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When a Loved One Is In Between Levels of Care, Let Him or Her Start at The Higher Level and Work Down From There

As a former Admissions Director of a continuing care retirement community (CCRC),* it was my responsibility (along with the community nurse) to assess prospective residents for placement in the appropriate level of care. During many consultations with my clients, I’ve found that people often don’t understand the different definitions of the levels of care that are offered by long-term care communities. Here are some very basic, broad definitions:

Independent living – The senior can perform all of the activities of daily living** on his or her own. S/he may want/need some assistance with meal preparation and housekeeping.

Assisted living – The senior needs help with some of the activities of daily living. It isn’t “hands on” care. It is normally stand by assistance. For example, a senior may need some assistance with a bath or a shower. However, the aide will hand the senior the wash cloth and soap and perhaps help wash any part of the body the senior cannot reach. It isn’t a full scrub down shower like those provided in the nursing homes. However, I will place a caveat on this definition. There are some assisted living communities that are based on a medical model where more “hands on” help is offered; e.g., the person needs total assistance getting in and out of bed. The presence of a nurse and his/her functions will vary according to each assisted living community.

Skilled Nursing – An individual requires hands on assistance with most or all activities of daily living and has a medical issue that requires 24 hour care and the presence of a nurse (e.g., a feeding tube or tracheotomy).

I was taught and continue to hold that, if a senior is in between one of the levels of care mentioned above, the rule of thumb is to start the senior at the higher level of care and then move the resident down if his or her health and ability to self care improves; e.g., from skilled nursing to assisted living. Starting a senior in a level of care that is lower than what he or she requires, then hoping or praying that s/he will succeed, is a recipe for disaster, as illustrated in this month’s real life story.

Real-Life Story

My clients were relatives of a man who has a debilitating and currently incurable neurological disease. When I was initially hired for the consultation, the senior, who was in his mid-sixties, was living independently in his own home. The senior’s income was around $6,600 a month. The son hired me because the full-time caregiver, a friend, developed her own health issues. The degenerative neurological disease was progressing and it was apparent that the dad was going to need a lot of help down the road. When I met with the family for the first time, I was pleasantly surprised to see that the senior was ambulatory, had a tremendous sense of humor, and, at worst, simply needed a medication reminder with some standby assistance with a bath or shower. This senior was willing to move to a retirement community because he wanted the benefitof the socialization. I went back within the next two weeks with three recommendations for a potential move to continuing care retirement communities near the senior’s sisters, as requested. The man’s adult child, however, lived in a suburb that was not close to the aunts. My intent was to have the senior move to independent living with some additional contracted services for the showers and medication reminders.

When I returned for the next appointment, the son met me at the door. He had found his father on the floor that morning, and now we were probably looking at a higher level of care. As I had chosen continuing care communities, my options were all valid. I recommended communities that accept Medicaid in the nursing home area in case the senior became unable to pay privately at some point.

Within the next two weeks, the senior suffered another fall and broke a hip. Two transfers occurred between two hospitals with an eventual stop in a short-term rehabilitation community. This community didn’t provide long-term care unless a bed became available. Such openings rarely occurred. The prognosis wasn’t positive, with the senior needing total assistance with all activities of daily living except eating. The senior could only walk a short distance with a walker and needed someone to walk with him.

I told the son that his father was no longer a good candidate for assisted living. At best, he was in between needing intensive assisted living or a nursing home. The best option was to choose a continuing care community with potential to move to a lower level of care if the senior got better. On a whim, the son chose to stop at an assisted living community that was aesthetically attractive, smelled of potpourri, and fresh baked cookies. The son was quoted a price that was slightly more than the senior could afford and as much as a nursing home. The method of payment was private pay only. The son favored placing his dad there because it was less than a mile from his house.

One of the son’s major concerns was that the senior’s age was too young for a nursing home. Yet, when I asked about the age of the residents at the assisted living community that was being considered, I was told the demographics were about the same. And what about the senior’s long term needs if his medical conditions worsened? The admissions person said the senior could age in place. All of the services he would ever need could be brought into the apartment (for an additional fee).

I asked my clients who planned to pay the costs above and beyond what the senior could afford. The son and his aunts said they would pick up the tab. I told them the cost of long-term care went up about 4% per year. With additional services, could they really afford to pay that sort of money? I pointed out that the senior’s medical condition was likely to get worse. I alerted them to the fact that a nurse was not at their favored community on a 24-hour basis. I mentioned that when private pay money was exhausted, another move to a nursing home that accepts public aid pending (a list that is growing smaller by the day) would be necessary.

The son admitted to me that he really didn’t understand the difference between the levels of care available and all its implications. I explained everything again and revised all of my recommendations to include communities that were closer to the son’s house.

When you are under the stress of having to make a decision, the senior’s long term financial realities and medical needs should always be the key focus. Avoiding a short-term “fix” to the problem will save the stress of having to repeat the process. That’s why my tagline is “Practical, affordable advice for senior living.”

I can help you and your loved one through the transition with lots of lots of evidence-based suggestions. Contact me to set up a consultation:

andrea-donovan100Andrea Donovan Senior Living Advisors
361 Nuttall Road Riverside, IL 60546 708-442-7174 708-415-2934 (cell)