CHAPTER VI - LONG-TERM CARE PROVIDERS

Long-term care facilities have come a long ways from the days of the first Long Term Insurance policy when long-term care was nearly synonymous with “nursing home.”  It has expanded into a large number of facilities providing various services to those who need long-term care.  Even the medical community has changed as there are now not just hospitals, but also “sub-acute” care facilities for those recovering from surgery for instance.  Those who do not need 24-hour care can receive services through a residential care facility.  This “evolution” can be seen and illustrated at a modern “total” care facility. 

This concept has been operating for several years and has proven quite successful, mostly for the patients/residents who have sufficient funds as these places can be quite “pricey.”  The concept is that retired persons (usually) will purchase a “condominium” in the facility which offers more than just living accommodations, by on-site restaurants, shops, etc.  As the resident ages and more personal care is needed, such as someone to help with shopping and condo cleaning, etc., such services are available.  In case of a health emergency, in one section of the facility there is always a doctor and a Registered Nurse in attendance, with the serious health problems treated on-site and then transferred to a hospital if necessary.  For recuperation, the facility will provide caregivers to that the person can stay at home.

If the person needs more nursing care, there is a portion of the facility that is an actual nursing home, properly licensed, etc., but reserved (generally exclusively) for the residents of the facility.  If home health care is needed, then experienced and professional caregivers are available on the premises.  There is usually a physical therapy section to provide those services by trained professionals.

In other words, whatever is needed is provided, either on the premises or by contract with other medical professionals and facilities.  These facilities are very successful, but there is a problem:  they are very expensive.  In fact, a person who can afford to reside in these facilities would usually not be interested in Long Term Care Insurance as they are in the financial position of being able to provide whatever they need when they need it.  But most people cannot afford these facilities. 

TYPES OF CARE

In addition to long-term care, medical care can usually be broken down into either acute or chronic care.  Acute care is typically the medical problems of the young, such as infectious diseases and broken bones, and childbirth by women.  In most cases, the person is able to recover and return to their previous lifestyle, occupation, etc.  On the other hand, the elderly suffer mostly from chronic care whereby they cannot be expected to have full recovery, and usually their condition worsens.

No surprise to anyone who had needed medical care recently, the differences have become rather blurred as medical care is not entirely concentrated on acute care, but now much of our health system is devoted to chronic care, by a variety of providers and in various settings.

Physicians, nurses and other medical professionals choose and deliver the treatment for acute care.  Contract that with long-term care which heavily involves family members who take on the roles of caregivers and decision-makers.  Stone and Kemper, 1989

As described earlier, long-term care involves a very wide range of assistance with help with activities of daily living (ADLs), sometimes also help with instrumental activities of daily living (IADLs).  Services include supervisory human assistance and many devices such as canes, walkers, wheelchairs, and newer “high-tech” assistance, i.e. motorized wheelchairs, computerized medication dispensers and emergency alert system.  Other “low tech” services involve wheelchair ramps, grab bars in the home and bath, etc.

“Acute Conditions” can be defined as conditions that require a high level of medical care, monitoring and treatment so as to restore the patient to health or the ability to perform.  In general usage, this refers to medical conditions that would be life threatening without immediate medical care and attention, usually provided in a hospital until such time that they are stable and can be released or transferred to a nursing home. 

“Chronic Conditions,” on the other hand, are those conditions that are long-lasting and that require continuing care, as opposed to emergency medical treatment.  These conditions usually require monitoring and some medical treatment, but usually involve non-medical care, such as with ADLs.  Chronic care is usually an evolving situation requiring more care as time passes.  Long-term care is, then, usually provided for chronic conditions instead of acute conditions.

SCHEDULED/ON-DEMAND CARE

Long-term care usually progresses from necessary services such as supporting services and assistance with ADLs and IADLs to more extensive nursing, physical and/or therapeutic services, depending upon the needs of the patient.  Activities of Daily Living eventually fall into either those that can be performed routinely and on a scheduled basis, or those that must be provided when needed—on demand.  Examples are the progression of aid for bathing or eating which would require scheduled care, to assistance with toileting or ambulating which would require services on demand. 

The reason that this distinction is mentioned here is that it is important to know as the cost of providing long-term care increases when on-demand services are needed as regular and full-time assistance must be provided for on-demand care.  This can mean the difference between receiving appropriate care in a nursing home or other facility, and receiving care at home as at-home care is usually not practical when continuous supervision becomes necessary.  Of those persons who enter nursing home, over half will have a total lifetime use of at least one year, and 21” will have a total lifetime use of five years or more.  Aging in America, 1991

 

LONG TERM CARE PROVIDERS

There area multitude of setting in which long-term care can be provided, from nursing homes to home health care, to community care facilities, to care by friend, neighbors, family, etc.  The term “Caregiver,” defines the person(s) who provide the care that is needed, regardless of the degree or level of care.  Generally, the majority of the care will be provided by a primary care giver, spouse or child for example, and other responsibilities being performed by others as secondary caregivers, such as home health care agencies.

LTCI policies carefully define the benefit limits in accordance with how the provider of care is defined.  This is a very important component when comparing policies and benefits.  For some time, LTC was defined according to Medicare’s definitions, but in recent years the policies and programs have expanded to provide a wider range of services provided by a number of providers.  Since the degree of coverage depends upon the specific definitions of covered services in the contract, policy, or program, it is most important that agents become very well versed on covered services—and what is not covered.  A professional agent will not only inform the prospect or policyholder as to what is covered, and as importantly, what is not.

HOME HEALTH CARE

In most situations, home health care is provided when the patient insists on staying at home, but can only do so with assistance from a home health care agency, family members, friends or other caregivers.  Many, if not most, seniors much prefer to live independently outside of any kind of institution and are quite happy with home health care, even when they depend more and more on the assistance as their physical or mental condition progresses.  Home health care can take many forms using a wide variety of medical and personal services in the patient’s home, such as services provided by nurses, therapists and home care aides.  Nursing services, social work, physical and rehabilitative therapy, monitoring of medication and medical equipment, plus person care assistance such as help with personal hygiene, dressing, bathing, exercising, housekeeping, shopping, meal preparation, etc., etc., can be provided in a home environment.

