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Approximately 40 million Americans today are caring for an elderly loved one. Are you one of them? The demands of caring for an elderly loved one along with your own family can be physically and psychologically challenging. If you are employed, the additional responsibility of becoming a family caregiver might not be feasible for your schedule. In addition, the role reversal experienced between the “adult-child caregiver” and the elderly parent can lead to resentment and stress. If you must relinquish caregiving responsibility, the question ultimately becomes, “Should I place my loved one in a long-term care community or hire someone to help care for him/her at home?

This question is continually 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 nine years that I have offered my senior living services, no two cases have ever 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 exemptions to the rule are if a senior is lonely and wants the social benefits of being in a community or medical issues no longer allow the senior to remain in the 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 his/her funds. However, caution needs to be taken with this strategy as many nursing homes require 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 entail months for a long-term care community to receive reimbursement (from the state) for a resident’s care.

If you have a senior loved one who may need some help with the activities of daily living in the future, ballpark figures (based upon national averages) for non-medical home care and long-term care community costs are listed below to assist in making your decision:

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Any situation involving a senior and the analysis of the best senior living option for him/her is going to be fraught with emotion. That is why you need to take extreme caution that your sources of senior living information is reliable. Occasionally, I’ll hear a client object to a certain long-term care community that I present among options. The client will say something like, “Oh, my cousin had a terrible experience there 30 years ago!” Please bear in mind that organizations and their philosophies change over time, as do their staffs, and most importantly the Administrator. Or, someone may tell me, “My friend had a big problem at that place!” Please be certain you get the specifics of what the big problem was. Many times, relatives of the senior may be to blame, as they might not comply with the requests of the long-term care community, or their expectations are too high. For example, I once had clients tell me they expected the Certified Nursing Assistants (CNAs) at their father’s nursing home to sit down and play a hand of cards with him. This is not a reasonable request when many nursing homes are understaffed.
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Real-Life Story
My clients were two siblings of a relative who had a terminal illness. Both siblings lived out of state. The relative had hit a plateau with physical therapy and was due to be released from the hospital in several days. The siblings both lived out of town and were grappling with whether to send the sibling home with non-medical home care and hospice care or to admit her to a long-term care community, with hospice care. While we were in the midst of the consultation, I learned that their friend, a retired medical professional, would be joining us.
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I recently had a conversation with a family whose loved one was diagnosed with terminal cancer. The loved one was taking a drug that caused some very severe reactions including nose bleeds, diarrhea, and skin outbreak. The person’s primary care physician encouraged the family to keep the patient on the drug, as it could add some precious time to her life. In contrast, the physician at the nursing home where she was completing her rehabilitation encouraged the family to place her on hospice, rather than prolong her life. As this raises very emotional and controversial issues, I have asked the experts at Rainbow Hospice to provide an explanation of hospice care, what it is and is not.

Understanding Hospice

Valerie Nikolas
Marketing & Communications Specialist
Rainbow Hospice & Palliative Care

What is hospice?

  • Comfort care
  • Support and encouragement
  • A celebration of life

Hospice is physical, emotional and spiritual support for patients and families living with serious illness. The goal of hospice care is to provide pain and symptom management as well as comfort, but not to offer a cure.

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089I remember when I received a phone call from an 82-year-old client who was crying piteously. She needed to move to a senior living community because the upkeep on her house was just too burdensome. She was terrified that she could not take her 80-pound Labrador with her. In addition, she wanted to continue to send the dog to the same doggy day care organization on a daily basis because the dog loved the socialization with the other dogs.

Although my initial phone calls to area senior living communities were met with some raised eyebrows from several of the Admissions Directors, I was able to find my client a beautiful apartment with a sliding back door and a backyard. She could lead the dog straight out the back door. In addition, it was within the specified distance so the doggy day care bus could still pick up the dog!

Generally, here are the rules regarding pets at senior living communities:

  1. Although a dog weighing under 40 pounds is typically not an issue, you can use some bargaining power for dogs that are bigger. Many independent living communities are not full. Most Admissions Directors will be willing to accept a dog as long as the senior can take care of it and it is well-behaved. Cats are not a problem.
  2. Assisted living communities (non-memory care) are willing to accept a dog or cat as long as some provision is made to take care of the animal. Many places charge an annual fee, up front, to assist with taking care of the pet.
  3. If your loved one needs to move to a nursing home, you need to make other arrangements for a pet. Many nursing homes have a community dog or cat. But, you will have to make arrangements to have your loved one’s dog visit.

