a 24-hour medical and nursing care services.

2The Geriatric Healthcare Center for Filipinos (GHCF) would also open its doors for admission to non-Filipinos who established bonding by embracing and cherishing in their hearts some of the Filipino cultural values that would make them feel very much at home while being cared for in a Filipino culturally-sensitive long-term care setting as indicated in the case of a 76 year old Caucasian female resident described in the this field study (Ch.4, IV, J.)

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6 GHCF Business Plan: Phase 1

Phase 2: Short-Term Care (Skilled) as a Medical Model 3. In due time and when necessary resources are made available, the Geriatric Healthcare Center

for Filipinos will move on to upgrade its services and phase in to the second stage of its development to provide “short-term care” services. A separate business plan shall then be prepared for the Phase 2: Short-Term Care Model for residents with skilled needs. This level of care provides skilled nursing which includes rehab services such as PT/OT/ST (physical therapy, occupational therapy, speech therapy).

The GHCF Facility The Phase 1 of the Geriatric Healthcare Center for Filipinos is to be located in the San Francisco-Bay Area that has the capacity to serve at least 75 to 100 residents with long-term healthcare (medical/nursing) needs. Since Filipino elderly require culturally-sensitive services to meet their long-term healthcare needs, the Center is poised to provide culturally-sensitive, in addition to psycho-socio-emotional and religious services, to positively effect a holistic healing process and significantly enhance their mood and behavior affecting positively their general psychosocial well-being, thus making them feel good about being cared for in an environment they may identify themselves with as, “being home, away from my home.”

B. Services and LTC Consumer Profiles

Phase 1 Program of the Geriatric Healthcare Center for Filipinos offers long-term care to Filipino residents who require a 24-hour medical and nursing service due to significant loss of their ADL functions, in addition to dietary, pharmaceutical and activity program. The Center provides culturally-sensitive services that could positively impact a holistic healing process for the residents, in addition to ethnic specific psycho-socio-emotional and religious services, to enhance their mood and behavior affecting their general psychosocial well-being. Residents who cherish Filipino cultural values in their hearts are bound to benefit most in a “culturally-sensitive service model environment” that would validate the hypothesis that Filipino elderly require culturally-sensitive services to meet their healthcare needs in the long-term care setting.

LTC Consumer Profiles

The following are descriptions of residents who would likelihood use the Phase 1 of Geriatric Healthcare Center for Filipinos (GHCF) as long-term care consumers that would require culturally-sensitive services to meet their healthcare needs:

o New Immigrants. Research (McBride, 2004) indicated that Filipinos living in the United

States aged 65 and over are 95% born outside the country and would, likelihood, to cherish in their hearts values that truly reflect their culture when they migrate to be reunited with their own children or families.

o Acculturated and Assimilated Filipinos. It has been noted, too, that 57% of the Filipinos

in the same study were naturalized and could be categorized as acculturated and assimilated but still bear deep in their hearts, some good Filipino cultural values. They are the Filipinos in America. They enjoy the blessings of life being in the United States, obey the laws of the land and contribute to the welfare of the society by paying their taxes, participate and exercise their duty in the body politic but remains having their cultural attitude and thinking process, as Filipinos.

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7 GHCF Business Plan: Phase 1 o US-born but Filipino in attitude and ways of life. This is a group of Filipinos, born and

raised in the United States, but because of the teachings and role modeling of their parents and/or families, they maintain their closer ties with the cultural values handed down from one generation to another. And for those who lost track of this important link in their childhood, they find themselves searching of their own cultural identity. At some point, if they fail to find their own cultural identity, cultural identity crisis arises.

C. Leadership and Corporate Management

1. Employee-Centered Leadership Style: To attain the highest level of participation of the employees (in all levels) and acquiring a sense of ownership in the operation and the carry-out of the Foundation’s mission at the Geriatric Healthcare Center for Filipinos, there are three questions needed to be considered and addressed in the process of decision-making: (1) Where are we now? (2) Where do we want to go? and (3) How do we get there? And employee-centered leadership style recognizes the value of giving importance to the input provided by the staff, integrate identified strength of their input to become part of the “content and process” of decision-making affecting the quality of care provided to the residents. As this is done, the intent of the management is to empower staff become partners in addressing issues to positively impact the healthcare services provided to residents guided by the following positions:

The administrator/manager presents a tentative decision, subject to change; the employees are further involved in the decision-making process itself.

• The administrator/manager presents the problem requiring solution, invites suggestions, and then makes the decision.

• The administrator/manager permits the subordinates to make the decision and functions within the limits defined by the administrator/manager.

2. Role of CYDF Founder to CYDF-GHCF Management

At present, the CYDF Founder/Writer, Antonio M. Mendoza, is spearheading the conceptualization efforts on the establishment of Geriatric Healthcare Center for Filipinos in connection with simultaneously meeting his requirement leading to the degree of Master of Arts in Gerontology at San Francisco State University. Superseding this academic accomplishment is his deep intent of formulating a healthcare model responsive and sensitive to the cultural values of Filipino elderly in a long-term care setting. The writer believes that Filipino elderly require culturally-sensitive services to meet their long-term healthcare needs, in addition to compliance with Title 22, Div. 5, Ch. 3 of the California Code of Regulations and OBRA ‘87. The Founder facilitates the content and process of establishing the Geriatric Healthcare Center for Filipinos and oversees its full implementation, unless and otherwise physically unable to do so; in which case, the general membership of the Board of Directors of the Foundation shall assume responsibility to address unfinished business initiated by the Founder regarding the proposed business plan.

3. Legal Structure of CYDF USA, Inc.

CYDF USA, Inc. is to be registered as a nonprofit public benefit corporation per California Code of Regulations Title 1, Div. 2, Part 2, Sections 5110 et seq. to oversee the establishment of the Geriatric Healthcare Center for Filipinos. The Center will exist as d.b.a. of the Foundation, CYDF

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8 GHCF Business Plan: Phase 1

USA, Inc., which shall be managed by its own board of directors, trustees and officers, but accountable to the Board of the Foundation, in accomplishing its mission of providing culturally-sensitive, in addition to ethnic-specific psycho-socio-emotional and religious services, to its target population. The mandate is derived from the 3rd objective articulated in the Articles of Incorporation and adopted by the general Board of the Foundation on August 7, 2004.

4. GHCF, d.b.a. of CYDF USA, Inc. and its Governing Body As d.b.a., Geriatric Healthcare Center for Filipinos (GHCF) shall have its own top management (Board of Directors, Trustees and Officers) with a sole purpose to advance the mission of providing culturally-sensitive long-term healthcare services to its target population and their accountability is to the Board of the Foundation, CYDF USA, Inc. The mandate of the GHCF Governing Body (top management) is derived from the 3rd objective of the Foundation that reads “to establish a chain of nonprofit medical model healthcare services center (i.e. Long-Term Care and Skilled Nursing Facility) imbedded with ethnic-specific psycho-socio-emotional, religious and culturally-sensitive services for the Filipino elderly living in the San Francisco-Bay Area and across the United States of America. GHCF Governing Body is designed to identify community members interested to participate per their skills, talents or resources they could positively share to advance the mission of the Foundation. Once it is fully organized and established, it will assume its role and responsibility to the Geriatric Healthcare Center for Filipinos.

Some of the functions that GHCF Governing Body will initially address are as follow: • Write By-Laws to govern their own business activity within the Center in consonance with

and guidance of the Foundation’s Articles of Incorporation. • The By-Laws will define their duties and responsibilities, as non-salaried volunteers but shall

receive stipend, to advance the Mission of the Foundation. In principle, the primary responsibilities of the Governing Body are as follows:

• The Board of Directors is the policy-making body. • The Officers are the implementing body to oversee that policies and resolutions promulgated

by the Board of Directors or Trustees are carried out. • The Board of Trustees, as a body, is the legal caretaker of the wealth and properties of the

Geriatric Healthcare Center for Filipinos. • The Governing Body has the sole responsibility to fulfill the mission of the Foundation and

take a lead, as a body, an active role in fundraising efforts to augment the resources of the Geriatric Healthcare Center for Filipinos.

D. GHCF Organizational Chart

The Organizational Chart in Figure 4 defines the flow of operation of the Geriatric Healthcare Center for Filipinos (GHCF). GHCF, as a DBA of CYDF USA, Inc. is the 3rd objective of CYDF USA, Inc., as articulated in its Articles of Incorporation. The GHCF has its own governing body (i.e., board of directors, trustees and officers) responsible to carry out the successful operation and implementation of the 3rd objective of the Foundation (CYDF USA, Inc.). The chart is federally recommended (Allen, 1997) for departments and staffing patterns for a 100-bed nursing facility covering non-skilled and skilled nursing services. Since, Geriatric Healthcare Center for Filipinos plans to provide only long-term care services for non-skilled residents during its Phase 1 Business Plan development, rehab services (PT/OT/ST) therefore shall not be covered in the discussion but shall be addressed later for the Phase 2 Business Plan.

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9 GHCF Business Plan: Phase 1 The dotted lines in the chart signify no direct line of authority to staff and those that are

marked with asterisks are line staff positions added in the operation of the Center.

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10 GHCF Business Plan: Phase 1

E. Functions of Staffing Requirements of Different Departments of the Geriatric Healthcare Center for Filipinos

The descriptive role presented in the proceeding discussions further defines the parameter

of responsibilities of every staff from different departments so as to maximize their capability and ability to function as an individual and collective unit to be able to provide, at best, a culturally-sensitive quality of long-term healthcare service delivery to the residents of Geriatric Healthcare Center for Filipinos.

1. ADMINISTRATIVE DEPARTMENT

a. Administrator (Licensed Nursing Home Administrator) • The administrator should have a working knowledge of the following government

regulations: (1) OBRA ’87 (Medicare and Medicaid), (2) Title XXII, (3) California State Department of Health, (4) California Department of Social Services, (5) OSHA, (6) Fire Safety, (7) EEOC, (8) Fair Employment Practices, (9) Federal Wage/Hour Law, and (10) legal, research and compliance.

• Knowledge of (1) Financial Reports, (2) Profit and Loss Statements, (3) Budget of Facility and Departments, (4) Facility Forms and Contracts, (5) Public Relations, community Resources and Marketing, (6) Complex Care Delivery System, (7) Consultants/Contracts (e.g., Information Technology)

• Familiar with Facility’s Philosophy regarding Resident’s Rights, Employee’s Rights and Provision of Care. Familiar with Reports, Policies and Procedures, Organizational Chart of the Facility, meets with Department Heads regularly and scheduled meetings.

