Introduction to Care Setting Options for Seniors
Reasonable thoughts from a Geriatric Nurse Care Manager & Daughter
By: Hildy Sheinbaum, RN Director of Senior Placement Services, Sterling Care Senior Living Choices LLC
If you are a child between the ages of 30- 65, there is a good chance that you will, at some point, be facing a health care crisis with your parent(s). To say that the crisis can be stressful is an understatement. I have been a geriatric nurse care manager in private practice for the past 10 years. My experiences have been vast, my clients all different, and quite honestly, I thought I had “seen it all” … until my own mother was faced with a health crisis that, despite my expertise and years of experience, tested my patience and ability to mobilize- in a way that I cannot describe.
This blog has been created in the hopes of providing sound logic to anyone “dealing with” (and I don’t mean that in a derogatory ?sense) an aging parent. I will provide you with information on a relevant topic each month to help you navigate a complex maze of geriatric care— be it healthcare, living environments, or social settings.
Given my current role as the Director of Senior Placement Services at Sterling Care Home Care, I thought I would use this first blog posting to provide guidance to individuals seeking an alternative living environment – for themselves or their loved ones. I have observed that often people do not truly understand the differences among living options available to our seniors, and so what follows is designed to provide a “ready reference.” It is by no means exhaustive, but rather offers a snapshot of senior living choices to help you understand basic concepts.
When should I start thinking about a change of living environment for my parent(s)?
There may be overt signs that a change is needed, OR there may be subtle indicators that prompt the thought that something is not quite right. Repeated forgetfulness that might pose a danger to your parent is one of the overt signs. Your mother was making hard boiled eggs—for two hours. The smoke alarms go off because the pot is empty (and burnt) and smoke has filled the kitchen. This has happened twice in the last month. Your father goes for his morning walk to get the newspaper at the 7-11 down the street. Despite the fact that he has been doing this daily for the past 20 years, he suddenly can’t remember how to get back to his house; he begins to wander, and a police officer finds him, and calls you to let you know your dad is lost. RED FLAG ALERT…
Then, let’s not forget the physical concerns related to aging that can also pose a danger to your parent. Your mother falls on her way to the laundry room which is just down the hall from her apartment. She sustains a hip fracture, undergoes surgery, goes to rehab, and then is discharged home. You arrange for an aide to come in for 4 hours a day (which is all your mother will allow because she really is “fine”). After two days, your mother tells you she doesn’t want the aide any longer—it’s simply “a waste of money,” and she sends the aide away for good. Two weeks later, she falls again on her way to the bathroom, and breaks her other hip. RED FLAG ALERT…
You go to visit your parents and happen to glance at the pill planner boxes. You notice that your dad hasn’t taken his evening blood thinners for three days last week. When you ask about it, he tells you that he always takes his pills and he doesn’t know why those pills are remaining in the planner. Another scenario…. Your dad passed away 2 months ago, and your very capable mother who has always prided herself on dressing in a pristine fashion, shows up to Thanksgiving dinner with stains all over her blouse. She says she didn’t realize the blouse wasn’t clean. Then, the following week, when you go to pick her up to take her out to lunch, you smell an uncharacteristic odor. She tells you she simply didn’t feel like showering. YELLOW FLAG ALERT…
The “red flag alerts” are overt signs that the current situation is likely to be unsafe. The “yellow flag alerts,” although more subtle, may indicate depression or early forgetfulness. Regardless, these situations can evoke feelings of angst and uncertainty for you and are likely to prompt you to begin to think that “something may need to change.”
What Living Options are Available to Seniors?