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Sometimes, the last person a senior wants advice from is his or her own child. After all, a senior loved one is the person who may have changed your diaper. The role reversal that occurs as a senior ages can be psychologically painful for him/her as the child now takes on the parental role. As a result, the senior may not want to listen to what the child has to say.

I am often hired to intercede in situations where a senior is reluctant to move or an independent senior is “sitting on the fence” as to whether now is the time to move or stay at home.

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Real-Life Story

I was hired by the child of a senior whose parents were taking a trial stay at a local Continuing Care Retirement Community (CCRC). I was hired after the trial move had occurred. The parents had lived in their own home, which was located two hours away from their two children. Although independent at this point, each parent had health problems that would require attention in the future. Both adult children had health issues of their own and admitted to me that travelling to the parents’ home to take care of housecleaning, errands, and well-being checks was getting to be too much for them to handle. One child had taken on more of the responsibility for their needs and was failing rapidly from a health perspective. I was informed that both parents had come to rely upon this particular child and were totally oblivious to the fact that it was becoming a burden to her. In addition, I was told that the neighborhood where the parents lived was changing, and the windows to the house had been shot out twice over a two-year period. Due to the neighborhood decline, home care wasn’t an option. The entire family was fighting, the parents would not list to their children, and one child told me they were considering family counseling. In addition, the 30-day trial at the CCRC was coming to an end, and the parents had their bags packed to move back home.

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When I started in the senior industry over 15 years ago, “independent living” at a senior living community meant that the senior could take care of him or herself. He or she might require some assistance with meal preparation and housekeeping; however, the senior had to be able to ambulate on his/her own. In the worst case scenario, a walker might be used. The resident also had to bath, toilet, eat, transfer, and dress without help. With today’s emphasis on having a senior “age in place” in their his or her own apartment, I’ve witnessed independent living become the new assisted living.

While this change has been evolving for years, I have noticed that the process of assessing the a prospective resident for independent living has become much more lenient. There are so many ancillary services that can be brought into the senior’s independent living quarters apartment that it resembles assisted living or a nursing home without the licensure. Here are some examples of the services that can be brought into independent living and the typical costs:

Morning and evening assistance – $18.00 per 20 minutes – includes getting the senior out of bed, helping with hygiene and dressing (not bathing)
Bathing – $24.00 per 30 minutes
Escorts to meals and activities – $9.00 per escort
Medication Set-up – $37.00 per week, Medication Reminder – $8.00 each
Laundry – $9.00 per load
Routine safety checks – $6.00 each
Other services such as live in companions can be hired starting at about $200 per day.

But if a senior needs additional help with activities of daily living (bathing, dressing, toileting, walking, eating, and transferring), the price increases. Extra housekeeping and additional meals can be purchased (in independent living, one meal is usually provided).

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There is always danger involved with the choice of hiring a non-licensed caregiver. This time, a disaster occurred right in my own backyard. The choice to hire a private caregiver directly instead of through an agency may have cost a North Riverside man his independence. Charlie Matuska, who is 79 years old, followed the advice of a neighbor (and friend) and hired David Kowalsky as a private caregiver.

Mr. Kowalky had cared for Mr. Matuska once before, prior to some hip surgery. At that time, Mr. Kowalsky had been employed by the Visiting Angels, a non-medical home care agency in Brookfield, Illinois. (Non-medical homecare agencies, like Visiting Angels, hold a license with the State of Illinois. Licensed agencies are responsible for the employer-employee relationships with their caregivers, conduct backround checks, adhere to a code of ethics, and participate in ongoing training). When it became apparent that Mr. Matuska needed to have a caregiver help him on a full-time basis, the friend assisted him with hiring Mr. Kowalsky on a full-time basis, but not through Visiting Angels.

