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.

Celebrating Nurses

 

National Nurses Week started yesterday, an annual celebration that is planned around the birthday of Florence Nightingale (the founder of modern nursing), on May 12th.

A unique strength of Elder Care Guides' geriatric care management services is our interdisciplinary approach to our work. In addition to nursing, our clinical staff represents the fields of social work, marriage and family therapy, public health, geriatric counseling, and nutritional science. While each of our clients develops a relationship of trust with a professional geriatric care manager who coordinates and monitors their care over time, they also benefit from the expertise of our full team. Our approach is a highly collaborative one, with weekly team meetings, close clinical supervision, and ongoing support and consultation. Our 24-hour on-call system is managed internally, so that clients experiencing a crisis receive a response from a professional who is knowledgeable about their specific needs.

Nursing is a critical component of this collaborative approach, and our nurse care manager Susan Bill, RN, brings invaluable expertise and perspective to the Elder Care Guides team. She earned her nursing degree from the University of South Carolina, and is a licensed Registered Nurse in California. A skilled and knowledgeable advocate for her clients, Susan builds relationships with a warm and empathetic approach. National Nurses Week is a good opportunity for us to publicly recognize her talents and skills, which Susan's clients and her families experience for themselves every day.

Long Term Care Planning: Bringing in a Professional

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 IV: Bringing in a Professional

This month we continue to outline the array of options for those planning for the care of an aging or disabled loved one at home. In addition to hands-on assistance with the activities of daily living, various professional supports are available to help families navigate the maze of long term care and manage complex caregiving situations, including fiduciaries and geriatric care managers.

Professional fiduciaries are licensed individuals who serve by court appointment as guardians, conservators, or personal representatives of an estate. They may also be designated by an individual to serve as trustee, representative payee, or agent under powers of attorney. If a disabled person is no longer able to manage their finances or health care decision-making, and no family members are available or appropriate to assume this role, a fiduciary may be brought in to undertake these essential functions.

Geriatric care managers are certified specialists trained in nursing, gerontology, social work, or psychology, with expertise in issues related to aging and elder care. Services include in-home assessments and care planning, arranging and monitoring care services, 24-hour availability for assistance during emergencies, liaising with long-distance family members, and health care advocacy. For many families and professionals caring for a person with chronic physical or cognitive disabilities, a professional geriatric care manager serves as an experienced guide and resource.

For more information, visit http://www.pfac-pro.org/, or http://www.caremanager.org/.

We've now covered some basics for planning for care at home, and next month we'll explore community-based resources that can serve as a bridge between home and facility.

National Home Care Aide Week

November is National Home Care and Hospice month, and although Elder Care Guides is not a home care company, we want to recognize and illuminate our wonderful employees, the professional caregivers. The National Association for Home Care and Hospice has named November 8th - 14th National Home Care Aide week, with the theme "Home Care Aide: Loving Hands and Compassionate Hearts." This special month and week was announced to bring attention to and celebrate those to spend their lives caring for others. A noble profession, caregiving doesn't often get the attention it deserves. Care Management support, a personalized care plan, and the expert care of a professional caregiver is what allows the growing elderly population to stay at home much longer than originally thought possible.

There are many ways to contribute to and acknowledge that special caregiver in your life, and we encourage you to branch out this month to increase awareness of this much valued career.

• Educate yourself about Care Management and Caregiving by requesting books and materials on the topic at your local library.


• Pass out small gifts or tiny treats to volunteers and caregivers at a local assisted or independent living retirement communities.


• Talk about Care Management with your neighbors and friends who may be struggling in the sandwich generation and don't know where to find help.

As you go about your days in November, stop and notice all the caregivers that surround you. These amazing people are sitting with an elderly person at a restaurant, helping them with their meal. They are reaching for an item on a high shelf at the grocery store for a person in a wheelchair. Every day, they are giving of themselves physically, emotionally, and spiritually, all to assist another person to live with dignity and purpose. To the professional caregivers, we salute you. Happy National Home Care Aide week!