It is the charge of the administrator to (Allen, 1997, pp. 113-114):

• Assure a satisfactory quality of care and of life for residents/patients and staff • Advocate for the residents and, as needed, staff and the facility • Monitor and control all the subsystems in the facility • Develop and manage the budget • Manage the interface between the facility and its many constituencies in the world outside • Monitor and manage the personnel functions • Coordinate or assure coordination of the work of all departments and functions in the

facility • Lead by providing stimulus on a daily basis to activities that implement the facility’s goals

and mission, • Forecast and lead the facility to a successful future • Assist all staff and residents to understand the nature and value of change • Interface with owners, inspectors, ombudspersons, third-party insurances, hospitals, fire

departments and the myriad of other persons, groups, and functions necessary to the survival of the facility

• Communicate with staff, residents/patients, others • Empower department heads and staff to accomplish their work • Facilitate the functioning of the facility by walking around (LBWA) and similar

management approaches.

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11 GHCF Business Plan: Phase 1 • Set the tone for the facility in matters of dress, taste, compassion, and concern by word

and behavior (e.g., Ethical Issues) • Settle territorial and jurisdictional disputes among staff, residents, and owners.

b. Assistant Administrator and Administrative Assistant.

An assistant administrator has line authority to represent the administrator, can make decisions on his or her behalf, and is usually assigned some area to oversee. An administrative assistant, on the other hand, has no line authority, cannot make decisions for the facility and does not represent the administrator except in an information-gathering or processing manner. The administrative assistant is a staff position.

c. Secretary and Advisory Functions.

Generally, the facility secretary works in the administrator’s office, in an area shared with the receptionist (who often is the telephone operator and office manager). As a rule, the administrator has several advisory persons or groups, represented in the Organizational Chart by dotted lines. The medical director and resident/family council often fit into this slot. Other consultants, such as the pharmacist or dentist and any other advisory committees might appear here. The administrator’s office is responsible for keeping on file the original of several types of information, such as reports of the state facility inspection teams, department reports, and other important documents.

2. MEDICAL AND ALLIED HEALTH DEPARTMENT

a. Patterns of Physician Care. As a rule, the typical 100-bed facility does not require the services of a fulltime medical

director. The Medical Director is normally paid a contractual monthly fee to provide medical supervision. Federal requirements for the role of a medical director are vague, stating only that the medical director is responsible for (a) implementation of resident care policies, and (b) coordination of medical care in the facility.

b. The open medical staff.

The predominant pattern for nursing facilities of approximately 100 to 200 beds is to allow any physician licensed to practice in the state to admit patients/residents to the facility and to provide their medical care while they reside there. No one can reside in a nursing facility without physician admitting orders and continuing physician supervision. Under this pattern the part-time medical director tries to assure that the medical needs of the patients/residents are met as they arise. The medical director often substitutes for the personal physician who fails to visit the patient on a timely basis or perform the annual physical periodically as required by federal and state regulations. As noted on communication behaviors, people prefer to talk with those of equal rank; thus a vital role played by the medical director is to visit on a peer basis with physicians who are not meeting the actual care needs or making the required visits to patients in the facility. Because there is normally no organized medical staff, the medical director advises the administrator of the facility concerning the quality of its physician and nursing care and assists the director of nursing to assure that good quality of patient/resident care is delivered. The medical director may or may not admit and care for patients/residents in the facility, but usually does so for some of them. This has the functional value of allowing the medical director to be in the facility frequently, practicing LBWA while seeing his/her patients.

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c. Dental Care. Dental care is a major, often neglected, aspect of services delivered in the nursing facility.

No one in the typical facility is trained in oral care. The mouth is not included in any significant way in the nursing curriculum; physicians do not focus on the mouth. Although the majority of residents in nursing facilities have dentures, the introduction of fluoride and other dental care efforts after WWII is resulting in increasingly larger proportions of residents having teeth rather than dentures. So long as any resident has dentures, the use of an inexpensive denture label kit will simplify life for the residents and staff at the facility. Solutions to this problem will vary, but any successful one will likely include appointment of a local or area dentist who specializes in geriatric dental care as the dental director. The position includes a monthly retainer fee of perhaps $2.00 to $4.00 per resident (much like a part-time medical director). This dentist will make monthly visits; perform needed care, and bill third-party payers for care given. It is customary for the dental director to assist the facility in hiring a dental hygienist who will make rounds seeing residents monthly or more often, and train the nursing staff to observe and meet the residents’ oral needs. One approach is to train oral care aides, regularly employed nurse’s aides who assume responsibility for maintaining the daily oral healthcare of residents in the facility.

d. Foot and Eye Care

There is a need for a podiatrist, a trained professional who is not a medical doctor, for care of the feet, including clipping of toenails for diabetics and others, and treatment of ailments such as corns and bunions. As the nursing facility population becomes less and less able to make health care visits outside the facility, a periodic visit by a podiatrist, who normally brings an assistant, is becoming a routine need of resident care. The podiatrist and assistant may arrange their work area in a room or even a hallway on a monthly basis and provide care to a large portion of the residents over the course of a morning or afternoon. Eye Care needs are similar to those for teeth and feet. As the population’s mobility becomes more and more restricted arrangement for a local optician to make periodic visits is becoming a routine health care need to be arranged for by the facility staff.

3. PHARMACY DEPARTMENT

The consulting or the facility pharmacist is responsible at the minimum for assuring that: • All medications are available as ordered • All medications are within expiration date and properly labeled and handled • All reorders and stop orders are implemented • Each resident’s medications are reviewed monthly for possible adverse reactions and/or

interactions • Appropriate pharmacy policy and procedures are followed. • Additional information may be found in Key Federal Requirements, ss483.60.

The consulting pharmacist is responsible for reviewing the drug regimen. He should observe medication passes and record and report drug error rates and any other problems observed. While the federal requirements require the consultant to report to the attending physician and the director of nursing, the administrator would be wise to stipulate in the consultant contract that the pharmacist also keep the administrator fully informed, either individually or at a meeting attended by the administrator and the staff. Besides receiving the required reports, the administrator can talk with the pharmacist, the nurses, the physicians, and the residents to learn in greater depth how the system is functioning. If drug reorders are not arriving on time, the nurses will be ready

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13 GHCF Business Plan: Phase 1 to share this information with the administrator. If the residents are not getting the medicines they believe they depend on, they will be quite willing to report it. But in this, as every such case, both the resident and staff must be queried.

4. NURSING DEPARTMENT

Among the tasks of the nursing service are the following responsibilities: • Providing nursing care to residents as ordered by the physician • Completing the Minimum Data Set (MDS), any required protocols triggered by the

Minimum Data Set, creating and implementing and updating the comprehensive plan of care

• Administering medications to the residents • Keeping resident records • Monitoring residents for changes in condition and notifying the responsible physician – in

short, serving as the physician’s eyes and ears on a 24-hour basis • Achieving optimal quality of care and quality of life for residents • Making certain that every resident is functioning at the highest possible level • Playing a coordinating role with other staff (e.g., assuring that planned activities,

physician office visits and the like take place) • Patient Care Planning Meetings and Care Plans • Doctor’s Role in Resident’s Care and Chart • Interrelationships with Resident and Family • Scheduling and Staffing • Hiring, Discipline and Termination • Nursing Supply, Purchasing and Budget • Supervision of patients (RN, LVN, CNAs, RNAs) • Charting of Treatment • Patient Chart Audits • Drug Storage and Disposal • In-Services • Incident Reports • Patient Admission and Discharge • Storage and Usage of Nursing Equipment • Infection Control • Dying and Death Policies and Procedures

In short, nursing is involved in a myriad of routines and situations: assessments, wound care, range of motion procedures, toileting, feeding, counseling, friendship, comfort, ambulation, transfer, assistance with the activities of daily living, changing incontinent briefs and pads, turning residents, use of assistive devices, bathing, dressing, cleaning up spills, washing hands, room tidiness, ice water, hospice, discharge planning, recruiting, training, disciplining, evaluating staff, interfacing with the other departments, observing the universal precautions, interface with physicians, pharmacists, numerous healthcare professionals, reassuring families and significant others, coping with volunteers, cooperating with the police, the fire department, doing infection control, working short, conducting in-services, charting, bowel and bladder program, fire safety

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14 GHCF Business Plan: Phase 1 disaster preparedness, answering call bells, checking on the residents hundred of times each day, participating in lengthy care sessions, afternoon and evening snacks, getting food substitutes from dietary, settling battles among residents, coping with Alzheimer’s, extensive dementia, learned helplessness, death and dying, emergencies, morticians, endless admissions, discharge planning, lost clothing, lost teeth, lost jewelry, running out of bed pads, hazardous waste rules, inspectors from everywhere for days at a time, electrical outages, failing equipment, room transfers, roommate dissatisfaction, refusal to eat, broken bed rails, restraint issues, snippy staff, arrogant physicians, dissatisfied residents, troublesome visitors, unresponsive decubitus ulcers, unresponsive medical directors, an on-call nurse or physician who doesn’t return calls for 45 minutes, overflowing linen bins, broken wheelchairs, epidemics among staff and residents, out-of-uniform staff, missing name tags, wandering residents, pool (contract) personnel who don’t know or don’t care, misplaced charts, emergency carts that were used and not restocked, constant phone calls, late lab reports, physicians who don’t sign orders or visit on a timely basis, and this is only the tip of the iceberg. Nursing is the quintessential embodiment of the reality that if it can happen it will.

a. Quality of resident life. There are unwritten dimensions to caring performed by the nursing service. It is not possible, and perhaps not desirable, federal efforts notwithstanding, to set them all down, for many of the nursing acts that increase the quality of life cannot be fully spelled out in policy statements. The quality of life enjoyed is directly proportional to the quality of the efforts given by the nursing staff.

b. Organizational interdependencies. Organizational interdependencies between nursing and virtually every other area exist within the facility. Nursing is dependent on dietary, housekeeping, laundry, maintenance, the business office, the social worker and the allied health professionals, to mention a few. In sum, for nursing to do its tasks properly, nearly every other department and functional area within the organization must also be doing its tasks in a cooperative manner.

c. Staffing. Three nursing shifts, 24 hours a day, 365 days a year, offer a staffing challenge. The proportional ratios between registered nurses, licensed vocational nurses, aides, and even geriatric nurse practitioners will vary with the staffing philosophy of the facility administrators and the resident profile. As acuity level increases in many facilities, the proportion of professionally trained nurses increases. Research suggests that permanently assigning nurses and nursing assistants to sets of residents leads to improved care through enabling holistic care and nurses’ becoming personally involved in and vested in their duties.

d. Administrative observations. Just as the director of nursing services is expected to make daily resident rounds, the administrator may decide to emulate nursing. The administrator must decide to what extent daily reports on admissions, discharges, changes in resident conditions, accidents, incidents, transfers, deaths, and the like should be part of his information system. The reports are not a satisfactory substitute for the administrator’s personal observation, on a daily basis, for learning by wandering around (LBWA) what is actually taking place in the facility. Also, one has to be on the scene to be the coach, energizer, communicator of one’s vision for the facility.

