Long Term Care Planning: What's Covered, and What Isn't

We were invited to write a series of brief articles for the monthly newsletter of our friends at MDK Insurance Services, describing the continuum of long term care, and how to navigate oneself through it. You can sign up for the newsletter on their website, and each month we provide a copy of the article here as well. Please share the information with someone you know who is thinking ahead about how to plan for (and pay for) their own or a loved one's long term care.

Volume VIII: What's Covered, and What Isn't

In previous issues, we’ve described the various settings in which long term careis provided, often referred to as the “continuum of care.” Many are caught off guard in the midst of a health care crisis by a sudden and surprising lesson inwhich types of care are covered by Medicare or other forms of health insurance, and which require private payment.

The simplest way to understand whether a particular type of care will be covered is generally this: if a physician orders it, it requires the services of a licensed healthcare provider, and its goal is to treat an acute condition, then Medicare or health insurance will cover at least a portion of its cost. If those conditions are not met, then it is not covered.

Care provided within a skilled nursing facility (SNF) is frequently an area of confusion. Up to 100 days of a short-term rehabilitative stay in a SNF while recovering from an acute illness or injury after a hospitalization will in large part be covered by Medicare, but long-term “custodial” care for an individual who requires assistance with daily tasks that cannot be provided within other settings is not, and must be paid for privately. Home health care (licensed nursing or therapy services provided on a short-term basis for rehabilitative purposes) is generally a covered health insurance/Medicare benefit, as is hospice care.

Care provided within residential care facilities, including assisted living apartments, board and care homes, continuing care retirement communities, and residential dementia care, is not covered by Medicare or other health insurance. Non-medical home care services are also not covered; this includes services to assist with activities of daily living such as bathing, toileting, and ambulating, and is often referred to as “custodial” or “private duty” care. Professional services such as those provided by a geriatric care manager or fiduciary require private payment, as do most community-based adult day programs and transportation services. These “non-medical” settings are where the majority of long term care services are provided, so thoughtful planning about how they will be financed is essential.

Next month we’ll wrap up this series with a look at the costs of long term care, and tips for developing a personal plan.

The Giving and Receiving of Care

On Tuesday afternoon, I made a home visit with a gentleman who has been a client of ours for nearly two years, and who has bonded deeply with his companion caregiver. As he described to me his gratitude for all of her assistance over the time that she's worked with him with tasks like bathing, preparing meals, and accompanying him on daily walks, I perceived his sense that the giving and receiving of care was a one-way street. I turned to his caregiver, and asked her to tell us something about what she has received during the time that she has been working with him. She told us about all of the things she has learned about San Diego from this client (an avid historian), her new appreciation for the beauty of a Protestant religious service (she is Catholic, but attends church with him at his chapel every Sunday), and about how much her English (which is her second language) has improved over the 18 months that they have been working together. Although her English is nearly grammatically perfect, she told him early on in their relationship that she was working to further improve it, and asked for his help when he noticed improper pronunciation or usage. She told us how invaluable she has found his assistance in this regard, how much she appreciates his kind ways of correcting her and teaching her about some of our language's oddities.

This struck me as an important lesson for us all, and brought to light a concept that is well-illuminated by William Thomas, M.D. in What Are Old People For?, his groundbreaking 2004 critique of the American long-term care system. He writes that "... the bulk of the suffering experienced by those confined to long-term care environments is due to the plagues of loneliness, helplessness, and boredom," and calls for a radical transformation in not only the provision of care but our deeply held beliefs about aging. The antidote to helplessness, according to Dr. Thomas, is the opportunity to give as well as to receive care. 

I watched my client's face light up in a huge smile as the caregiver spoke that afternoon, and knew that he was seeing for the first time the positive impact their time working together has had upon her as the care giver, as well as himself as the care receiver. It gave me a chance to reflect on the ways that we as care managers, and all of us who care about an older person, can create opportunities for late-life development. The moments are all around us.

Restraint Use Declining in Nursing Homes

There was an article in USA Today recently that described a decline in the use of restraints in nursing homes in the United States. This is good news for nursing home residents across the country, and for those of us who advocate for seniors.

Restraints were once commonly used in nursing facilities to control the behaviors of residents with dementia or other psychiatric conditions and to prevent falls. The use of restraints in facilities has declined over time, but education is still needed to help families and health care professionals seek alternatives. In fact, California is one of the U.S. states with the most room for improvement. The most recent data from Medicare in 2007 indicated that 10% of nursing home residents in CA were restrained, while the national average was 5.5%

What is a restraint? The National Consumer Voice for Quality Long-Term Care (NCCNHR) defines a physical restraint as an object or device that an individual cannot remove easily and which restricts freedom of movement or normal access to one's body. Common restraints include: seat belts on wheelchairs, vest restraints, geri-chairs, hand mitts, side rails and lap trays.

Many families and health care providers believe that restraints help nursing home patients to be "safer," though research shows that often times the opposite is true: individuals who are agitated frequently become more agitated when they are restrained. Behavioral approaches such as validation and redirection, as well as activity engagement, can often help agitated people to become less agitated.

As a Geriatric Care Manager monitoring the well-being of clients in nursing homes and in the home setting, it is my responsibility to advocate for no restraint use, or minimal restraint use that is re-evaluated frequently and discontinued as soon as possible.