“Home Health Care" encompasses a wide range of health and social services which can be provided at the patient’s residence if they are recovering from health problems, disabled, chronically or terminally ill, and to those who need medical, nursing, social, or therapeutic treatment and/or assistance with the essential Activities of Daily Living (ADL).

Home health care is usually the result of a doctor’s direction, but there are other ways to arrange for home health care, such as telephoning the local Area Agency on Aging, or other similar organizations.  References from family members or friends are often used as a good home health care agency will become known to the elderly in the area.

The advantages to the individual are numerous, and depend upon the individual situation, but it would be safe to say that one of the main advantages is that the person receives care in a familiar environment where they feel safe and comfortable.  Generally they face an uncertain future with dignity if they can still maintain their independence by staying in their home where they know their neighbors and family and friends can come to see them.

It should be noted that if a person is unable to perform household chores or some ADLs, they will still want to remain in their home as long as is possible.  But, for them to continue to live at home, they will need help and assistance from trained professionals can become expensive.  Therefore, most of the simpler chores should, if possible, be performed by family members or friends, leaving the more technical and difficult services to the professionals, such as visiting nurses for medication, therapists, etc.

The type of home health care provider that can best serve the individual in their home can be health care services provided by professions, such as nurses and therapists, or social services provided by organizations or agencies who provide homemaker and personal care.  Obviously, the type of care that is needed determines the type of caregiver that is needed.

Home health care can range from help from family members or close friends, or home health care organizations, or independent caregivers such as personal care attendants.  Care can be provided from “checking” on the individual at specific times, to specialists on a full-time basis.  Services can be usually provided as often as is needed—full-time, part-time, hourly, or on a shift.  Generally home health care services can be available 24 hours a day, 7 days a week.

It has been pointed out and often stressed that home health care can be just as expensive as nursing home care.  Further, very little of that expense is covered by Medicare, and as any home health care agency can attest, the Medicare rules keep changing all the time.  Actually, home health care can average about $50,000 in some areas.

HOME HEALTH CARE PROVIDERS

Starting “from the top,” physicians can provide home health care services by diagnosing and treating illnesses in the same fashion that they would if the patient was in a hospital.  Physicians will interface with home care providers to determine exactly what care and services are needed by the patients and which specialists can perform what is needed in the way of care and services.  They can also determine how often services need to be rendered.  In effect, the Physicians prescribe the medication and services that are needed and provide a plan of care for the patient.  If the patient is covered by Medicare, physicians and home health agency personnel are required to review these plans of care as often as required by the severity of patient medical conditions, and at a minimum, every 62 days.  For hospice patients and their families, the care plans are reviewed at least once a month, but usually they are reviewed more often as the condition of the patients deteriorates.

Registered nurses (RNs) and licensed practical nurses (LPNs) provide skilled services that cannot be performed by nonprofessional personnel, including injections and intravenous therapy, wound care, and dispensing of medication.  RNs can provide case management services but LPNs are only licensed to work under the supervision of RNs.  The severity of the patient’s condition and the treatment that is prescribed determines whether that can be provided by an RN or LPN.

Physical therapists (PTs) apply therapy to patients who are limited or disabled because of physical injuries, in an effort to restore their ability to function and to restore the mobility and strength of patients.  In addition to providing exercise and other methods to the patient, they often use specialized equipment to alleviate pain and to help restore injured muscles.  Part of their function is to educate the patients and their caregivers in using special techniques and methods to walking and ambulating.

Social workers frequently work as case managers when a variety of services are needed.  They provide important information as to available resources within the community, and they also often provide personal counseling. 

Occupational therapists, language pathologists and dieticians are all professions that can assist with home health care.  The language pathologists, for instance, work with the patient to develop and restore the speech of those with communication disorders, and they may even work with patients who have difficulties in breathing, swallowing and muscle control.  Occupational therapists work with the patients in the use of special rehabilitation techniques and equipment(OTs) help individuals who have physical, developmental, social, or emotional problems that prevent them from performing the general activities of daily living (ADLs).

—Dietitians provide information and assistance to those who need help in determining the proper diet when such is required.  Homemakers can perform light household duties

—Dietitians provide counseling services to individuals who need professional dietary assess­ment and guidance to properly manage an illness or disability.

—Homemaker and chore workers perform light household duties such as laundry, meal preparation, general housekeeping, and shopping.  Their services are directed at maintaining patient households rather than providing hands-on assistance with personal care.

—Companions provide companionship and comfort to individuals who, for medical and/or safety reasons, may not be left at home alone.  Some companions may assist clients with household tasks, but most are limited to providing sitter services.

—Volunteers meet a variety of patient needs.  The scope of a volunteer's services depends on his or her level of training and experience.  Volunteer activities include, but are not limited to providing companionship, emotional support, and counseling and helping with personal care, paperwork, and transportation.

Services Provided By Home Care Agencies

Home care agencies offer a range of services, from assessing an individual's needs to putting together and arranging care.  Skilled health care by nurses, therapists, and other licensed health care profes­sionals, may be delivered in the home.  Also included are the use of devices, such as crutches, canes, walkers, IV setups, hospital beds, wheelchairs, ostomy supplies, prostheses, and oxygen.  Personal care such as assistance with ADLs and IADLs is available.

Home Care providers deliver a wide variety of health care and supportive services, ranging from pro­fessional nursing and home care aide care to physical, occupational, respiratory, and speech thera­pies.  They also may provide social work and nutritional care and laboratory, dental, optical, pharmacy, podiatry, x-ray, and medical equipment and supply services.  Services for the treatment of medical conditions usually are prescribed by an individual's physician.  Supportive services, however, do not require a physician's orders. An individual may receive a single type of care or a combination of ser­vices, depending on the complexity of his or her needs.

