Senior-Care-Options

Senior Care Options Finding the perfect option for your loved one

This book is based on research conducted by 2nd Family Home Health Services, LLC and is intended as educational material for those looking for senior care. No financial figures in this book should be considered quotes for service and each user should conduct independent research.

This book is protected under the copyright laws of the United States of America. Any reproduction or other unauthorized use of the material or artwork herein is prohibited without the express written permission of the author.

First Edition: February, 2014 Introduction to Senior Care Options The next several pages will provide you with a brief overview of the different senior care options available. With so many different providers available in each category, it’s important that you thoroughly research all of your available options, asking questions at each step along the way.

At the end of this book, you’ll find some sample scenarios of elderly folks in need of care. Each scenario will include the recommendation of a licensed Geriatric Care Manager based upon their professional opinion of the senior’s needs.

We hope that you find this information helpful as you continue to educate yourself to the vast array of possibilities available to you. As we like to say at 2nd Family – family comes 1st!

Table of Contents

Care Options

Adult Daycare………………………...... 5

Senior / Independent Living………..……...7

Assisted Living…………………………………….….9

Home Care …………………………………….……….12

Nursing Home………………………………………..14

Fictional Sample Care Scenarios

Robert Harris………………..……………………….16

Martha Johnson…………..………………………..17

Ellen Saunders……………..………………………..19

Reginald Owens…………..……………………….20 Adult Daycare Overview

Adult Day Care centers are generally broken down into 3 distinct categories: those that provide social interaction, those which offer medical programs, and those which focus on Alzheimer’s and dementia. The needs of the senior will obviously dictate which Adult Day Care facilities are appropriate.

A typical Adult Day Care facility will offer some, if not all, of the following: . Wellness programs (including exercise) . Meal service . Social activities . Transportation to / from the center . Medication assistance . Basic assistance with Activities of Daily Living

Adult Day Care facilities are regulated by the state. A typical staff would include a social worker, an activity director, and an activity aide. The staff may or may not have medical training (such as a CNA or GNA certificate) depending upon the facility. Many facilities also rely heavily on neighborhood volunteers to coordinate the daily activities.

Benefits to Adult Day Care

. Allows family caregivers to run errands, attend work or school, etc. during daytime hours of the week . Provides respite care on an as-needed basis . Out-of-the-house socialization and activity opportunities for the senior . Transportation to and from makes attendance easy . Senior is able to continue living at home . Some facilities provide additional services such as Physical Therapy or Counseling

Potential drawbacks to Adult Day Care

. Very high senior-to-caregiver ratio . Frequently undertrained staff . Inability to accommodate dietary needs . Programs offered are not of interest to your senior . Quality varies greatly from one facility to another

Cost and Payment

The average Adult Day Care facility’s rates start at $75 per day, with some of the nicer facilities charging well over $100 per day. Prices typically fluctuate depending upon the staff-to-senior ratio, as well as the number of amenities available at the facility.

Private pay and Long Term Care Insurance are the two most prevalent methods of payment. Medicare Part C, in some instances, will cover a limited portion of Adult Day Care. However, most seniors only possess Medicare Parts A & B.

Tip – Remember to speak to some of the “hands on” staff when you visit. The “welcome committee” might say all the right things, but speak with several employees and seniors to make sure everything checks out. Senior / Independent Living Overview

Senior Living and Independent Living communities are best suited for the active senior who is interested in simplifying his or her lifestyle while maintaining a sense of independence. These communities can be arranged either as condominium-like units, or as single-family houses. Most are prepared with amenities such as grab bars, roll-in showers, etc.

Usually there will be on-site amenities such as a beauty salon, bank, fitness center, community meal facilities, and more. These amenities allow the senior to enjoy social interaction without worrying about home maintenance, cooking, driving, etc.