Aging-in-Place with Home Care:
There are circumstances where a person can remain in his/her home and be cared for by professionals. In such cases, it is crucial to have a thorough understanding of the needs of the senior—in an emotional, social, and physical sense- and to shop around to find a caregiver who can support those needs. While some people look for “private help” in this regard, a reputable Home Care agency can provide reliable assistance in an expedient manner. Home Care agencies offer a wide variety of services in the home including nursing care, aide assistance, and therapeutic modalities, such as physical, occupational, and speech therapy. Home Care agencies typically have nurses, social workers or care coordinators conduct home visits to assess the needs of the client, coordinate staffing schedules, develop care plans, select appropriate caregivers, and provide oversight to the caregivers to ensure that the client is receiving the proper care according to the plan set forth. Having a nurse, social worker or a care coordinator oversee the caregivers provides a set of watchful eyes.
Independent Living
communities are buildings in which seniors live independently in a residential setting. Typically, apartments within these communities have scaled down, small kitchens because residents dine in a communal setting for 2-3 meals/day. Studio, one and two-bedroom apartments may be offered. Activities are structured throughout the day, local transportation is available, and there is a concierge service that can help residents set up appointments. The monthly fees usually include apartment rental, utilities, weekly housekeeping and laundry services, limited transportation, and activities. Residents are living independently in their own apartments, but there is a built-in social network filled with food, scheduled activities and basic support that can enhance the quality of living for a healthy senior. There is no medical support within these communities, although arrangements may be made by the community itself for physicians to periodically come in for resident consultations. The fees for independent living communities are not supported by any insurance or long-term care coverage, and residents must be able to pay privately.
Assisted Living
communities provide aging individuals with a safety net of services to support activities of daily living. Residents in these communities have a wide variety of needs that can be addressed along a continuum of care. It is important to note that some assisted living communities provide a “social model” while others are more “medically” oriented. Most have registered nurses on staff who can provide ongoing evaluation and support with ambulation, medication administration, treatment and basic care for such things as blood pressure monitoring, diabetic management and other health issues. Licensed practical nurses (LPN’s) and nurse aides are usually on staff to help residents maintain as much independence as possible. Communities differ in the amount of nursing coverage provided; some have 24-hour coverage, while others will have nurses on staff during weekdays.
Apartments in these communities are built with senior safety in mind; most have walk-in showers, safety rails, pull-cords, and ease of navigation. Three meals a day are provided; special diets may or may not be accommodated. Limited local transportation is usually built into monthly fees, as are utilities, housekeeping, and laundry services. Organized activities are scheduled throughout each day and cater to a wide variety of interests. Typically, assisted living communities offer different care levels based upon individual needs and supplemental cost is associated with each level above the monthly rental fees. If considering an assisted living environment, it is extremely important to understand whether the community can support the very specific needs of your loved one. Fees in assisted living communities may be covered by long term care insurance provided there is a definite indication that a resident requires assistance with one or more activities of daily living. Costs in assisted living communities are not covered by Medicare or Medicaid or third-party insurers.
Memory Care
Communities can be available as a separate living environment within larger assisted living communities, or as a separate standalone building. In either case, staff working with those with memory impairment are trained in techniques to effectively communicate and care for individuals who may be forgetful, may become easily agitated, or can no longer express their needs or feelings in a cogent manner. Memory care units within a larger assisted living community are usually secured on a lower level floor. Studio or one-bedroom apartments are available with a small kitchenette and a private bathroom, all built with safety in mind. Glass identity boxes with familiar pictures and personal items are often placed outside each doorway, providing a memory trigger for residents. All of the services described in the “assisted Living” segment above are also provided for the memory care unit residents. Activities are often separate from the greater community; however, many communities do have larger venues in which all residents participate. A Wellness Center with nursing staff is present for all residents; skilled nurses may or may not be available 24/7, dependent upon the philosophy of the community at large. Nurse aides work around the clock to assist with all activities of daily living, including dressing, toileting, eating and cuing.
Standalone Memory Care communities are usually smaller and have been designed with a combination of freedom and safety in mind. Many of these communities allow residents greater mobility throughout the building because of the smaller environment. All activities cater to those with a memory impairment. Wellness centers may or may not be staffed with nurses around the clock, but here again, nurse aides work 24/7 to provide assistance with all activities of daily living.