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5. BUSINESS OFFICE DEPARTMENT In a typical 100-bed facility one full-time and often an additional part-time employee staff the business office. Briefly, the business office:

• Keeps financial records (e.g., maintenance of Resident Business Records, Bank Accounts and Trusts)

• Manages accounts receivable, accounts payable • Maintains vendor files • Assists in monitoring the budget • Prepares the payroll • Keeps required records, makes financial reports • Deals with third-party payers (Insurance and Private Pay), Medicare (for residents with

skilled needs), Medicaid (for non-skilled residents in the long-term care), and PPS • Safeguards and controls resident funds, and • Often acts as receptionist, answering the telephone. • Patient admission, Transfer and Discharge, Daily Census Sheet Analysis • General office duties, mail, filing and correspondence

6. MEDICAL RECORDS DEPARTMENT A full-time employee must, by federal requirements, be assigned to keep the medical record service up to date. Usually this person is called a ward clerk. Facilities are required to keep a great number of records, among the most important of which is the medical record. If medical records are not complete and current, federal and state inspectors will normally issue a directive that they be corrected within a specific time period. Increasingly, medical records require a full-time person operating a computer for RAI and MDS input, records management (filing and retrieval), statistics.

7. ADMITTING/MARKETING DEPARTMENT In states where first-come-first-served rules do not exist, the person (s) in charge of admissions influence the care mix of the facility. Usually a person with social work background is employed as the admission’s coordinator. Often a single employee will head both admissions and social work. Sometimes, the director of nurses does admissions. In most cases, the admission process is shared jointly by the director of nursing and the admission director. In any case, admissions have profound effects on the facility’s workload, atmosphere, ability to achieve its goals, and to provide appropriate care. Who is admitted from where and with what care needs and reimbursement rates are the life blood of the facility. The admission person (s), must find, screen, process, facilitate, and manage case mix, while keeping financial, light versus heavy care, goodwill of the hospital, managed care of other source elements all balanced. The admission person (s) are important promoters of the facility, marketing to all the relevant world, which includes hospital discharge planners, the local physicians, third party payers, HMO’s and workers compensation bureus.

8. DIETARY DEPARTMENT

Food is an essential ingredient in the quality of resident life. Satisfaction with the facility is as often influenced by the food as by the quality of nursing care. Some families feel they may not have enough medical background to judge the adequacy of nursing care, but most do themselves experts in the matter of food. Tasty food is important to a satisfactory quality of life. Hospital food,

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16 GHCF Business Plan: Phase 1 eaten for a relatively short period of time, can be tolerated. Nursing home food, consumed for much longer periods, sometimes for the rest of a lifetime, is subject to much greater scrutiny by both residents and their families/significant others.The dietary department’s influence extends 24 hours a day. The availability of bedtime snacks or midnight snacks for insomniac residents is as much a part of the ambiance of the facility as the availability of continuous nursing services. This department is heavily interactive with nursing services (e.g., preparing refreshments for social activities) and with most other departments. The food service depends on other departments as well: laundry for linens and maintenance to keep the kitchen functioning. Some facilities contract for food service with outside vendors. In this situation, the head of dietary may be an employee of the food service contractor. The administrator can monitor food services in a number of ways. Daily, randomly timed walks through the kitchen, eating with residents in the dining hall, assisting with feeding in resident rooms and in the dining rooms are productive. Much can be learned by getting a tray and eating its contents under circumstances similar to those experienced by the resident. Achieving the nutritional diet prescribed by the physician and developed by the registered dietitian or registered dietitian consultant, assuring tasty food at the right temperature, doing nutritional assessments, monitoring weight gains and losses, monitoring I/O (intake and output), providing food substitutes as requested would include CULTURAL FOOD upon approval of the attending physician, catering for facility functions and its many visiting groups, maintaining the dietary area according to cleanliness standards are but a few of the critical functions of the dietary department. Other issues to attend to are: menu planning, nutrition needs of the elderly, infection control, staffing, supervisory requirements, therapeutic diets, tray set-up and delivery, disaster preparedness, quality control, budgeting, state and federal regulations.

9. SOCIAL SERVICE DEPARTMENT

Social Services are concerned not only with the resident’s initial adjustment to the facility, but also his continuing accommodation to the environment. The social worker is also responsible for monitoring each resident’s socio-psychological experiences and orientation in the facility. It is the social worker who is often most directly in contact with the resident’s family or significant others. This staff member is the one involved in assisting residents who have current or approaching financial needs that will be met by a public agency. In short, the social worker functions in the nursing home in a manner similar to social worker employed by the local public department of social services. Maintaining the quality of each resident’s social well-being in a facility is a complex function. Significantly assisting each resident to meet various social, psychological, physical, environmental, family, financial and related needs is never achievable by the social worker alone. The social worker must stimulate the various other staff members to participate in this process. A typical problem to which the administrator must be attuned is a tendency for responsive residents to receive an excessive share of the social worker’s time and attention. The less responsive and unresponsive have needs also. At this juncture, a FILIPINO GERO-PSYCHOLOGIST could play a significant role to provide psycho-socio-emotional services geared towards enhancing mood and behavior of residents affecting their general psychosocial well-being. Other issues to consider are support services, family interaction, discharge planning (in and outside facility), and interaction with community-based social and health programs, patient care planning, policies, procedures and regulations. Private/public grants may be sought to finance some of the psycho-socio-emotional activities for the elderly residents.

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10. ACTIVITY DEPARTMENT & RELIGIOUS SERVICES

Nursing services primarily address the medical needs of the residents, and in that process partially meet their social and interpersonal requirements. The activity coordinator’s task is to assure that the physical, social and mental well-being of each resident is included in each comprehensive resident assessment and the required comprehensive plan of care. For the nearly comatose, disoriented or agitated residents, this assignment is indeed a challenge. The activity director and social services worker are assigned primary responsibility for attention to the quality of psychosocial life that exists within a facility. It is difficult to imagine a more complicated undertaking in shaping the quality of the resident life. Attending to the spiritual life of the residents by having an access to RELIGIOUS SERVICES will contribute to their holistic healing process. A religious service staff will coordinate making arrangement with a minister/pastor/priest to facilitate services for the group of residents wanting to have their religious activity to take place in the facility. Other issues to consider are: program activity planning and scheduling, activity evaluations, supplies, volunteers, interaction with community and activities outside facility.

11. HOUSEKEEPING AND LAUNDRY DEPARTMENT

Housekeeping. Good housekeeping is of utmost importance in nursing homes. Not only do federal and state inspectors make intuitive value judgments about a facility based on its cleanliness and physical appearance, so also will most of the residents themselves and their significant others. Dirty floors and walls, empty toilet paper holders, yellowing toilets and lavatories and offensive odors associated with them communicate a message to the residents, staff, and visitors revealing what the facility thinks about itself. Inattention of housekeeping details leads inspectors and the public alike to wonder to what extent it carries over into resident care, sanitation in food preparations, and cleanliness of the residents themselves. The head of housekeeping may have excellently designed job assignments for the four to eight housekeepers. The administrator can tell how effective these schedules are simply by walking around (LBWA) the facility. On these tours, the administrator must be able to “see” dirt. There is a surprising amount of regulation surrounding the housekeeping area, such as the required Material Safety Data Sheets for all chemicals, to which the head of housekeeping and the administrator must give attention.

Laundry. Clean linens, clean resident clothes, the availability of linens and clothes when needed, safe and sanitary handling techniques for both soiled and clean linen are areas of responsibility of the head of laundry. Whether it is better to do laundry in house or to contract with a linen service (known as outsourcing), the purchasing of portions of services from outside providers is a subject of continuing debate. Whatever the decision, there will be procedures for handling linens that the administrator can observe for conformity to regulations and to facilitate policies. Other issues to consider are: staffing, hiring, disciplining and termination, sanitation and odor prevention, in-services, infection control, product evaluation, inventory and supply control, storage, cleaning schedule, equipment, safety measures and precautions, facility and resident’s laundry system.

12. MAINTENANCE DEPARTMENT

• Distinguishing between maintenance and housekeeping responsibilities is often an issue. If a wall has a hole in it, it is clearly maintenance’s job to fix the hole. It that same wall is only dirty and needs washing, it is probably housekeeping’s job. Each facility must designate, through established policies, the respective responsibilities of these two functions.

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18 GHCF Business Plan: Phase 1 The repair and upkeep of physical systems is clearly the responsibility of maintenance. Preventive maintenance, anticipating when a machine will need servicing or risk ceasing to function, is a complex task requiring experienced judgment. A well-trained maintenance director can do much to anticipate troublesome, unnecessary breakdowns of equipment. The administrator can participate in the maintenance process by occasionally assuming a “maintenance mind-set,” then walking through the facility touching, feeling, and judging the state of repair of all he encounters. This department shall look at the following: state and federal building codes, life safety codes, fire and disaster preparedness, policies and procedures, fire and disaster equipment usage, preventative maintenance, Title XXII on documentation requirements, pest control procedures, repair and maintenance procedures, sanitation and infection control, ground upkeep, ADA requirements (handicapped ramps).

