Aging Services The Not-for-profit Difference Standing the Test of Time
Mar 31, 2016
The Not-for-profit Difference
Aging Services The Not-for-profit Difference
Standing the Test of Time
The Not-for-profit Difference
St. Martin de Porres Manor in Louisiana, serving its community
for 167 years.
The Not-for-profit Difference
Playing a crucial role in American society for more
than 250 years has earned not-for-profi t organiza-
tions the trust of their local communities and the
respect of the entire nation. Telling the not-for-profi t
story continues, as modern-day scholars stress the
importance of the not-for-profi t sector in our demo-
cratic system. Peter Drucker, a leading management
consultant, characterized not-for-profi ts as one of three
major institutions in America, the others being govern-
ment and business. His 1990 publication, Managing
the Not-for-Profi t Organization, suggests that govern-
ment’s role is to protect and oversee, and the role of
business is to generate an economy.
“The role of not-for-profi ts, as one of three major institu-
tions in America, is nothing less than to change lives.”3
—Peter Drucker
Benjamin Franklin penned these words
in the 18th century, acknowledging the
value of committed individuals coming
together to solve shared concerns through collective
action. Franklin’s Leather Apron Club was the vehi-
cle for his philosophy to become practice – the fi rst,
“not-for-profi t movement” in America.
A century later, French aristocrat Alexis de Tocqueville
suggested that communal action for the public good
was not only honorable, but was uniquely American.
His 1835 classic, Democracy in America, attests to this
belief as follows:
“Feelings and opinions are recruited, the heart is en-
larged and the human mind is developed, only by the
reciprocal infl uence of men upon one another…these
infl uences are almost null in democratic countries; they
must, therefore, be artifi cially created, and this can only
be accomplished by associations.”2
—Alexis de Tocqueville
Not-for-Profits: Standing the Test of Time
“Th e goo d that men may do separately is small compared with wh at they may do coll ectively.” 1 –Benjamin Franklin
The Not-for-profit Difference
Lester M. Salamon (Johns Hopkins University), a
leading expert on the not-for-profi t sector, suggests
that this sector is the centerpiece of American culture.
His book, The Resilient Sector (2003), offers facts and
fi gures on the size, scope and impact of this sector on
both our economy and way of life.
“[The not-for-profit sector] represents a faith in the
capacity of individual action to improve the quality of
human life.”4
—Lester Salamon
Jim Collins, best known for his Good to Great book,
also wrote a monograph entitled Good to Great and
the Social Sectors: Why Business Thinking Is Not the
Answer (2005), in which he details special characteris-
tics of mission-driven versus profi t-driven enterprises.
“A great organization is one that delivers superior
performance and makes a distinctive impact over a long
period of time. For a business, fi nancial returns are a
perfectly legitimate measure of performance. For a social
sector organization, however, performance must be
assessed relative to mission, not fi nancial returns.”5
— Jim Collins
Many not-for-profit aging-services organizations
have existed in the same communities for genera-
tions, offering a stability that fosters peace of mind
for both older Americans and their families.
Twenty–four of the AZ100 have been in
operation over 100 years. The average
inception date of the AZ100 organiza-
tion is 1937. 6
— AAHSA Ziegler 100, April 2007
The Not-for-profit Difference
Neville Manor in Massachusetts, serving its community for 228 years.
The Not-for-profit Difference
Telling Our Story — Pers onal Testimonials
The Not-for-profit Difference
“Having worked in senior services for over 20 years, and
having worked in ‘for-profi t’ and ‘ nonprofi t,’ I can tell
you that there are tremendous differences in the ‘envi-
ronment or climate’ of the community. In the for-profi t
community, emphasis was on the ‘numbers’ and I began
feeling like a number as a staff member. At RHF, I feel
like I am part of a family; myself and the entire staff are
committed to the mission. We are not here for the mon-
ey; we believe in the philosophy of the company, and the
residents benefi t from the commitment and compassion
of the staff. Several of my residents have told me that
there is so much love and life in the building, and that’s
why I work for RHF…it is very gratifying.”
—Stacey A. Montero, Property
Manager, St.Catherine Retirement
Community/Retirement Housing
Foundation (RHF), Florissant, Mo.