Home Care vs. Home Health Care

Home Health Care

Home Health Care -Home Health Care provides medically-oriented care for acute or chronic illness in the patient's home, usually as a follow-up to acute or other facility care.

Regulation - Licensed and Medicare and Medicaid certified by DHS.

Payment- Funded primarily through Medicare, with limited coverage through Medicaid, private insurance and private payments.

Home health care may include part-time skilled nursing care, such as occasional visits by registered nurses or licensed practical nurses. It may include speech, physical or occupational therapy, and part-time services of home health aides. It almost always includes some degree of custodial care, such as assistance with meal preparations, personal hygiene, and taking medications.

Advances in medical science have made the delivery of health-related care to the home much easier. Smaller, portable equipment enables respiratory therapy, drug therapy and chemotherapy to be done in the home rather than in the hospital. In addition, hospital beds, power lift chairs, walkers, wheelchairs and monitoring devices are available for rent so that most people can return home sooner.

Home health care can be found through State or Area Agencies on Aging, social service agencies, public department of family services, private home care agencies, Red Cross, Visiting Nurses Asso­ciation, public health department, hospital social services or discharge planning, United Way, and the Yellow Pages.

Home Health Agencies

The term home health agency often indicates that a home care provider is Medicare certified. A Medi­care-certified agency has met federal minimum requirements for patient care and management and therefore can provide Medicare and Medicaid home health services.  Due to regulatory requirements, services provided by these agencies are highly supervised and controlled.  Some agencies deliver a variety of home care services through physicians, nurses, therapists, social workers, homemakers and HCAs, durable medical equipment and supply dealers, and volunteers.  For cases in which an individual requires care from more than one specialist, home health agencies coordinate a caregiving team to administer services that are comprehensive and efficient.  Personnel are assigned according to the needs of each patient.  Home health agencies recruit and supervise their personnel and they assume liability for all care.

Personal Care & Homemaker Services

Personal Care Services - Personal care services are provided for people who need assistance with daily living but do not require nursing.

Regulation - No separate license required.

Payment - Primarily funded through In-Home Supportive Services for those eligible. Some Medicaid for those eligible, and private payments.

Personal care means non-medical services to assist older persons with ADLs and/or IADLs provided by a skilled or unskilled person under medical direction.

Homemaker services involve supporting care for the house or environment rather than directly for the care recipient. Services often include yard work, minor household repairs, general maintenance, cleaning or installing ramps or grab bars to make the person's home more accessible to them.

State or Area Agencies on Aging, social services departments, religious groups, and service and civic organizations and clubs may provide chore services. The Red Cross, Visiting Nurses Association, home care agencies, or local area agencies on aging may offer homemaker services. Check the Eldercare Locator for services near you.

If the patient is receiving "skilled" home health care services, paid for by Medicare, Medicare may cover a portion of the cost of a homemaker/home health aide to help with personal care. The local Social Security office can provide information. For those with low incomes, Medicaid will sometimes help. Check with the local Medicaid office.

Homemaker and Home Care Aide Agencies

Homemaker and HCA agencies employ homemakers or chore workers, HCAs, and companions who support individuals through meal preparation, bathing, dressing, and housekeeping. Personnel are assigned according to the needs and wishes of each client.  Some states require these agencies to be licensed and meet minimum standards established by the state.  Most homemaker and HCA agencies recruit, train, and supervise their personnel and thus are responsible for the care rendered.

Other Providers of Home Care Services

Staffing and Private-Duty Agencies

Staffing and private-duty agencies generally are nursing agencies that provide individuals with nursing, homemaker, HCA, and companion services.  Most states do not require these agencies to be licensed or meet regulatory requirements.  Some staffing and private-duty agencies assign nurses to assess their clients' needs to ensure that personnel are properly assigned and provide ongoing supervision.  These agencies recruit their own personnel.  Again, responsibility for patient care rests with each agency.

Registries

Registries serve as employment agencies for home care nurses and aides by matching these provid­ers with clients and collecting finder's fees.  These organizations usually are not licensed or regulated by government. Registries are not required to screen or background-check the caregivers, but some do undertake these tasks routinely.  In addition, although not legally required to, some registries offer procedures for patients to file complaints.  Clients select and supervise the work of a registry-referred provider.  They also pay the provider directly and must comply with all applicable state and federal labor, health, and safety laws and regulations, including payroll tax and social security withholding require­ments.

 

Independent Providers

Independent providers are nurses, therapists, aides, homemakers and chore workers, and compan­ions who are privately employed by individuals who need such services.  Aides, homemakers, chore workers, and companions are not required to be licensed or to meet government standards except in cases where they receive state funding.  In this arrangement, the responsibility for recruiting, hiring, and supervising the provider rests with the client.  Finding back-up care in the event that the provider fails to report to work or fulfill job requirements is the client's responsibility.  Clients also pay the provider di­rectly and must comply with all applicable state and federal labor, health, and safety requirements.

Pharmaceutical and Infusion Therapy Companies

Pharmaceutical and infusion therapy companies specialize in the delivery of drugs, equipment, and professional services for individuals receiving intravenous or nutritional therapies through specially placed tubes. These companies employ pharmacists who prepare solutions and arrange for delivery to patients. Nurses also are hired to teach self-administration in patients' homes.  Some pharmaceuti­cal and infusion therapy companies are home health agencies, certified by Medicare.  In addition, some states require these organizations to be licensed.  Each company assumes responsibility for person­nel and the services rendered.

Durable Medical Equipment and Supply Dealers

Durable medical equipment and supply dealers provide home care patients with products ranging from respirators, wheelchairs, and walkers, to catheter and wound care supplies.  These dealers employ staff who deliver and, when necessary, install these products as well as instruct patients on their proper in-home use.  Durable medical equipment and supply dealers usually do not provide physical care for patients, but there are a few exceptions.

Some dealers offer pharmacy and infusion services, where a nurse administers medication and nutri­tional formulas to patients and teaches them the proper techniques for self-administration.  Some com­panies also provide respiratory therapy services to help individuals use breathing equipment.  Durable medical equipment and supply dealers that bill the Medicare program are required to meet federal minimum standards.  Some states require that these organizations be licensed.  Each dealer is liable for its personnel and the services provided to patients.

