Articles Posted in Skilled Nursing Homes

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During the week, I was presenting my “Senior Living Myths Unmasked – Separating Fact From Fiction,” to a group of business owners. As a senior living advisor, I told them that I always make certain that a skilled nursing community is certified for Medicare and Medicaid and to understand any stipulations relating to both. The response from several members of the audience was “Do you mean some aren’t?” Therefore, I would like to share an unusual incident that encourages exercising due diligence in understanding your loved one’s terms of permanent admission.

For the past several weeks, I have been assisting a woman whose husband was at home with a 24 hour caregiver. This arrangement had been in place for a number of years and the cost was becoming prohibitive. As much as she wanted to keep the current arrangement in place, she needed to move him in enough time to afford placing him in a top notch skilled nursing community. There were enough assets to pay privately for a number of years. But like many seniors, he would need to file a Medicaid application once his funds were depleted.

When I sat down with the wife, she gave me some location parameters. I immediately came up with a suggestion for a community that I felt would be perfect for him. My client was pleased because her husband’s primary care physician happened to be the community’s Medical Director. Although she was elated with my suggestion, she wanted to look at other communities for the purpose of comparison. I went home and chose 2 other communities to present to her.

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I remember when my 91 year old mother was admitted to the hospital after a mini-stroke (TIA), I was not caught off guard. She has had a history of having TIA for many years. As a senior living advisor, I have toured and evaluated over 400 senior living communities in the Chicago metropolitan area on the basis of cost and method of payment, level of care, staffing, quality of care, and other quality of life factors such as food and housekeeping. Therefore, I was prepared when it came time to choose a rehabilitation community for her. However, the institution of the 30 day readmission rules for Medicare recipients has made me more vigilant with watching as to whether she is admitted as an inpatient or under observation.*

The following story may not necessarily be directly related to the 30 day readmission rule, but it makes for some very interesting food for thought as you monitor your senior loved ones’ admissions, re-admissions, and discharges.

During a recent hospital stay, my husband was in a semi-private room because it was otherwise full. Due to the fact that he and his roommate were separated by nothing but a curtain, I overheard the situation involving his roommate’s admission. The man was a gentleman who was in his late seventies. He had been living at home, suffered a heart attack, and had broken his neck in some sort of fall or other incident. Most recently, he was placed in a senior community and was assigned to some rehabilitation. He was not cooperating with the therapists and was sent back to the hospital. His re-admission occurred at 1 A.M. Later that morning a social worker was in the room at 9 A.M. telling the gentleman that he was set for release that day. However, he was not able to go home alone; and, his daughter felt she was incapable of taking care of him.

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If a Medicare recipient needs to be admitted to the hospital in the near future, you will need to watch the category into which his/her stay is classified. The Medicare 30-Day Readmission Rules have imposed two classifications into which a hospital admission can be classified. The first classification is “inpatient” status. The second classification is “observation” status.

What is the difference between the two classes? If a loved one stays in the hospital for three days and is classified as an inpatient, they may receive up to 100 days of short-term rehabilitation or sub-acute care in a skilled nursing community that is covered under Medicare Part A. If an individual enters the hospital and is placed in the “observation” category, the stay is categorized as outpatient and benefits are paid under Medicare Part B. This sort of classification means that an individual is subject to co-payments and will not be eligible to receive the rehab. services in a nursing home. The bottom line is that the burden of paying for care is shifted to the patient who is in the “observation” category. The problem is that many people may not be aware of the difference between the two classifications, and that the patient does not benefit from being placed in the observation category. The Medicare program, however, will be saving a lot of money.

The new rules came to fruition through the Affordable Care Act. They are meant to cut back on the number of hospital readmissions that cost the government billions of dollars ie. the assumption is that the patient should be given the right care and discharge plans that will avoid readmitting him/her to the hospital within thirty days. If a readmission occurs within 30 days, the hospital will not be reimbursed by Medicare. The types of diagnosis that are being affected by these parameters include heart attack, pneumonia, and congestive heart failure.

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Whether you are moving your loved one into a high end assisted living community or a nursing home that will eventually accept public aid, it is mostly a heartbreaking event that is stressful for the senior and their family. Because it is such an emotional event, you need to be careful with what you promise to your loved ones who are lucid. Please read the following Real Life Story and you will understand what I mean.

REAL LIFE STORY I was hired to coordinate the transfer of and elderly loved who had children in the south suburban Cook county area of Illinois and a child living out of state. They had filed an application at one the supportive living communities. They had experienced some communication problems with regard to the admission and asked me to step in and expedite the process.