“In my 26 years in long-term care, I’ve worked in both
for-profi t and nonprofi t organizations. Nonprofi ts pro-
vide better quality because our focus is on our mission
of service to the community versus the pressure to deliver
on quarterly earnings. We attract committed community
volunteers to lead us and enhance the quality of life of the
people we serve. We provide higher staffi ng ratios, living
wages and benefi ts to our employees and their families.
These advantages translate into better quality and conti-
nuity of care and the ability to risk innovation.”
—Kevin Jones, Chief Operating
Offi cer, Saunders House,
Philadelphia, Pa.
“If it wasn’t for the help I got from my organization, I
probably wouldn’t have even gone back to school. It’s hard
for someone who is self-supporting, and can’t afford the
tuition, to do it on their own. I got the days off I asked for
and needed, so I wasn’t exhausted from school. It made
me appreciate working here even more.”
—Tabitha Menendez, Certifi ed
Nursing Assistant, Rosewood
Heights Nursing Facility,
Syracuse, N.Y.
The Not-for-profit Difference
“At a member council meeting in July 2007, residents
were asked for their comments about the nonprofit
difference. Here are some of their words:
• ‘We are not driven by a need to make
money.’
• ‘Because a not-for-profi t is service-driven,
not profi t-driven; we don’t cut corners.’
• ‘Our people are driven by the desire to
make a good community instead of being
driven by a ledger sheet.’
• ‘They are caring people.’ ”
—Judith A. Lamoureux, Director of
Sales and Marketing, The Atrium at
The Cedars, Portland, Maine
“It’s a not-for-profi t. People here are committed to care
for the elderly. When we toured, one of the staff ’s mother
was here, and that said something about the place. The
staff knows everybody. My mother has lived at three or
four other communities and they were nothing like this.”
—Jeanne W., daughter of resident
Marie S. at Franciscan Communities/
Addolorata Villa, Wheeling, Ill.
“I’m proud to be a member of the staff at Marjorie Doyle
Rockwell Center, a not-for-profi t residence for individu-
als with Alzheimer’s disease in Cohoes, N.Y. We recognize
that the needs of the residents come fi rst, and we know
how important it is to treat them with the compassion,
dignity and respect that they deserve as senior citizens and
as human beings. I’ve worked for both for-profi t and not-
for-profi t providers, and it’s a great feeling to be a part of
the not-for-profit mission and a strong commitment
to helping seniors and their families.”
— Barbara Ashley, Unit Secretary,
Marjorie Doyle Rockwell Center/
The Eddy, Cohoes, N.Y.
The Not-for-profit Difference
Setting the StandardOur nation’s not-for-profi t housing, community service
and long-term care providers are on a mission. Their
objective: to provide the highest quality and most com-
passionate care to those they serve. The good news for
older people, persons with disabilities, their families
and the entire aging-services profession is that they are
succeeding.
At a time when not-for-profit aging-services orga-
nizations are under intense government and media
scrutiny, not-for-profits are showing by example
that there is a difference when it comes to qual-
ity. By continuing a tradition of mission-driven,
consumer-centered management and competent,
hands-on care, not-for-profits set the standard in
the continuum of housing, care and services for
the most vulnerable Americans.
Not-for-Profi ts: Fulfilling Our Miss ion
What are not-for-profit responsibilities?AAHSA’s values guide the work of our members, pro-
viding an example to aging-services organizations and
motivating them based on following ideals:
• Quality that people can trust.
• Services people need, when they need them,
in the place they call home.
• Dignity of all persons at every stage of life.
• Mission-driven, not-for-profi t values.
• Advocacy for the right public policy, for
the right reasons.
• Leadership through shared learning.
Are we fulfilling our responsibilities?Diana Aviv, president and CEO of the Independent
Sector, testifi ed on July 24, 2007, at a hearing on tax-
exempt charitable organizations held by the House
Ways and Means Subcommittee on Oversight. In her
testimony, Aviv observed:
“No matter who you are, or where you are in this coun-
try, your life is touched and enhanced by the work of
nonprofi t organizations.” 7
— Diana Aviv
The Not-for-profit Difference
“The ultimate form of generosity is the investment in people, property and ideas.” 8
“Generosity helps to distribute rather than concentrate wealth and oppor-tunities in society. Generosity is the moral juice that has kept us heading towards the founders’ ideals.” 9 — Claire Gaudiani Author, The Greater Good
Poydras Home in Louisiana, serving its community for 190 years.