Care Management Featured in the New York Times

An article titled "When Elder Care Problems Escalate, You Can Hire an Expert" appeared in Saturday's New York Times Health Section (9/26/09). It provides some excellent, concrete examples of situations in which the interventions of a professional geriatric care manager can make a positive impact on the lives of elderly parents and their adult children who are caring for them. The author provides some guidelines for identifying a good match, and a list of questions to ask when interviewing a professional geriatric care manager.

We encourage families to call Elder Care Guides with their list of concerns, and the particular criteria they seek in a care manager for their aging parent. We welcome the opportunity to meet face-to-face at our office or in a parent's home at no charge, to discuss the needs and how the services of a care manager may be of assistance, and to determine whether there is a good personal "fit" between the family and the care manager.

Geriatric Care Management: A Profession, and Not Just a Business

I recently received an inquiry from someone considering starting a business managing the medical, legal, and financial affairs of retirees, who sought my feedback regarding the feasibility of such a consultancy. He has several years of experience managing his father's affairs, and a business education; he is a person that I know, and for whom I have a great deal of professional respect. I sat down and sent him a thoughtful response and, when it was sent, realized it was a great reflective exercise that may have some value to others. And so I decided to post parts of it here (with adaptations made for a wider audience) as an open letter to those who would consider a career in this unique service to our aging population:


Care management is more than an interest in the well-being of elders, or a passion for service. It is a profession, and requires education and supervised experience, as well as a healthy dose of discretion -- we need to know what we don't know, and work collaboratively with others to create a support system that protects and honors the elder client. The management of an individual's medical, financial, and legal affairs should not be provided by one person or organization (unless it is under the careful supervision of the courts), and while it's generally acceptable - although not ideal - for an individual family member to serve in multiple roles when necessary, it is inappropriate for a professional to do so. A single entity that helps members of this vulnerable population make decisions regarding their long-term care, provides and/or manages those services, and then arranges for payment to be made for the services has a very clear conflict of interest and a lack of objectivity.

As geriatric care managers, we are usually the hub of a team of professionals working together in service to our client, often alongside devoted and hard-working family members. We assess and manage medical, psychiatric, cognitive, social, and care needs, while private fiduciaries manage financial affairs and can serve as legal representative (power of attorney, conservator, guardian, etc.) when necessary. Estate planning and elder law attorneys assist in the preparation and continuous update of documents such as the estate plan and advanced directives, and there are often other professionals involved as well, including financial advisers or trust administrators.

This might all sound like overkill (does one client really need all of these people involved in their affairs?), but the fact is that young and healthy seniors do not want or need this type of assistance. Families that hire care managers are usually dealing with complex circumstances, often after years of familial strife and decline due to advanced age and a chronic, disabling condition (usually several). Every day, we are negotiating long-standing family conflicts, working with physicians regarding complicated medical conditions and treatments in an increasingly fragmented health care system, and shepherding people through the spiritual journey at the end of their lives, helping them continue to find meaning and purpose. These are not simple transactions.

As an adult child, one has the time (albeit limited) to do one's research, to learn what needs to be known about a parent's health insurance coverage, medical conditions, and financial/legal affairs as one goes along. There is also an understanding, a permission of sorts, to make mistakes along the way: to hire a home care company that did not fulfill their commitments, to churn through several health care providers before finding the one with the right skills to manage your loved one's medical situation. Expert consultants do not have this time or permission. Families rightfully expect a paid professional geriatric care manager to understand the national and local health care landscape, to know which facilities in their area provide the best dementia care, how to effectively supervise in-home caregivers, which medications are considered unsafe for elders according to the Beers criteria, the basics of applying for Medicaid, how to help a conflicted family reach consensus regarding a plan of care, etc. When we come to a new client untrained in these issues, or without the skills to efficiently obtain necessary information or services, we are not being good stewards of their resources. Experience as a family caregiver is an enormous asset to a professional geriatric care manager, but it is not enough.

My advice (for those who would seek it) is to find a service niche that makes the best use of your interests and skills, and seek out the education, training, experience, and certification/licensure that is required. It is a road that may take several years, but it will be a rewarding journey that will serve you and your clients in countless ways.

For more information, please visit the websites of the National Association of Professional Geriatric Care Managers, and the National Guardianship Association.