Elder Incontinence

VIII. When is it time to consider nursing home placement? (3. selecting a facility) by C. D'Ambrosio, RN, PhD

Selecting a Long-Term Skilled Nursing Care Facility for your Elder

by Catherine D'Ambrosio, RN, PhD  dambrosi@uw.edu 

Choosing a nursing care facility that meets your needs, requirements, expectations, preferences and budget will require some research, some planning and some soul searching.  Having knowledge of your elder's actual financial assets will be essential to making some of the decisions.  Many elders wish to keep their finances private and return only vague, obtuse answers about their finances, such as "We have plenty of money dear." (which might they have assets amounting to $200 to $300), or "I don't know how I am going to afford anything." (with a financial portfolio worth tens of millions of dollars).   Most people fall somewhere in the middle.

I've organized this set of blogs (on nursing home placement decisions) around three questions most often asked of me by elders and their family caregivers who are considering relocation to a nursing care facility.

This entry addresses the third (III) question of how do we select the very best nursing care facility for our elder?  Questions I and II are addressed in separate blog entries (but are listed below along with their links).

I.              What are some of the signs that it may be time to being exploring nursing home placement?

II.            How much do nursing homes cost and who pays for nursing home care?

III.           We only have so much money, so how do we select the best nursing care facility for our elder?

1.    Location of the facility

2.    Cost of the facility

3.    Smell

4.    Ignore the décor, the chef, and any gourmet menu –until after you consider NURSING STAFFING RATIOS, and speak with a number of people.

5.    Nursing Staffing Ratios

6.    Interview the Nursing Staff

7.    Look around you and take note of whether elders are tied-up or restrained.  Ask the tour guide and the nurses about the facility’s policy on restraints.

8.    Talk to the Patients in the Facility

9.    Talk to Family Members of Patients in the Facility

10. Ask yourself some questions about your elder’s current condition

11. Some things I would like for you to know

 

This blog entry addresses the third question of:

III.  We only have so much money, so how do we select the best nursing care facility for our elder?

Choosing a nursing care facility that meets your needs, requirements, expectations, preferences and budget will require some research, some planning and even some soul searching. 

1.   Location of the Facility

The locations most ideal are near or easily accessed by family caregivers, friends, and relatives.  Elders who are well-tended by out-spoken advocates can sometimes be less vulnerable to neglect than elders who receive no or infrequent visitors and without an advocate.

Like real estate, there is location, location, and location to be considered.  Sometimes it is not enough to consider the city or town, but the neighborhood, and the location (such as a busy corner, a secluded park, or a river bank) within the neighborhood.

 

2.   Cost

You must consider how much your elder can afford to pay, and how much they are willing to allocate to their care in the nursing facility. 

Having knowledge of your elder's actual financial assets will be essential to making some of the decisions.  Many elders wish to keep their finances private and return only vague, obtuse answers about their finances, such as:

·         "We have plenty of money, dear." (which might mean they have assets amounting to $200 to $300), or

·         "I don't know how I am going to afford anything." (with a financial portfolio worth tens of millions of dollars).

·         I have worked with plenty of people at both ends of the spectrum and contorted perceptions.  Most people fall somewhere in the middle.

Knowing if and precisely how much any family, relatives or friends are willing to contribute to funding the elder’s long-term care will also need to be factored-in on the decision.

 

3.   Smell

The very first thing people notice when they enter a facility is the smell.  People are immediately turned-off by the overwhelming odor of urine and feces.  Any odor you once smell is unlikely to alter or diminish over time.  Your sensitivity to and awareness of this odor will however become less acute.

4.   Ignore the Décor

While sumptuous lobby décor and a gourmet chef and menu are doubtless appealing, even enticing, they are not the reason you are there.  Please try to ignore the décor in your initial assessment.  After you consider and make a decision based on #5 (below), then factor-in the lobby décor and the gourmet menu with the location, the cost, and the smell.

 

5.   Nursing Care Staffing Ratios

Ask to see the facility’s actual patient care nursing staffing ratios for both the facility and for the unit where your elder would be placed. 

A.   This is not the number of RN’s, LPN’s and CNA's employed by the facility, divided by the number of patients, because

                                              i.        Many nurses and nursing assistants work part-time.

                                            ii.        Many nurses and nursing assistants work per diem (on-call).

                                           iii.        Nurses do not work 24/7.  They work approximately 40 hours per week, and they take vacations and sometimes get ill and take sick days.

                                           iv.        Many of the RNs employed by nursing homes perform management, staffing, planning, marketing, and administrative functions, and do not provide patient care.

                                            v.        Facilities often employ many RNs are to do only paperwork, to fill-out Medicare, Medicaid and insurance forms necessary for reimbursement, often on patients they have never taken care of

 

B.   Look at the facility’s actual –not their planned or optimal staffing ratios. 

                                              i.        What are the patient care staffing ratios today? (remembering to subtract the number of nurses and nursing assistants who did not show-up today.

                                            ii.        What were the patient care staffing ratios yesterday?

                                           iii.        What were the staffing ratios last week, last month, and last year?

                                           iv.        Fill-out the chart (below) for each shift (days, evenings and nights).  Expect that day shift staffing ratios will be higher than evenings, and evening staffing ratios higher than night shift staffing ratios.  Weekend staffing ratios are often lower than weekday staffing ratios.

 

C.   Make sure you know and understand the facility staffing ratios and how that breaks-out for each unit on each shift, including weekends and holidays.  Some units such as Medicare Skilled Nursing and Rehabilitation units often have higher staffing ratios than other units that are not mandated to comply with Medicare’s more stringent requirements. 

 

D.   Awards are interesting but sometimes of little or no consequence.  All too often awards for “Best Nursing Home in the World” or whatever, are meaningless marketing tools. 