The Not-for-profit Difference
Mission-Driven ValuesNot-for-profi t organizations manage their fi nancial
resources in accordance with their missions. Many
of these housing and service providers were founded
by faith-based and civic groups of rich tradition, and
their long-standing values are refl ected in their gover-
nance and management.
They are not driven by daily pressure to increase their
“bottom line” for owners, investors or shareholders.
The pressure to make a profi t is felt the most by the
consumer, due to an inevitable array of cost-cutting
reductions in staffi ng, services, supplies and overall
quality.
Quality, not earnings, is the barometer of a not-for-
profit organization’s efforts. All proceeds in a
not-for-profi t are reinvested in improving the physical
environment, serving more people, offering more
and better accommodations and services and,
ultimately, fulfilling the organization’s mission.
Claire Gaudiani (Yale University), author of The Great-
er Good (2003), often speaks of generosity within the
American culture. Translating our mission-driven,
not-for-profi t values into policies, procedures and
daily operations is clearly an enduring example of gen-
erosity in action.
AccountabilityNot-for-profi t organizations are accountable to vol-
untary boards of directors, who donate their time and
talent to ensure that ethical management, fi nancial
integrity and quality services are maintained.
Not-for-profit finances are always open for public
inspection; with such information readily available
on the Internet, the information is literally at our
fingertips.
Volunteer board members also have their fi ngers on
the pulse of evolving local community needs, there-
by bridging internal and external communities.
Not-for-profits have a responsibility to be active,
contributing members of their localities. Social
accountability opportunities and measures continu-
ally help not-for-profi ts not only to identify but also
to exercise leadership in meeting local community
needs.
We all desire compassionate, knowledgeable and
dedicated staff overseeing the needs of our loved
ones. Not-for-profi t organizations recognize that staff
satisfaction and commitment are related to having
suffi cient numbers of staff, fair wages and benefi ts,
fl exibility when needed, continuing education/growth
opportunities and an environment of respect.
The Not-for-profit Difference
Quality Measures Not-for-Profi t For-Profi t
Total Defi ciencies 11.67 19.08
Serious (F+) Defi ciencies 0.74 1.25
Not-for-Profi t Nursing Homes Have More Nursing Staff than For-Profi ts10
• Residents receive 6.1% more hours per day
of licensed practical nurse care.
• Residents receive 10.4% more hours per day
of certifi ed nursing assistant care.
• Residents receive 37.2% more hours per day
of registered nurse care.
• Residents receive 22% more hours per day
of care from other licensed staff.
Not-for-Profi t Nursing Homes Have Signifi cantly Fewer Total and Serious Defi ciencies Than
For-Profi t Homes11
The mission of AAHSA Quality First is to achieve excellence and earn the public’s
trust in aging services. Quality First was launched in 2002 by three national associations
representing providers of aging services. Not-for-profit providers have a longstand-
ing tradition of leading with quality. Quality First reinforces that tradition with a
commitment to maximize quality of care and quality of life for older adults.
How Do We Know This? Research Affi rms Our StoryNumerous credible sources have conducted research and reported fi ndings that support our leadership in quality
housing, care and services.
Not-for-Profi ts: Leading With Quality
R
For profi t 19%
Quality Outcome Measure: Percentage of Skilled Nursing Facility Patients Discharged Home in
First 30 Days, 2004 (higher is better)12
Not-for-profi t 29%
0
5
10
15
20
25
30
The Not-for-profit Difference
From “For-Profi t versus Not-for-Profi t Delivery
of Long-Term Care”:
“…for-profi t long-term care facilities had higher rates
of acute care hospital admission of residents because of
several quality of care related diagnoses than did not-
for-profi t facilities.”14
From a General Accounting Offi ce (GAO) Report
on HUD Housing:
“For-profi t and limited-dividend property owners had
a higher percentage of opt-outs* than other types of
property owners…conversely, nonprofi t owners had
the lowest percentage of opt-outs at two percent. The
percentage of foreclosures and enforcement actions for
nonprofi ts was also slightly lower [than] for all other
types of ownerships.” 15
*Note: “Opting out” occurs when a housing provider decides to end its participation in a federal program serving low-income residents.