Please note that this sort of hiring takes place all the time. If a caregiver starts out caring for a client through an agency, the client often hires them directly at a cost that is significantly lower. For instance, it was reported in the Landmark Newspaper, that Mr. Kowalsky was being paid $700.00 a week to care for Mr. Matuska. As a Certified Care Manager, I know the price of a 24-hour caregiver can cost $220-$240 a day in the western suburbs of Chicago. And by hiring a caregiver directly, a client will also forgo the supervision of agency management ie., the unannounced check-ins that are performed by a person of supervisory capacity to see the client is being cared for appropriately.

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In my opinion, Medicare Advantage plans were never a smart purchase. That’s because many people don’t understand they are not a Medicare product. They are programs that are underwritten by private insurers. The claims are adjudicated by the private insurer as well. Upon purchasing a “Medicare Advantage” plan, the insured waives the right to have his or her claims paid by Medicare. Yes, the private insurers do have to follow all of the rules of Medicare. But, the private insurers can offer different plan designs, including different deductibles and out of pocket limits that are the insured’s responsibility.

I worked in the health insurance business as both a broker and company representative selling group health insurance to medium and large size corporations. I remember the company underwriters would cringe when they saw a group submission that contained more than 20% retirees on the census. Elderly people tend to be sicker and submit more claims than younger folks, so a large proportion of retirees on a census sent out signals that the case wouldn’t be profitable. So what was the solution? Many companies removed the seniors from the group plan and purchased Medicare supplements for them and their spouses. I saw many major corporations buy Medicare Advantage plans for the retirees due to the cost savings offered by the plans at that time. Today, so many companies have discontinued covering retirees that any coverage is a gift.

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During a recent presentation to a group of independent seniors, a gentleman asked me if there were any rating systems available for Continuing Care Retirement Communities. Here are the some resources that I find helpful:

If you are looking into the financial strength of a Continuing Care Retirement Community (CCRC), the Fitch Ratings are helpful. Lest this recommendation sound too “money oriented” to some readers, here I note that it is only natural – and prudent – to want a senior living option where the community has both the resources and the stability to ensure a high quality of service to its clients, and for years to come. Fitch Ratings were founded over 100 years ago by the Fitch Publishing Company, a provider of financial statistics. The ratings are comprised of credit rating scales that give a snapshot of the organization’s potential to honor its financial obligations. This could include repayment of principal, interest, dividends or insurance claims.

Basically, Fitch Ratings are credit rating scales that indicate an organization’s potential for honoring its financial obligations to its investors. (In one sense, seniors “invest” when they select a CCRC). Grades ranging from ‘AAA’ to ‘BBB’ (described as investment grades) are assigned to those operations that fall into the low to moderate risk category. Grades of ‘BB’ to ‘D’ are assigned to operations with “speculative grade” or a greater level of credit risk. Some operations carry a grade of “NR,” which indicates they have not been rated by Fitch.

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The recent CBS investigative report regarding the cases of alleged neglect at a national assisted living chain held no surprises for me. I began my career in the elder care industry fifteen years ago when assisted living provided only “stand by,” assistance with activities of daily living (ADLS = bathing, dressing, toileting, transferring, walking, and eating). Several years ago, I made the observation that many of the assisted living communities were offering more “hands on” care to their residents. At the same time, I also observed that they were accepting residents who really belonged in intermediate nursing care or a skilled nursing community*. Being a former Admissions Director and with my current position as a senior living advisor, I thoroughly understand the current long term care market conditions.

The Admissions Director is the most important contact at a long-term care community. He or she is responsible for attracting and residents, while maintaining a high census. Many Admissions Directors also act as marketing liaisons. They provide your first impression of a long-term care community, and often are a direct reflection of the care your loved one is going to receive. They are also responsible for the initial assessment of the type of care that is appropriate for the senior. It is important to bear in mind that Admissions Directors are often commissioned salespeople. They are accountable to, “the powers that be,” for maintaining a high census. I can remember the terrible pressure that was exerted upon me by the management in order to keep filled the continuing care retirement community where I was working. Scarcely was a bed emptied before pressure came to fill it. The passing consolation that the seniors, “were called home by God,” just didn’t cut it in terms of lightening the pressure for quick turnarounds. I know that with a bad economy, the pressure is even worse.

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