Long-Term Care In Facilities

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Legal Planning for Illness and Aging
Long-Term Care in the Home
Long-Term Care in Facilities
government funds

Many people think that older adults still have only three residence options – continue to live alone or with a spouse in the happy older couplelong-time home or apartment, move in with a child or grandchild, or move to a nursing home.  Not true.  There are so many more options available today!  The appropriate choice of residence depends on the individual, his or her desired and needed services and the ability to pay for services.  A wide variety of senior residence options are available to offer different levels of care and services.

Independent living buildings and active adult developments are often called retirement communities.  They offer services and special amenities for older adults, but typically do not offer health care.  Continuing care retirement communities offer independent living, but also offer additional higher levels of care on the same grounds.  Low to moderate levels of care assistance are generally found in assisted living, residential group homes and specialized dementia care facilities.  Higher levels of health care are found in skilled nursing facilities, rehabilitation facilities and long-term acute care facilities. 

Due to the size of this topic, we will break down information on the different types of care below by categories.  This material only summarizes basic information on each residence type.  

1. Retirement communities 

Retirement living communities typically require residents to be over a certain age (for example, at least one resident in the household may need to be age 55+).  While younger family and friends may visit, they may not be full-time residents of the community.  The more uniform age of residents makes it likely that many residents will have similar interests and hobbies.  The somewhat older population also makes these communities quieter and safer than many traditional neighborhoods.  Residents tend to watch out for each other, which helps residents feel welcome and secure.

Many residents who have made the move to retirement living say they wish they had done so years earlier.  No one ever dreams of retiring so he or she can work around the house all day or watch reruns on TV; we dream of having time to enjoy friends and family, to pursue hobbies and interests and to travel.  In a retirement community, much of the work and worry of maintaining a home are gone and the opportunities to enjoy life dramatically increase.  Residents often say they feel better, are more active, and even eat better as a result of their new lifestyles.

Apartments and houses in these communities are designed for ease of living.  They typically have one-story floor plans, walk-in showers, lower counters and cabinets, raised electrical outlets and other handy features.

Your apartment or house in a retirement living community is your home.  While the community generally does not provide medical services, should you become ill or injured, you may arrange to bring needed health care or other services into your home privately.

Residents in retirement communities typically pay for their homes and services from their own income and assets (known as private-pay).

Independent living apartments:  Independent living apartments for seniors seem to be around every corner these days.  They typically offer residents a variety of services.  These may include:

Additional amenities may include pools, golf courses, fitness centers, community centers, craft or woodworking rooms, fishing ponds, walking trails, religious services and special interest groups or clubs.

If you think an independent living apartment might be right for you or a loved one, tour those in your desired area.  Ask for an invitation to lunch so you can try the meals.  Examine the property and its condition, ask about rents (or any required buy-in), deposits, whether pets are allowed, the services provided (ask which are included in your rent and which for an additional fee), whether you must sign a lease or can rent month-to-month, clubs and social groups, meal plans, etc.  Ask for a brochure and price sheet.  Compare the buildings you like, and their proximities to family, shopping, your doctors and your place of worship, before you make a decision.

Senior housing developments:  Senior housing developments are also springing up around the country.  Ownership of the individual homes in these developments is generally limited to mature adults (typically 55+),  usually with no children under 19 permitted to live full-time in the home.  Younger children may come for visits.  In most developments, a resident will purchase a private home as he or she would in any other housing development.  These developments generally offer a variety of home styles, prices and community amenities for their residents.  Unless the housing development is part of a continuing care retirement community, there is no health care assistance provided by the builder or community itself, but residents may bring privately-arranged services into their homes. 

Housing communities for active older adults are often situated on a lake or golf course and residents have access for boating or golfing.  The developments typically have trails and landscaped public areas for residents to enjoy and residents may be permitted to travel within the community by golf cart.  Many communities have swimming pools and health clubs.  Some have community centers for neighborhood classes and activities.  There may be a clubhouse and/or restaurants on the property for use by the residents.  Residents may pay a membership or association fee to use some, or all, of these facilities. 