Benefits to Senior / Independent Living

. Meals provided (usually breakfast and dinner only) . Housekeeping and linen service (weekly or bi-weekly) . Suites include kitchenettes or full kitchens . Plethora of on-site and off-site activities . 24-hour building security . Transportation services are available

Potential drawbacks to Senior / Independent Living

. Some communities have a rather steep entrance fee in addition to the monthly fee . No personal care is provided, this is strictly a place to live . If the money runs out, the senior will be asked to move . Downsizing can be difficult for some seniors . Moving out of “home” and into a “facility” can be a difficult transition . Hidden fees - not all amenities are included in the monthly fee Cost and Payment

Most Senior / Independent Living communities start around $3,000 per month, which will include rent, utilities, and at least a partial amenities package. Check with each individual facility to know exactly what is included in the monthly fee. While less reputable communities may be around $2,000 per month, the high end facilities can be as much as $5,000 per month or more.

These communities are private pay, meaning out-of-pocket. Long Term Care Insurance, Medicare, and Medicaid will NOT cover any portion of the expense. Assisted Living Overview

Assisted Living is simultaneously perhaps the most well-known and most often misunderstood senior housing option. Since first appearing in the early 80’s, Assisted Living facilities have popped up all across the country as a popular “bridge” from senior independence to nursing home care. Often lauded for their ability to provide care while allowing a senior to maintain independence, Assisted Living facilities do just that…for the seniors who match the profile of the “perfect candidate.” Those who are not the perfect match often find Assisted Living to be frustrating and misleading.

The question of the day then is, “Who is the ideal candidate for Assisted Living?” At its core, Assisted Living is geared toward the social senior who needs minimal living assistance. To approach Assisted Living with social activities as the primary focus and any personal care as a bonus would be proper. To approach Assisted Living with personal care (bathing, grooming, ambulation, etc.) as the primary focus and social activities as a bonus would be a mistaken approach. Those who are expecting any more than 30- minutes of one-on-one attention from trained nursing staff will be disappointed, while those looking for lots of activities and a helping hand here and there will be very pleased.

Benefits of Assisted Living

. Most have beautiful facilities and numerous activities . Some offer private rooms including a kitchenette . On-site amenities could include a pool, spa, general store, beauty parlor, garden (depending on the facility) . Meals are provided in the dining room . Transportation shuttles are available for group outings . Weekly or bi-weekly housekeeping is provided . Basic assistance with Activities of Daily Living

Potential Drawbacks to Assisted Living

. High ratio of residents per staff member . Level of Personal Care provided is often far less than expected . “Exclusionary Clause” allows the facility’s management to evict the resident for any number of reasons, including personality mismatch, requiring an increasing level of care, and financial concerns . The basic monthly fee often includes very little. A la carte services including incontinence assistance, dispensing medication, complete personal hygiene assistance, escorting to meals, etc. are often charged per service and can add up to several hundred additional dollars per month . Some communities have a rather steep entrance fee in addition to the monthly fee

Cost and Payment

The average Assisted Living facility’s rates will start at $5,000 per month. A less reputable facility maybe be as little as $3,500 per month, while a well known facility could very easily cost $8,000 or more per month. As noted above, the a la carte services (those which are not included in the monthly rent) can add up very quickly, easily totaling another $500 or more per month for a resident who needs more personal attention.

Perhaps the largest misnomer of Assisted Living is related to Medicare, which does NOT pay for the monthly rent. The vast majority of residents either use Long Term Care Insurance or pay privately (out-of- pocket). There are also some other ancillary benefits, such as Veterans Benefits, which can help to pay for a portion of Assisted Living. Medicaid will, in a very few cases, pick up the tab for Assisted Living. However, the facilities are reimbursed a fraction of what the normal rate is for a private-pay resident. Quite often the “Exclusionary Clause” is enacted by the facility if they have a private-pay resident who needs a room. Keep that in mind when pursuing the Medicaid route – you could be asked to leave at any point in time.

Tip #1 – Check out the energy level of the other residents when visiting. A high energy level is often a sign that 1) residents enjoy living there, 2) their health is a priority of the facility, and 3) there is a good assortment of activities available to them.

