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During the past several months, I have been hired to find senior living options for many clients who have been diagnosed with depression. Some of them have been at the independent living level of care. I was fortunate to sit down with several of my clients and find out what it is like to have the disease. I must admit that I have a new sympathy for anyone with the diagnosis.

Depression is a disease that is characterized by feelings of sadness and at times uselessness that affect an individual’s ability to function. The causes aren’t known, but some of the things that are thought to to cause it are changes in the brain, family history, environment, and life’s experiences. For example, senior’s become very depressed after the loss of a spouse. During the holidays, the depression often intensifies as the senior further contemplates the loss of a loved one.

My clients have shared that they often feel tired, restless, irritable, worthless, and have trouble sleeping. On the other hand, they may sleep too much or overeat. They also experience symptoms like a stomach ache that won’t go away, excessive crying, strange thoughts and thoughts of suicide. No one’s symptoms are ever the same. The depression can also be masked by other illnesses for which the senior has already been diagnosed and is taking medications.

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I read the attached article, “Adult Children Ignoring Confucius Risk Lawsuits in China,” about the elderly having the option of suing their children if they don’t visit them enough while they are in a long term care community. I used to be the Marketing/Admissions Director of a large Continuing Care Retirement Community where I dealt with admitting seniors who were at the independent, assisted, or nursing home levels of care. The article made me reminisce about acting as, “manager of the weekend,” and some of the experiences I had with family members who were regular visitors. In other words, the families were the polar opposites of the “no shows” referred to in this article.

As manager of the weekend, each staff member at the community had to take a turn at watching over the place. This meant taking care of the needs of the residents, as well as meeting and greeting the family members who came to visit on the weekends. The manager was instructed to walk the hallways to observe cleanliness and anything that seemed out of the ordinary. Another assignment was to circulate in the dining rooms during meal times, ask the residents about the acceptability of the food, and to eat the food to make our own assessment. The best part of acting as the “manager of the weekend” was that I got to see all of the visiting family members that I had previously been involved with during the admissions process. However, I chuckled at the content of this article because some of the families didn’t deserve to be penalized because they didn’t visit enough. They deserved to be scolded for what they did while they were they visiting loved ones, particularly the seniors who were at the independent level. Let me share some of the events with you.

There was a woman who had lived at the community for a number of years and was practically a model resident. She never had a single hair out of place and was always dressed in the latest fashions with a hand bag to match. She had a son who lived in the neighborhood. He visited her each weekend without fail. One time I noticed a large bottle of liquor in her room. Residents at the independent level were allowed to keep liquor. Since independent living is just like an apartment building, there were no rules against it. I was told by another staff member that she kept it to offer her son a cocktail when he visited. The problem was that while I was walking the hallways after the son had left, I found her wandering the hallways half looped on several occasions. I had to escort her to the dining room to make sure that she ate. The same thing happened with another resident whose girlfriend picked him up on Saturdays to take him out for dinner.

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I am often confronted with some interesting family dynamics when a family hires me to consult with them. At times, the children are willing to accept my advice without reservation. Sometimes, there is often one child who wants to prove that s/he can “do this on her/his own.” While there is usually one child who emerges as the spokesperson for the family, the choice of the right care should be the result of a family consensus and not the persuasive skills of a ringleader. Consensus should be coupled with careful comparison of cost and methods of payment, level of care needed, staffing considerations, location, and quality of care involved with all the senior living options. Please read the following “Real Life Story,” that exemplifies my point

Real Life Story

One of my clients who did not follow my initial advice contacted me last week. She was unhappy with the care that her Mother was receiving at an assisted living community that specializes in memory support.

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When I am hired by a family whose loved one has Alzheimer’s or some other form of dementia, my thoughts immediately turn to my Father. My Mother, who is a registered nurse, insisted upon caring for him at home until his medical conditions forced his transfer to a nursing home. He had been one of the charter physicians who helped open a major hospital in the 1960’s. Because of this fact, my Mother felt obligated to place him a nursing home that was owned by the hospital. It was centrally located for most of my family members, except for my husband and me. We would travel 25 miles every night after work so that I could visit him. The commute exhausted both of us. The poor care resulted in my Mother making a decision to move him to a nursing home that was closer to her, but even further away from us. The care and compassion that he received at the new nursing home was the difference between night and day. I just had to resign myself that I was going to see him less. As a senior living advisor, I always tell my clients that location is important but it shouldn’t be the sole factor in choosing a long term care community.