 

E.   In addition to focusing on the patient care staffing ratios, inquire and request specific information about the degrees and certifications of the registered nursing staff, and training seminars attended by the nursing assistants.  Ask questions including:

                              i.                How many Master’s prepared nurses are on-staff at this facility? 

                            ii.                How many Master’s of nursing consult with the facility?  When?  How often?  What do they do?  What training education and training seminars do they provide to the nursing staff?

                           iii.                How many patient care nurses employed by the facility have bachelor’s degrees in nursing (BSN)?

                           iv.                How many nurses in the facility have a wound, ostomy, or continence care certification?  How often do they provide inservices (training seminars) to the other nurses and the LPNs and nursing assistants?

                            v.                How many nurses in the facility have other certifications –such as Gerontological nursing?

                           vi.                How often are nursing assistants required to attend education and training seminars on provision of basic nursing care? 

                          vii.                What types of training seminars are offered to the facility’s nursing assistants?  -or are basic nursing care seminars even offered at the facility?

 

6.   Interview the patient care RNs, LPNs, and nursing assistants

Optimally –if you can, take the opportunity to speak to the nurses and nursing assistants individually -away from the marketing director or facility tour guide. 

Or, if you have a friend, neighbor or relative who is residing in this particular facility, visit them and talk to the nurses and nursing assistants who come to your friend’s or relative’s room to care for them. 

If you are a gregarious or more sociable soul, offer to meet and host a nurse for coffee in the cafeteria or a local coffee shop. 

When you speak with the nurses and nursing assistants, ask them:

A.   How many patients do you have today?

 

B.   If you are speaking with an RN, ask:

 

                              i.        How many LPNs (licensed practical nurses) and CNAs (certified nursing assistants) do you have assigned to you?

                            ii.        What do your duties include?

                           iii.        Do you provide any direct patient care?

                           iv.        What is the most number of patients you’ve ever been assigned in this facility?  How often does this happen (being assigned so many patients)?

                            v.        What is the least number of patients you’ve ever been assigned in this facility?  How often does this happen?

                           vi.        How many patients do you think would be optimal –for you to care for at one time?

Compare the RN’s optimal numbers with the actual number of patients she’s caring for.  How substantial is the difference?

C.   If it is an LPN you are speaking with, ask:

                              i.        How many CNAs do you have assigned to you?

                            ii.        What do your duties include?

                           iii.        What is the most number of patients you’ve ever been assigned in this facility?  How often does this happen (being assigned so many patients)?

                           iv.        What is the least number of patients you’ve ever been assigned in this facility?

                            v.        How many patients do you think would be optimal –for you to care for at one time?

                           vi.        Compare the actual numbers with the stated optimal numbers.

 

D.   If you are speaking with a CNA, ask:

                              i.        How many of your (X –number of patients) are physically and cognitively independent?  (expect this number to be none to exceedingly few in a skilled nursing care facility)

                            ii.        How many of your patients are in a completely dependent or a vegetative state?  (hopefully this number is as low as the independent number, with most of the patients ranging somewhere between these two extremes)

                           iii.        What do your duties include?

                           iv.        How many of your (X –number of patients) required the assistance of more than one nursing assistant?

                            v.        What is the most number of patients you’ve ever been assigned in this facility?  How often does this happen (being assigned so many patients)?

                           vi.        What is the least number of patients you’ve ever been assigned in this facility?  How often does this happen?

                         vii.        How many patients do you think would be optimal –for you to care for at one time?

Ø  Compare the CNA’s optimal numbers with the actual number of patients for whom she is currently providing care.  How substantial is the difference?

Recommendations for interviewing nursing home staff 

Highlight and print several copies of the questions listed below.  Take them with you to the nursing home and fill them out as you speak with each nurse and nursing assistant.  

Fill-out a separate form for each person you speak with.  

Compare what the marketing director says about the nursing staffing ratios (the number of patients assigned to each nurse or nursing assistant) with the numbers the nurses and nursing assistants give you.

 

Date __________  Time of day:  ________________

 

Name of Facility: __________________________________________

 

Name & Title of the person you’re speaking to:  ___________________

 

Location in the facility:  ___________________________________

------------------------------------------------------------------------------------------------

 

1.     How many patients are you assigned to take care of today?_______

 

2.     Can you please tell me what is a normal or average assignment (how many patients each) for RN’s, LPN’s, and Nursing Assistants here (in this facility)?:

Weekday	Day Shift	Evening Shift	Night Shift
RN’s
LPN’s
Nursing Assistants

 

Weekend	Day Shift	Evening Shift	Night Shift
RN’s
LPN’s
Nursing Assistants

 

3.    What is the worst staffing ratio you’ve ever seen here?

Worst Time	Day Shift	Evening Shift	Night Shift
RN’s
LPN’s
Nursing Assistants

 

How did this happen? (i.e., a blizzard or a hurricane) ___________

 

How often do these sorts of (worst) staffing ratios happen (in your experience)? 

E.   TOILETING

Ask any of the RNs, LPNs or CNAs the following questions.  They should know the answers.  More than half of all patients or residents in skilled nursing care facilities suffer from incontinence.

                                    i.    How many of your patients toilet themselves independently?

                                  ii.    How many of your patients require cognitive prompts to toilet themselves?

                                 iii.    How many of your patients require physical assistance to toilet themselves?

                                 iv.    How many of your patients are completely incontinent, diapered and dependent on the nursing assistants for diaper changes?

·         How often are diapered and incontinent patients cleaned and changed?

                                  v.    How many of your patients require the physical assistance of more than one person to toilet themselves?

                                 vi.    How many of your (X number of) patients receive *Prompted Voiding?

                                vii.    Can you please tell me about how you provide *prompted voiding*, and how often?  Please note the following:

·         Providing prompted voiding every hour (while awake) is optimal, but every two hours while awake is also effective and quite acceptable;

·         Providing prompted voiding to support the existing toileting capabilities takes three times as long as diapering the elder in a dependent position.