 

HOW DOES MEDICARE (MEDIGAP) PARTICIPATE?

Among the large for-profit nursing facility companies, Medicare usually comprises 10-15% of the number of residents and about 25% of revenue.  The revenue has dropped because of the Balanced Budget Act of 1997 and the changes in reimbursements in 1998 (as mentioned above). 

While state and federal governments participate to some extent in long‑term care costs, a very small percentage of that participation occurs through Medicare.  While many people today are aware that Medicare covers very little of the cost of long‑term care, there are many that are not so informed.  It is important that a summary of the Medicare rules for paying for such care in order be studied so as to advise potential LTC Insurance clients.

Medicare covers nursing home care only when:

• The individual is admitted to a skilled nursing facility (SNF).
• The SNF is Medicare ‑ certified.
• The individual is receiving skilled medical care that can be provided only in the SNF and only by skilled medical personnel.
• The individual was previously hospitalized for at least three consecutive days.
• The individual is admitted to the SNF no more than 30 days after discharge from the hospital.
• Admission to the SNF is to receive care for the same illness or condition for which the individual was previously hospitalized and the individual must be improving..

Every one of these requirements must be met in order for Medicare to pay any part of nursing home costs.  Then, coverage lasts for no more than 100 days.

Medicare pays the full cost only for the first 20 days.  The individual must pay part of the cost for days 21 through 100.  In the year 2005, the individual's part is $114 per day.  The individual's portion changes every year as prescribed by the Social Security Administration.  If more than 100 days of care are required, the individual must pay all costs.

Conversely, what does Medicare not pay? There is no coverage for:

• Care in an intermediate or custodial care facility or any community‑based residential facility.  About 75% of nursing facilities are this type; only about 25% are skilled.
• Care in a SNF that Medicare has not approved.  Only about 40% of SNF's are Medicare ‑ certified.
• Custodial care, even if it is provided in a Medicare ‑ certified SNF, if that is the primary type of care being provided.
• Admissions not preceded by three consecutive days in the hospital.
• Admissions later than 30 days after hospital discharge.
• Care where the patient does not show increasing improvement in the health condition for which they were admitted. 

 

The facts are that most people who require long‑term care (1) do not require the one type of care Medicare pays for ‑ skilled nursing ‑ and (2) are not hospitalized prior to admission to a nursing facility.  One study for the U.S. government found that as many as 95% of people requiring long‑term care need only custodial care‑help with the activities of daily living.

Medicare Supplement regulations do not allow the sale of any insurance policy that duplicates Medicare Supplement coverage; however, a Long-term Care Insurance policy is now excluded.

Some companies require the insured to sign a statement attesting to the fact that the LTC Insurance policy may not cover all long-term care costs incurred and the insured is requested to review the policy carefully.  Conversely, some companies or General Agencies, require that an applicant for a Medicare Supplement policy, sign a statement that the Medicare Supplement does not cover most types of long-term care and that the agent has explained how such coverage can be obtained.  This accomplishes two things – (1) if a family member would ever accuse the agent of not offering LTC coverage when the insured becomes unable to take care of themselves, and Medicare does not cover the disability, this will avoid an errors-and-omission suit, and (2) it forces an agent who is making a (relatively) easy Medicare Supplement sale, to introduce his client to possible new coverages.

HOME CARE

Because so many services are now available in an Individual's home, from professional nursing care to housekeeping, it is difficult to attach an actual dollar figure.  People are likely to think of home care as being considerably less costly than care in an institution, and in some cases that's true.  For example, a home health aide, earning $10 an hour in some locales, who helps in the home for two hours a day three times a week does create a large expense.  However, HIAA estimates that many people receiving help at home with ADL’s alone currently pay as much as $1000 per month ‑ $12,000 annually.  Skilled professionals such as a registered nurse or physical therapist may be paid up to $70 per hour for home visits.

Adult day care is no less expensive than day care for children—and is often more expensive because of the availability of extra services, particularly those related to health care.  Daily charges can range from $50 to $200 according to the American Association of Retired Persons (AARP), probably the best known organization serving older people in the U.S.

These figures emphasize both the lower and upper extremes.  Recent figures from a state located in one of the average‑cost geographical regions of the, U.S. indicate that home care, adult day care, respite care and hospice care costs average $15,000 or less per year.  However, the more frequently the services are provided and/or the more skilled the person providing them, the more costly they will be in any region.

According to the Centers for Medicare and Medicaid Services, expenditures for home health care dropped from $18 billion in 1997 to $10 billion in 2002.

 

 

 

HOME HEALTH CARE UNDER MEDICARE

As quoted in the Medicare Guide: "Medicare pays the full cost of medically necessary home health visits by a Medicare-approved home health agency.  A home health agency is a public or private agency that provides skilled nursing care, physical therapy, speech therapy, and other therapeutic services.  A visiting nurse and/or home health aide provides services on an intermittent or part-time basis, not full-time.”

 

 

"To qualify for coverage you must:

• Need intermittent skilled nursing care, physical therapy, or speech therapy,
• Be confined to your home,
• Be under a doctor’s care.

 

A stay in the hospital is not needed to qualify for the home health benefit, and you do not have to pay a deductible or coinsurance for services.  You do have to pay 20 percent of the approved amount for durable medical equipment such as wheelchairs and hospital beds provided under a plan-of-care set up and reviewed periodically by a doctor.”

“You pay:

• For full-time nursing care and drugs.
• For meals delivered to your home.
• Twenty percent of the Medicare-approved amount for durable medical equipment, plus charges in excess of the approved amount on unassigned claims.
• For homemaker services that are primarily to assist you in meeting personal care or housekeeping needs.”