REAL LIFE STORY

My clients were an 82 year old woman and her children. Their Father was at home with two caregivers who took care of him in 12 hour shifts. He was diagnosed with Alzheimer’s disease. His behavior was becoming very difficult to the point where he was a two person assist. The family was in favor of placing him in a long term care community. There was one child who volunteered to move him into her home. Her intent was hire a number of caregivers to accommodate the two person assist.

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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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The firestorm controversy regarding the refusal of a retirement community nurse to administer CPR to an 87 year old resident of its independent living section has been fueled, in part, by faulty media coverage. On the morning of March 4, 2013, I heard a reporter on a local news radio station in Chicago refer to the Glenwood Retirement Community in Bakersfield, California as a “nursing home,” which is a mistake. Many national news announcers made the same mistake. The more accurate terms would have been “senior retirement community” and “independent living.”

The distinctions do make a difference — not necessarily for the moral and ethical implications of the case (which are gravely serious and merit solemn discussion in a nation founded on life-affirming Judeo Christian values), but for the majority of Americans who might not understand the wide range of senior living options.

Glenwood Gardens is a community that offers independent living. The independent living unit where the decedent lived does not require any sort of licensing. Glenwood’s licensed assisted living units and nursing home are located on adjacent property. The independent living facility is not unlike a regular apartment building. Its residents are supposed be able to function with very little assistance except, perhaps, for some meal preparation and housekeeping help. Therefore, during the widely reported incident, the Glenwood nursing staff member was following business protocol when she called 911. Her choice not to administer CPR to the resident who later died is something that she will have to live with for the rest of her life.

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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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The prospects of alternative living options for people with dementia who are under the age of 65 are not plentiful. Although there are assisted living communities offering memory support for prospective residents under the age of 65, the pay source is strictly private. I have been faced with situations where the prospective resident has been in their early 50s and had severe Alzheimer’s disease. Unfortunately, the family lacked the funding to pay privately at an assisted living community. I had no other option except to assist the family with placing the individual in a nursing home that would accept Medicaid.

As a senior living advisor, I must persuade my customer’s to accept options that are less than optimal because there is nothing else available. In the following Real Life Story, I had the long term solution to my prospect’s problem, but the individual is still contemplating other arrangements.

REAL LIFE STORY My client’s sibling is only 51 and has early onset dementia. The individual was living alone in an apartment quite far away from the rest of the family. The person had worked at the same job for many years until it was apparent that the symptoms caused poor job performance. The person was dismissed from the job. The person had a monthly income of less than $900. The person also had a 90 pound dog that needed to be cared for. Yet, the individual could perform all of the activities of daily living. A recent neuropsychological report stated the person was capable of holding down a job with repetitious tasks. However, her sister was worried about her care on a long term basis and safety issues.

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I have been working with a lot of families who are not familiar with the differences between types of services that are provided at the independent living, assisted living, and nursing home care levels. The result is that they waste a lot of time touring communities that are inappropriate for their loved one. It is even worse when a loved one is placed in a community at the wrong level because it is cheap. I have seen instances where an admissions director often convinces an uneducated family that their loved one can survive at a level of care that is inadequate for their needs. Bear in mind, there are a lot of communities with low censuses and apartment/rooms that need to be filled. The bottom line is that if the senior cannot function at a level of care that is too low for them, s/he is the one who suffers!

A Real Life Story Continued From Chicago Senior Living Advisors Blog November 18, 2012

I had written a partial Real Life Story about this incident recently. Here is part two of the story. My client is an 86 year old woman. I am her Power of Attorney For Health Care. She has severe short term memory issues, is incapable of handling her finances and medications, and as of late needs standby help with her activities of daily living. Her former Power Of Attorney For Healthcare (who resigned from the position and resides out of state) placed her at the independent level because it was cheap. Independent living means the senior can function on their own, with some help with housekeeping and meal preparation. I was assigned to the position the day before she was supposed to move. She was already objecting to the move. It was too late and she really needed to be in an environment that had some semblance of supervision. In my opinion, she really needed to be in an assisted living community with a memory care unit. Memory care units provide structured activities, 24 hour supervision, and heavy cuing plus standby assistance with activities of daily living.

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