Discharge Time…You Can’t Go Home But You Can’t Stay Here
What do you do when mom or dad falls, breaks a hip, rehabilitates in a skilled nursing facility, and the case manager informs you that it is not safe for mom or dad to go back home, but discharge is imminent? It is important to be informed about long-term care before this emergency-type situation occurs. Long-term care consists of services and supports that meet non-medical personal needs. Assistance with activities of daily living (ADLs or personal tasks of everyday life) include eating, bathing, dressing (grooming), transferring (from bath to wheelchair or to/from bed), and toileting (including incontinence care). Instrumental activities of daily living (IADLs) such as housework, managing medications and money, grocery shopping, telephone or other communication, caring for pets, and responding to emergency alerts are also included in long-term care.
Types of long-term care include assisted living communities; dementia/memory care communities; residential care homes (“board and care”); continuing care retirement communities (CCRCs); and skilled nursing facilities (“nursing homes” or “SNFs”). The key differences between each are caregiver ratios; levels of care costs; programs and activities available; staff training; and job specificity among staff.
Financing long-term care is mostly done through private payment; Medicare does not cover any aspect of long-term care, but it does cover some home health or hospice. Families use savings; money from pensions; Social Security income; sell homes; sell life insurance policies; and obtain money from friends or other family members to help pay for long-term care. Sometimes a spouse is able to pay for care of the disabled spouse by continuing to work. Long-term care insurance provides full or partial coverage depending on the type of plan; type of facility and number of ADLs are taken into account with each policy. VA Aid and Attendance provides funds for Veterans who have served during specific wartimes or surviving spouses; it is need-based and is provided for assisted living or in-home caregivers. California has an Assisted Living Waiver Program but only certain places take this waiver, and beds/space is limited; eligibility is restricted and based on need as well; quality of care is typically greatly diminished due to limited staffing in facilities. In some counties, Medicaid (MediCal in California) only covers long-term care within specified SNFs.
Assisted living communities are larger and typically licensed for 40 or more beds (studio, one-bedroom, or two-bedroom private or shared apartments). Caregiver ratios are usually 12 residents to one caregiver; a downside if your loved one needs higher levels of care; or if your loved one is more independent and wants to age in place. As far as costs, most larger communities state a base rent and add costs for levels of care; another downside if higher levels of care are required. Upsides to larger communities are more activities and quality programming, which can enhance overall wellness; including socialization, which is vital for older adults. In addition, larger communities might provide better staff training and have the ability to hire more experienced caregivers. Larger communities hire specialized staff such as activities directors; kinesiologists; chefs; nurse case managers; housekeeping supervisors; and marketing directors who make everyone feel welcome. Aside from providing safe care, larger communities enhance quality of life with good food; families enjoy visiting; holiday and birthday celebrations; and the ability to include interests of everybody with varied activities that address all abilities and skill levels.
Dementia/memory care communities can be a wing of an assisted living community or be a stand-alone community that focuses solely on dementia or Alzheimer’s disease programming. A wing could be licensed for 20 or more beds (usually shared rooms for more advanced stages of dementia); while an entire community could be licensed for 40 or more beds. Caregiver ratios are 8–10 residents to one caregiver; slightly better than assisted living. Levels of care costs are generally included in the total cost of the memory care fee; excluding incontinence care in most cases. Memory care communities almost always have very specialized, routine programming for various stages of cognitive decline. Quality of life is enhanced when well-balanced, expert activities/programming have the capability of reducing use of unneeded antipsychotic medications. Staff training is more specialized with dementia care; and job specificity also applies with these larger communities, with a dedicated dementia activities director. If your loved one is experiencing cognitive decline (not the normal memory loss associated with aging) or has been diagnosed with dementia in the early stages, it would be better to choose a community that is assisted living with a memory care wing for an easier transition when more care is needed (if a larger community is preferred over a smaller residential care home).
Residential care homes are by and large licensed for six beds, but could be licensed for up to 15 beds. Caregiver ratios are six residents to every one or two caregivers. The home could have all shared rooms (costs much lower); or a mix of private and shared rooms. The home could be mixed with males and females; and there are homes with only males and only females. Homes are sometimes specified by level of care, according to cognitive or physical functioning; again, some homes are mixed care and other homes might solely care for dementia. Quality of life is enhanced in residential care homes when a “family-like” environment is maintained: residents eat together, play games together, participate in family-type activities; caregivers, owners of the home, or administrators might live in the home and truly treat the residents like family members. If residents own pets, the pets become part of the home. Residents often enjoy delicious, home-cooked meals; and birthday and holiday celebrations include family and friends.
CCRCs have the ultimate ability for older adults to age in place because they range from independent living, assisted living, memory care, and even skilled nursing. Caregiver ratios change between each transition of level of care, but follow the same ratios as an assisted living or memory care community. The main difference with CCRCs is that a buy-in, similar to buying a condo, is required. Each CCRC differs in its buy-in rates and long-term care costs; some do not include the cost of care while others are all-inclusive. CCRCs are beneficial in rural areas where various types of care might be hundreds of miles apart. When considering a CCRC, speaking with a financial advisor is recommended.
Skilled nursing facilities are typically used for short-term rehabilitation; when someone requires a skilled need such as a feeding tube, tracheotomy, stage 3 or 4 pressure sores, tuberculosis, staph or other serious communicable infections. SNFs have a limited number of long-term care beds for low income individuals on MediCal (Medicaid in states other than California). SNFs are not necessarily meant for non-medical long-term care assistance, and the quality of care is not as good as licensed assisted living. There are some SNFs that have implemented the Eden Alternative: “a philosophy asserting that no matter how old we are or what challenges we live with, life is about continuing to grow” and instead of using terms such as caregivers/receivers they use Care Partners. The Eden Alternative program in a SNF would be the highest quality of care a SNF could provide.
The best way to prepare for long-term care is to expect that it will be necessary someday for yourself or a loved one. Consulting with local experts such as Placement Specialists who are Certified Senior Advisors (CSA) and gerontologists from reputable companies like CarePatrol is the best way to receive unbiased assistance at no cost. There are close to 1,000 licensed assisted living communities and residential care homes in Orange County, California alone, and these experts have personally toured them; have sat down and talked with the caregivers, owners, and administrators; and have reviewed recent evaluations and complaints completed by state licensing. CarePatrol specialists complete an assessment of the loved one that needs care and “match” 2–4 safe places that can handle the level of care, while providing the activities necessary to enhance health and wellness. CarePatrol also offers to take the family to tour each community or home, and are there as advocates with the family through the entire transition; including regular follow-ups after move-in. Finding long-term care for a loved one can be stressful, and utilizing experts to find safe, quality care in limited time can be vital; especially if your loved one cannot go home and discharge is imminent.
Read more articles by Amy Blackburn: “Cohort Research and Marketing Language”