Long Term Care Planning: Specialty Community-Based Long Term Care

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 VII: Specialty community-based long term care

Last month’s issue provided an overview of the basic types of long term care facilities. Here we review a few models of specialty care that are available in the community.

There are several types of specialty Skilled Nursing Facilities (SNFs) in California. A Distinct Part/SNF (DP/SNF) is a hospital-based unit, rather than a freestanding facility. Intermediate Care Facilities (ICFs) provide inpatient care to those who need nursing and supportive services, but who don’t require continuous skilled nursing care.

A Continuing Care Retirement Community (CCRC) is a configuration in which Independent Living, Assisted Living, and Skilled Nursing Facility services are provided on one campus. A resident contracts for care regardless of changing needs, usually for their lifetime. Most CCRCs have a large entrance fee, ranging anywhere from $100,000 to $1 million. CCRCs are regulated by California’s Department of Social Services Continuing Care Contracts Branch.

Some residential care facilities offer specialized services for people with dementia. Dementia Care can be provided within a freestanding facility, or as a separate unit within an Assisted Living facility. Staff are trained to work effectively with people with Alzheimer’s and other types of dementia, and activity programs are tailored to the special needs of the residents. Buildings have secured perimeters to prevent unsafe wandering.

Hospice Care provides comfort and support to patients with terminal illness that is not responding to cure-oriented treatment. Hospice may be provided within the home or in a facility setting, with the goal of maximizing quality of life through effective symptom and pain management. Services provided by an interdisciplinary team address the emotional, spiritual, and social impact of the illness upon the patient and their family.

Long Term Care Planning: Community-Based Care Settings

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 VI: Community-based care settings

Previous installments of this series have described the resources available to those planning for care at home, and the goal of this issue is to describe the basic options for community-based long term care. Those who choose to move out of a private home and into a "senior living" setting do so for a variety of reasons. For some, it is a financial decision, while for others it is a lifestyle choice - freedom from the day-to-day responsibilities of managing a household, or the opportunity to interact socially with more people on a daily basis.

Independent Living communities are also sometimes referred to as "retirement communities." Some amenities such as communal dining, light housekeeping, transportation services, and planned activities may be available, but no personal care is provided. In these communities, residents must usually be able to ambulate independently.

Residential Care refers to a range of different housing providers that are licensed (in California by the Department of Social Services' Community Care Licensing division) to provide assistance with activities of daily living such as bathing, dressing, and medication management. A Board and Care home is a small residence (usually a single family home) with between six and twelve residents and a small staff of attendants. An Assisted Living facility is a larger community that usually offers several different levels of care and more supportive services.

Skilled Nursing Facilities are sometimes referred to as "nursing homes." They are licensed (in California by the Department of Public Health) to provide skilled nursing and supportive services for those who require assistance with most - or all - of the activities of daily living.

Next month we'll explore some additional specialty community-based residential services that are available, and then we will move on to a discussion of fees and funding sources for each level of care.

Elder Abuse - A Personal Story (part 2)

Continuing story from Elder Abuse - A Personal Story (part 1):

As already described, while visiting with my mother in the nursing home, I discovered that she was being abused by someone in the facility. Although her cognitive abilities were intact, she did have aphasia caused by her stroke and the only word she could verbalize was "waiter" which really held no specific meaning.

Since my mother couldn't identify her abuser by naming her, I had to come up with another way for mom to let me know who this person was. I wanted to inform the facility Administrator immediately but my mother, in her way, begged for me to hold off. She had such a look of fear, I realized she was afraid of retribution so I devised a new plan.

The plan was to push my mom in her wheelchair throughout the facility coming at various times of the day so I could cover all the different shifts. When we came upon the individual, my mom was to put her foot down, stopping the wheelchair, grab my hand and acknowledge the person.With this plan understood and agreed to, we entered the building and proceeded towards her wing.

It was a busy time and many of the staff were in the area. All at once, a caregiver (I'll call Mary- not real name) stepped out from a room. My mother put her foot down and grabbed my hand. Mary came directly over to mom, putting her arms around her in a hug and giving her a big kiss. The look on my mother's face said everything, there was fear, disgust and revulsion.

Mary had worked with my mother for a few years and was a very friendly type. Because of this, I had to ask my mom if she was sure that Mary was the abuser. She nodded yes, but I still hesitated because this all happened so quickly. I looked mom directly in the eyes and asked again, she grabbed my hand squeezed it, nodded and started to cry.

We immediately went to the Administrator, explained the situation and resulting discovery. He asked mom a few questions and agreed to take Mary off her care. Because of mom's aphasia she could not identify Mary verbally so they couldn't fire her but two years later, after my mother had passed away, I met some people who had had their relative at the same nursing facility and at the same time. They told me they had personally caught Mary abusing their relative. She was fired on the spot.

This experience ignited my resolve to help advocate for those who have no one to speak on their behalf and it is why I became an Ombudsman and ultimately a geriatric care manager. Sadly, my mother's story is not unusual but with more awareness of elder abuse and involvement in the programs helping prevent it, we will make a change.

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.