13. PERSONNEL MGT. & STAFF DEVELOPMENT DEPARTMENT

In a 100-bed nursing facility, personnel are the responsibility of each department manager. The department managers do initial interviews, perhaps bringing the administrator in on the final selection. Personnel managers do not “manage” employees except for those who work under them in the personnel department, if there is more than one employee in that unit. Personnel management is a staff function; it has no line authority in the organization. All the employees in the organization are directly managed by their department supervisors, who hold line authority. It is the line managers who, in fact, are responsible for performing most of the personnel functions for the employees under them. The department heads do the actual hiring, require in-service training and development, give performance evaluations and promotions, award raises, and discipline, suspend, and discharge their staff. The role of the personnel manager and staff is to assist the line supervisors (e.g., the department heads in the nursing facility) to carry out personnel responsibilities according to policies set by facility ownership. This staff makes an important contribution to overall employee satisfaction by assuring that personnel policies are carried out as consistently as feasible from one department to another. Some of the typical personnel department functions are usually given to one employee who, in effect, serves as part-time personnel staff in the facility. This person is sometimes designated as “staff development coordinator” or a similar title. Alternatively, assisting the department managers with personnel matters such as record keeping, assuring that employees are tested for TB, and are offered hepatitis B vaccinations (as required by the blood borne pathogens regulations), may be assigned to an assistant administrator, an administrative assistant, a staff nurse, or an employee in the business office. Other issues to consider are: union contracts, interviews, hiring, discipline, termination, employee evaluation, insurance claims processing, worker’s compensation claims processing and follow-up, maintenance and update of personnel records, State Certification Program (CEU), in-service training, employee orientation, fire and disaster drills, documentation, resource materials, worker’s compensation and incident reports, budgeting.

14. CENTRAL SUPPLY AND PURCHASING (Medical/Purchasing) The central supply is for medical/nursing use only. Staff in this position is in charge of receiving and dispensing supplies, does inventory control and documentation.

15. TEAMWORK

Some areas and issues require special attention to teamwork from the administrator: • Patient care planning and implementation of resident care plans

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19 GHCF Business Plan: Phase 1 • Successful billing, from recording supplies consumed to required wording for claims • Housekeeping versus maintenance • Dietary/nursing coordination in getting food to residents on a timely basis, at the right

temperature attractively presented with attention to accommodating resident preferences • Differentiating between activity functions and the social worker functions – dangers of

persons’ needs falling between the cracks • Discharge planning • Resident advocacy to the staff and families • Nursing/housekeeping/laundry coordination

F. REGULATORY IMPACT ON NURSING FACILITIES

1. Regulations Affecting Nursing Facilities (Geriatric Healthcare Center for Filipinos) Nursing facilities operate under the oversight of a large number of regulations, as do all healthcare organizations. Those regulations originate at the national, state and even local government levels. Their purposes are generally to assure that:

• Care received by consumers is safe and of high quality • Care is not unnecessarily expensive for consumers or government agencies • Services are uniformly accessible as possible • The rights of workers are protected.

Most of such long-term care regulations stem, either directly or indirectly, from federal legislation, particularly the Social Security Act and the many amendments that have been attached to it over the past several decades. Most notable of those amendments are Titles XVIII and XIX, which created the Medicare and Medicaid programs. Because those programs represented the federal government’s first major incursion into health care financing, they came with extensive regulations to assure that those funds are being spent effectively. The other federal legislation with the most impact on nursing facilities is the Omnibus Budget Reconciliation Act (OBRA’87).

2. Regulations Affecting Residents

The regulations with the most direct impact on nursing facilities are those directly affecting the care given to residents in those facilities. They are multitudinous, very detailed, and sometimes in conflict with other applicable regulations. OBRA, Medicare, Medicaid, and state licensing regulations prescribe the level and type of care given, the types and numbers of professional staff needed, the layout and condition of the facility, and many other specific details of how care is provided. Other regulations directly affecting residents in nursing facilities include the Older Americans Act (OAA) and American with Disabilities Act (ADA).

3. Regulations Affecting Administrator Regulations directly affecting the managers of nursing facilities include state licensure and related national regulations. The National Association of Board of Examiners of Long-Terms Care Administrators (NAB) coordinates the process of testing administrators of nursing facilities and administers as national licensure examination. In most states like California, administrators must as the American College of Health Care Administrators (ACHCA), which has developed both a Code of Ethics and a set of Standards of Practice for Long-Term Care Administrators (Pratt,1999).

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20 GHCF Business Plan: Phase 1 4. Regulations Affecting Employees

Other employees of nursing facilities are also affected by numerous regulations designed to protect them. Those regulations are associated with a number of laws and regulatory organizations, including the Occupational Safety and Health Act (OSHA), the Department of Labor Wage and Hour Division, the Equal Employment Opportunity Commission (EEOC), state worker’s compensation acts, the American with Disabilities Act (ADA), the Fair Labor Standards Act (FLSA), the Family and Medical Leave Act (FMLA), and too many others to list here.

5. Regulations Affecting Building Construction and Safety Regulations pertaining to environmental safety also apply. Nursing facilities must conform to the Life Safety Code, OSHA, and local building codes to assure that residents live in an environment that is safe and comfortable.

G. QUALITY, INFECTION, SAFETY PROGAM COMMITTEES

In addition to “Quality Assessment and Control Program Committee,” the following program committees shall not be fully addressed in this discussion but merely to mention that they are part of the ongoing business plan development of the Geriatric Healthcare Center for Filipinos, namely:

• An Infection Control Program Committee • A Physical Plant Health and Safety Program Committee

These program committees are to be in place of not only to address compliance issues as mandated by federal, state and local government regulations affecting the operation of the Center but to also assure that quality of care is provided with utmost sensitivity as reflected in the business plan model that is imbedded with ethnic-specific psycho-socio-emotional, religious and culturally-sensitive services to the Filipino aging population in the San Francisco Bay-Area.

The quest for quality in the nursing facility is challenging due to the complexity of the organization and its limited resources. Even then, the managers have valuable functions to perform for the facility such as (1) comparing (evaluation) and (2) controlling the quality of facility outputs. Comparing is judging the extent to which actual results of the facility’s efforts achieve the outcomes proposed in the plans. Controlling quality follows comparing. Controlling is successfully taking the steps necessary to adjust the policies and plans of action to more satisfactorily achieve stated goals. Over and above these mandated expectations, the role of each staff is significant for “the quality of life enjoyed by the residents is directly proportional to the quality of the efforts given by the nursing staff.”

And there are three (3) factors that quality of care is measured by inspectors:

• Structure – When nursing industry began to assume its present size and shape in the late 1960s, quality measurements were primarily focused on structure – an adequate physical plant, the proper equipment, enough trained staff, enough income. The idea was that Medicare, Medicaid, and state nursing home inspectors should assure that the “structure” needed to give good care was in place. Structure, in the system model described, means inputs. The quality of care, however, remained unsatisfactorily low.

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• Process – Attention of the federal and state inspectors was then expanded to include both structure and process. Inspecting for process meant assuring that all the organizational arrangements believed needed are in place. Process, as the processor, is the work that the organization accomplishes. Structure measures the capacity to give resident care. Process measures the way in which resident care is given. For example, are the Minimum Data Sets (MDS) appropriately filled out? Is a well-developed plan of care in place? Are all the resident assessment protocols triggered by the minimum data set appropriately filled out and being followed?

• Outcome –even after measuring for both structure and process, Congress ruled in 1987, through the Nursing Home Reform Act (Omnibus Reconciliation Act), that inspectors must focus not only on structure (capacity to give care) and process (the giving of care), but also on the outcomes of the caregiving. Outcome, the third part of the system model, is the result of the efforts made, the measurable impacts on the resident of the nursing facility. Outcome focuses on measuring whether residents are in fact enjoying a high quality of life, full benefit of the Patient’s Rights established by Congress in 1987, and receiving high quality nursing and medical care. Federal requirement section 483.25 phrased these outcome measures in the following manner:

“Quality of Care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.”

The following examples of outcome measures need to be enforced, such as:

• A resident’s abilities in activities of daily living (ADL) cannot diminish unless circumstances of the individual’s clinical condition demonstrate that diminution was unavoidable. This reasoning is extended to vision and hearing, urinary incontinence, range of motion, mental and psychosocial functioning, nasogastric tubes (skilled), accidents, nutrition, hydration, special needs, unnecessary drugs, and medication errors.

• Regarding pressure sores, the outcome measurement is that a resident who enters the facility without pressure (decubitus) sores does not develop them unless the individual’s clinical condition demonstrates that they were unavoidable.

Nursing homes, today, are inspected for and required to successfully achieve acceptable levels of structures, process and outcome. There are several current methods for controlling quality in the nursing facilities, such as: (1) Deming Method, (2) Benchmarking, (3) Reengineering, and (4) Continuous Quality Improvement/Total Quality Management (CQI/TQM). The GHCF Business Plan will seek to follow the CQI/TQM model for its “assessment and control of quality services program.”

1. QUALITY ASSESSMENT AND CONTROL PROGRAM COMMITTEE

Total Quality Management (TQM) is difficult to define because it is a philosophy of total organizational involvement in improving all aspects of quality service. There is no single set of steps that has gained broad acceptance as the TQM methodology. Employee empowerment in decision-making, the use of teams in the organization, the use of individual responsibility for services and customer service are characteristics of most TQM efforts. TQM is a customer-driven

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22 GHCF Business Plan: Phase 1 approach and is a process of continuous improvement, of continuously striving to exceed customer expectations. Problems in the organization are viewed as problems of processes used, not of individuals within the organization – processes that can be improved using TQM approaches. Six Factors for Success

Six factors are viewed as keys to a successful total quality management program: • Visionary leadership. The CEO, middle and lower-level managers, via quality vision

statement, deploy goals throughout the organization, empower employees to implement TQM, evaluate and recognize TQM progress, promote commitment to customers, and serve as role models of TQM behavior. The CEO and managers act as coaches, not bosses. Coaching implies mentoring employees, assisting them to develop needed skills to perform their job.

• Commitment to customers. Anticipate, meet, and exceed the expectations of internal and external customers, linking reward systems to customer satisfaction.

• Trained teams. The entire workforce must participate in teams, applying TQM in their daily work. Use managers as trainors. Quality is the leading agenda item at all meetings.

• Physician involvement. Involve them in TQM training so they function as TQM enablers for the nursing staff.

• Processes. Have a management process in place that plans and organizes the overall managing of the organization, Have an improvement process that solves specific problems, improves specific processes and maintains these changes over time.

• Avoid a separate TQM system. Make the TQM management the sole management process in the organization.

Managing for quality can also be viewed as a threefold process for which experience suggests that it takes 5 to 10 years to fully implement a TQM process:

• Quality planning. Decide who the customers are, what their needs are, develop features that respond to their needs, and develop processes to respond.

• Quality control. Evaluate the actual outputs, compare output to expected output, and act on the difference.

• Quality improvement. Establish the needed infrastructure, identify improvement projects, establish project teams. Train, motivate, and empower the teams to diagnose the causes, find remedies and maintain gains.