If you are interested in purchasing a home in a senior housing development, visit the developments in your desired location.  Use the same caution you would in buying a home in any neighborhood – check home values in the neighborhood, hire a home inspector to examine the property, have the property appraised, etc.  Life in this type of development can be secure and filled with new friends and activities.  One note of caution, however – because only mature adults can live in the home, your ability to sell the home during your lifetime, or to leave the home as a part of your estate after death, has some limitations.  

Continuing care retirement communities:  Continuing care retirement communities (CCRC) offer older adults a variety of care options in one location.  For instance, an independent living apartment building may be across a driveway from an assisted living building and next to a skilled nursing facility.  The idea behind such communities is that once you move in, you never have to leave.  You may move around the campus a bit, but you can stay until death. 

What are the greatest advantages of a CCRC?  Residents do not have to move again.  Moving is difficult, stressful and expensive, especially when health issues are involved.  Knowing all the care you could need in the future is located on the grounds can be a great stress reliever.  Spouses can also live in the same community, even when they cannot live together.  If one spouse is very independent and the other quite frail, the healthier spouse might choose an independent living apartment while the ill spouse requires the skilled nursing facility.  The healthy spouse can visit daily and share meals and activities with the frail spouse, without worrying about transportation, yet can still enjoy an active lifestyle with other residents.  The couple can make and socialize with mutual friends, all on campus.   Families can enjoy visiting both spouses at the same time. 

Some sections of the CCRC may be private pay, while Medicare, Medicaid or other insurance or benefits may cover some of the higher levels of care.  Some communities ask residents to “buy in” to the community and that buy-in amount is used to pay for higher levels of care as needed.  It is vital to understand the care options in the community, to be sure that all levels of care are already built or nearing completion, and to fully understand the financial terms of any agreement with the CCRC.  Will unused buy-in funds be returned to the family after you die or will they be kept by the facility?  Can you ever incur any uncovered costs?  Are there restrictions on selling your home or apartment?  What happens to your investment if you decide to leave the CCRC?  These can be wonderful residence choices, but residents must understand the terms.  It may be helpful to have an attorney review any contracts for you before you sign on the dotted line.

Assisted Living Communities2. Residences offering low to moderate levels of care

Assisted living:  Assisted living communities are designed for adults who require ongoing assistance with one or more of the activities of daily living (ADL’s).  What is an ADL?  Health care professionals use this term to discuss the basic capacity a person  has to care for herself, which they break down into specific activities.  How much assistance does she need to bathe or shower, to dress, to eat, to get in or out of bed or a chair, to walk and to use the toilet?  These very basic abilities can be affected by physical, cognitive or mental health difficulties.

Assisted living residents may receive, based on individual needs, assistance with bathing, dressing, medication management, dietary management, monitoring of blood pressure or other vital signs and limited supervision for individuals who may experience some minor memory loss or confusion.  Residences generally provide nutritious meals and snacks, provide housekeeping and laundry services, coordinate care with residents’ physicians, transport residents to medical appointments, if needed, and to shopping and special events, and offer a variety of activities and entertainment.  Some have fitness centers, computer centers, libraries or beauty salons.  There is staff on duty 24 hours, although staffing may be light on evenings or weekends.

The level of health care offered by assisted living is lower than the level of care offered by a skilled nursing facility.   The needs of residents tend to vary.  Some will be quite mobile, but find the prepared meals and housekeeping assistance helpful.  Some residents may be very alert and independent, but may have problems with mobility, bathing or dressing.  Some residents may have early dementia (such as Alzheimer’s disease) and would not be safe at home alone, but do well in a community with some supervision and direction from the staff. 

Most newer assisted living residences offer small private apartments, with private baths, and large, cheerful community areas for residents to enjoy.  They often have lovely landscaped grounds or courtyards where residents may enjoy being outside, perhaps to garden a bit or simply to take a stroll.  Most apartments are private, or larger apartments might be shared by spouses or siblings.  Some older buildings will occasionally have semi-private rooms (two residents per room).