I always do an assessment of every senior that I place. When I went to conduct the assessment, I found the senior was not appropriate for supportive living. Here is a quick review of the type of care the supportive living program provides:

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For the first time in the seven years that I have been a senior living advisor, I actually told a prospective client not to move their loved one out of the current long term care community. About 50% of my clients come from the children of elderly loved ones who “did it themselves” the first time around. The result is often placement at the wrong level of care, or at a community that “looked nice,” but delivers poor care. This time, I actually discouraged my prospect from making a change.

The elderly loved one had been placed at a county facility and was paying privately. If I had done the initial placement, I probably wouldn’t have selected it as one of my top three choices. However, the community has a respectable reputation. The senior had begun rehabilitation in the short term rehab. unit. After the senior hit a plateau under Medicare, the decision was made to keep the individual in the long term care area.The family expressed concern over the fact that the staff was much smaller in the long term care area versus the staffing in the short term rehab. unit. Staffing is always better in the short term unit in opposition to the custodial care that the residents receive in the long term areas, a fact that the family was unaware of.

They also told me that they were disappointed that the staff appeared disinterested and was not “engaging with” their loved one. My answer was that most of the communities are understaffed. Nursing home care is not one-to one care, a fact that many of my prospects don’t understand until I explain it to them. On the average, a loved one could be sharing a certified nurse assistant with nine other residents, another fact they were unaware of. I explained if the expectation was to “engage” their loved one, they should hire a companion from one of the licensed home care agencies.

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In this past week, I have had many clients approach me with long term care placements involving potential shortages of funds. All of them were approaching what I call the long-term care “black hole.” Let me explain exactly what I mean by that as it will vary according to the level of care your loved one needs.

If your loved one needs skilled nursing care the costs in Illinois run about $6,000 – $9,000 a month. Some of the Alzheimer’s or dementia units can cost more. Right now, It is taking Medicaid (The Federal program designed for those who cannot pay for long-term care and administered by each state) close to a year to reimburse the nursing homes for residents who are participants in the Medicaid program. Therefore, most of the nursing homes want to see a resident pay privately for a year before submitting an application for Medicaid. Even the nursing homes that deliver less than desirable care are not making access to public aid easy. So, the bottom line is, if your loved one going to need nursing care, you should try to set aside at least $72,000 for their care if you’d like them to enter a better nursing home . If your loved one has less than that, they are in the black hole. You should expect some difficulty with the placement.

In the case of skilled nursing care, the number for the black hole is much easier to quantify. If your loved one needs assisted living, the amount of funds needed is more difficult to pinpoint. That’s because you have no way of knowing how long your loved one will remain at that level of care. Assisted living in Illinois can run $3,500 to $6,000 a month. I have seen some of the memory care units run as high as $7,200. You will have to make some financial assumptions if your senior may need nursing home care down the road.

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As a senior living advisor and Certified Care Manager, I always conduct a face to face assessment of my client. This gives me an opportunity to evaluate him/her from a cognitive and functional standpoint. I observe the environment s/he is living in, talk with the family about the individual’s personal history, finances, and support system. That way, I can make an assessment of how I can improve the senior’s quality of life by recommending services that allow them to remain at home (That is, via the most economical and efficient services). Or, I can help them ascertain whether placement in a community would be more appropriate. In either case, I always include the senior in the care plan if they are able to participate. Just as I do my “in person” due diligence, you should do the same when researching senior living options. Here is what you should expect if you rely on the internet as a credible source of information:

1. I recently used Google to research the words “Chicago nursing homes.” I received over 44,000,000 returns. When you look at the websites for long term care communities, they rarely give you in depth information, and the prices are almost never listed.

2. Some of the websites will show the viewer the most newly decorated or beautiful areas of the property. They neglect to show the overall big picture. I have arrived at many of these organizations to find that the pictures on the site were no reflection of what the community was really like. Conversely, some of my clients have looked at the sites for the communities I have recommended to them. One my my clients reportedly logged on, and told me she was disappointed with how dingy and oppressive they looked. In truth, the facilities were beautiful and the pictures that were posted didn’t do them justice.

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I have been involved in two recent cases where I was hired to provide a second opinion to seniors who were seeking to move to a Continuing Care Retirement Community* (CCRC) in Cook County of Illinois. I wasn’t surprised to learn during my initial consultation that neither of them knew how to differentiate between the types of contracts that were available. I have listed a summary of each type of CCRC contract below and a broad definition of the entrance fee that grants access to them:

Entrance fee – An amount of money that allows a senior admission to the community and guarantees the future health costs of all the residents that reside there. A portion of the fee can be refunded to the individual or his/her estate if s/he moves out or passes away. The money is usually not refunded until the unit has been re-occupied, which is a fact that most people aren’t aware of.

