Cost of Hiring Help for Continence Care
by Catherine D'Ambrosio, RN, PhD dambrosi@uw.edu
The (single biggest), most
expensive healthcare conundrum we face over the next half century is not how to
provide or pay for high-tech medical procedures, sophisticated pharmaceuticals,
or intensive nursing care, but how to provide and finance ongoing basic nursing
care to the legions of elders successfully reaching advanced ages.
Our mortal vulnerability to infectious diseases have been substantially reduced over the past 150 years primarily through improvements in public sanitation such as public sewers, plumbed potable water and public health initiatives including immunizations, antibiotics, and access to safer, cleaner injury and episodic illness care. Safer working conditions and childbirth advances have also contributed to the expansion of the mean human life expectancy. More people can now expect to survive infancy, childhood and young adulthood. Improved access to high-tech medical procedures, sophisticated pharmaceuticals, and intensive care nursing allow more of us to reach even older ages.
Despite being less mortally vulnerable to injuries and accidents, our physical function
still continues to deteriorate with advancing age. Forty percent of all
elders over 75 years and over fifty percent over 85 years require some basic
nursing care (assistance with eating, bathing, grooming, dressing, toileting
and mobility). Currently elders have only four options when they require
assistance with these activities:
1. Family caregivers
2. Paid caregivers
3. Institutionalization
4. Neglect
This blog addresses the question of how much does it cost for the second option -private duty paid caregivers who come to your home to assist in maintaining toileting continence?
The real problem confronted by elders who are having difficulty maintaining their toileting continence and independence is that toileting cannot be reliably confined to particular appointments or times of day. An elder who requires cognitive and / or mobility assistance to maintain their toileting continence will require constant access to rapidly responding nursing care.
Below is a conservative break-down of private duty nursing care costs followed by descriptions of each type of nursing care:
Conservative cost estimates for hourly in-home (private duty) nursing care
per hourcost | 24-hr/day cost | weekly cost | monthly cost | yearly cost | 5-year cost | 10-year cost | 15-year cost | |
Nursing Aide * | $15 | $360 | $2,520 | $10,800 | $131,400 | $657,000 | $1,314,000 | $1,971,000 |
Certified Nursing Assistant ** | $20 | $480 | $3,360 | $14,400 | $175,200 | $876,000 | $1,752,000 | $2,628,000 |
Licensed Practical Nurse *** | $30 | $720 | $5,040 | $21,600 | $262,800 | $1,314,000 | $2,628,000 | $3,942,000 |
Combinationof RN (8hrs @ $50/hr) and LPN(16hrs @ $30/hr) | $37 | $880 | $6,160 | $26,400 | $321,200 | $1,606,000 | $3,212,000 | $4,818,000 |
Registered Nurse **** | $50 | $1,200 | $8,400 | $36,000 | $438,000 | $2,190,000 | $4,380,000 | $6,570,000 |
* A nursing aid is a care worker who has not completed the recommended 75 hour training course on the provision of basic nursing care. The care they provide is typically not directed, designed, or directly supervised by an RN. Depending upon their place of employment, they may or may not have access to professional nursing advice or supervision on the care they provide.
** A Certified Nursing Assistant (CNA) has -in most circumstances completed a two-week (75-hour) long vocational education and training course on the provision of basic nursing care. Your nursing care plan is optimally written by an RN who has assessed your immediate physical needs and directly supervises the CNA's work. In reality unfortunately, you and the RN may never meet and the nursing care plan may never be customized to suit your immediate individual needs and promote your highest level of function.
*** A Licensed Practical Nurse (LPN) has completed a one year long course on nursing care either at a community college or a technical college. Many are expert at hands-on direct, non-invasive patient care, others work primarily passing medications and supervising nursing assistants. Care provided by an LPN is optimally directly designed and led by an RN. An LPN's practice is more tightly restricted than RN's and their educational knowledge and scope of practice is less broad
**** A Registered Nurse (RN) has completed one of three programs and passed a state examination demonstrating proficiency in the minimal amount necessary for nursing practice.:
- a three year-long diploma program (roughly 20% of all nurses), or
- a two to three year-long Associate's Degree in Nursing (ADN) degree at a community college (roughly a third of all nurses are prepared at this level), or
- more than a third are university educated and have completed a Bachelor of Science in Nursing (BSN) degree.
- Ten percent of registered nurses have completed advanced (Master's) degrees in Nursing (in addition to their bachelor's degree), and around 1% have doctoral degrees in nursing.
Another problem is that too often people harbor century-old ideas about how much nursing care costs. When I owned a home health care agency, I frequently received calls from people who were first encountering incontinence problems and wanted 24-hour per day, 7 day per week RN care. It was my sad duty at that time to tell my callers the bad news about how much private duty nursing care costs. Every single person was flabbergasted by the cost of in-home private duty nursing care (see above). Only a few had the means to afford private duty care.
When I asked my callers how much they expected to pay, it was then *my turn* to be flabbergasted. I got many responses like the following:
- "I expected 24-hour per day RN care to cost about $20 a day." (for those of you who don't have a calculator handy, that's about $0.83 an hour)
- "My parents are 75 years-old and they have set-aside $50,000 for their long-term care. I expected that for $50,000" said the caller, "you would be able to provide 24-hour per day care to them starting today, and lasting until they die. We would need an RN only during the day, the rest of the time a practical nurse would do just fine." ($50,000 -no meager sum to be sure, would pay for just about 57 days of that level of care.)
- "OK, so I can not afford nursing care. I still need help with my parents. Can you just import a couple Mexican gals to come take care of my parents?" (did you say *import*? -like they're bananas?) "I can not probably afford to pay them anything, but I *can* afford to maybe help pay for their airfare to get here. They can eat the food in the house and we have space and a toilet in the basement where they can live."
