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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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Intermediate care is a level of nursing care available for those seniors who are in need a little bit more care than what is provided in assisted living communities. Yet, it provides a level of are that is lower than what is provided in a skilled nursing home. Here is a brief explanation of what each level provides to the senior:

Assisted living – The senior needs help with his/her activities of daily living (ADLs) meaning bathing, dressing, walking, toileting, transferring, and eating. The care is normally standby assistance. However, hands on care is available at some communities for an additional charge.

Intermediate care – The senior needs hands on help with some of his/her activities of daily living and needs 24 hour supervision with a nursing home staff present. S/he doesn’t require skilled nursing care yet.

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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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Many of my clients are surprised when they are told their senior loved one has “reached a plateau,” with his/her assessment for the appropriate level of care upon their release from the rehabilitation community is going to be key for your loved one’s long term plan of care. If your loved one requires two people to assist him/her with activities of daily living (bathing, dressing, eating, toileting, transferring, and walking) they are not suited for skilled nursing care. It is always in your loved one’s best interest to begin at a higher level of care and move them down (ie. from skilled nursing to assisted living) to a lower level of care.

2. While your loved one is partaking in their short-term rehabilitation, take a look at their long-term financial picture. Most of the nursing homes in the State of Illinois are requiring one to two years of private pay before allowing an application for Medicaid to be filed. It is taking the State of Illinois up to 14 months to reimburse the nursing homes for their public aid residents. That is the reason for the stringent qualifications. The temptation to place a loved one in assisted living in order to avoid the stigma of placement in a nursing home will be present. If your loved one needs the medical care, think with your brain and not your emotions.

3. When you are ready to begin tours of communities, remember there are advantages to making a confirmed appointment rather than taking a “walk in” tour. Then, you will have an opportunity to speak with the Admissions Director who is an expert on what the facility has to offer. Otherwise, you will be given a tour by whoever is available. This may result in a poor tour and cause you to discount a perfectly good community.

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If you carefully scrutinize the activity schedule at a long term care community and correlate it to the seniors needs, his/her independence could be enhanced.

I was the Admissions Director of a Continuing Care Retirement Community located in Cook County near the Chicago metropolitan area. Many of the children who came to tour the home told me they were concerned that their loved one would lose their independence if they moved to a retirement community. It used to amuse me that after expressing this concern, the children would spend so little time studying the activity schedule. Instead they would remark, “Oh this is great! They have bingo, baggo, and bunco!” I used to refer to it as the “three Bs!” While it is important to many seniors to have bingo available, you will have to be more thorough when assisting them with finding the right retirement community if you aim to preserve their independence. Studying the activity schedule to ensure that a community is providing serious mental stimulation for seniors is a task that shouldn’t be taken lightly. As a senior living advisor who has evaluated hundreds of long term care communities in the Chicago area, I can share some activity tips with you.

I have seen many of the retirement communities offer brain fitness programs in order to keep their residents mentally fit. Some of the homes will allow your loved one to participate in their brain fitness programs as a non-resident of the community. I enrolled in one of the classes at a local retirement community because I was curious to see what the programs had to offer. They were offering the brain training program created by Posit Science, that can help anyone exercise their memory and enhance the ability to focus. Although the program is computer based, the senior doesn’t have to be computer literate. They only need to operate a mouse. There were many independent seniors who were taking the course to enhance their driving skills. One of the programs simulated a fictitious car ride where dangers such as a child chasing a bill into the street popped up on the screen. The program requires the driver to react quickly in order to avoid having an accident.

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If your loved one requires a Medicaid bed in the Chicago metropolitan area and the payor source is Public Aid Pending (PAP), you may be in for a difficult encounter. What do I mean by Public Aid Pending? It means that an individual needs the support of the Medicaid program (Federal system administered by each state that grants assistance for long term care to people who can’t pay privately.), but his/her application is in the process of being prepared. Or, the application has been prepared, filed, but isn’t approved with a case number. Due to the implementation of the SMART Act (Save Medicaid Access and Resources Together), Illinois is now one of the toughest states in which to obtain Medicaid.

Right now, the nursing homes aren’t too willing to accept residents who are in PAP status. That’s because if a resident enters in this status, the nursing home receives no reimbursement for their care until the case is approved and stamped with a number. In addition, it can take up to three months or longer to get an application approved. Plus, many of the nursing home representatives that I deal with are reporting that reimbursement from the state is currently nine months or more in arrears. In total, you may be looking at a year before a nursing home receives payment for a public aid resident. Therefore, most nursing homes are asking that a resident has at least one or two years of funds to pay privately before filing a Medicaid application.