From a 2007 Publication of the Joint Center for
Housing Studies at Harvard University:
“The unassisted private housing market generally
does not provide sufficient profit [for] for-profit
developers to build or maintain decent quality
housing that is affordable to lower income house-
holds. In comparison with for-profi ts involved with
subsidized housing, nonprofi ts typically focus on
more distressed areas and their developments are
typically targeted to harder-to-house populations.”
“Supporters of nonprofi ts point to their commitment
to produce housing that is affordable to lower income
people over the long-term, as well as to stimulating
investment in neighborhoods in need of revitaliza-
tion…. In addition, nonprofi t housing providers are
credited for their connections to community and
residents, their commitment to providing services for
residents, and their potential for accessing affordable
land and buildings.”16
Business Segment Percentage of CNA LTC Insureds (2004)
Number of Closed Claims*
Average Paid Indemnity
Average Paid Expenses
Average Total Paid*
Not-for-Profi t 45% 526 $82,562 $28,803 $102,056
For-Profi t 55% 1,808 $119,152 $35,065 $146,88
Not-for-Profi ts Experience Fewer Liability Claims and ExpensesMix of Insureds and Severity of Closed Claims by Business Segment13
* The number of closed claims includes claims with no paid expense; therefore, the denominator used to calculate average paid expenses
may be different from the denominator used to calculate average paid indemnity. As a result, the average total paid may not be equal to
the average paid indemnity plus the average paid expenses.
The Not-for-profit Difference
Warren Haven in New Jersey, serving its community for 173 years.
The Not-for-profit Difference
From Advocate - “Bad Nursing Home Care Persists”:
“Not-for-profit nursing homes generally provide
better care than those operated by for-profit, an
analysis of state inspections for some 16,000 homes
nationwide found.”17
From “Multifamily Properties: Opting In, Opting
Out and Remaining Affordable”:
A 2006 study found that only .9 percent of all U.S.
Department of Housing and Urban Development
Section 202 affordable senior housing communities
chose to ‘opt out’ of the program and market the units
for another use.18
From “Nursing Home Profi t Status and Quality
of Care: Is There Any Evidence of an Association?”
“This review suggests that despite increased awareness
and numerous high-profi le government reports and
publications, residents of for-profi t nursing homes
were more likely to be the recipients of poor qual-
ity compared with similar residents in not-for-profi t
facilities.”
“The pattern of quality indicators indicates that
not-for-profit homes are less likely to have poor
quality-of-care practices and outcomes. For-profi t
nursing homes were found to have provided lower
quality of care when judged by structure, process
and outcome criteria…residents of for-profi t nursing
homes were more likely to be the recipients of poor
quality compared with similar residents in not-for-
profi t facilities.” “Patients in for-profi t homes tended
to have higher rates of pressure ulcers.”19
From “Testing for Ownership Mix Effi ciency:
The Case of the Nursing Home Industry ”:
“The policy implication is that more quality of care
per dollar might be obtained by attracting a greater
percentage of nonprofi t nursing homes into most
market areas.”20
From “For-Profi t vs. Not-for-Profi t Hospice:
It Is the Quality that Counts”:
“For-profit hospices, being more focused on the
‘bottom line,’ are ‘selecting’ patients who, because of
the nature of their terminal illnesses (non-cancer)
and where they reside (nursing homes), are more
likely to have a length of stay exceeding 90 days, and
require a lower percentage of skilled nursing services,
and hence, cost less to care for.”21
From “Does Investor Ownership of Nursing Homes
Compromise the Quality of Care”:
“Investor-owned nursing homes provide worse care
and less nursing care than do not-for-profi t or public
homes.”22
The Not-for-profit Difference
Not-for-Profi ts: Advancing th e Greate r Goo d Th rough Leaders hip and Innovation
Not-for-profi t organizations consistently apply their
resources to streamline and enhance their housing,
health care and services to meet the evolving needs and
wants of consumers. Initiatives of change, encompass-
ing philosophies and practices of person-centered care,
deinstitutionalization, healthy work environments and
empowered staff, are also growing.