 

Note the key requirements:

• Services must be skilled nursing care, physical therapy, speech therapy or other therapeutic services.  Many Seniors are convinced that they will receive full time care and Medicare or their Medicare Supplemental policy will cover it.
• The patient must be homebound, confined to the house, and not able to go shopping or visiting with friends and family.
• The patient is fully responsible for homemaker services to assist them in personal care or housekeeping needs.

In the past, doctors have been very lenient and have continued Medicare home health care even after the patient no longer needed skilled nursing care.  With the recent emphasis on Medicare abuse, these abuses have diminished and ceased almost entirely in most areas.

An important point to remember is that a Medicare Supplement only pays for those costs that are Medicare approved, i.e. as a general rule, if Medicare does not pay, the Supplement will not pay.  (There are some exceptions, such as a physical examination under certain Select policies and some drug benefits under the more expensive H, I and J Supplemental plans)

ADULT DAY CARE

Adult Day Care has often been considered as a place to drop off a person who is unable to care for themselves, at a facility that will “baby-sit” them until they can be picked up on the way home from work.  There actually is a little truth in that matter, but Adult Day Care offers much more.  They are closely regulated and they offer structured, comprehensive programs providing a variety of health, social, and other related support services.  Hours are flexible usually, but they offer less than 24-hour care, usually operating only during normal business hours five days a week, with some offering weekend and holiday services also.  They offer medical monitoring, occupational and physical therapy, counseling, and other services to not only the patient, but also for the families.

Obviously, Adult Day Care centers are designed for the caregiver who must work during the day but who also has a family member to care for.  For many situations where the caregiver is a family member, this may be the only way that they can both work and take care of their parent or disabled family member.

It should be remembered that for the person who needs the care, this can be a frightening experience as they will be with strangers initially, therefore care coordinators if they have an LTCI policy, or otherwise, the caregiver, must bring the patient into the decision-making process if at all feasible. 

 

TYPES OF ADULT DAY CARE FACILITIES

ADULT DAY CARE (ADC) centers are community-based programs that provide non-medical care to persons 18 years of age or older in need of personal care services, supervision or assistance essen­tial for sustaining the activities of daily living or for the protection of the individual on less than a 24-hour basis.  These must be licensed by the State community care facilities.

ADULT DAY SUPPORT CENTER (ADSC) is a community-based program that provides non-medi­cal care to meet the needs of functionally impaired adults.  Services are provided on a less-than 24 hour basis, according to an individual plan of care in a structured comprehensive program that will provide a variety of social, psychosocial and related support services in a protective setting. These are licensed as community care facilities.

ADULT DAY HEALTH CARE (ADHC) centers are community-based day-care programs that provide medical, rehabilitative and social services to elderly persons and other adults with functional impairments, either physical or mental, for the purpose of restoring or maintaining optimal capacity for self-care.  These centers provide services through an individual plan of care and target adults who are at the institutional level of care or at risk of institutional placement.  ADHC is a Medicaid benefit.  The health, therapeutic and social services are provided to those who are at risk of being placed in a nursing home. 

The centers are licensed by the State certifies each center so that the center can qualify for Medicaid reimbursement.  'The stated primary objectives of the program are;

• “Restore or maintain optimal capacity for self-care to frail elderly persons and other adults with physical or mental disabilities; and
• Delay or prevent inappropriate or personally undesirable institutionalization.”

The program works closely with the participant, the family, the physician, and the community in working towards maintaining personal independence.  This program has been successful in some instances of placing formerly-institutionalized individuals back into the community

ALZHEIMER DAY CARE RESOURCE CENTER (ADCRC) is another community-based program that pro­vides day care for persons in the moderate to severe stages of Alzheimer's disease or other related dementias, and provides various support and educational services for family caregivers and the com­munity at large.  ADCRCs identify the psychosocial, mental, functional, and cognitive needs of these participants, and assist participants to operate at the highest level possible within individual degrees of mental and physical capacity. Although the law permits ADCRCs to function without a license, the majority of these programs are located in licensed facilities under an established licensee category.

The ADCRCs work with those who have moderate to severe levels of dementia and to provide support and respite for caregivers.  They also provide day car3 services needed by patients with dementia and they make opportunities for professionals in take care of and treating these patients.  They also have a public service function of increasing public awareness and knowledge about Alzheimer’s and related disorders.  They provide services that support the physical and psychosocial needs of persons with Alzheimer's disease or related dementia.  Individual care plans are developed for each program participant with activities scheduled in accordance with these plans.  Persons who have been diagnosed as having Alzheimer's disease or other dementia are eligible to participate, without regard to age or financial resources.  In particular, they target those persons having moderate to severe levels of care needs and behavioral problems which make it difficult for them to participate in other care programs.

In respect to funding. participants are requested to share in the cost of care through fees based on the cost of services and a sliding fee scale that is specific to each site.  Approximately one-third of the sites are administered under Adult Day Health Care licensure and certification, permitting them to accept Medicaid eligible persons.

FORMAL LONG-TERM CARE SERVICES AND FACILITIES

NURSING HOMES

A nursing home is defined as a privately operated establishment where maintenance and personal or nursing care are provided for persons (as the aged or chronically ill) who are unable to care for themselves properly.

Nursing homes are licensed by the state to provide nursing care, personal care (help with things like bathing, dressing, going to the bathroom, and more), and medical services. They also offer different kinds of therapies—physical, occupational, and speech—for their patients when such therapy is medically necessary.  Meals, laundry and housekeeping are furnished. Nursing homes provide various activities for its patients, such as art classes, parties, religious services, etc.

Basically, nursing homes or skilled nursing facilities, are designed specifically for those who are in need of 24 hour nursing care.  They are usually beyond the physical and emotional resources of family and friends—and often, monetary resources. 

Nursing homes provide more than close medical supervision from skilled professionals as they offer care from very skilled to custodial care that can be provided by supervised nursing assistants.  Nursing homes are tightly regulated by the states and they continually audit the services  and quality of care.