Here are some issues I have encountered while searching for Medicaid beds for my clients. many of the nursing homes are simply not accepting anyone in Public Aid Pending status because their censuses already have too many residents applying or waiting for approval. Please don’t panic. You will find a bed for your loved one, but it may not necessarily be at your first choice of communities. If your loved one is currently at a nursing home for a Medicare stay (That is the federal program for short term rehabilitation at a long term care community.), and you know there is no way the senior can return home permanently, begin your application process immediately. Ask the Admissions Director if there is a Medicaid bed available so your loved one can transition from Medicare to Medicaid. If a bed will not be available, use your loved one’s remaining Medicare days as a bargaining tool with another community that might have a Medicaid bed available. That way, your loved one can transfer and their new home can be reimbursed by Medicare while you are filing the Medicaid application. The Admissions Directors are more likely to help you if they know the community is going to get some payment from Medicare while waiting for the Medicaid application to be approved. I will also note that many of the nursing homes want the prospective residents to use their, “financial specialist,” to file a Medicaid application, rather than using an alternative source. If the resident uses their resource, the home is assured of collecting as much private pay from the resident as possible.

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I have been receiving a fair number of requests to assist families with the placement of loved ones who have psychiatric issues. Many of them have had episodes with violent behaviors. Unfortunately, there are no easy solutions to these types of placement problems, and under no circumstances do these placements resemble a typical nursing home placement. A nursing home is simply not a dumping ground for a senior who exhibits psychiatric behaviors. If you call a nursing home to inquire about a bed for someone who has bipolar manic depression, schizophrenia, or Alzheimer’s disease with disruptive behavior disorder, it is likely the response you receive won’t be positive. That is because there is a real lack of Geriatric-Psychiatric (“Gero-psych”) care available for seniors around Cook, Du Page, Will, and Lake Counties in Illinois. For instance, there are only about 6 nursing homes in Du Page County that can handle psychiatric illness effectively. There are more in Cook County. Most nursing homes don’t have the staff with training to accommodate the one-on-one type of attention seniors with mental health issues require. They may be a danger to themselves and their fellow residents.

Here’s what you can expect if you enter the senior psychiatric arena in the Chicago metropolitan area:

1. Most of the homes that handle mental illnesses (Institutions for Mental Disease or IMDs) are at the intermediate care level. The residents are often ambulatory and many are not elderly. The residents need their medications administered to them and sometimes need help with some of their activities of daily living. Depending upon the seriousness of his or her mental condition, the resident may be allowed to check in and out of the facility on a daily basis. There is a lack of locked units that treat psychiatric illnesses that many seniors who wander require.

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As a senior living advisor, I recommend that my clients who are at the independent living or assisted living level take a trial stay at a long-term care community before they make a commitment to move in. This will allow a senior to sample the food, try the activities, socialize with potential fellow residents, and decide if they like congregate living.

Sometimes the communities will not allow a trial stay. At other times, it may be required that the senior stays for at least 30 days. Personally, I am in favor of the 30 day requirement, because a stay of two days or a week isn’t going to give the senior the ,”big picture,” of retirement community life.

A short stay or “respite” at a senior living community is normally treated like a regular admission. The senior may have to submit a medical history and physical form from their primary care doctor, along with the results of a TB test that is negative. This information ensures that a community can meet the resident’s medical needs. I recommend that my clients request the medical information several weeks prior to the anticipated admission. Collecting the information from a physician’s office can be extremely slow and often delays the admission process. Many physician’s will not complete the forms unless they have seen the patient recently. The homes also will not accept medical information that is too old.

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A recent article published in the Washington Post portrays a very biased picture of assisted living communities. The writer is a former Zen monk and journalist. I encourage you to read the article and take note of the facts that were left out of his side of the story.

The author writes the he, “decided,” to move out of his home at age 53 to an assisted living community because he had Parkinson’s disease. He neglects to mention the reason as to why he made the decision to move. Did he move because he wanted the socialization of being with other people? Was his condition becoming too complex to be handled at home? Were his funds being depleted? Could his caregiver have been experiencing “burn out?”

The article states that he knew his future fellow residents were going to be much older. Yet, he complained about watching his table mates, “waste away,” and die.

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