The following AAHSA members represent just a few
examples of not-for-profi t leadership and innovation:
• Specialized, Urban Care – In the mid-1800s,
Eliza Simmons Bryant turned her concern for
the lack of care options for aging black Americans
into action by opening the fi rst black charitable
organization in the region and one of the oldest
African American based nursing homes nation-
wide. For more than a century, the Eliza Bryant
Village in Cleveland, Ohio, has pioneered
inner-city, specialized senior care.
• All-Inclusive Care – Founded in the early 1970s
by citizens concerned for the frail elderly and
their lack of community service options, the On
Lok organization in San Francisco, Calif., was the
fi rst to provide a comprehensive array of medical
and support services to enable seniors to live
at home as long as feasible. The Program of
All-Inclusive Care for the Elderly (PACE) evolved
from the On Lok model.
• Green Houses – The Mississippi Methodist Senior
Services organization transformed its nursin home
culture by developing Green Houses in Tupelo,
Miss., to accommodate elders needing long-term
care with increased privacy, community and choice
in small, home-like settings. Person-centered care,
empowered staff and universal worker models are
all aspects of this innovative care model.
• Elder Abuse Prevention – The Weinberg Center
of the Hebrew Home at Riverdale, N.Y., “provides
the nation’s fi rst and only long-term care based
shelter dedicated to elderly victims of emotional,
physical and fi nancial abuse.” 23 In addition,
the center offers community training programs
on the signs and symptoms of elder abuse as well
as elder abuse prevention/intervention services.
“Consumer Reports’ analysis found that not-for-profi t homes are more likely to provide good care than for-profi ts, based on our analysis of inspection surveys, staffi ng and quality indicators.” 24
The Not-for-profit Difference
Maple Knoll Village in Ohio, serving its community for 159 years.
America’s future is fi lled with older faces. By 2020, one
in six Americans will be age 65 or older. AAHSA and
its members are working today to ensure that housing,
community services and long-term health care services
not only meet the needs of tomorrow’s elderly and dis-
abled Americans, but exceed their expectations.
AAHSA is the leader in joining providers, poli-
cymakers, researchers, advocates, regulators and
consumers to develop policies and practices that
continue to make our field the center of innovative,
quality housing and care for those who need it most
in our society.
Not-for-Profi ts: Th ere Is a Diff ere nce
Setting the Standard
Mission-Driven ValuesAccountability
Quality
LeadershipInnovation
Six Elements – Numerous Examples
One Clear Difference: People Before Profi ts
The Not-for-profit Difference
1Isaacson, Walter. Benjamin Franklin: An American Life. New York: Simon and Shuster.
2Tocqueville, Alexis de. 1835. Democracy in America, vol. II, the Henry Reeve text, as revised by Francis Bowen (Vintage Books, 1945), p.117.
3Drucker, Peter. 1990. Managing the Nonprofi t Organization. New York: Harper Collins.
4Salamon, Lester M. 2003. The Resilient Sector: The State of Nonprofi t America. Washington, DC: Brookings Institution and the Aspen Institute.
5Collins, Jim. 2005. Good to Great and the Social Sectors. www. jimcollins.com. Boulder, CO.
6AAHSA Ziegler 100. 2007. Ziegler Capital Markets, a division of B.C. Ziegler and Company.
7Aviv, Diana. July 24, 2007. Testimony before United States House of Representatives, Ways and Means Subcommittee on Oversight, Hearing on Tax-Exempt Charitable Organizations.
8Gaudiani, Claire. 2003. The Greater Good: How Philanthropy Drives the American Economy and Can Save Capitalism. New York: Henry Holt and Company.
9Gaudiani, Claire. 2003. The Greater Good: How Philanthropy Drives the American Economy and Can Save Capitalism. New York: Henry Holt and Company.
10CMS Data. 2007. National Nursing Home Survey.
11“Quality of Care in Nursing Homes: An Analysis of Relationships Among Profi t, Quality, and Ownership,” (Table 2). 2003. Medical Care, Volume 41, Number 12, pp 1318-1330.