State and federal authorities regulate nursing homes and report that the quality of care has improved over the past few years.  However, nursing homes still suffer in the opinion of the public.  Isolated incidents, such as the elderly patient in a nursing home who died of fire ant bites while immobile in her bed, gather considerable publicity.  The states all license nursing homes and they review the operations of each nursing homes at least once a y ear.  In 1987, the Omnibus Budget Reconciliation Act (OBRA) resulted in national reform of nursing homes.  As a result of this act, nursing homes were required to add more and more qualified nursing home staff Key.  Each nursing facility must have individualized resident care plans and the patients must become involved in the care plan.

 

LEVELS OF CARE

There are three categories of care and nursing homes usually provide all three types of service, all involving full-time residence and include room and board, monitoring, personal assistance, nursing and other health care for those who cannot take care of themselves, mentally or physically.

Long-term care services are usually classified into three categories: Skilled Care, Intermediate Care and Custodial Care.  LTCI policies are not always uniform in describing the care categories, therefore it is very important that policyholders be fully informed as to the various levels of care and is aware of the coverage descriptions and exclusions in the policies.

All of the following levels of care are usually covered under LTCI policies with a nursing facility (nursing home) benefit:

Skilled Nursing Care

Nursing Facilities aka skilled-nursing facilities, nursing homes or convalescent hospitals, facilities provide comprehensive nursing care rehabilitation and specialized medical programs for chronically ill or short-term residents of all ages.  They are licensed by the state department responsible for licensing such facilities and certified for Medic and Medicare.  Fees are usually provided by Medicaid, with some funding through Medicare, managed care and individual and private payments.

These skilled nursing care facilities provide daily nursing and rehabilitative care performed by or under the supervision of, skilled medical professionals or technical personnel.  Basic skilled and custodial care for "activities of daily living" are delivered in addition to one or more of the following: specialized rehabilitation pro­grams, respiratory therapy services, ventilator care, tracheotomy care, IV services for hydration/pain management, hospice services, respite care services, Alzheimer's and dementia units.

Skilled nursing care is available 24 hours a day, must be ordered by a physician and must be performed directly by or under the direct supervision of a registered nurse.  Regulations require that there be a formal medical treatment plan.

Subacute-Care Facilities

Subacute-Care Facilities many times operate in a separate section of a nursing facility.  They focus on intensive rehabilitation, complex wound care and post-surgical recovery for patients of all ages who no longer need hospital care.  These facilities are licensed by the state and Medicaid and/Medicare certified.  They are funded through Medicaid primarily, with some from Medicare, managed care and private payment.

Intermediate Care

Intermediate-Care Facilities provide room and board, medical, nursing, social and rehabilitative services for people not capable of full independent living.  They are licenses by the state and Medicaid and/or Medicare certified.  They are funded primarily by Medicaid, with some funding by Medicare and private payment.

The Intermediate Care facilities provide assistance needed for stable conditions that require daily, but not 24-hour, nursing supervision and it must be ordered by a physician and supervised by registered nurses.  It does not take the specialized nursing care of a skilled nursing facility, but usually involved personal care for an extended period of time.  The services fall between the skilled nursing care of a hospital or skilled nursing facility, and custodial care.  Physician supervisions is needed, care if provided by licensed medical personnel, primarily RNs or LPNs under the direct supervision of an RN.

The typical patient in this setting is relatively independent but may need help with some ADLs, and they do not need continual nursing services or supervision. These are usually lower in cost than the skilled nursing facility.

Maintenance or Personal Care Services Definition

Typical regulations state that maintenance or personal care services means any care the primary purpose of which is the provision of needed assistance with any of the disabilities as a result of which the individual is a chronically ill individual, including the protection from threats to health and safety due to severe cognitive impairment. 

CUSTODIAL CARE

Custodial care is the “lowest level” of care and is provided simply to allow the patient to function from day to day.  This is an important category as LTCI is designed to provide such services, and such services are not covered under Medicare. 

 

Basically, custodial care includes assistance in the activities of daily living (ADL)  For the purposes of LTCI, the state may dictate these "activities of daily living" to include each of the following items (not necessarily in this order):

(1) Eating.  ) "Eating" means feeding oneself by getting food into the body from a receptacle, feeding tube, or intravenously

(2) Transferring. "Transferring" means moving into or out of a bed, chair, or wheelchair.

(3) Dressing.  "Dressing" means putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs

(4) Bathing.  "Bathing" means washing oneself by sponge bath in a tub or shower, including the task of getting into or out of the tub or shower.

(5) Toileting.  "Toileting" means getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.

(6) Continence.  "Continence" means the ability to maintain control of bowel and bladder function, or when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene, including care for catheter or colostomy bag.

Custodial Care is the most common type of long-term care and it is provided in a variety of settings, ranging from nursing homes to other facilities, convalescent homes, and the patient's home.  These services can be given safely and reason­ably by a nonmedical person.  This is considered the “lowest level” of care because it does not involve any medical care and unskilled volunteers or family members may provide it.  Custodial care is none­theless essential for a person who cannot be self-sufficient.  On a day-by-day basis, custodial care is the least expen­sive daily cost, however, it can easily become the most expensive level of care because of the length of time-it is needed.

Durations of Nursing Home Stays

How long the average stay in a nursing home is depends on how the statistics are read. In its Annual Report of Long-Term Care Facilities for the 1991 calendar year, the Health and Welfare Agency of the California Office of Statewide Health Planning and Development provides the following figures:

 

DURATIONS OF NURSING HOME STAYS

 

While it appears that nearly half of all nursing home stays are less than a month, the figures can be misleading because SNFs are increasingly being used for convalescence from acute illnesses and surgeries and nursing facility stays are interrupted by brief hospital visits, the return from which is counted as a new admission.

ASSISTED LIVING/RESIDENTIAL CARE FACILITIES FOR THE ELDERLY

Assisted Living/Residential Care Facilities for the Elderly (RCFE) facilities provide personal care and safe housing for people who may need supervision for medication and assistance with daily living but who do not require 24-hour nursing care.  They are regulated by the a state Social Services Department and are funded primarily through private payments, with about 30% of the RCFE residents relying on SSI/SSP non-medical out-of-home-grants.