Tip #2 – Remember the “Exclusionary Clause” when reviewing financial information. When the money starts to run low, so does your time at that facility. At management’s discretion, they can ask you to leave at any time. Home Care Overview

A relatively new and increasingly popular option, Home Care is a modern take on a very traditional approach to senior care. The most attractive quality of Home Care is the one-on-one care approach in the familiar setting of “home,” wherever that may be. Home Care is split into two main categories – Medical and Non-Medical. The differences are distinct and important to understand when making a decision on care option.

Medical Home Care offers just that, medical care in the home. The services are typically ordered by a doctor for a specific need, such as wound care, catheter care, physical therapy, etc. With a doctor’s note, Medicare will usually cover the cost of the visits. Without a doctor’s note, any requested services will be private-pay only.

Non-Medical Home Care is what usually comes to mind when referring to “aging in place.” This type of care comes in all shapes and sizes, but generally includes assistance with bathing, grooming, personal hygiene, meal preparation, light housekeeping, medication, transportation, companionship / hobbies, and more.

The best feature of Non-Medical Home Care is that it is highly customize- able, so an immobile, non-social senior with Alzheimer’s can benefit just as much as a social, active senior with a touch of dementia who needs a little “monitoring.”

Benefits of Home Care

. Highly customize-able depending on the senior’s needs and wants . No upfront entrance fees . Can increase / decrease scheduled care as needed . Senior is able to remain wherever he/she currently lives . One-on-one care ensures that the senior is properly attended to . Provides all the benefits of other senior care options on an as-needed basis without any commitments . The senior is able to build a relationship with the caregiver instead of having several different nursing staff present

Potential Drawbacks to Home Care

. Any activities outside of the home will require transportation . Some seniors prefer to have more interaction with peers . Quality of care varies greatly from one agency to the next . Unless using 24/7 care or living with a family member, there may be times during the day/night when the senior is left alone

Cost and Payment

Like most things in life, when it comes to Home Care, you get what you pay for. The quality of a Home Care agency is directly related to the quality of Nursing Aides which perform the actual care services. The agencies that pay more are able to attract higher quality caregivers.

Average Non-Medical Home Care services cost around $24-25 per hour, with non-reputable agencies using uncertified personnel charging $20 per hour or less, and the upper echelon agencies charging $28 per hour or more. Since Non-Medical Home Care is not covered under Medicare or Medicaid, private pay and Long Term Care Insurance are usually the only two available payment options. In some rare instances, VA Benefits or State waiver programs will provide for Home Care. Nursing Home Overview

The Nursing Home is the place that most folks refer to when they make their kids promise to “never send me away to one of those places.” Generally speaking, there are two levels of Nursing Homes – Skilled Nursing Facilities and Intermediate Care Facilities. While both are staffed with 24/7 medical personnel, it’s the qualifications and services provided by those personnel which differ.

A Skilled Nursing Facility is staffed with Registered Nurses who provide skilled nursing functions such as wound care, respirator management, post- surgery recovery, etc. for patients who require continuous care. An Intermediate Care Facility is one step down and is primarily staffed with a mixture of nurses and aides. Residents here do not require continuous monitoring, but do require ongoing assistance with daily activities.

Benefits to Nursing Homes

. The senior has round-the-clock access to medical attention . Medicare will pay for the first 20 days . The use of restraining devices such as rails, belts, and vests has been Federally outlawed except in cases where safety is a concern

Potential Drawbacks to Nursing Homes

. Quality of care varies dramatically from one facility to the next . Medicare will only pay for 20 days . Not all facilities accept Medicaid . Some facilities use less-than-acceptable means of managing patients, up to and including drugging them to remain docile . Nursing Home contracts include important details in the fine print, so read carefully . Asset transfers and giveaways are actively monitored by Medicaid

Cost and Payment

Nursing Home care is expensive, with most right around the $8,000 to $10,000 per month range. Depending on the services required, some can be substantially more. One example would include specialized care in an Alzheimer’s unit.

As stated above, in most cases, Medicare will cover the first 20 days of skilled nursing care in a Medicare-approved facility and up to 80 additional days after a daily coinsurance fee that's adjusted annually. After that, it’s down to private pay, Long Term Care Insurance, or Medicaid.

