When a Loved One Needs Long-Term Care

Author:

Published on:

Introduction

It may be the most difficult decision you ever have to make. A spouse, parent, or other family member can no longer live independently, and the care needed to enable her or him to remain at home is not available. This may be a temporary situation, which can frequently follow an acute illness, hospitalization, or injury. It may be necessary when usual caregivers are drawn away by an emergency or simply need to get away for a break. Or it may be necessary on a long-term basis when the loved one declines physically or mentally.

Types of Care

The array of care facilities now available can be very confusing. Choosing the right one depends on the level of care needed, and on doing a good job of investigating the possibilities.

Assisted-living facilities, personal-care homes, and retirement communities are all names of facilities that provide for people who are nearly independent, but for reasons of either mild physical or mental impairment, need some help with tasks like cooking, housecleaning, or shopping.

Most assisted-living facilities have on-site staff who can assist with medications and are available 24 hours a day for problems that come up. They either have on-site care, or they contract agencies that can provide personal attendants, nurses, and physical and occupational therapists on an as-needed basis. Often they provide congregate meals and a number of social activities. Most residents of assisted-living facilities are able to perform their own self-care activities like dressing, bathing, and eating. Some facilities are either contiguous with, or have arrangements with facilities that provide higher levels of care should the resident become more impaired, but others require residents to move when they become too dependent.

Subacute care units are designed for a patient's continued treatment in a setting where the intensity of care is less than that in a hospital setting, but still provides continuous registered nurse supervision. An example would be the need for extended intravenous antibiotic therapy for some types of infections. The development of subacute care has been driven largely by attention to cost containment and the desire to limit extremely expensive hospital care.

Rehabilitation units are similarly designed for patients whose hospital stay has left them too weak to return home, or who need more time and physical therapy to regain their independence. A good example would be a patient with a hip fracture. Some rehabilitation units are located in a special area of the hospital, but more commonly they are separate facilities, or special units in a nursing home developed especially for this purpose. Patients must qualify for rehabilitation units by being deemed able to participate in aggressive therapy for a minimum of four hours a day, five days a week. Generally, the social worker or case manager at the hospital will make arrangements for transfer to a subacute or rehabilitation unit. The social worker or case manager will work with the family to consider their preferences, but often applications must be made to several facilities, and the patient must be transferred to the first bed available. If the patient does not improve enough to allow return home, or if the family is dissatisfied with the quality of care, then arrangements can be made for transfer to another facility.

Respite care units are special units, usually within nursing homes, that are specially designed to provide very short-term care for patients whose caregivers need a break. Medicare will cover respite care for one or two weeks per year.

Skilled-nursing facilities (SNF), nursing homes, and extended-care facilities are all names given to facilities that provide chronic care. Stays may be short, less than six months, for those patients in special units designed for subacute, rehabilitation, respite or terminal (hospice) care. Other patients generally stay longer than six months. Although only five percent of people over the age of 65 live in nursing homes, there is a 20 percent chance that someone who lives to 65 will spend some time in a nursing home before she dies. As the population has become older, and forces have moved to discharge patients more quickly from the hospital, the population of patients living in nursing homes has become older and sicker. Two-thirds of patients in nursing homes have some type of mental or cognitive impairment that limits their ability to live independently; the rest are physically impaired. Nursing homes provide 24-hour nursing care and supervision; most residents require some assistance with self-care functions like bathing, grooming, toileting, and eating. A healthcare team of physician, nursing staff, dietitian, pharmacist, physical and occupational therapist, and recreation therapist monitor a broad range of patient functions such as medical, psychological, nutritional, and functional status. Social and physical activities are planned to promote emotional and physical well-being.

Who Pays?

Most assisted-living facilities must be paid for by out-of-pocket payment. They can be very expensive, with rents upward of  $3,000 per month, and additional services extra. Some facilities require a very large buy-in fee, but then generally guarantee lifetime care, including moving patients to higher levels of care if necessary. Although the development of assisted-living facilities is one of the largest growth areas in senior living, most development is driven by a profit motive, and there is a huge need for more  moderate-priced assisted living.

Subacute care and rehabilitation care are generally covered, at least partially, by Medicare, up to a maximum of 100 days post-hospitalization, for patients who qualify for this level of care.

The lack of coverage of long-term care is considered to be one of the largest gaps in our healthcare system. Nursing homes are extremely expensive, and Medicare does not pay for them. Patients must pay out-of-pocket until their savings are exhausted, and then Medicaid, the entitlement program for the poor, will take over. Nationally, about 50 percent of nursing home expenses are paid by Medicaid.

How to Evaluate a Long-Term Care Facility

Once you have made the decision to seek a long-term care facility for your loved one, you will need to know what to look for. There are a number of sources of information you can consult. If your loved one will be transferred to long-term care from the hospital, the hospital social worker or case manager should be able to recommend the facilities that he or she regards most highly. Your doctor may be able to make recommendations. If your loved one is still at home, you may find the services of a private care manager, or case manager, helpful. This person is generally someone with a social work background who is especially knowledgeable about the local resources for care, as well as about funding guidelines and practical legal issues, such as guardianship, which may arise. Ask your local Department of Aging or your state Department of Health for names of care managers. These agencies may also have guidebooks concerning nursing homes in your area, with information about services available, special care units (for example, for patients with stroke or Alzheimer's Disease), costs, and insurance coverage.

Nursing home regulations
Nursing homes are the most highly regulated facilities in healthcare. There are regulations governing every aspect of care, and federal and state agencies continuously monitor compliance with these regulations. Regulations dictate everything from the staff-to-patient ratio, to the temperature of food, to the privacy and dignity of residents, among other things. Nursing homes are required by federal legislation to minimize the use of physical restraints and behavior-modifying medications. The healthcare team is required to monitor patient status closely, and to look for and address warning signs of problems, such as falls, weight loss, and skin breakdown. The family must be included in periodic reviews of these status reports.

Don't be afraid to ask questions about the nursing home's compliance with regulations. Ask to see the results of their latest survey. Find out if there are any financial problems, or labor problems. Check to see whether the physical environs is in good shape and attractive.

Most important, look at the long-term care facility as a potential home. The staff working there are the people who create an environment of care. Visit the home and observe how the staff treat residents, and how they interact with each other. Try to answer the following questions:

Conclusion

Moving a loved one to a long-term care facility is a life event charged with emotion. It is the culmination of an involved, stressful process. Feelings of relief about having finally made the decision are counteracted by feelings of sadness or failure, and worry about whether the decision was the right one. Your loved one, even if he or she is cognitively impaired, will have emotions about leaving home, and will need to adapt to the new setting. You will need to adapt to a major change in your caregiver role, and will want to make decisions about how often to visit. Staff are very used to dealing with these needs, and can offer valuable advice about making the transition.

A carefully made decision based on as much information as possible, provides the best reassurance that your loved one will be safe and content in her new home.