These type of facilities have various names in various areas, such as personal care home, adult congregate living facility, home for the aged, etc.  They are used by those who require some assistance in their daily activities, but do not require the care provided by a nursing home.  Usually these places are structured as condominiums or apartments houses, and the residents can receive assistance with housekeeping, meals and personal care.  For those that need additional help in such as eating, bathing, dressing, etc., these services may be provided.  There are staff members on duty 24 hours a day to assist the residents when needed. 

Assisted living facilities take different forms but usually are part of a retirement community or nursing home.  The appearance and grandeur of the surroundings dictate the cost as much, if not more than, the services that are available.  They can range from a simple apartment-house type of structure, to that of an exclusive country club or hotel.  Such facilities offer a combination of independence and service for individuals where varying levels and intensities of care and supervision, protective supervision, personal care, or health-related ser­vices are provided based upon their varying needs.  Assisted Living/Personal Care may be included with the monthly fee or residents may be charged according to the level of services used.  The fees charged can be based on an hourly rate for different types of services, or according to the level of care provided.

Many facilities now offer specialized Alzheimer's care and the facilities may be used only for the care of people suffering from dementia.  They offer special activities and programming, and most offer enclosed areas where the residents can walk around safely without injuring themselves or others.

Residential Care Facilities for the Elderly

Residential Care Facilities for the Elderly (RCFE) serve elderly persons age 60 and older.  They provide room, board, housekeeping, supervision, and personal care assistance and usually offer basic activities like personal hygiene, dressing, eating, and walking.  Facilities usually centrally store and distribute medications for residents to self-administer.

They are not medical facilities and so are not required to have nurses, certified nursing assis­tants or doctors on staff.  They may also be called board and room homes, board and care homes, rest homes, assisted living facilities of part of a Continuing Care Retirement Communities (CCRCs) that provide personal care and supervision.

24-hour supervision and assistance are provided for residents with minor medical problems or who need assistance with such things as bathing, grooming, dressing and meals (ADLs & IADLs). Most of these communities offer private, semi-private rooms, or efficiency apartments with or without kitchen­ettes. They typically provide common living areas (card/games room, library, lounge, social activities, and central dining room), housekeeping, linens (towels and sheets), from one to three meals, and transportation.  These facilities are licensed by the State Department of Social Services, Community Care Licensing Division as Residential Facility for the Elderly (RCFE) and they may also su­pervise and distribute medications to residents.

Not all Assisted Living Facilities are licensed, and therefore, their services may not be covered by the LTCI policies.

As the Baby Boomers enter their retirement years, it's inevitable that some of these seniors, who may once have headed companies or traveled the globe, might start to need assistance with day-to-day activities. But they are understandably reluctant to forfeit their independence. Someone accustomed to managing a business (or a family) can have a difficult time acknowledging that they forget to take their medication, or need help getting bathed and dressed.  Because they do not need daily medical care at this point, Assisted Living can be a good housing option.

WHAT IS AN ASSISTED LIVING FACILITY?

An Assisted Living Facility provides care for seniors who need some help with activities of daily living yet wish to remain as independent as possible. A middle ground between independent living and nursing homes,  Assisted Living Facilities aim to foster as much autonomy as the resident is capable of.  Most facilities offer 24-hour supervision and an array of support services, with more privacy, space, and dignity than many nursing homes—at a lower cost.

There are approximately 33,000 Assisted Living Facilities operating in the U.S. today. The number of residents living in a facility can range from several to 300, with the most common size being between 25 and 120 individuals.
Assisted Living Facilities are also called:

Personal care homes Residential care facilities Domiciliary care

Sheltered housing Community residences

An Assisted Living Facility helps seniors with personal care (also called custodial care), such as:

bathing dressing toileting

eating grooming getting around

Daily contact with supervisory staff is the defining characteristic of an Assisted Living Facility. Medical care is limited in an Assisted Living Facility, but it may be possible to contract for some medical needs.

The key characteristics of Assisted Living Facilities include:
Activities of Daily Living (dressing, personal care)	comprehensive assistance provided
Community Activities (social events, outings,   golf, etc.)	some activities offered
Community Services (laundry, cleaning, etc.)	many / most services provided
Health Services (medications, nursing care)	some services provided; not skilled  nursing
Environment (personal freedom)	residents are somewhat independent
Overall Health (physical, emotional)	residents have average health problems

Adapted from SeniorHousingNet®

HOW DOES ASSISTED LIVING FOR SENIORS DIFFER FROM A BOARD AND CARE HOME, NURSING HOME, OR CONGREGATE HOUSING?

Assisted Living Facilities offer help with activities of daily living (personal or custodial care), but no or very little medical care. Board and Care Homes and Congregate Housing have been around for many decades, and offer about the same services as an Assisted Living Facility.  Many Board and Care homes are set up to serve just two to six residents in a converted single family home though some are converted apartments; but Congregate Housing and Assisted Living Facilities generally serve larger numbers of residents.  Congregate Housing was originally government subsidized housing, but nowadays various types of senior communities call themselves “congregate housing.”  In recent decades, as more and more Assisted Living facilities have been created with different combinations of services, the differences between Board and Care, Congregate Housing, and Assisted Living have become blurred to the point that all three are often considered varieties of Assisted Living.

An Assisted Living Facility differs from a Nursing Home in that:

• an Assisted Living Facility does not offer extensive medical care, as a nursing home does, and
• an Assisted Living Facility places greater emphasis on personal privacy and autonomy.

A nursing home is set up for people who need skilled medical professionals providing care and services on a daily basis.

WHO IS AN APPROPRIATE CANDIDATE FOR ASSISTED LIVING?

It's estimated that one million Americans currently live in Assisted Living Facilities. Assisted Living residents can be young or old, affluent or low income, frail or disabled. A typical resident is a widowed or single woman in her eighties. Residents may suffer from memory disorders, or simply need help with mobility, incontinence or other challenges. Assisted Living is appropriate for anyone who can no longer manage to live on their own but doesn't require medical care.