Medicaid has a strict and complex process for determining eligibility, and as such, not every Nursing Home accepts Medicare. Eligibility is based upon the depletion of assets, as well as the transfer of income to the facility, minus a stipulated living allowance. Please view the Medicaid eligibility details at Medicaid.gov for more information.

* Please note, Medicaid DOES NOT allow asset transfer or giveaway in order to meet eligibility standards. When applying, Medicaid will review financial records for the previous 5 years. It truly is, in all aspects, a last resort. Fictional Sample Care Scenarios

Scenario 1 – Robert Harris

Robert is an 85 year old man who currently lives with his daughter’s family. A lifelong lover of farming and outdoor activities, Robert was always adamant that he never wanted to be “put in one of those places.” Once his wife passed away, the family decided that it would be best for Robert to come live with them instead of living by himself. Using some of the money from the sale of his house, Robert’s daughter and her husband built a small addition on their house to accommodate an in-law suite. Over the course of the past year or two, Robert has begun displaying tendencies which the family believes to be a sign of dementia. Still as energetic as ever, Robert likes to be outside on the family’s farm. However, with both his daughter and son-in-law at work all day, Robert is alone from 8am until 6pm most days. The family is concerned that, due to his recent behavior, he should not be alone all day.

The family reluctantly brings up their concerns with Robert, who immediately dismisses the need for “a babysitter.” In addition to their concerns about Robert being alone, they are becoming increasingly involved in maintaining his personal hygiene. Though recognizing the need, both his daughter and son-in-law are uncomfortable with participating in that aspect of Robert’s care.

Recommendation – Robert clearly prefers the “freedom” of living with his family, and it seems to be working well for his daughter’s family, since Robert has his own in-laws suite. However, due to the family’s concerns, it appears as though Robert should not be unsupervised for large periods. Having a home aide stay with Robert during the day would alleviate the concerns that he’ll harm himself, and the aide will be able to take over the bathing and personal hygiene responsibility. In this case, Home Care seems to be the optimal route.

Scenario 2 – Martha Johnson

Martha is a 76 year old woman who lives alone. Recently Martha has been increasingly unsteady on her feet, having fallen 4 times in the last 2 months. The most recent fall sent Martha to a rehabilitation facility for a few days because she was complaining of discomfort in her hip. While she has several children who leave nearby, Martha does not have an especially close relationship with any of them. Her children describe her as cold, aggressive, and stubborn, and none of them are too interested with involving themselves in her care process.

During her stay in the rehabilitation facility, Martha’s aggression and abrasive personality were exacerbated, making the staff’s job increasingly challenging. She was not a willing patient, and repeatedly expressed her intent, using some colorful language, to return to her home as soon as possible. Due to her aggressive behavior, staff members were frequently on the phone with Martha’s children to report a new issue.

Martha is now back in her home, alone. In addition to her history of falls and decreasing mobility, Martha is showing some signs of forgetfulness, which could be the beginnings of dementia. Martha’s children want someone to take over care for their mother so that they do not have to be involved any further.

Recommendation – The two main factors at play here are Martha’s instability on her feet and her abrasive personality. Since her children are disinterested in participating in her care, the initial thought would be to send her to Assisted Living. The potential drawback is that if the staff at the facility eventually determines that too much of their time is being spent on one resident, they may make a financial decision to remove Martha from the facility. She clearly does not yet require Nursing Home assistance, and Day Care doesn’t seem to be a great fit due to her personality. Home Care would place Martha in familiar surroundings, so while she may be resistant to care, at least she will feel like it’s happening on her terms. Her falls will dramatically decrease and the aide can monitor her mental abilities on a day-by-day basis. Scenario 3 – Ellen Sanders

Ellen and her husband John, both in their early 80s, have lived together in the same house for the last 25 years. A few years ago, Ellen was diagnosed with a degenerative disease which deteriorates her muscular strength. Mentally she is of average cognitive ability for someone her age. John is also of average physical and cognitive abilities for a man in his early 80s, however, their children have begun to privately question his ability to properly care for Ellen.