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Part II

MARKETING PLAN A. Background on the Need for Marketing

Why should the nursing facility administrator be concerned with marketing? It is said that high occupancy rates seem guaranteed for the foreseeable future especially when the “baby boomers” come of age. A number of factors, however, are coming together which may threaten any seeming guarantee of continued high occupancy rates (Allen, 1997). The ability of the nursing facility to survive economically is affected by an increasing variety of pressures, such as: (1) federal and state reimbursement policies like prospective payment system (PPS) and diagnosis-related groups (DRGs), (2) the types of services offered by the facility, and (3) the sources of resident payment. Over the past decade government regulators, who pay for care of Medicare and Medicaid residents in nursing facilities have sought ways to narrow the margin of facility profit to achieve mandated government cost savings. At the same time, facility costs have increased in meeting the additional regulatory requirements under the 1987 Nursing Home Reform Act and subsequent amendments. Such bills as the Americans with Disabilities Act, the Family Medical Leave Act and the more rigorous universal precautions requirements of the Department of Labor all add costs, often unreimbursed, to providing care. Increasing personnel costs, particularly as the level of acuity increases the need for well-trained staff, threaten profitability. One geriatrician has observed that over the next 10 years, if present trends toward increasing acuity of care continue, nursing facilities’ staff costs will approach those of hospital beds. The patient/resident profile of the typical nursing facility is shifting toward an increasing level of acuity and a rising number of sources of payment. Providers include health maintenance organizations, worker’s compensation, long-term care insurance, the Veterans Administration, and private insurance companies. B. The Challenge to Marketing Long-Term Care to Filipinos

A Filipino elderly bound for long-term healthcare facility finds himself under a healthcare system that provides care as defined within the parameters of all the bodies of federal, state and even local government regulations. In addition to all these regulatory and bureaucratic backgrounds are realities that Filipino families are hesitant and uncomfortable to deal with in using the healthcare system due to their cultural thinking and attitude towards the use of institutional care for their aging parents and/or family members. The sense of filial responsibility to their aging parents is so strong that only after exhausting all means available to them that they may concede to bring their loved ones to the institutional long-term care environment.

C. Response to Marketing Challenge: A Culturally-Sensitive Nonprofit Medical Model LTC Environment

Being aware that most Filipinos believe in the filial responsibility of taking good care of their aging parents at all costs while the latter live to cherish some of the cultural values in their hearts, the Geriatric Healthcare Center for Filipinos (GHCF) should be presented to them as a “Home, Away from Home” The GHCF should be marketed as a culturally-sensitive service care model to meet their healthcare needs while at the Center, in addition to providing them with ethnic-specific

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24 GHCF Business Plan: Phase 1 psycho-socio-emotional and religious services, in a nonprofit medical model long-term healthcare environment. D. Competition To increase occupancy rates especially among hospitals and nursing facilities, they are competing with each other. For hospitals, they introduce other services like outpatient surgery, nursing facilities and home health agencies for patients, attempting to distinguish themselves from their competitors. Competition occurs when two or more organizations seek to serve the same individual or group in an exchange process. Competition for patients among public, not-for-profit and for profit hospitals, is a new experience. Administrators of nursing facilities are similarly encountering a need to “market” their services. With regard to the Geriatric Healthcare Center for Filipinos, the defined response to marketing challenge is good enough reason for the Filipino community to see its value that although it is an institutional care, it is in reality providing a very “homelike environment” wherein residents are provided with a 24-hour medical and nursing service care due to the loss of their ADL functions and other chronically-ill healthcare conditions. As far as competition is concerned, the market is untapped and rich for cultivation because no known competitor is in existence for the Filipino community in the San Francisco-Bay Area or even across the country. E. Target Market: Filipino Elderly in Need of LTC Setting Marketing is a process of planning and executing the conception, pricing, promotion, and distribution of ideas, goods and services to create exchanges that satisfy both individual and organizational objectives (Allen, 1997). The Geriatric Healthcare Center for Filipinos is in the business of marketing its services that are culturally-sensitive to meet the healthcare needs of its target population in the long-term care setting. The Marketing and Community Relations Officer will have the responsibility to help design and implement marketing strategies through network, outreach and linkage with the following recommended venues for which the services of the Geriatric Healthcare Center for Filipinos will ring through and reach the target population, the Filipino elderly in need of Long-Term Care services.

• Bay Area Hospital Discharge Planners • Link with SFVA Hospital/Nursing Home Discharge Planners • Skilled Nursing Facilities DC Planners • Filipino Community Centers • Filipino Medical and Allied Health Professionals: Referral Source • HMO, Worker’s Compensation, Long-Term Care Insurance • Private Insurance Companies, Home Health Agencies

F. Advertising and Marketing Strategy via Pro-Bono Services In addition to networking, outreaching and linkages facilitated by the Marketing and Community Relations Officer, the Center shall make its mission known in the public arena through public exposure and community saturation campaign via the following venues:

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25 GHCF Business Plan: Phase 1

• The Filipino TV Channel (TFC) and Filipino Print Media in the Bay Area (e.g., Philippine News, Manila Mail, Pinoy Balita, and others)

• Flyers to Filipino Senior Centers and Filipino Social Organizations • Community Involvement and Public Events • Web Advertising & Facility Quarterly Newsletter • Local Public TV (Channel 9, 26 and some Cable Channels) and Print Media (e.g., SF

Examiners, Independent Newspaper, SF Chronicle)

G. Assessment of Marketing Effectiveness Marketing and Community Relations Officer shall design a mechanism to assess the effectiveness of the advertising and marketing strategies in reaching out for the Center’s target population. H. Marketing/Community Relations Officer The Geriatric Healthcare Center for Filipinos will employ one full-time staff to serve as Marketing/Community Relations Officer. Her main responsibilities are articulated in the marketing plan of the proposed business plan with an ultimate objective of securing a sustainable high occupancy rate at the Center without necessarily compromising the quality and culturally-sensitive service care delivery to residents in the long-term care environment. The Officer shall take charge, too, of Customer Service with inquiries related to the services provided for in the Center. Also, every staff should feel adequate and comfortable, too, in sharing with others about the services in the Center.

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Part III FINANCIAL DOCUMENTS

CYDF USA, Inc., as a nonprofit public benefit corporation, does not have physical and/or financial assets to address the “structural needs” of the proposed business plan, re: the establishment of Geriatric Healthcare Center for Filipinos, except expertise to address the “process” of translating the model into reality. It is expected that if the structure is in place, the process could be established to implement the proposed business plan, and this would, likelihood, generate positive outcome because the model is designed to provide quality and culturally-sensitive service care delivery to the target population. These three components, structure, process and outcome, are basic requirements for a successful operation of the facility per Title 22, Div. 5, Ch. 3 of the California Code of Regulations and the OBRA ’87 (Medicare and Medicaid).

A. Source and Use of Fund (Seed Money) to jump start GHCF

The Geriatric Healthcare Center for Filipinos requires about $4,000,000.00 to jump start the implementation of the proposed business plan, beginning with the establishment of its “structure.” Sources of fund will be derived from fundraising activity to target key supporters, benefactors, philanthropists, private and public funding institutions through grants, from ticket sales to the general membership of Filipino Social Organizations and advertising sponsorship to a series of Live Concert/Show by Philippine Performers. This will continue until such time the fundraising objective is met within a 2-3 year period.

Filipino Social Organizations are potential sources of financial support through sales of tickets for Live Concert/Show in the San Francisco-Bay Area; and at the same time, to target them for information and education on the plan to put up the Geriatric Healthcare Center for Filipinos. Cognizant to the fact that by tapping them as a resource for financial support would at the same time bring not only information but awareness on the need to put up a culturally-sensitive Long-Term Care Facility in the San Francisco-Bay Area. It is said that there are about 300 Filipino Social Organizations3 in existence in the San Francisco-Bay Area. Although the writer cannot, at this time, verify as to the accuracy of the report, evidence indicates that almost all-year round Filipino Social Organizations can be noticed celebrating in different hotels and public places in San Francisco and the Bay Area for their social functions. Their visibility in this social gathering has been observed by the writer when he was invited to attend in March 2004 at a hotel in Newark, CA. that there were more than 500 guests in attendance. This is usually a typical number of guests in attendance of a social function that Filipinos love to attend and get acquainted with their fellow countrymen. Also, they love to watch live concerts, too, especially when showbiz talents (actors/actresses) are from back home, the Philippines. It is always, almost, showbiz performers do not go home empty-handed for they are being warmly welcome and supported by the Filipino community in the San Francisco-Bay Area.

3 Partial List of Fil. Social Organizations: Bulldog Club USA, Masantoleno Association USA, The Masantoleno, St. Michael Archangel, Mr. & Mrs. Club of California, Apalitenos of San Francisco-Bay Area, St. Nicholas Association of Macabebe, Sta. Lucia Association USA, San Isidro Barrio Fiesta Association, The Masantoleno Club, Todo-Todo Club USA, Sta. Rita Club USA, Pangasinan Charitable Foundation, Inc, United Villasinians of America, Inc., The Lambingan Club USA, Magsingal Association of California, Fil-Com of Santa Clara County, Inc., Dagupan Ass. of Stockton & Vicinity, Mangaldan Ass. of Northern California, Floridablancans (USA) Inc., San Carlos City Ass. of California, Inc., Guagua Batu Balani of N. Californoa, San Carlenians of Pangasinan, USA, Bonuan International, Dagupenos Charitable Foundation, Inc., Balungao Ass. of America, Urdaneta Assosiation of America, Inc., Banians of the USA, Inc., Manaoag California Residents’ Ass, Dagupenians Ass. of America, Inc., Lingayen Circle of America Ass, Rosales United Club, Federation of Dasol Ass. of America, United Pozorrubians of N. CA., Inc,, Fil-Am Association in SF.

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27 GHCF Business Plan: Phase 1 It is important to take note that licensing fees, salaries and wages, replenishing supplies, food supply, including emergency supplies, are budgeted for 6 months. Budget for one month per month needs to be good for 6 months and available in the Bank for inspection by licensing department.

Table 3: Source and Use of Fund (6 Months) REVENUE 1. Cash Donation from CYDF USA, Inc. Membership.......................... 2. Cash from Fundraising Activities a. community supporters and benefactors......................................... b. philanthropists............................................................................... c. Filipino Healthcare/Medical Professionals.................................... (Imputed Cost of Services Rendered with IRS approval) d. grants from private foundations.................................................... e. grants from public funding institutions......................................... f. live concerts revenue f1. sponsorship from the Filipino business community............... f2. ticket sales to Filipino Social Organizations/Membership............... 3. Medicaid Reimbursement for 50 Residents during State Licensure (45-day waiting period) to the first 6th months operation..............................