·         Special training on provision of prompted voiding is required.  Prompted voiding is not terribly complicated, but it is not intuitive either.

·         Be mindful of what is within the realm of physical possibility and the time constraints of caring for multiple patients.

                              viii.     Do you provide *prompted voiding* to patients who require more than one nursing assistant to physically assist them to and from the toilet?

·         Be mindful that dedicating the time and expertise of more than one highly trained nursing assistant to support the toileting continence of one single patient is a very time-consuming, labor-itensive process, and thus very expensive to provide.

·         Do the math.  If the CNAs each have 8, 10, or 15 patients, they will not have the time to reliably provide *prompted voiding* to even one patient, much less more than one patient, or for patients who require the assistance of more than one nursing assistant.  This does not mean the nursing assistants don’t try or that they wouldn’t like to provide this intensive level of care, but they simply won’t have the time to dedicate so much time to the toileting continence of one single patient.

·         Compare the answers given by the different people you speak with.

·         Confrontation is not your purpose.

·         You are not there to prosecute the nurses and nursing assistants for doing their job the best they can, or for dealing with their assignment and the staffing ratios as they are.

·         You are asking these questions in order to gather information and decide whether placing your dear one in their care is a good idea.

                                 ix.    Have you attended any special conferences or training seminars on mobility assistance, cognitive prompting, and toileting care?

                                  x.    How often do you attend training seminars on toileting care?

 

* prompted voiding references:  Schnell, Ouslander, Hu

 

F.    Eating

                                    i.    How many of your patients feed themselves independently?

                                  ii.    How many require some assistance with eating, but are not entirely dependent?

                                 iii.    How many of your patients are entirely dependent in order to eat?

                                 iv.    Do you feed your patients who require assistance, or does your facility have a “feeding team”?

 

G.  Bathing, Grooming and Dressing

                                    i.    How many people do you have to (or have you given) a bath, or assisted with bathing today?

                                  ii.    If the nursing assistant answers zero, ask whether the facility employs bathing teams.

                                 iii.    How much time do you generally spend assisting each patient with their bathing (or showering), grooming, and dressing?

                                 iv.    How often are patients bathed or showered on your unit?

                                  v.    Do you get everyone up and dressed every day?

·         If not, why not?

·         Under what circumstances? (answers you might expect include when an elder:

Ø   is ill, or

Ø  recuperating from an illness and simply too weak, or

Ø  requests to remain in bed, or

Ø  refuses to get out of bed.)

                                 vi.    How many of your patients move-about independently –with or without any mechanical assist devices (such as a cane or a walker)?

                                vii.    How many of your patients require two or more people to transfer and assist them from one place to another (i.e., from the bed to the chair, from the chair to the toilet)?

                              viii.    How many of your patients require the use of a mechanical lift to transfer them from one place to another?

 

7.   Look around you and take note:

A.  Are any of the patients tied to their beds?  (you might notice straps hanging from the side of the bed)

B.  Are any of the patients tied to their chair or wheelchair?

C.  Are any of the patients restrained to their chair with a lap table secured to their chair?

D.  In total, how many patients do you see restrained?

E.  Ask the nurses and your tour guide about the facility’s policy towards restraints.

 

8.   Talk to the patients. 

    A.  How do they like the facility?

    B.  How do they feel about their nursing care?

    C.  It can be advantageous to already know someone –even distantly- -whom you can speak with and ask about the facility.  Sometimes however people want to say only good things about the facility for fear of casting themselves or the nurses –whom they maybe attached to- in a bad light.

 

9.    Talk to the Family Members of patients in the facility.  Ask them:

    A.  What do they think of the nursing care provided to their elder?

    B.  Do they feel the facility has worked to improve their elder’s health, function, and / or quality of life?

    C.  Do they regret having placed their elder in this facility?

 

10.       Ask yourself some questions about your elder’s current condition:

Ø How many people does it currently take to get your elder out of bed, and to and from:

Ø    the toilet?

Ø    the dining room or kitchen table?

Ø    the living room chair or sofa?

Ø    the rocker on the front porch?

 

Ø Know that if your elder requires assistance from more than one person for mobility, that your elder’s mobility will likely diminish after admission to the skilled nursing care facility –unless of course you are able to afford to place your elder into a uber luxury skilled nursing care facility with very high nursing staffing ratios.

 

11.       Some things I would like for you to know:

A.    Most elders who are physically and cognitively independent now live in retirement communities or Assisted Living Facilities where:

                              i.        They do not have to pay as much as skilled nursing facilities cost.

                            ii.        They do not have to share a bedroom and a bathroom with a virtual stranger whose habits (such as watching television 24/7, or frequently filling the room with their visitors).

B.   Odds are that in facilities with very low staffing ratios, a frail elder’s existing function (unless independent) will likely be allowed to deteriorate to a dependent state.

C.   Caring for a dependent elder is much easier to manage and less time-consuming than to care for and promote the highest level of function possible among elders who are struggling to maintain their function and independence –because such elders tend to move very slowly.

D.      Some States do not specify minimum nursing staffing ratios for non-Medicare funded beds.  This means that:

                             i.        each RN could potentially have as many as 90 patients –far too many to provide or even to competently supervise minimal nursing care.

                           ii.        Each LPN could potentially have as many as 50 patients to whom she is passing medications, far more than is safely or optimally handled.

                          iii.        Each CNA could potentially have as many as 15 patients.  Such an enormous number of patients is far too many for a single nursing assistant to provide even minimal care.

 

E.    Just because your elder is in a skilled nursing care facility does not render them invulnerable to neglect and its potentially devastating effects on their health, function, independence, and quality of life.

 

F.   Some skilled nursing facilities provide “assembly line” nursing care where, for example:

                              i.    One team of nursing assistants (sometimes) called “feeders” feed all elders who are dependent upon or require assistance from others for eating.  Elders are typically fed in the common dining room where the feeding team members often move from one patient to another.