12“Understanding Temporal Changes in and Factors Associated with SNF Rates of Community Discharge and Rehospitalization.” June 2007. Andrew Kramer, Theresa Eilertsen, Glenn Goodrich, Sung-joon Min. University of Colorado at Denver and Health Sciences Center.
13Comparison of Claims Data in Long Term Care – January 1996 through March 2005. September 2005. CNA HealthPro.
14“For-Profi t versus Not-for-Profi t Delivery of Long-Term Care.” Jan. 2, 2007. Kimberlyn M. McGrail, Margaret J. McGregor, Marcy Cohen, Robert B. Tate and Lisa A. Ronald, Canadian Medical Association Journal.
15General Accounting Offi ce (GAO) Report on HUD Housing. http://www.gao.gov. 07-290.
16Joint Center for Housing Studies at Harvard University. http://www.jchs.harvard.edu/publications/rental/revisiting_ rental_symposium/papers/rr07-12_bratt.pdf
17Advocate - “Bad Nursing Home Care Persists.” Aug. 6, 2006. Consumer Reports.
18“Multifamily Properties: Opting In, Opting Out and Remaining Affordable.” January 2006. U.S. Department of Housing and Urban Development/Offi ce of Policy Development and Research.
19“Nursing Home Profi t Status and Quality of Care: Is There Any Evidence of an Association?” April 2005. Michael B. Hillmer, Walter P. Wodchis, Sudeep S. Gill, Geoffrey M. Anderson and Paula A. Rochon, Medical Care and Research Review, Volume 62, No. 2.
20“Testing for Ownership Mix Effi ciency: The Case of the Nursing Home Industry.” February 2005. Rexford E. Santere and John A. Vernon, National Bureau of Economic Research.
21“For-Profi t vs. Not-for-Profi t Hospice: It Is the Quality that Counts.” 2002. Editorial, Journal of Palliative Medicine, Volume 5, No. 4.
22“Does Investor Ownership of Nursing Homes Compromise the Quality of Care.” 2001. Charlene Harrington, PhD, Steffi e Woolhandler, MD, MPH, Joseph Mullan, PhD, Helen Carrillo, MS and David U. Himmelstein, MD, American Journal of Public Health, 91:1452-1455.
23“23 The Hebrew Home at Riverdale website: http://www.hebrewhome.org/abuserecovery.asp
24“Nursing Homes: Business as Usual,” September 2006. Consumer Reports.
The Not-for-profit Difference
The Heritage in California, serving its community for 154 years.
The Not-for-profit Difference
The members of the American Association of Homes and Services for the Aging (www.aahsa.org)
help millions of older people, their families and those who support them every day through
mission-driven, not-for-profi t organizations dedicated to providing the services that people need,
when they need them, in the place they call home. Our 5,700 member organizations, many of which
have served their communities for generations, offer the continuum of aging services: adult day
services, home health, community services, senior housing, assisted living residences, continuing
care retirement communities and nursing homes. AAHSA’s commitment is to create the future of
aging services through quality people can trust.
AAHSA’s Center for Aging Services Technologies (CAST) leads the national charge to develop and deploy emerging
technologies to improve the aging experience in America. Established in 2003, CAST has grown to be a national
coalition of more than 400 technology companies, aging-services organizations, research universities and
government representatives. To advance its agenda, CAST produced and disseminated a vision video depicting technology’s potential for
transforming aging, published several white papers and sponsored symposia, demonstrations and workshops.
Creating th e Future of Aging Services Th rough Innovation
AAHSA’s Institute for the Future of Aging Services (IFAS) conducts research and publishes landmark reports across the
continuum of housing and long-term care services with the overarching goal of improved quality. IFAS is committed to
the development of nationally replicable, innovative models of housing and supportive services and is a recognized leader
in the study of long-term care workforce issues. Recent applied research projects include, but are not limited to, Better Jobs Better Care and the
National Affordable Housing with Supportive Services Initiative. When applied research, policy and practice are connected, evidence-based
approaches emerge that facilitate continuous improvement in care and service delivery.
Many of AAHSA’s members have been involved in applied research and innovative programs since their founding.
It’s no surprise that AAHSA created the Institute for the Future of Aging Services and the Center for Aging
Services Technologies to advance our commitment to research and innovation.