$ 50,000.00 $200,000.00 $500,000.00 $500,000.00 $1,000,000.00 $1,000,000.00 $100,000.00 $600,000.00 $1,321,300.00

Total Revenue( Fundraising Activity & Medicaid Reimbursement) $5,271,300.00

LESS: OPERATING EXPENSES

1. Start-Up Expenses............................................................................. • Business License, Taxes, Legal Fees, Corporate Filing

2. Variable Expenses............................................................................. • Pharmacy..................................................................................... • Activity........................................................................................ • Maintenance................................................................................ • Marketing.................................................................................... • Administration/Office Supply..................................................... • Training and Education............................................................... • Consultants.................................................................................. • Utilities........................................................................................ • Supplies (see Worksheet 8 for details) ($73,087.50)

*Nursing Supply ......................................................................... *Central Supply........................................................................... *Food/Dietary Supply................................................................. *Laundry/Cleaning......................................................................

3. Fixed Expenses (Administrative)..................................................... • Lease for 6 mos. @ $18,000.00...................................................

$158,000.00

$231, 677. 62

$ 20,000.00 $ 6,000.00 $ 40,000.00 $ 10,000.00 $ 10,000.00 $ 20,000.00 $ 50,000.00 $ 15,000.00 $ 12,410.00 $ 2,555.00 $ 55,412.50 $ 2,710.00

$776,000.00 $108,000.00

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• With one month advance payment.............................................. • Employee Benefits...................................................................... • Insurance.....................................................................................

4. Payroll Expenses................................................................................ • Salaries and Wages

a. Nursing Staff (basic and differential pay, please see Worksheet 7 for details).............................................................. b. 5% of Nursing Budget Allocated for Overtime......................

c. Administration/Departmental Staff (see Worksheet 8).................

4. Assets (Long-Term Purchases)........................................................ • Equipments.................................................................................. • Repair and Maintenance.............................................................. • Replacement Expenses................................................................

5. Liabilities............................................................................................ • Cash outlay for retiring debts, loans and/or accounts

payable........................................................................................

$18,000.00 $350,000.00 $300,000.00 $1,319,718.30 $806,355.90 $ 40,317.79 $464,044.68

$230,000.00 $70,000.00 $80,000.00 $80,000.00 $ 0.00 $0.00

Total Operating Expenses.................................................................... $2,715, 395. 90 PROJECT NET OPERATING PROFIT............................................ $2,555,904.10

B. Income Projection Geriatric Healthcare Center for Filipinos (GHCF) Phase 1 Business Plan is designed to provide long-term care service to individuals receiving Medi-CAL benefits. Medi-CAL reimburses Long-Term Care facilities based on a PPD (per patient day) rate at a maximum of $146.00/day without “a share of cost” from residents. PPD rate may decrease when a resident has a share of cost (meaning, a resident has some resources but not enough to meet one’s own financial obligation while at a long-term care center) and final determination of PPD rate will be issued by Medi-CAL. The “share of cost” of the resident determined by Medicaid will augment the PPD rate decreased paid to facilities and will add to compensate the total PPD rate of $146/day per resident while in the long-term care facility. The computation to arrive at the amount of Medicaid reimbursement for 100 residents should assume the following information: (a) No. of Residents =100, (b) No. of Days in a Month = 31, 30 and 28, (c) No. of PPD (patient per day) = 1ppd/1day, (d) PPD rate = $146.00/resident per day. Thus, 100 residents multiplied by 31 days is equals to 3,100 ppd. Then, multiply 3,100 by $146.00 which gives you a $452,600.00 Medicaid reimbursement in the month of January for 100 residents.

28 GHCF Business Plan: Phase 1

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29 GHCF Business Plan: Phase 1

Table 4: Three-Year Income Projection

Activity Year 1 50 Res. x PPD

Year 2 75 Res. x PPD

Year 3 100 Res. x PPD

3 Yrs Total Amount

Income Begin Res. 25 Endg Res. 50

$164,250.004

$2,336,000.00

$2,664,500 (50r) $1,332,250 (25r)

$3,996,750 (75r) $1,332,250 (25r)

$11,826,250.00

Gross Profit $2,500,250.00 $3,996,750.00 $5,329,000.00 $11,826,250.00

Expenses $3,219,735.70 $4,039,956.00 $4,675,156.30 $11,934,848.00 LicFee,Tax $ 158,000.00 $ 155,000.00 $ 155,000.00 Variable $ 463,335.24 $ 463,355.24 $ 463,355.24 Fixed $1,516,000.00 $1,516,000.00 $1,516,000.00 Payroll Nurs OtherStaff

$ 806,355.90 $ 464,044.68

$1,209,533.80 $ 696,067.02

$1,612,711.80 $ 928,089.36

Assets $ 230,000.00 $ 0.00 $ 0.00 Liabilities $ 0.00 $ 0.00 $ 0.00 Net Income - $719,485.70 -$ 43,206.00 +$ 653,843.70 -$108, 848.00 Net Profit (Loss) Before Taxes

- $719,485.70

- $43,206.00

+$653,843.70

Taxes/Federal Sate/Local

-$155,000.00

- $155,000.00

-$155,000.00

Net Profit (Loss) After Taxes

(- $874,485.70)+ (-$198,206.00) =

= -$1,072,691.70

+$498,843.70

-$573,848.00

Taking a close look at Table 4, few things can be surmised in relation to the business plan discussed in this field study:

o It gives the impression of the financial difficulty of rising above to meet the Center’s objective of becoming a self-sustainable facility by being able to generate enough revenue through the Medicaid PPD Reimbursement System.

o Even after three years of operation, the facility tends to lose money. However, it appears that on the third year of operation it is showing some positive gains and has generated a net profit of $498,843.70 after taxes. As a whole, the facility has still lost money and posted a negative revenue of $108,848.00 when all net income are computed as one unit in the three years period.

o But as a non-profit facility, the Center may benefit from some tax-credit for its operation. So, in addition to the posted net profit indicated on the third year of operation, a tax-credit may be an added income for the facility during the year to offset loss of income.

o There is an indication, nevertheless, that a Long-Term Care Model funded by Medicaid PPD rate can still rise up against a heavy drain of financial resources after the third year of operation. On the assumption that the facility will sustain a high occupancy rate after the third year of operation, there is a strong likelihood of moving up positively its financial health. It may sound unsound from a business point of view, especially if the facility will continue to financially bleed and unable to rebound on its own resources and able to sustain itself through the revenue it could generate as it provides healthcare services to its target population.

4 During the first 45 days of operation, it is advisable for the facility to have 25 residents while waiting for the license to

be approved. Beyond 45 days, the facility can start admitting 25 new residents for a total of 50, during the first year of operation. Every year, thereafter, additional 25 new residents can be admitted until it is full of capacity (100 residents) on its third year of operation.

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30 GHCF Business Plan: Phase 1 o On the other hand, the writer believes that this apparent predicament can still be redeemed

and make its financial health become healthy, viable and sustainable to support its own operation by including at the actual implementation of the business plan, the Phase 2: Short-Term Care Service (Rehab Services like Physical, Occupational and Speech Therapy) to be provided to the residents at the facility.

o A healthcare facility should be aware that Medicaid-Medicare reimbursement is through a PPS system that uses DRG (diagnosis-related group), as a basis for determining payment to healthcare facilities.

For purposes of the field study, the writer intends to wrap up the discussion on proposed business plan. As an iota of information, he intends to continue his research on Phase 2: Short-Term Care Model in conjunction with the objective of CYDF USA, Inc. mission of serving the Filipino elderly population and have a facility that is imbedded with ethnic-specific psycho-socio-emotional, religious and culturally-sensitive services and determine its feasibility for self-sustainability by including in its investigation, the Medicare Part B PPS reimbursement system to facilities like the proposed business plan for the Geriatric Healthcare Center for Filipinos.

Dr. Anabel Pelham and Rita ll N. Mendoza on May 28, 2005, during the Reception of Graduates of the Gerontology Program at San Francisco State University, San Francisco, CA.

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Part lV SUPPORTING DOCUMENTS

There are four main sections presented in worksheet format to support and better

understand the financial statement discussion, namely: (1) A 100 Medicaid-bed Reimbursement and Revenue Analysis, (2) Nursing Expense Account Analysis and the Staffing Pattern Model, (3) Administrative and Staff Payroll Budget Analysis, and (4) Facility Supply Budget.

Section 1: A 100 Medicaid-bed Reimbursement and Revenue Analysis Worksheets 1,2 and 3 presents a PPD reimbursement for residents who are on full medical benefits and have no share of cost. It provides a detailed information on how the facility may be reimbursed based on the number of residents on a daily basis against the total number of PPD accumulated during the month. This is a determinant factor for reimbursing facilities under the Medicaid program. Worksheet 4 presents an income projection analysis for a given calendar year and serves as a guide for the facility-provider to keep track of record related to PPD.

Section 2: Worksheets on Staffing Pattern Model and Expense Account Analysis Worksheet 5 presents a nursing staffing requirement for federal model against a recommended state model addressing the ratio of required number of hours that each resident in the facility should receive nursing care with a ratio of 3.2 hours per resident The federal model (Pratt, 1995) is usually for facilities with both long-term and short-term care nursing service care model. Similarly, Worksheet 6 addresses staffing pattern for the administrative and support staff. The federal model is closely adopted with some inclusions of staffing that need to capture the business plan model of providing culturally-sensitive services to residents. For one, the ratio of CNAs to residents is 1:6.25 that gives staff more time to implement the model through “task-oriented talk”. As a culturally-sensitive service model, staff are encouraged to interact more with residents and provide an environment of “feeling at home, away from home.” Worksheet 6 presents a staffing model for the administrative and support staff. The most evident inclusion in this model is the Filipino Gero-Psychologist who plays a very significant role in implementing the “psycho-socio-emotional services” required to be provided in the facility. Outsourcing for Religious Services could be facilitated by a Volunteer in coordination with the Activity Department. Worksheet 7 presents an Overview of Budget/Wage Scale Analysis for Non-Skilled FT/PT Staffing in the Nursing Department On the assumption that nursing staff working on a 24-hour 3 shifts with a full house occupancy rate of 100 residents, the facility needs to provide 320 hours of nursing care to meet and comply with the State’s requirement of providing a required number of 3.2 hours each resident is entitled to receive daily.