                            ii.    Another team of nursing assistants (sometimes) called “showers” wear shower thongs on their feet and shower each patient in-turn.

                           iii.    Another team of nursing assistants (sometimes) called “beds” change all the bed linens in the facility.

                           iv.    The remaining nursing assistants take elders to and from the toilet, clean-up incontinent messes, and perform any other duties assigned such as taking and recording temperatures, blood pressures, heart rates and respiratory rates..

 

G.    Ask the facility director or marketing representative about what kind of nursing is practiced in the facility (i.e., team, assembly line, primary nursing, etc.).  Although primary nursing (where the same nurses and nursing assistants are assigned to particular elders) is an optimal ideal, it may be impractical –even logistically impossible in situations where staffing ratios cannot support it (primary nursing care). 

 

Team nursing and assembly line nursing, while typically never optimal, maybe the most efficient way (particularly in facilities with very low staffing ratios) to ensure each patient receives a bath, timely assistance with meals, and reliably toileted or diapered on a regular basis.

 

H.   There is not a cardinal right or wrong type of nursing (i.e., primary nursing, team nursing, or assembly line nursing) for a facility to practice.  What matters most is the level and quality of nursing care provided to the elders in the facility.  Having very low staffing ratios is not a crime.  It is simply less than optimal and as such, can in many circumstances, be reasonably expected to result in less than optimal outcomes for many of the recipients of the care.

 

When is it time to consider nursing home placement? (2. cost & payment) by Catherine D'Ambrosio, RN, PhD

When is it time to consider nursing home placement? (2. cost & payment) 

by Catherine D'Ambrosio, PhD, RN                  dambrosi@uw.edu 

You want to do what is most beneficial for your elder and to take the very best care of them possible.  It is most likely why you're here on this site.  I will try to give you information that can help guide you through this process.

Having (and taking) the time to plan and consider your (nursing home placement) options and preferences before you are in a dire situation gives you power and leverage you will not otherwise possess.  

Delaying or postponing information gathering is not the same thing as delaying or postponing nursing home placement.  Ignoring the need for knowledge until you are in an urgent or emergent situation -can place you and your elder in a very compromised position.  Seeking-out the necessary knowledge and information (about nursing home placement decisions) in advance will reveal to you options and preferences you might never otherwise realize -until perhaps it is too late.

ORGANIZATION:

I've organized this set of blogs (on nursing home placement decisions) around three questions most often asked of me by elders and their family caregivers who are considering relocation to a nursing care facility.

This entry addresses the second (II) question of how much does nursing home care cost, and who pays for it?  Questions I and III are addressed in separate blog entries (but are listed below along with their links).

         I.    What are some of the signs that it may be time to being exploring nursing home placement?

    II.        How much do nursing homes cost and who pays for nursing home care?

A.   Does Medicare pay for nursing home costs? 

B.  What does Medicare cover? 

C.   When does Medicare cover the cost of nursing home care? / For how long?

D.   What are my options when Medicare payment for the nursing home runs-out?

E.   How do I qualify for Medicaid?

F.    What about long-term care insurance?

III.        We only have so much money, so how do we select the best nursing care facility?

 

This blog entry addresses the second question of:

 II.        How much do nursing homes cost and who pays for nursing home care?

Moderately priced nursing home care costs between $4000 and $8000 per month.  That amounts to $48,000 to $96,000 per year –every year for an average to a decent nursing home.  Up-scale nursing homes can cost substantially more.  

HOW AND WHY DOES NURSING HOME CARE COST SO MUCH?

Nursing care –because it is wholly and completely dependent upon human labor- -is extraordinarily expensive.  Nursing care provided in a facility (whether the facility is called a skilled nursing care facility, a nursing home, or a rehabilitation facility) -while extraordinarily expensive, it is still generally less expensive than private duty nursing care (LINK). 

WHY DOES MY ELDER'S CARE KEEP TAKING MORE OF MY TIME AND COSTING MORE AND MORE MONEY TO TAKE CARE OF AT HOME?

A frail elder’s functional capabilities will quite likely deteriorate over time, and for a (maybe protracted) period during this functional decline, your elder's basic nursing care needs will increase -in both intensity and complexity.

Oddly enough however, caring for a person in a vegetative state is less intensive, less complex and demanding, and far less time-consuming than caring for and assisting an elder who is struggling to maintain their function and independence.  

You can therefore reasonably assume the cost of necessary basic nursing care will increase over time -to a point.  The most intense and complicated basic nursing care needs occur while the elder is still struggling to maintain function, not generally after they have lost function. Supporting an elder's existing, but waining function is much more time-consuming, therefore expensive -than the provision of basic nursing care to an elder in a vegetative state.

What you want to avoid when you place your elder in a long-term nursing care facility -is the acceleration of this functional decline to the vegetative, totally dependent state.

If your elder is already in a totally dependent, vegetative state, determining your options and selecting the best nursing care facility becomes a much less complicated process.

 

A.   Who pays for nursing home care?

About half* of all nursing home costs (in the US) are paid for out of private pockets.  This means that half of all nursing home costs are *not* paid for by Medicare, Medicaid or private insurance of any form, but by the private savings and investments of individuals and their families. 

*This does not mean "you pay half and Medicare, Medicaid or long-term care insurance pays the other half."

By the time an elder requires routine and constant access to skilled nursing care, they have typically depleted or even exhausted their personal financial assets.  Consequently, most elders cannot afford to finance or pay for their stay in a nursing home for very long before they run out of money.

The rules for who pays, when, and under what circumstances can be quite complicated and there are many things you need to know and understand in order to navigate your way through the process of considering nursing home placement for your elder.  Four things I really want you to know -that don't really fit any place in particular in the questions are:

1.    The United States does not have filial liability laws.  The children of elders can be “rich as Roosevelt”, but are not legally liable for the payment of their parents’ health care expenses or long-term care needs.  This does not mean the children of elders cannot pay for their elder’s health care expenses, only that the children are not legally required to do so.