Type A Contract -This is referred to as a “true” Life Care contract. Certain types of care are included in the CCRC’s contract for individuals who enter the community at the independent level (ie. the senior can care for themselves) and have passed the requirements of a financial application. Monthly fees don’t increase as a result of moving to a higher level of care such as assisted living or skilled nursing, except for the cost of extra meals and other personal expenses. If you have a member of a couple who requires the higher level of care, but the other does not, one can remain in the independent living area while the other moves to the higher level of care. The couple continues to pay only for the monthly fees charged for independent living. For example, a couple enters at the independent level and the monthly fee is $2,000 per person. One of them suffers a stroke and needs to move to the assisted living area. S/he is still only responsible for the $2,000 fee plus the cost of extra meals and expenses. The person remaining in independent living pays $2,000 as well. This is a wonderful contract as the costs of future care is predictable!

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This is a question that is asked of me and often causes controversy among the families that I serve. My goal is to find the best answer, and every situation is different. In the seven years that I have owned my senior living business, no two cases have been exactly alike. However, when a senior is still capable of making his/her own decisions, s/he almost always wants to remain in the home as long as possible. The only exceptions to the rule are if a senior is lonely and wants the socialization of being in a community, ot if medical issues no longer allow the senior to remain at home, or s/he can no longer afford the luxury of in-home care. Placement in a community is often the second choice to remaining in the home and normally arises when the senior is exhausting their funds. However, caution needs to be taken with this strategy, as many nursing homes are requiring a year or even two years of private pay before a person is admitted. This insures against the immediate filing of a Medicaid application, which can take up to a year for a resident’s reimbursement.

If you have a senior loved one who may need some help with his or her activities of daily living, I share below the ballpark figures for non-medical home care and long-term care community costs in the Cook, Will, Dupage, Lake. and Kane Counties in Illinois.

Non-Medical

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Couples who want to remain together but require different levels of care always present some very complicated challenges. One person may want to stay in the home, the other may not. A member of a couple may develop health challenges that may necessitate a move to a nursing home due to medical and financial reasons. I always show people the costs of both stay-at-home care and moving to a community. The problem with the latter is that many communities are not set up to accommodate different levels of care. A community’s capacity to handle multiple levels of care depends upon the way its apartments are licensed. Some communities are capable of handling residents who are on the independent level and who need assisted living (standby care and some hands on care with bathing, dressing, eating, toileting, transferring, and walking), often referred to as “swing apartments” because they are licensed to accommodate people at both levels. The situation becomes more complicated when one person needs nursing home care and the other remains at the independent or assisted level. Nursing home care requires yet another level of licensing which doesn’t allow couples to remain together unless their health issues require it. (For example, a person who is independent cannot occupy a nursing home room with his/her spouse unless s/he too needs the care). I recently worked with a couple who needd help sorting through these issues, as exemplified in the following real life story.

REAL LIFE STORY

My clients were the children of parents in the Chicago metro area who were in their early seventies (clients who were much younger than those I normally work with). Their parents were living in a lovely home with an urban setting. Their mother had been suffering from a disease that caused recurring seizures every few years. The latest bout with the disease caused her to be sent home with a full-time, non-medical caregiver who was costing them $350 per day. Their mother needed help with most of her activities of daily living, but could feed herself and walk with a walker. Their father, on the other hand, was independent. The caregiver was also preparing their meals, doing light housekeeping, and running errands. The children hired me because they lived in a suburb more than 20 miles away from their parents and were busy with their own families. They wanted their parents to move to the same suburb. In addition, they were uncomfortable with the existing home care arrangement because they felt there was no ongoing support system in case their mother became more ill. They were not comfortable with the “live in” situation and preferred to order a lesser number of hours if possible. The cost of maintaining the home plus the home care services was becoming prohibitive. The parents had been married for 50 years and wanted to remain together as long as possible. The dad was not social and wanted to “do his own thing.” During rehabilitation, the mom had enjoyed art therapy classes, such as water color painting, and music appreciation classes. I was instructed to find a community that would allow the couple to continue their current living situation, with a continuing care support system, in the kids’ suburb, with opportunities for socializing for their mom. I was able to come up with three options in their requested location.

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