• Ratio of CNAs to residents on a scale 100 is (a) day shift = 1 is to 6.25, (b) evening shift = 1 is to 11, and (c) night shift = 1 is to 16.5. Night shift has the biggest ratio because residents are asleep and CNAs have less work required to attend to. With this ratio, a task-oriented talk imbedded with cultural sensitivity paves the way for implementing the model. Please see Fig. 4 on page 91, re: Organizational Chart, for further staffing distribution information. Nursing budget covers the regular and reliever nursing staff. Regular nursing staff is a full-time position.

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32 GHCF Business Plan: Phase 1

budget covers the regular and reliever nursing staff. Regular nursing staff is a full-time position and a reliever nursing staff is either a part-time or full-time position with a budget to cover differential pay for those working in the evening and night shifts.

• RNA is an item recommended for the day shift to address and respond to residents’ need to be assisted in walking exercise upon doctor’s order and instructions..

• What the worksheet analysis does not indicate is a budget for inevitable overtime expenses which could almost always happen in a long-term care facility due to call-in (sick calls and emergencies). The facility may create an overtime item budget, perhaps at 5% on top of the budget at a cost of additional $80,635.59/year. Overtime may be inevitable, but not to be encouraged, so as not to compromise the quality of care provided to the residents.

• Looking at the current capacity and the financial health of the facility receiving its reimbursement from Medicaid, the facility may start experiencing some gains on the third year of operation. However, since the overhead expenses are too heavy and high, it will have a hard time gaining a momentum to pursue further growth and development.

• To offset drag and gain momentum of the flow of growth and development of the facility, the Center has to move on beyond Medicaid reimbursed facility and has to embrace at the initial stage the inclusion of Medicare Part B in its services, so as to increase its revenue. Meaning, it shall attempt to include Rehab Services in its menu of services like physical, occupational and speech therapy and other skilled nursing needs of the residents.

Section 3: Administrative and Other Staff Payroll Budget As already noted, nursing budget and wage scale have the most extensive need to meet its staffing requirement and address the 3.2 hours ratio per resident receiving nursing care during a 24-hour operation on an on-going basis. And Worksheet 8 demonstrates the wages and salaries of the support staff who are equally important and indispensable in the operation of the facility so as to be able to provide a culturally-sensitive quality care service to the residents.

Section 4: Budget for Facility Supply Worksheet 9 indicates that the over-all cost of supply is the least expensive compared it to resources like wages/salaries and the physical upkeep of the facility. Replenishing supplies, food supply including for emergency use are budgeted for 6 months. The budget for one month per month needs to be good for 6 months and should be available in the Bank for inspection by the licensing department.

Rita Nabong-Mendoza, R.N. and Maureen, a Gerontology Graduate!

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33 GHCF Business Plan: Phase 1

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34 GHCF Business Plan: Phase 1

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35 GHCF Business Plan: Phase 1

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36 GHCF Business Plan: Phase 1

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37 GHCF Business Plan: Phase 1

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Chapter 6

SUMMARY OF FINDINGS, CONCLUSIONS AND RECOMMENDATIONS

The primary purpose of the field study was to develop a business plan for the

establishment of Geriatric Healthcare Center for Filipinos per CCR Title 22, Div. 5, Ch. 3, OBRA 87 and JCAHO Shared Visions – New Pathways. It is a 100-bed non-profit medical healthcare facility that is imbedded with ethnic-specific psycho-socio-emotional, religious and culturally-sensitive services. The study completed a comprehensive review of the current literature, deemed not only relevant to the business plan but related to ethnogerontology, with a specific focus on Filipino cultural values in order to address the hypothesis that all elders, i.e. Filipinos, in the long-term care setting would require culturally-sensitive services to meet their healthcare needs. There are four key issues that the study attempted to address, namely:

1. What is the proposed business plan model for a Geriatric Healthcare Center for Filipinos?

2. What kinds of services are required to meet and be responsive to the needs of Filipino elders in the long-term care setting?

3. What are some of the Filipino cultural values that one needs to be aware of as service delivery is being provided?

4. How can an awareness of these cultural values be useful to provide quality of care among the Filipino elderly in the Center?

The responses to these inquiries were mostly sought through review of the

current literature in ethnogerontology by using a computerized and traditional search processes such as ERIC, Psychinfo, Info Trac and visits to public and academic libraries, and to some extent getting consultation directly from some authors and publishers in the Philippines on cultural values via long-distance communication.

FINDINGS

A. Some findings based on inquiries from the four key issues: 1. As to the first inquiry, the study’s proposed business plan is a nonprofit medical

healthcare service model to benefit the Filipino elderly in need of long-term care.

• However, review of current literature indicates that there is a lack of or even an absence of a non-profit medical model healthcare facility designed to serve the Filipino elderly in need of long-term care facility.

• Literature also reveals that we have a “one size fits all” (Pratt, 1995) model healthcare system which might have contributed to the lack of

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interest of multi-ethnic groups like the Filipinos to pursue an endeavor in medical healthcare setting to benefit the Filipino elderly. And, many of the healthcare models in place are social models

2. As to the second inquiry, the kinds of services required to meet and be responsive to the needs of the Filipino elders in a long-term care setting are to be facilitated by a Filipino gero-psychologist. These services are psycho-socio-emotional, religious and culturally-sensitive services.

• Examples of psycho-socio-emotional services are support group, individual contact session, group and individual counseling, reminiscent group activity, Pilipino Poetry reading, living at the moment group activity and tactile stimulation activities such as (1) task-oriented talk (i.e. talking to residents while care is given even if response is not indicated), (2) access to ethnic-specific multi-media venues like TFC (Filipino TV), and others.

• Religious services would be facilitated through the priest, pastor, and any recognized religious leader of the residents choice, provided is available. This will facilitate residents’ longing and desire to deepen their sense of spirituality and feel comfort and peace in themselves.

• Culturally-sensitive services. Literature reveals that there is so much to learn about Filipinos coming to the United States bringing with them “a culture” that they cherish in their hearts. Knowing where the person is coming from (i.e. region, dialect spoken, choice of food, cultural idiosyncrasies, and many more) would invite building a rapport between the resident and the staff, thus making the stay of the Filipino elderly in the facility a “homelike” one. There is an extensive material on cultural values per literature review and consultation with some authors and publishers from the Philippines. If the staff is aware and made aware of the importance and understanding the different cultural values of the residents in the facility, it will likely make the residents “feel at home away from home”.

• It is important to recognize where and which part of the country the Filipino elderly is coming from. The region from where the residents come from the Philippines will indicate their cultural idiosyncrasies, a cultural value practice that may differ from one region to another neighboring region. Take note, the Philippines has 111 linguistic, cultural and racial groups spread out over an area of 7,100 islands.

3. As to the third inquiry, staff in the facility should be aware to some of the cultural values that Filipino elderly cherish in their hearts and these are:

• Respect for the elderly is exemplary. In the Philippines, we take care of our aging parent at home. This is also evident in the United States. Sending them to a home for the aged is unthinkable and most feel it is

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inhuman to “send away” their old folks when they can no longer take care of themselves. Filipino parents caring for their children have no time frame, even if their kids are already full-grown adults. So, when they advance in age, their children take care of them in return.

• While most Filipinos practice Christianity, they can also be superstitious. Staff in the Center need to be aware of these superstitious beliefs for they might encounter a resident who may be resistive to care, without knowing that it has something to do with what the person believes. A list of superstitious beliefs are found in Ch.4. lll.C of this field study.

4. Awareness of Filipino cultural values are useful in providing quality of care service delivery to residents in the facility.

• Being aware of the cultural values of the Filipino elderly could lead to improved communication. Communication with an elderly in a long-term care facility is an important factor of the person’s life while being cared for.

• Caution: When a staff tends to normalize communication with a resident, insensitivity to the healthcare needs of the person is compromised, more so, being unable to provide culturally-sensitive services.

• Providing culturally-sensitive services could lessen the emotional anxiety, insecurity and loneliness of the Filipino resident. This could lead the resident to experience their life’s worth and meaning by being engaged in activities familiar to them.

• Being aware that the Center is a nonprofit medical healthcare model providing culturally-sensitive services by Filipino healthcare professionals is a good welcome sign for them to feel at home, away from home.

B. The Proposed Business Plan: “Geriatric Healthcare Center for Filipinos”

• The proposed business plan appears to be a good model, being imbedded with ethnic-specific psycho-socio-emotional, religious and culturally-sensitve services meeting the healthcare needs of the Filipino elderly in the long-term care setting.

• What appears to be a setback in its full implementation is the apparent lack of strong capacity to become self-sustainable if the business plan would initially start as a “long-term care” facility where reimbursement is constraint to slow down its growth and development due to high overhead cost and low Medicaid reimbursement.

• However, some figures on the third year of operation in the Three-Year Income Projection indicate that the facility will be posting a net revenue. However, when counted against the financial performance of the Center during entire three year period, the overall result is that the Center is posting a loss revenue because of the overhead cost.

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• The Center needs cash reserve good for at least five years to become more of a viable Medicaid funded facility, with the assumption that the Center must always be at full capacity (100% occupancy rate) in operation.

CONCLUSIONS

On the basis of the limited data presented in the body of the study and in the light of the findings, the following are concluded:

• The literature provides realistic insights on the establishment of a culturally-sensitive services for the Filipino elderly in need of a long-term care facility.

• It is evident that given resources, the proposed business plan is viable and feasible and would be an effective healthcare model to address the healthcare needs of Filipinos because it is imbedded with ethnic-specific focus on cultural values of the target population. When resident and staff share a commonality of background, lifestyle and cultural values, it will bring forth a desired effect of making residents feel comfortable and at ease, enhancing their general psycho-social well-being emanating from their good mood and behavior.

• There are three basic components that are important in the establishment of a healthcare center, and these are: (1) structure, (2) process and (3) outcome. The strength of the field study is in the formation of the process that involves designing the proposed healthcare business plan as a culturally-sensitive service model as opposed to a “one size fits all” model that the current healthcare system provides to its consumers. If the process is responsive to the needs of the residents, there is likelihood that the outcome would be good and desirable so as to make them feel about being cared for in the facility. The weakness of the study is on the capacity of the facility to become self-sustainable because Medicaid reimbursement would hardly support its financial health. Most of the financial resources are heavily drained on overhead cost which would leave less financial resources generated from Medicaid to support generously the Center’s becoming a self-sustainable facility. Thus, the structure component of the proposed plan is the main concern about being able to fully implement the project. There are ways in which the “structure” issue can be resolved which will lead us to the next discussion: recommendations.