These were not *bad* people who are asking these questions. These were generally caring individuals who were in way over their heads, trying (sometimes desperately) to help their aging and ailing parents. And in many ways, the callers were right. There surely are a lot of people who want to move to the United States and European countries from more economically depressed countries.
Such potential immigrants are willing and even eager to leave their home, their family, their culture, and their language with the idea of being able to get rich, or at the very least be able to live a better life. But if you think it through, even people who desperately want to immigrate to the US are not going to be interested in living in your basement as an unpaid, indentured servant, tending to your toileting needs and subject to your wants and whims.
Additionally, nursing care knowledge and skills are not in anyway innate or intuitive to women of limited means and good intentions.
Provision of necessary, sufficient and accurate basic nursing care is currently hamstrung by its complete dependence upon human labor. Human labor is extraordinarily expensive. The cost of providing necessary nursing care escalates with advancing age and accumulation of health fragilities.
The consistent and
accurate provision of necessary and sufficient basic nursing care can and often
does make the difference between an elder who functions independently in the
privacy of their own home and an elder who is tied to a wheel chair, parked in
an odiferous nursing home hallway, and diapered at the convenience of the
institution’s (over-worked, under-paid, and under-appreciated) nursing
assistants.
Need for Nursing Care -and the Ability to Pay for Nursing Care
An elderly individual’s escalating need for nursing care unfortunately corresponds directly with depletion of personal financial resources and exhaustion of income earning potential. The median net worth of a 75 year-old American householder is $101,000 (including home equity), and $19,000 (excluding home equity). The median income for a 75 year-old American householder is $19,000.
A single daily visit from a $10 per hour cash under the table unskilled caregiver will cost approximately $20 to $25 per day, or roughly $8000 per year.
A certified nursing assistant who has completed a two week long course on basic nursing care will cost between $14,600 and $200,000 a year for that same two-hour long daily visit.
Nursing care provided by registered
nurses will cost between $36,500 and $657,000 a year depending upon the number
of hours, the complexity, the geographic region, and the predictability of the
care required.
The functional decline
naturally occurring with advancing age combined with broad access to
life-extending technology and sophisticated pharmaceuticals increases the probability elders will lose functional
independence as they live longer with more fragilities and physical
impairments.
We as a society need to develop basic nursing care options that are not dependent upon human labor, that can address the actual ongoing day-to-day basic nursing care needs of elders experiencing functional decline, assisting the elder in maintaining their physical independence –without either bankrupting elders or leaving a legacy of debt to future generations.
We need to expand the number of
options for the growing number of elders (also younger people with
disabilities) who are living through and despite illnesses, injuries, diseases
and ailments with more physical fragilities, functional impairments, and
cognitive challenges.
Many elders can expect to live a decade or more with their functional impairments that render the elder dependent on the care of other people. Not only is it difficult and undesirable for most of us to be in this position, it is financially beyond the means of all but a few of us.
I have detailed two other in-home options for long-term care including companion and intermittent nursing care visits. Even these conservative cost estimates are staggering and well-beyond the means of most of us -at any point in our lives, much less after we are no longer able to reliably work and earn an income:
|
In-home
Companion Cost Estimates |
24-hr/day cost |
weekly cost |
monthly cost |
yearly cost |
5-year cost |
10-year cost |
15-year cost |
|
Licensed
companion (sleeps at night; limited care; no incontinence care) |
$300 |
$2,100 |
$9,000 |
$109,500 |
$547,500 |
$1,095,000 |
$1,642,500 |
|
Unlicensed
companion (sleeps at night; no care) |
$150 |
$1,050 |
$4,500 |
$54,750 |
$273,750 |
$547,500 |
$821,250
|
|
Intermittent
Nursing Care Visits |
per visit cost |
24-hr / day cost |
weekly cost |
monthly cost |
yearly cost |
5-year cost |
10-year cost |
15-year cost |
|
Unlicensed,
un-trained, un-insured assistant paid under the table for morning &
evening home visits |
$20 |
$40 |
$280 |
$1,200 |
$14,600 |
$73,000 |
$146,000 |
$219,000 |
|
Nursing
Assistant (CNA) Morning & Evening home visits |
$75 |
$150 |
$1,050 |
$4,500 |
$54,750 |
$273,750 |
$547,500 |
$821,250 |
|
RN
Morning & Evening home visits |
$150 |
$300 |
$2,100 |
$9,000 |
$109,500 |
$547,500 |
$1,095,000 |
$1,642,500 |
Retirement Apartments and Assisted Living Facilities typically offer fee-based nursing care services. Unscheduled nursing care services generally cost substantially more than scheduled services. So receiving scheduled help with a shower or bathing three times a week will cost a lot less than unplanned shower assistance and incontinence clean-up occurring any time of day or night.
At some point either:
- the incontinence frequency will exceed the capacity of the Retirement Apartment or Assisted Living Facility's nursing care capabilities and they will recommend your transfer to a skilled nursing care facility, OR
- the odor of frequent incontinence episodes will negatively effect or disturb the other residents and the facility will recommend a transfer to a skilled nursing care facility, OR
- the cost of accessing frequent unplanned nursing care at the Retirement Apartment or Assisted Living Facility will exceed the cost of a Skilled Nursing Care Facility.
(Please see my blog on institutionalization costs.)
In (other sites on) this blog, I therefor propose and describe a series of system innovations and integrations designed to improve access to and delivery of basic nursing care assistance with toileting and mobility to community-dwelling elders by combining existing systems and technologies to develop Personal Nursing Care Robots.