2.    Nursing care can currently be provided only by human nurses and nursing assistants.  Regardless of whether the nurse providing your care has a bachelor’s degree or a master’s degree from an Ivy League or other prestigious university, an associate’s degree in nursing from the local community college, is an LPN with a certificate from a vocational college, or is a nursing assistant who may have dropped-out of high school and completed a 75-hour (2 week-long) course on basic nursing care, human labor is exceedingly expensive. 

3.    Nursing care is currently wholly reliant upon human labor.  Human labor, particularly highly educated, dedicated and compassionate human labor is extraordinarily expensive to provide on a continuous basis.  Even elders who have lived frugally and saved a tremendous amount of money, will run through their carefully accrued savings very quickly once they are in need of continuous nursing care.

4.    Just because your elder needs the type of constant and on-going nursing care provided in an institution does NOT mean Medicare, Medicaid, or any private insurer –including long-term care insurance policies are going to pay for this institutional nursing care. 

B.   Does Medicare cover nursing home costs?

Medicare covers quite a lot of nursing home care, but does not pay for long-term nursing care that is deemed “custodial”.  Below is an explanation of how and what Medicare typically covers and some of the parameters for coverage:

1.    What does Medicare cover?

Medicare covers acute care hospitalizations for medically-diagnosed conditions.  Such (Medicare-covered) hospitalizations are determined, covered, and reimbursed according to the elder’s *medical diagnoses*, not their nursing care needs. 

Medicare will cover a pre-determined amount of post-hospitalization nursing home care in a Medicare-certified rehabilitation or skilled nursing care facility.  The duration of the elder’s stay in such a facility is based on the medically-diagnosed acute care condition that precipitated the hospitalization.

The (dollar) amount, duration, and circumstances under which Medicare pays for rehabilitation or skilled nursing care in a nursing home are very specific.  The amount of Medicare payment for an elder's stay in a nursing home is predetermined -often by factors that have little to do with the elder's chronic and on-going basic nursing care needs.

Medical diagnostic indicators largely determine the amount of Medicare reimbursement to the nursing home -which defines the maximum length of stay in the nursing home.  

While an elder's medical diagnoses might give some indication of the nursing care needs commonly (sometimes) associated with a particular medical diagnosis, such medical diagnoses are not however determinants of an individual's nursing care needs.

Medicare rates are determined by a formulaic labyrinth of rules based on geographic location, medical diagnoses, and many other (sometimes arcane) factors.  Private pay rates in a nursing care facility are generally substantially more than Medicaid rates.  

2.    When does Medicare cover nursing home (rehabilitation or skilled nursing) care?

Medicare may cover your elder’s transfer to and stay in a Medicare-certified nursing home (skilled nursing care facility or rehabilitation facility) after a minimum of a 72-hour long hospitalization.  Medicare coverage of this transfer and stay in a skilled nursing care facility is determined largely by your elder’s nursing care needs, but hinges also on your elder’s qualifying medical diagnosis.

Medicare does NOT pay for any stay in a skilled nursing facility, nursing home or rehabilitation facility if the stay is not immediately preceded by at least a 72-hour long hospitalization.

Having been hospitalized for 72 hours or more does not assure or in anyway guarantee that a subsequent stay in a skilled nursing or rehabilitation facility will be covered by Medicare.

 

3.    How long will Medicare pay for my / my elder’s care in a skilled nursing care facility / nursing home / rehabilitation facility?

a.    Once transferred to a rehabilitation or skilled nursing care facility, your elder’s length of stay in such an institution will depend upon their qualifying medically diagnosed condition and their rehabilitation potential. 

b.    In any case, Medicare will not under any circumstances cover more than 100 days in a skilled nursing / rehabilitation facility. Their (Medicare-funded) stay will most likely last no more than two to six weeks.

c.    Once your elder either:

                                                                  i.    Reaches their rehabilitation goals, their maximum function, or realizes their rehabilitation potential (meaning they’re not going to get any measurably better),

OR

                                                                ii.    Reaches the reimbursement cap (Medicare pays a pre-designated amount of money to the nursing home.  This pre-designated amount is determined by the medically diagnosed condition(s) that precipitated your elder’s admission to the rehabilitation facility).

-your elder will be discharged from the Medicare reimbursed portion of their stay in the rehabilitation facility. 

This is not to say that your elder is in any way ready to go home and function independently, or that you are prepared and able to provide the care your elder needs.  This is only to say that Medicare is done paying for your elder’s stay in the rehabilitation facility.

 

4.    What are our options when the skilled nursing care facility / nursing home / rehabilitation facility says “It is time for discharge.”?

Your elder’s options will vary widely depending upon precisely three things:

·         Your elder’s functional independence (which boils-down to their physical mobility and their cognitive ability to function)

·         Your elder’s personal financial assets

AND

·         Your elder’s access to (unpaid) family caregivers.

 

a.    After completing a qualifying 72-hour long hospitalization (with or without a stay in a rehabilitation facility), your elder may qualify for Medicare covered home health care visits. 

b.    In order to be eligible to receive any Medicare reimbursed home health care visits, the elder MUST (by law) be house-bound.  This means that if your elder is capable of being transported in a car, a taxi, a bus, or a car service to appointments or even out to dinner, they cannot legally receive Medicare reimbursed home health care visits.

c.    Medicare-reimbursed home health care is often not consistent with the expectations of elders and their family caregivers.  Families often tell me they expected 24-hour per day, private-duty RN care.  Many family caregivers are upset when they learn they must care for their ailing elder in addition to employment and childrearing responsibilities.

d.    Medicare covered home health care consists of home visits by several different professionals including:

                                                                  i.    Physical, occupational and speech therapies.