Assisted living apartments may look small, but one of the important goals of assisted living is to provide social interaction for residents.  They are encouraged to spend a great deal of the day in common areas, such as sitting areas, the dining room, the library, crafts areas, game rooms, or other areas where residents congregate for fun, meals and conversation.  Optimally, the time a resident spends in his or her apartment will be limited.

Assisted living residences are licensed by the state.  They may also be specially licensed to provide dementia care.

Some assisted living communities charge each resident a flat rate per month, based on the size of the resident’s apartment.  Others may offer several levels of care and, depending on the needs of a resident, he or she will be billed for that level of care in addition to the base rent for the apartment.  Many residents will need increasing care over time and their rates will increase accordingly.  Some communities charge per resident, so a husband and wife will pay twice the single rate.  Others charge per apartment, with an extra small fee for the second spouse.

The cost of assisted living is less than the cost of skilled nursing care, although high level assisted living services, especially high level dementia care, may approach the cost of low level skilled care.  The level of care provided, the size, age, condition and location of the facility and the size of the resident’s apartment all factor into assisted living pricing.

Residents in assisted living in Texas generally pay for care from their own income or assets (private pay).  Some veterans and spouses may qualify for VA benefit assistance .   Some states pay limited Medicaid benefits for assisted living.    Some long-term care insurance policies cover assisted living.   

Residential group homes  A residential group home (also called a residential care home) is a home, usually a large one-story house, in a typical residential neighborhood, where care is provided for a small number of older adults with physical and/or cognitive needs.  The homes may accept as few as three or four or as many as 10 or 12 residents in a home, depending on the size and layout of the building.  There should be 24-hour care staff on duty to assist residents at all hours.  Quite often, these homes focus on providing assisted living services or care for residents with dementia.  Some homes accept mentally ill or mentally disabled adults of varying ages.  The small, very personal atmosphere can be wonderful for many older adults.  These small homes allow residents to feel they are “at home” instead of in a care facility.  Close bonds are formed with other residents, the residents’ families and the staff. 

Small residential care homes (3 or less residents) are not required to be licensed under Texas law.  Larger homes are required to be licensed as assisted living or dementia facilities and often the very small homes elect to be licensed as well.  Licensed homes are monitored by the state.  The small, unlicensed homes do not receive state oversight.  Unlicensed homes may be excellent care providers, but the burden is on the family to monitor care.  Unfortunately, some residential care homes  have been found to be negligent care providers, with inadequate staffing, unclean conditions and inadequate care and nutrition for residents.  This is the exception, and not the rule, but these few “bad apples” in the barrel make it absolutely necessary for an individual or family considering use of a residential care home to inspect that facility, observe the cleanliness, activities and relative contentment of current residents, eat a meal with the residents, observe the home itself for cleanliness and safety factors, and ask for references.   It is also prudent for families to visit loved ones regularly to observe the care rendered, but this is true in all sizes and types of care facilities.

The majority of residential care homes provide safe, clean, supportive and secure environments for older adults who can no longer live alone at home.  They are a cozy alternative to larger facilities.  Residents are generally encouraged to participate in normal household tasks, such as cooking, folding laundry or dusting, so they feel more at home.  These homes often have a house dog, cat or bird to provide affection to residents (and to receive love from them in return).  The homes may offer private bedrooms or semi-private bedrooms.  Some have individual bathrooms and some are shared.  Residents receive three nutritious meals per day and snacks.  Their medications are administered to them.  Many homes will take residents to their medical appointments if family members cannot do so.  Residents receive assistance with bathing, dressing and grooming.  Most residential care homes are secured, which means that a code is required to enter or leave the property.  This keeps residents from wandering away, but permits family members ready access to the home.  Most secure the outdoor areas as well, so residents can be indoors or outdoors, but are always safe.  Activities should be offered throughout the day and should be designed for the functional level of the residents in the particular home.  Residents should NOT be left in front of a television all day long, they should be kept busy and active.  If the home accepts dementia residents, staff should be specially trained in dementia care.