Due to her increasing weakness, Ellen has begun to fall more frequently, having been taken to the Emergency Room as a precaution twice after falls in the last 6 weeks. While they do live in a single-story home, there are several dangers present for someone who is a fall risk (area rugs, a dog, etc.). Ellen is a woman who knows what she wants. As a younger woman, Ellen was a fantastic cook and world traveler, so the mental effects of her current condition have taken a toll on her. No longer able to cook and with time in the bathroom becoming increasingly dangerous, she is more and more dependent on John for daily tasks.

John too is having some difficulty adjusting to the new reality of Ellen’s condition. He still encourages her to participate in dance classes, taking long walks near their country home, and still hopes they can go on the trip to Greece this fall that they’ve been planning for the last 2 years.

Recommendation – It’s clear that Ellen needs assistance, but that could come from either Home Care or Assisted Living. The decision comes down to what John and Ellen prefer, to stay in their own home or to move into a facility. At the end of the day, it’s up to the Sanders to decide where they will feel most comfortable. While the 1-on-1 level of care for Ellen will be much greater using Home Care, John may prefer some of the social activities that an Assisted Living has to offer. Scenario 4 – Reginald Owens

Reginald is a 75 year old man who lives with his wife in their suburban home. Reginald has been relatively immobile for the last several years.

Recently his wife, Sheila, dropped Reginald as she was trying to transfer him from the chair into his bed. Due to the fall, he spent several weeks in a rehabilitation center where he developed bed sores. Due to what they describe as “neglect,” his family is very eager to get Reginald home.

Sheila is in declining health herself, with 2 bad knees that frequently bother her. She is also an inherently distrusting, irrational, and somewhat erratic person, often accusing repair men of stealing items such as mayonnaise and the TV remote. She also has some jealousy issues, keeping a close eye on each female nurse who attends to her husband.

The Owens’ have children nearby, but while concerned about their parents’ health, the children are busy with their own families and rarely involve themselves in the care process. Now that he is home from rehab, Reginald is mostly bed bound. He is also taking quite a large selection of medication due to the various complications of both long term inactivity as well as some standard effects of aging. At this point, Sheila is administering his medication, though there are some serious concerns over whether or not Reginald is receiving the proper medications and doses at the proper times. Due to her bad knees and his complete reliance on others for mobility, Reginald is not able to get to the bathroom; instead he is using a bedpan and receiving sporadic bed baths from Sheila. Recommendation - Reginald’s case is a difficult one. His declining health, immobility, and dependence upon a caregiver necessitate some sort of response as Sheila is clearly no longer capable of caring for him. Home Care may be an option if he would prefer to remain at home. The home aides could assist with personal hygiene, meals, ambulation, etc. while also keeping an eye on Sheila’s declining condition as well. Nursing Home care would also be an option, though that would separate the Owens’, which could accelerate Mr. Owens’ decline if he is emotionally distraught over being removed from his wife and home. Conclusion The range of care options for a senior is vast and comprehensive. It’s important to ask questions and educate yourself on what is available in your area. Again, the choices are broad.

If you have questions and want a professional, non-biased opinion on which option is best for you, contact a Geriatric Care Manager. The Geriatric Care Manager will, for a fee, do a full assessment of your senior and give a recommendation of which Home Care company or Facility would be the best fit.

Other services which are free to the family, like A Place For Mom, will do an over-the-phone consultation and give their recommendation on which Home Care company or Facility would be the best fit. One caveat here is that A Place For Mom charges a fee to the Home Care company or Facility to gain your business, so you’re more likely to only be provided a partial list of their “preferred” choices.

No matter what route you choose, the happiness and well-being of your senior is paramount. Best of luck with your search! Bibliography

In alphabetical order:

Caring.com

CaregiversLibrary.com

ChangingAging.com

LongTermCare.org

MarketWatch.com

Medicaid.gov

SeniorCareHomes.com

SeniorHomeBlog.com