                                                                ii.    RN home visits which last anywhere from 15” to two hours at the most.  This does not mean the RN is there to physically take care of your elder –as is often hoped. 

The Medicare-reimbursed RN visit is there to assess key health parameters including, but not limited to: 

Ø  temperature and

Ø  other indicators of infection,

Ø  heart rate,

Ø  blood pressure,

Ø  respiratory rate,

Ø  pulmonary function,

Ø  problems with pain,

Ø  effectiveness of the current pain control regimen,

Ø  strength,

Ø  mobility,

Ø  medication regime, side effects, adverse reactions, compliance with medication regimen, or problems with medications

Ø  provision of any necessary wound care, and

Ø  Education of the elder and any family caregivers regarding the provision of nursing care to the elder.

                                                               iii.    Nursing assistant bath services.  The nursing assistant will arrive at or around appointed times up to three times per week to assist the elder with bathing or showering.  This does not mean that the elder will not need to be bathed at other times.

Provision of any or all of the above home visits does not imply or in any way guarantee that the elder will be happy or satisfied with the quality of therapy, nursing care assessment, or bathing service provided.  Ultimately, it only means the Medicare-reimbursed home visits will be made, any progress towards goals documented (keeping in mind these goals established for your elder are for Medicare reimbursement purposes.  These goals may or may not be of any consequence to you or your elder), and any visits will be charged to taxpayer-funded Medicare.

e.    Any Medicare-covered home health care visits will continue until one of the following occurs:

                                                                  i.    Your elder is no longer house-bound.

                                                                ii.    Your elder has reached the maximum number of Medicare-reimbursed home visits –as determined primarily by your elder’s medical diagnoses..

                                                               iii.    Your elder has achieved the goals established for their care or therapy.

                                                               iv.    Your elder is no longer improving or otherwise measurably benefitting from the home health care visits.

The home health care agency cannot and will not provide Medicare-reimbursed home visits that fall outside ANY of the above conditions.  There are two very simple reasons for this:

First, the home health care agency cannot obtain Medicare reimbursement for any visits made outside of these above stated conditions.

Second, if the home health care agency does provide home health care visits that fall outside of these above stated conditions and bills Medicare for such visits, that home health care agency, its owners, administrators, and its nurses will have committed something called “Medicare fraud”.  Medicare fraud is a crime.  This crime is punishable by substantial fines, revocation of licenses, prosecution, and even imprisonment. 

Although exceptions can be made if the home health care agency is willing and able to both obtain the necessary approval and assume the potential risk of denial of coverage, exceptions remain just that:  exceptions. 

f.     After discharge from the Medicare-reimbursed stay in the skilled nursing facility and / or the Medicare home health care, Medicare may continue to cover out-patient therapy appointments with physical therapists, occupational therapists, and speech therapists as long as:

                                                                  i.    the patient continues to improve, and

                                                                ii.    has not exceeded their predetermined visit allotment. 

 

g.    Medicare does NOT cover appointments with nurses, and does NOT cover or otherwise pay for any nursing care services not addressed in qualifying Medicare RN home visits or Medicare nursing assistant bathing services.  

Once your Medicare reimbursed home health care visits are finished, you will have no further access to professional nursing care unless you either hire privately and pay out of your own pocket, or place your elder in a skilled nursing care facility.

h.    Through a separate provision in Medicare law, Medicare will continue to cover physician visits for Americans who are 65 years and older.

 

5.    What is Medicaid and how do I qualify for it?  

Medicaid does cover (pay for) long-term institutional nursing care for qualifying elders.  There are several things you need to know about what it means to “qualify” for Medicaid and a Medicaid-funded nursing home bed.  Because of the tremendous State-to-State variation, this information is very general and is likely not entirely accurate for every State.  Please consult with a specialist in your area, your local Medicaid office, and / or the Federal and State Medicaid web pages (LINK).

a.    Medicaid, like Medicare –is federally funded.  Unlike Medicare though, Medicaid is also funded and administered by the individual States.  So each individual State runs its own Medicaid program.  Medicaid qualification criteria and Medicaid-covered health care services therefore vary quite a bit from state to state.

b.    Medicaid is not an entitlement available to everyone.  Medicaid is designed to meet the needs of America’s financially indigent (poor).  These are the people who have completely run out of money and must rely upon the State for their care.  Medicaid is a safety net.  It is a flawed program and therefore vulnerable to abuses and misuses by some as well as missing or denying coverage for others who are more deserving, or who should be covered.

c.    Because there are substantial differences regarding Medicaid coverage of children and persons under the age of 65 who are suffering from severe and permanent disabilities (such as spinal cord injuries), I will speak here only of persons 65 and over who have not previously been beneficiaries of Medicaid.

d.    Because this information I’m providing on qualifying for Medicaid is a general guide, please use this information only as a starting point, not the ultimate source.  I am a nurse, not a social worker, a lawyer, or a State Medicaid advisor. 

 

QUALIFYING FOR MEDICAID IN YOUR STATE:

Please consult with the Medicaid advisors, social workers, and privately hired lawyers who are familiar with the specific Medicaid laws in your State.  The people working in your local Medicaid office –while knowledgeable about Medicaid eligibility in your State -are not financial advisors.  They CANNOT advise you on how to manage your money (if you happen to have any). Therefore, if you have money or assets in excess of that which is allowable for Medicaid qualification, I urge you to consult with certified, master's prepared social workers and with lawyers in your geographic area.

 

A privately hired lawyer or a social worker *can* give you financial and legal advise you about your particular situation and likely eligibility for Medicaid.  They can assist you in protecting what assets can be protected –primarily to prevent impoverishment of the (Medicaid recipient’s) spouse. 

 In some states, even if you are not yet financially indigent, you can assign assets to Medicaid and obtain Medicaid rates for your elder's stay in the nursing home.  The advantage to this is that Medicaid rates are substantially less (sometimes by half) than the private pay daily rates for the same nursing home bed.