The costs of residential care homes can be equal to or lower than larger assisted living or dementia care facilities.  If the home is unlicensed, then generally residents will be “private pay”.  Long-term care policies may pay for care in licensed residential care homes for insured residents.  These homes generally do not qualify for the Medicaid program.  War veterans may be eligible for veterans’ benefits to help pay their costs.  

Dementia care residences:    Dementia is a term used to describe conditions in which persons experience declines in mental functioning, such as memory loss and confusion, frequently with accompanying neurological changes, such as problems with balance, movement, speech, incontinence and swallowing in latter stages of the disease.  Dementia has several causes.  Alzheimer’s disease is a major cause of dementia and persons who have had head trauma, major strokes, or a series of mini-strokes, may also develop dementia.  Parkinson’s and other diseases also produce related dementias.   

Individuals with mild dementia need support and supervision to make sure they are safe and well-nourished.  When dementia worsens, as it does with many of the dementia-causing diseases, individuals may not be safe at home alone due to problems with judgment, confusion, forgetfulness, paranoia and physical problems related to the illness.  When family caregivers cannot provide 24-hour supervision for the person with dementia, and very few families have the resources to have an awake and alert caregiver on duty 24 hours per day, it may be time to move the individual with dementia to a care facility to keep him or her safe and healthy.

Specialized dementia care facilities, at both the assisted living and skilled care levels, have been developed in the last few years to tailor care to individuals with dementia.  Staff ratio to residents is generally higher than in traditional facilities and that staff is trained to understand the challenges faced by individuals with dementia.  Activities are designed to stimulate cognitive and social skills and to provide needed social interaction.  Buildings are designed to make it simpler for residents to find their way around and to return to their own apartments without assistance.  Frustrations in the environment are minimized.  Staff helps the resident and family adjust to changes in condition and function.  Residents are respected and helped to maximize the abilities they have in order to fully enjoy life despite their disease.  The plan in many dementia residences is that the resident will be able to stay there, with increasing levels of service, for the rest of his or her life.

If you are interested in a smaller, more specialized care facility for your loved one with dementia, please investigate the dementia residences in your area.  Ask for which levels of care they are licensed, how charges are determined (many have several levels of care with differing charges) and what they will do if they cannot provide adequate care for your family member if he or she declines severely.  Is the building secured?  Does a physician visit the facility?  Does a psychiatrist visit?  Tour and observe activities.  Try a meal.  Get all the facts you need to make a good decision.

Many patients in dementia residences are “private pay”.  A long-term care insurance policy may also help pay for dementia care.  Specialized dementia care inside a skilled nursing facility may be paid by Medicaid, if the individual qualifies financially.  The smaller dementia residences, especially those licensed as assisted living, generally are not covered by the Medicaid program because Medicaid regulations were put in place long before such homes came into being.  

Rehabilitation Facilities3. Residences offering high levels of care  

Rehabilitation facilities:  Rehabilitation involves recovery and regaining strength after an individual has been injured or has suffered a debilitating illness or medical event.   Common examples of conditions from which patients require rehabilitation are strokes, heart attacks, hip fractures, knee replacements and brain injuries.  Physical therapy helps patients regain strength and mobility.  Occupational therapy helps patients regain the ability to perform simple tasks, such as grooming, dressing and feeding themselves.  Speech therapy helps patients improve their language skills and the ability to be understood when speaking.   These therapies may begin when patients are hospitalized, but it takes time for patients to receive full benefits from these types of therapies.   If a patient returns home after leaving the hospital, therapists may come to the home, or the patient may be required to go to a medical office or to a hospital’s outpatient department to receive ongoing therapy.  Another option is a specialized long-term care facility designed to support the patient and continue aggressive therapies.  These can be free-standing facilities, but are often a part of skilled nursing facilities (sometimes called nursing homes).  When they are housed inside skilled nursing facilities, the rehabilitation resources may be located in a special “rehab” wing of the building, in which residents are expected to continue to improve and to eventually leave the facility.