Assisted Living Facility residents may need help with activities of daily living, including:

bathing dressing toileting grooming

cooking/eating getting around housekeeping transportation

If a senior needs a number of services, an Assisted Living Facility may become a more economical alternative to home care services.

An Assisted Living Facility is often the first stop for an elder who needs to get help with daily living. Some residents move on to a Nursing Home; others may come to Assisted Living from a Nursing Home or hospital after a period of rehabilitation.

WHAT TYPES OF ASSISTED LIVING FACILITIES ARE AVAILABLE?

While Assisted Living Facilities are residential in character, there is no standard blueprint because consumers' preferences and needs vary so greatly. Assisted Living residences can range from a high-rise apartment constructed as an Assisted Living Facility, to a converted Victorian home, to a renovated school. They can be free standing or housed with other options, such as independent living or nursing care. They may be studio apartments, or one-bedroom apartments with scaled-down kitchens.

An Assisted Living complex will typically be built with 25 to 110 units, varying in size from one room to a full apartment. This larger type of Assisted Living Facility may have a group dining area and common areas for social and recreational activities.

WHAT SERVICES DOES AN ASSISTED LIVING FACILITY PROVIDE?

The basic services an Assisted Living Facility provides include:

• Three meals per day, often served in a restaurant-like setting, with menus and salad bars
• 24-hour supervision
• Personal care assistance (bathing, dressing, grooming, eating)
• Housekeeping and laundry
• Transportation
• Minor medical supervision, such as assistance with medication
• Security and emergency call systems
• Health and exercise programs
• Social, cultural and educational activities

In addition, some facilities offer:

• Recreation rooms
• Exercise rooms
• Outdoor gardens
• Libraries
• Chapels

An Assisted Living Facility may also arrange for residents to receive senior services in the community, such as adult day care, shopping and recreation, and may provide social work assistance to coordinate these services.

CAN ASSISTED LIVING FACILITIES FOR SENIORS MEET SPECIAL NEEDS?

Some Assisted Living Facilities can handle special needs, such as:

• Cognitive disabilities
• Short-term care
• Respite Care (to give regular caregivers a break)
• Interim medical care after a hospital stay
• Alzheimer's
• Parkinson's
• Terminal illnesses (Hospice Care)

 

STUDY QUESTIONS

CHAPTER SIX

1.  There are long-term care facilities available that are part of a larger concept, where an elderly person can purchase an apartment and if his health deteriorates, all treatment is available on premises, including long-term  care.  This may be considered the "optimum" by the residents, but for Long Term Care Insurance purposes

      A.  these facilities are expensive and generally the residents can afford long-term   care as it would be in their building.

      B .  this can be a bonanza and agents can set up an office in these buildings as residents of this type of facility will nearly always purchase LTCI policies.

      C.  the policies can usually be sold only if they pay some sort of "tribute" or "administrative fee" to the operators of the facility.

      D.  agents are forbidden by law to market policies in such a place.

 

2.  In addition to long-term care, medical care can usually be broken down into

      A.  geriatrics or family care.

      B.  short-term care and intermediate care.

      C.  either acute or chronic care. 

      D.  institutionalized and non-institutionalized.

 

3.  Those conditions that are long-lasting and that require continuing care, as opposed to emergency medical treatment, are

      A.  chronic conditions.

      B.  acute conditions. 

      C.  personal care.

      D.  covered by Medicare in nearly all situations.

 

4.  In most situations, home health care is provided when the patient insists on staying at home, but can only do so

      A.  when they are covered by some form of long-term care insurance.

      B.  if they have a special form of the LTCI that does not accept nursing home care

      C.  with assistance from a home health care agency, family members, friends or other caregivers. 

      D.  if they are covered by Medicaid.

 

5.  For Home Health Insurance coverage, skilled services that cannot be performed by nonprofessional personnel other than medical doctors, including injections and intravenous therapy, wound care, and dispensing of medication must be performed by

      A.  Registered Nurses or Licensed Practical Nurses (RN or LPN).

      B.  Certified Nurse's Assistants (CNA) or Registered Nurses (RN).

      C.  an active member of a Home Health Care organization with special training.

      D.  Medical Doctors and family members who have been personal instructed by the     doctor.

 

6.  Those who deliver a wide variety of health care and supportive services, ranging from professional nursing and home care aide care to physical, occupational, respiratory, and speech therapies are

      A.  Home Care providers.

      B.  Adult Day Care providers.  

      C.  special trained immediate family members.

      D.  only Registered Nurses (RN).

 

7.  Agencies who employ homemakers or chore workers, HCAs, and companions who support individuals through meal preparation, bathing, dressing, and housekeeping, are

      A.  Hospice services.

      B.  Homemaker and HCA agencies.

      C.  Medicaid.

      D.  Medicare.

 

8.  For those requiring Skilled Nursing Care in a Skilled Nursing Facility, Medicare

      A.  pays for 100 days of coverage in every situation.

      B.  pays nothing at any time.

      C.  may pay up to 100 days of confinements subject to several conditions, including the fact that the patient must be showing improvement.

      D.  does not require any previous hospitalization.

 

9.  To qualify for home health care under Medicare,  "To qualify for coverage you must:

Need intermittent skilled nursing care, physical therapy, or speech therapy, Be confined to your home, and

A.  Be under the care of a Registered Nurse.

B.  Be under a doctor’s care.

      C.  Have previous hospitalization for at least 3 days.

      D.  Be taking no medication prescribed for the home-confinement illness or condit      ion.

 

10.  Facilities whose aim is to foster as much autonomy as the resident is capable of—most facilities offer 24-hour supervision and an array of support services, with more privacy, space, and dignity than many nursing homes—at a lower cost are generally called

      A.  Nursing Homes or Long-Term Skilled Nursing Facilities.

      B.  Continuing Care Community Centers.

      C.  Rest Homes.

      D.  Assisted Living Facilities.

 

ANSWERS TO STUDY QUESTIONS

1A     2C     3A     4C     5A     6A     7B     8C     9B     10D