RECOMMENDATIONS

It is being recognized that the proposed Geriatric Healthcare Center for Filipinos meets all the basic components of a healthcare facility except on the “structure”. Without healthy financial resources through reimbursement, no matter how good the “process” is designed to benefit the target population, it would hardly

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make it through to being fully developed. The Geriatric Healthcare Center for Filipinos is initially designed to start as a “Long-Term Care” facility where all residents are funded through reimbursement by Medicaid PPD rate of $146.00/day on the assumption that they do not have a “share of cost”.

• To make the business plan more feasible and viable, it is being recommended that it should move on to include Phase 2: Short-Term Care services to the target population at the very onset of the plan’s full implementation.

• The writer should continue the research to include Medicare Part B and find out the details of reimbursement process. With a 100-bed facility funded by Medicaid-Medicare Part B, and having the same overhead cost, chances are the facility will experience a better financial health status compared it to when the facility is under a Medicaid program.

• It is being recommended, too, that any non-Filipino with bonding to Filipino cultural values may be admitted. It is not surprising to know that some non-Filipinos bond and share with Filipino cultural values. A distinct example is evident as in the case of a Caucasian resident presented in the field study where she resisted receiving care unless she would be served “rice” in her menu. There are some of these individuals who have ties in the Philippines but are in the US and still cling to some of the cultural values of Filipinos they have learned to cherish in their hearts.

Dr. Anabel Pelham, my first Mentor in the Gerontology Program at SFSU.

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___________ (2002). Understanding the Values of the Metro Manilans and Tagalogs. Quezon City, Philippines: Giraffe Books. Book One, pp. 46-56

____________ (2003). Understanding the Values of the Malabon People. Quezon City, Philippines:Giraffe Books. Book Two, pp.14-26. ____________ (2003). Understanding the Values of the Bulakenos. Quezon City, Philippines: Giraffe Books. Book Three, pp. 24-39.

_____________ (2003). Understanding the Values of the Cavitenos. Quezon City, Philippines: Giraffe Books. Book Four, pp. 27-48. ______________ (2003). Understanding the Values of the Tarlakenos. Quezon City, Philippines: Giraffe Books. Book Five, pp.12-15. _______________ (2003). Understanding Pampango Values. Quezon City, Philippines: Giraffe Books. Book Six, pp 1-37. _______________ (2003). Understanding the Values of Nueva Ecijanos. Quezon City, Philippines: Giraffe Books. Book Seven, pp.9-25. _______________ (2003). Understanding the Values of Nueva Ecijanos. Quezon City, Philippines: Giraffe Books. Book Seven, pp.9-26. _______________ (2003). Understanding the Values of the People of Bataan. Quezon City, Philippines: Giraffe Books. Book Eight, pp. 9-25.

_____________ (2003). Understanding Ilocano Values. Quezon City, Philippines: Giraffe Books. Book Nine, pp. 11-39.

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Antonelli, K. I. (1997). Ethnic Diversity Issues In Long-Term Care: Administration-In-Training Observations. A Field Study in Gerontology Graduate School. San Francisco: San Francisco State University

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Cole, T.R., Van Tassel, D.D. and Kastenbaum, R. (Eds.) (1992). Handbook of the Humanities and Aging. New York: Springer Publishing Co., pp. 405-407.

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Lesnoff-Caravaglia, G. (Ed.) (1985). “Caring for the Elderly, Religious Institutions”, Values, Ethics and Aging. New York, N.Y.: Human Sciences Press, Inc., pp. 117-135. Mayers, M.K. (1984). A Look At Filipino Lifestyles. Dallas, Texas: International Museum of Cultures, pp. 91-100. McBride, M. (2004). Health and Helathcare of Filipino-American Elders, A Curriculum In Ethnogeriatrics and Ethnic-Specific Modules. SGEC, Stanford University School of Medicine. Retrieved on Sept. 9, 2004 from www.stanford.edu/group/ethonoger/Filipinos.html

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Fact Sheets from Colleges/Vocational Schools, SY: 2000-2003 Pampanga Agricultural College, Magalang, Pampanga APO Computer School, Floridablanca, Pampanga Megabyte College of Science and Technology, Floridablanca, Pampanga Philippine State College of Aeronautics, Basa Air Base, Floridablanca, Pamp.

Nini could hardly wait to go to College. First thing first, Nini...Study hard to finish your high school, ok!

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GLOSSARY OF PILIPINO TERMS Pilipino Terms English Translation and Discussion of Some Words

A Ako I Amor-propio Self-esteem Anitos

Spirits that early Filipinos believe and worship. Due to Christianity, this is slowly disappearing but still present mostly among “natives” or as they are now called in the Philippines as: cultural minorities.

Anting-anting Amulets Ate, Ditche, Sanse

Bulakenos’ way of respecting their elder sisters.

B Babi Pig, hog Baka-may-masabi

What others might say

Bayanihan A spirit of camaraderie to help one another in times of needs Binat, begnat, belnat

Recurrences of an illness

Bugok na itlog Partially incubated eggs without the embryo Bulao Cotton

K Kabunian An Ilocano term for Supreme Being Ka Kaka

A respect given to an older person from the Tagalog region, irrespective of blood ties like Ka Pedro and among Ilocanos, it is Manong Pedro (for male) and Manang (for female).

Kami we Kawit hook Kapitbahayan Neighborliness, neighborhood Kayo You (plural form) Kumpadre (m) Kumadre (f)

A term used to indicate formal social relationship developed between two male/female adults, one serving as a sponsor of the other’s child in mostly Catholic Christian rituals such as Christening, Confirmation and Wedding

Kuripot Being tightfisted in money matters Kusang loob A person’s voluntary act Kuripot Stingy Kuya, Diko, Sangkong

Bulakenos’ way of respecting their elder brothers

D Dambana ng Kagitingan

Shrine of Valor

E

NO ENTRY

G

NO ENTRY

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H Herbolarios Faith healer Hiya Shame Ho See “opo”

I Ikaw, ka You (singular) Ilocano Refers to the people and dialect of the Ilocos Region Isa, adua, atlu One, two, three

L Lola Grandmother Lolo Grandfather Lumanog guitar A family in Pampanga famous for their guitar-making

M Mahirap lang kasi kami

An Ilocano value which connotes “because we are just poor”

Malabong Young bamboo shoots Malakas

The literal meaning of “malakas” is “strong.” However, for an Ilocano this connotes a value that does not necessarily mean being “strong physically” but “strong in connections,” that is, having acquaintances with prominent people or political figure. This is a value of “whom” and not “what” you know. This rings counterproductive when seen against a person wanting to apply for a position/job because he has a skill but can’t go through because he does not know anybody to back him up. This leads to inefficiency, even in the government sector.

Malunggay Horseradish, and its leaves are used as a vegetable Manang An Ilocano word for sister as a show of respect Manghihilot Sprain curer Manilad Place grown with nilad – a small tree bearing with flowers. Manna Inheritance, heritage Mano

A tradition in which the young person kisses the hand of an older person or parents as a sign of respect.

Manong An Ilocano word for brother as a show of respect Maramdamin A sensitive person, one whose feeling easily gets hurt Matipid Thriftiness, frugality Ma-yi Ancient name of Bulacan province Minum drink

N

Nilad A small tree bearing with flowers Nasi

Refers to a Pampango word for cooked Rice, but when it’s uncooked – it is called Abias; and when it is unpeeled – it is called Pale. Pale is Palay for Tagalogs which means Rice.

NG

NO ENTRY

O A traditional and polite way to speak to an elderly person,

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Opo, Po, Ho equivalent to addressing somebody with respect as “Sir”

P Pakikisama The ability of a person to get along well with others. Paggalang Respect Pagkakaisa Act of unity, solidarity Paglilingkod An act of service to others Pagmamano Kissing of the hand Pagtutulong-tulong

A Bulakeno specific value related to education where one is expected to help other family members when done with schooling

Palay, Nasi

Palay is Tagalog word for Rice (unpeeled) and Nasi is Pampango word for Rice (cooked peeled rice). Rice as an English term , therefore, will give you two meanings when translated in Tagalog and Pampango, two distinct Philippine dialects but with two different meanings. This is called “connotation.” And rice is the staple food of the Filipinos.

Pampango Refers to the dialect spoken in Pampanga Pampangueno Refers to the person born and residing in Pampanga Pansit Malabon

A cuisine prepared by using seafoods such as shrimps, oysters and other small fishes as ingredients together with a variety of noodles

Payung umbrella Pilipino Refers to the national language of the Philippines Pinoy A colloquial term used for Filipino Po See “opo”

Fiesta Feast or Festivity Filipino

Refers to the Philippine-born Filipino citizen. Take note tho’ that Philippines does not have letter “F” in its alphabets but uses “F” to refer to its people and letter “P” is used to refer to the national language, Pilipino. In the Bay Area and probably across the United States, most Filipinos including perhaps some academicians hardly make a distinction anymore and would justify to use of letter “P for Pilipino” to signify both the people and the national language of the Philippines

R

NO ENTRY

S Sabit-sabit Pinning of money Sab-ong Dowry Samtoy The dialect/language we use here Sila He or she (singular) Sipag at tiyaga Industriousness and perseverance

T Tagalog

One of the major languages in the Philippines for which it is closely connected with Pilipino

A Caviteno value taking off their hats when greeting people, they call out “Tao po”. Literal meaning of Tao is person and

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Tao Po Ho is an expression of respect when talking to an older person Tayo-tayo Collegiality in terms of “us” being exclusively together Tiwala Faith, confidence Tiya or Nana Auntie (female) Tiyo or Tata Uncle (male) Tulak , Torak To push Tupak-tupak Cash on the table

U Ugaling Malabon Typical trait among the people of Malabon – being irritable Utang-na-loob

A sense of indebtedness; a sense of obligation to reciprocate a person who has done you a good favor and in turn, you are expected to express your gratitude by doing the same good favor to him. Failure to do this is a violation of “utang-na-loob” for which you may be labeld as “ingratitude” or “walang-utang-na-loob.” A person can even be ostracised from the family, if he happens to be a member of the family. An example of this is the value of “pagtutulong-tulong” of the Bulakenos wherein a member of the family is sent to finish school so that he can help younger siblings to get and finish education themselves, but instead, got married and unable to do what he is expected to. He is, then, guilty of “walang-utang-na-loob or ingratitude.”

W

NO ENTRY

Y

NO ENTRY

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