Nursing homes do not (of course) like for people to take advantage of this option (in the States where such options are possible) -for obvious reasons -they make less money.

This is not something I would advise you to try to accomplish on your own without either substantial research about your State Medicaid laws and provisions, or without consulting with a certified, Masters-prepared social worker or an attorney.

Please, PLEASE be careful when choosing a lawyer, social worker, case manager, or other privately paid Medicaid consultant to guide you through this process.  If it sounds too good to be true, it probably is (too good to be true).  Medicaid fraud is a crime and such crimes are punishable by law.

e.    In general, in order to qualify for Medicaid (not Medicare, the federal health insurance plan for American elders, but Medicaid a federal and State-funded health insurance plan for the poor), an elder must first be deemed and officially designated “financially indigent”.  This means (in general, noting there is substantial State-to-State variation in what I’m about to tell you, and even more variation in how the various laws are interpreted):

                                                                  i.    An individual’s income cannot exceed a State-specified percentage of the federal poverty rate (LINK).  There is wide variation in how this is interpreted and what is and is not allowed.  The individual and couple’s annual income cannot exceed somewhere between $10,000 for an individual and $30,000 for a couple –depending upon the geographic location and the individual State’s laws and provisos.  Some States require lower annual incomes, others allow higher.

 

Many individuals assign their income to Medicaid in order to qualify to pay the Medicaid rates in a nursing home –which are consistently lower than out of pocket rates paid to the same nursing home.  Again, please consult with the specialists in your State! 

 

                                                                ii.    In general, an individual or a Medicaid-qualified couple may retain ownership of the following:

·         their house or primary residence (some states limit the value of that qualifying home to $500,000, others maybe less, and many states do not stipulated a limited value)

·         one car (again, some states stipulate a value on the car, most do not), and

·         a burial plot and funeral allotment (noting wide variation from one State to another, the burial allotment allowed is sometimes around $1500).

                                                               iii.    In general (noting there is tremendous variation from State to State and many, many ways of interpreting these limits), in order to qualify for a Medicaid-funded Nursing Home bed, an individual elder who is living alone can possess up to, but not exceeding $5,000 in assets over and above their home, car and burial plot.  Assets include (but are not limited to):

·         Bank checking accounts

·         Bank savings accounts

·         Stocks

·         Bonds

·         Annuities

·         Certificates of Deposit

·         Trust funds (revocable and non-revocable)

·         Real estate and land holdings

·         Second homes

·         Summer, weekend and vacation homes

·         Rental properties

·         Boats –including, but not limited to: yachts, sailboats, and motor boats

·         Businesses

·         Shops and stores

                                                               iv.    A couple can possess up to, but not exceeding $10,000 in assets (as defined above) outside of the value of their primary residence, their one car, a burial plot and funeral allotment.

f.     Financially qualifying for Medicaid-funded services does not imply or infer that Medicaid will indiscriminately or even necessarily cover an elder’s stay in a Skilled Nursing Facility, Assisted Living Facility, Adult Family Home, or Senior Living Community.  Like the financial need, the physical need for nursing care must be quite desperate to qualify for Medicaid-funded care.

 

I have seen, taken care of, and consulted with a very wide array of elders and their families.  Just about every single elder I have encountered residing in a skilled nursing facility (nursing home) who is on Medicaid –is really in a very desperate situation.

 

A few of the elders I have met on Medicaid do have wealthy children.  Most do not.  Filial liability laws do not exist in the United States, so adult children are not liable to pay for their parents’ welfare or health care costs. 

 

g.    Obtaining a Medicaid-funded nursing home bed is *NOT* under any circumstances an ideal or enviable situation to be in.  Medicaid-funding is calculated to be the minimum amount necessary to feed, house and provide basic nursing care for impoverished American elders -who are typically physically frail and disabled.  The nursing care provided to poor American elders in Medicaid-funded beds is only rarely ideal nursing care. Medicaid is a safety net for the poor, paid for by the US taxpayers.  It will never therefore be ideal.

C.   What about long-term care insurance?

Nursing home coverage by long-term care insurance policies varies quite widely.  Some Long-Term Care Insurance Policies cover virtually nothing -under any circumstances.  Others cover all or a substantial portion of nursing home care for many months.

All Long-Term Care Insurance Policies come with lots and lots of fine print. My best advice to you is to:

• *Read it VERY carefully.*
• Ask any and all questions you can think of, and
• Get any and all answers in writing -signed and dated by a person (preferably a titled executive or officer of the company) who can be held accountable in the event of a dispute.

Some of the Long-Term Care Insurance Policies I have seen paid-out, pay the co-pays on the Medicare reimbursed portion of the elder's stay in a skilled nursing or rehabilitation facility.

Other Long-Term Care Insurance Policies pay all or a portion of the daily rate in a skilled nursing care facility after the Medicare-covered portion of the stay is completed.

Others cover many things, but only under some arcane (almost unachievable) conditions.

Remember, insurance policies are gambles.  You are betting against yourself when you buy an insurance policy.  You are betting you will get sick and need the insurance.  The insurer is betting you will not.

Insurance companies exist to make money.  They are not charitable organizations.  They will pay precisely what they agreed to pay, under the precise conditions they agreed to pay, and no more.  To default upon such an agreement is a prosecutable offense.  

If you feel your long-term care insurance policy is not paying as agreed, AND you have exhausted your communication with the insurer and are still certain they are not holding-up their end of the deal, you can inquire about obtaining assistance from your State's Insurance Commissioner.