Patients with Medicare are generally covered for a maximum of 100 days of in-patient rehabilitation care.  To continue receiving benefits, a patient must continue to improve.  If a patient “plateaus” and stops improving, Medicare coverage will also end, even if the patient has not used his 100 days.  There are some criteria that must be met to qualify for coverage and some limitations on multiple stays.  Long-term care insurance may also pay for some rehabilitation expenses.  Qualifying Medicaid patients or war veterans may also receive some benefits from Medicaid or the VA, respectively.

Long-term acute care hospitals:   Long-term acute care hospitals are a fairly recent concept. Their niche in the health care system is to help patients who require fairly lengthy in-patient hospital stays for serious medical conditions or injuries. Acute care hospitals (those we have traditionally simply called hospitals) often transfer patients who require ongoing high-level care to these long-term acute care hospitals. These specialty hospitals are often much smaller than acute care hospitals and can provide more personalized care and a more relaxed atmosphere for the patient during recovery. Long-term acute care (LTAC) hospitals often provide the following types of in-patient medical services: treatment for infectious diseases; wound care for surgical wounds, amputations or bed sores; breathing support with intubations, tracheotomies or ventilators; slow-paced rehabilitation therapies (speech, physical and occupational therapy) for patients who require a cautious pace of therapy; recovery after surgery; care for congestive heart failure; management of difficult-to-control diabetes; treatment for sepsis or other infections; care for multi-system diseases; care after a brain or spinal cord injury (for example, after a stroke or head injury); care and therapy after joint replacement; long-term care after serious burns; care for patients with cancer or heart or renal diseases; and care for many other complex long-term illnesses. The level of care provided in an acute care hospital can be quite high and is greater than that provided in a skilled nursing facility (what we might think of as a nursing home).

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Skilled nursing facilities When someone says nursing home, he or she usually means a skilled nursing facility.  Today’s skilled nursing facilities, however, are far different from those of past generations.  Because of the wide range of alternative long-term care residences available (as discussed above), as well as the array of services that can be brought into a patient’s home, skilled nursing facilities today tend to house older and sicker residents than in days past when they were sometimes as much “retirement homes” as nursing facilities.  Additionally, hospitals now discharge patients earlier than they used to do, meaning that patients are less well on discharge and often not well enough to return home.  Instead of heading directly home, patients may spend an interim stay in a skilled nursing facility to help them regain enough strength to return home successfully. 

Skilled nursing facilities often house rehabilitation units (as discussed above), whose purpose is to strengthen residents and return them to their homes.

Skilled nursing facilities also provide custodial care (a low to moderate level of health care with a high level of supervision) for many residents with Alzheimer’s disease or other dementias who cannot live safely at home any longer.  The more confused dementia residents may live in a secured unit to prevent them from wandering and becoming lost or injured.  Specially trained staff should care for residents with dementia and skill-appropriate activities and therapies should be offered.

Skilled nursing facilities may also offer hospice care to residents, either through their own programs or by partnering with outside hospice programs.  Hospice provides compassionate care for residents with terminal illnesses and emotional support for their families.

Skilled nursing facilities typically charge a daily rate based on a resident’s required level of care.  Residents who require constant supervision as well as physical cares (such as a resident with advanced dementia), or someone on a ventilator, will pay more for these higher levels of care.  Some skilled nursing facility residents are private pay, those who qualify financially for Medicaid (and whose facility will accept Medicaid) may receive benefits from that program, long-term care insurance may provide benefits and some war veterans may qualify for VA assistance.  Medicare rarely covers skilled nursing facility costs, other than during the rehabilitation stays discussed above, and only for a short period of time when there is any Medicare coverage at all.  Medicare will pay hospice costs for insureds, but not the basic room and board costs for the care facility.  Facility rates differ throughout the country, with both coasts, Alaska and New York having some of the highest care costs in the nation.  

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