While memory care is not covered by basic health insurance, Medicare or Medicaid, most long-term care policies will cover a portion of fees in memory care communities, provided that there is medical documentation that the resident has a memory impairment and needs assistance with basic activities of daily living.
Enhanced Assisted Living
residences are available in New York State and hold specialized certificates from the New York State Department of Health that allow them to provide more hands-on assistance than a typical assisted living community. Enhanced Assisted Living communities provide an increased level of care to its residents- somewhere in between that provided by a basic assisted living community and a nursing home. So, for example, individuals who require a two-person transfer, transfer via lift, sliding scale insulin coverage, or close monitoring of a medical condition, may be cared for in an Enhanced AL environment. These communities are more “home-like,” with individual apartments similar to those in basic assisted living environments and provide a good option before nursing home care is indicated.
Neither Medicare nor third party insurers will provide coverage for enhanced living environments. Long term care policies, however, will often provide an allowance for people residing in these types of communities.
Continuing Care Retirement Communities (CCRC), also known as “Life Plan Communities” provide a continuum of care from independent to assisted living to nursing home living. They allow for the ultimate in “aging in place” as residents in a CCRC can remain in their community as they face different heath care crises throughout their life cycle. Residents have access to different levels of care on the same campus and are moved along this spectrum as the need arises. These communities often require assurances that individuals are healthy at the onset, and that they are financially sound, as the cost is quite high. Often a life-care contract is required along with an entry fee that can be equal to the purchase of a home. These fees are reimbursable upon death of the resident. Services within CCRC’s are quite comprehensive, focusing on both the social and medical needs of an aging population.
A Nursing Home, or Skilled Nursing Facility provides a wide range of health and personal care services for individuals who cannot care for themselves due to physical or mental disorders. These facilities are staffed with skilled workers around the clock; typically physicians and other ancillary support practitioners are on staff to provide a full range of services such as physical, occupational, and speech therapy, respiratory therapy, specialist consultation, wound care, IV therapy and care for many other medical conditions. Nursing Home residents do not live in apartments, but rather reside in a private or semi-private room, much like a hospital setting. Nursing stations are located on each unit in order to provide a watchful eye on a frailer population. Nursing homes for long term care are not covered by Medicare or Third-Party insurers; long term care policies often cover a portion of the cost. Some Nursing Homes may accept Medicaid once private funds are exhausted.
Short Term Rehabilitation
is offered under the auspices of a nursing home to individuals who need short term therapy post-surgery or following an injury or medical crisis. Physical therapy, occupational therapy and/or speech therapy, are provided to individuals in a hospital-like setting with skilled nursing staff present around the clock. Short term rehab is very useful for individuals who need time to convalesce and cannot go home because there is not adequate care to allow them recovery. Short term rehab is also useful for individuals who might need extensive IV antibiotic therapy, wound care, or continued monitoring of a medical condition under the watchful eye of skilled staff. Costs for short term rehab are covered for a limited time under Medicare and/or third-party insurance, provided that the rehab need is preceded by a 3-day hospital stay. Upon conclusion of a short-term rehab stay, social workers in those communities will assist with discharge planning and thereby address care needs with the family in order to make an educated decision about next steps and the need for longer term care.
How to Make an Informed Decision — What is Right?
Transitioning into a new living environment can be both emotional and difficult for the person transitioning as well as family and caregivers. The most important bit of advice I could give would be to educate yourself as much as possible. Visit the communities several times, ask a lot of questions, keep your eyes and ears open. If needed, seek professional assistance of experienced nurse care managers and senior living experts who can assist in objectively evaluating whether a community is right. Most importantly, take your time- don’t rush into any decisions and don’t cave under pressure. Stay tuned for a later posting on what to look for when making a decision about the next “right place to call home.”
Stay well!
Hildy