Family Caregiving and Toileting Assistance: Answering Some Questions by Catherine D'Ambrosio, RN, PhD

Questions on Family Caregiving and Toileting Assistance

by Catherine D'Ambrosio, RN, PhD      dambrosi@uw.edu 

Supporting an elderly family member's toileting continence is a very important responsibility.  It is also however labor-intensive, time consuming, unpredictable, -and sometimes thankless, unpleasant, irritating, provocative, and even dangerous.  Maintaining continence is essential to your elder's self-esteem, pride, and dignity.  Preventing incontinence is also imperative to your elder's healthy, well-bing and their ability to stay in their own home.  Incontinence that cannot be self-managed is the single biggest reason for institutionalization (nursing home placement) of elders.

Is incontinence a normal part of aging?

No.  Although the risk of incontinence increases with advancing age, incontinence is NOT a normal part of the aging process.  Any incontinence should be evaluated by a qualified professional -optimally by a board-certified urologist- -prior to purchasing large quantities of incontinence undergarments.  Some people suffer from multiple forms of incontinence.  Some incontinence problems can be resolved with surgery.  Other types can be effectively treated or reduced in frequency and severity with daily medication.  Other types of incontinence can be effectively managed through the use of behavior modification.

What causes incontinence?

Many things can cause or precipitate incontinence (ranging from infection and dehydration to a prolapsed bladder, enlarged prostate, and detrusor (bladder) muscle instability).  Some medical and surgical treatments can resolve the incontinence entirely.  Other medical and surgical treatments can only lessen the severity of incontinence for some individuals under particular circumstances. 

Some types of incontinence are caused by mobility and / or cognitive impairments (problems).  Other types of incontinence are made worse by mobility and / or cognitive impairments.  Incontinence that is caused by -or made worse by cognitive or mobility impairments are called "functional incontinence".

So while your elder:

1. may have a normal bladder, or
2. may have had a bladder surgery to correct a problem that was causing incontinent episodes, or 
3. maybe getting medication that might lessen the severity of their incontinence, 

the incontinence may still be a problem.

WE HAD THE PROBLEM FIXED WITH SURGERY AND TREATED WITH MEDICATION EVERY DAY.  SO WHY IS MY ELDER STILL INCONTINENT?

Incontinence is often still a problem after surgery and despite being on incontinence medication because your elder may have "functional incontinence" (a nursing care issue) on top of their medically or surgically-treatable incontinence.

Functional incontinence is defined as incontinence caused by physical access or mobility problems, or cognitive impairments -such as stroke or dementia that prevent or impinge upon an individual's ability to get to the toilet and use it appropriately in a timely manner.  Functional incontinence can exist independently, worsen the effects of other forms of incontinence, or continue to persevere after other forms of incontinence have been effectively treated.

Being diagnosed with something like "detrusor muscle instability" and treated with incontinence medication, or having the prostate removed or prolapsed bladder repaired isn't going to affect your elder's ability to get up out of bed and safely get to the toilet.  Likewise, if your elder is confused -because for example, they are suffering from some form of dementia, the incontinence medication is not going to help your elder figure-out how to resolve the sensation of a full bladder.  The incontinence medication doesn't help your elder figure-out what steps they need to take when they feel the urge to urinate or have a bowel movement.

Once an elder requires routine assistance with toileting, they have only FOUR options for obtaining toileting assistance:

1. Obtain toileting assistance from family caregivers.
2. Hire and pay nursing assistants (out of pocket money) to provide toileting assistance.
3. Leave their home and enter an institution -such as a nursing home.
4. Suffer the deleterious (bad) effects of neglect.

Because most elders desire to remain in their own homes and cannot afford to pay for private duty care, by the time they need assistance with toileting, elders are entirely dependent upon their family caregivers. Family caregivers are often carrying many heavy loads and managing a wide range of responsibilities including:

1. raising their children,
2. managing work responsibilities,
3. maintaining spousal relationships,
4. managing their household, and
5. often tending to the needs of more than one elder
6. routinely spending time commuting between their obligations and responsibilities

Determining how best to help your elder to and from the toilet can be a very complicated process -but if it is done correctly- -can make life easier for all parties and postpone or even prevent your elder's need to ever be institutionalized.

There are two areas where your elder may need your assistance to maintain their functional toileting continence: Cognition and Mobility.  An elder's physical mobility needs and their cognitive prompting needs around toileting cannot necessarily be predicted by or from each other.  So while some elders require detailed cognitive prompting and minimal physical mobility assistance, other elders require minimal cognitive prompting and intensive physical mobility assistance to get to the toilet.  Other elders require both detailed cognitive prompting and intensive physical mobility assistance to get to the toilet.  The easiest elders to assist are often (but not always) elders who require minimal prompting and minimal physical mobility assistance.

Cognitive Assistance:

There is a wide range of cognitive assistance your elder may need in order to support and maintain their toileting continence.  Too little cognitive guidance can be confusing and frustrating for all parties.  Too much (cognitive guidance) can be labor-intensive and time-consuming for you (as the family caregiver), and irritating and even provocative for your elder.  

Determining the optimal level of cognitive support can be a tricky business and the amount can vary a bit depending on the time of day and other factors.  A substantial change in the amount of cognitive prompting required for a successful toileting episode can be an early indication of bigger problems (such as delirium) that need to be addressed. 

1. Some elders need only the question:  "Do you need to go to the toilet?" and require no further cognitive prompting.  They know exactly what needs to be done to get to the toilet.  They still may need physical assistance, but you won't need to narrate each step.
2. Some elders may need additional prompting after the initial question of "Do you need to go to the toilet?"  Such as:  

• "Stand-up." 
• "Walk this way."  
• "Step-up here."
• "Watch your step here."
• "Turn around."
• "Pull your pants down."
• "Pull your underwear down."
• "Sit-down."
• "Its OK to go now."
• "Are you finished?"
• "Wipe yourself"
• "Pull your pants-up", etc.

3.  Others require even more intensive prompting with continuous feedback and redirection.

Cognitive prompting can be the most challenging component of assisting the elder to the toilet, requiring time, kindness, patience,