Home Health Care v.s. Facility Placement:
Options in Elder Care

Contributed by Sonja Kobrin,M.P.S., CMC, Geriatric Care Management
V.I.P. Care Management
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 It always makes me sad to hear the families of an elder say “ Mom made me promise to never put her in a nursing home.”  That is simply a promise that most families today cannot keep. If a caring son or daughter finds that they have to break that promise, they may feel guilty for the rest of their lives. Mom probably asked for that promise because the nursing homes she remembers were dark, institutional places, which would be considered substandard in America today. Today’s family structure and the financial challenges of elder care, make facility living a very common choice. When an elder shows signs of not being able to perform the basic activities of daily living, families or concerned professionals must step in. It is actually against most state laws for a professional to be aware of an elder in trouble without taking some reasonable action to secure their safety. There are many indicators that an elder is no longer safe at home alone. The basic litmus test is to ask yourself: “ Could this person save him or herself if their home were on fire? Would they be able to call 911 and communicate their exact location? If left alone for any period of time are they at risk for physical abuse or financial exploitation? Do they have the skills and resources to meet their daily hygiene and nutritional needs? The answer is “NO” for many American elders who live home alone. 

Independence vs. Isolation

Many of my elderly clients who were trying so hard to maintain their independence by living alone at home actually maintained nothing more than an isolated existence punctuated by the occasionally call or visit from friends and family. This type of isolation was also coupled with medication errors or abuse, self-neglect and unsanitary housekeeping. A person living in this situation will often “bloom like a flower” in the right retirement facility environment. It is amazing what three hot meals a day, social interaction, clean sheets and regular administration of medications can do for a person’s mind, body, and spirit. A person who lives alone is more likely to fall and lay alone on the floor for days without being found. A person who lives alone may make poor choices such as keeping (or worse, eating) spoiled food in the refrigerator. If a person lives alone, there are many signs of illness that no one will notice during sporadic short visits. Medical appointments may be missed and prescriptions left unfilled. Many people feel that they are honoring their aging loved one by letting them live alone, even though all the tell tale signs of self neglect are apparent. There is no honor or dignity in being found on the floor after one has lain in his or her own excrement for three days. Unfortunately, many families will wait for this type of incident before insisting on either home health care or facility placement. If an elder is physically or verbally abusive to family and caregivers, they are much more likely to be left alone to make their own decisions, regardless of how dysfunctional their situation may be. Elders with difficult personalities are many times more likely to be abused by caregivers. They need more supervision, not less.

American Family Dynamics and the Pressures of Today’s World

I hear people say “Americans don’t take care of their elders like other countries do.” Well that is not my experience. The adult children who consult with a Geriatric Care Manager or other eldercare professionals are very concerned about their parents. They love them and they want the best care their money can buy. That’s the clincher: what their money can buy.  In America, caregivers, maids, etc, are expensive. Perhaps in another country where slave labor is commonplace, people can afford plenty of care. But in this country it costs $12.00 per hour (or more) for a home health aide. At eight hours per day, that is $96.00 per day. That is $2,880 per month or $34,560 per year – more than the average working American earns per year. The average woman gets a social security check of less than $500.00 per month. Do the math and you will soon see that unless you are wealthy, many people cannot afford to keep their elders in their own home with a part time caregiver or even in their children’s home with a caregiver.

Now couple this financial problem with another very real problem. Most middle income women in their fifties who are caring for their elderly parents, are also trying to hold down a job, help their young-adult children and maintain a marriage. If a middle-income woman stops working to care for her parents, she and her husband either cannot pay their bills or they must significantly reduce their standard of living. I know a few husbands who are fifty-something and feel they have worked too hard and too long to have their dreams of retirement evaporate because someone else’s needs are suddenly more important than their own. Now that Americans have come to grips with the concept that it takes two incomes to live well in this country, they are more determined than ever to have a retirement. Paying $35,000 per year for a caregiver can take a huge chunk out of the retirement savings. Frankly, most people couldn’t afford to do it even if they wanted to. Because most Americans’ net worth is in the equity of their home, selling the family home is the most common way to finance elder care services. If the family home sells for $100,000.00 and the average cost of an Assisted Living Residence is $36,000.00 per year, an elder can afford to live in that Assisted Living for 2.7 years. Coincidently, the average amount of time a person lives in an Assisted Living before moving on to a nursing home is 2.5 years.

Many adult children, who do have the desire and financial means to bring their elders to live with them, still cannot. They cannot because the medical or psychological needs of the elder are beyond their capacity to manage. For example, if Grandma is sweet and docile by day, but “sundowns” or grows agitated as evening falls, this poses a difficult problem for the caring family. When some people experience dementia or other medical issues, they may stay awake all night. They sometimes wander out of doors or rummage through drawers and closets. This behavior will keep the whole family awake at night. If a working family cannot sleep at night, this situation will become intolerable very quickly. Some adult children have been raised by violent, aggressive parents who are now violent aggressive elders. Children who have been raised under these conditions need not feel obligated to bring their parents to live with them, despite the pressure they may get from outsiders who do not know the real story.

Elders and their families who are trying to make difficult choices about elder care benefit from a professional assessment from a geriatric specialist. Professional care managers can offer an objective opinion based on a clinical evaluation of the physical and cognitive status of the elder. Physicians, hospital case managers, facility admissions coordinators and social workers can also offer advice about appropriate placement of an elder or even suggest how to set up services in the home to best meet the elder’s needs.

Home Health Care – Stay Home Without Being Alone

At the very least, any elder living alone should have a medical alert system. This is a necklace or wristband with a panic button that can be pushed in case of emergency. If the button is pushed a dispatch center receives the signal and makes and attempt to communicate with the elder through a speaker placed in the home. If the elder needs help or does not respond to attempts to communicate, emergency services will be dispatched to the home. Many services will also contact friends and family to notify them that assistance is needed. A good candidate for this device is one WHO DOES NOT have memory loss, as memory loss makes it difficult to learn to operate new appliances.

There are two basic types of home health care services: Medicare and Private Duty:

Medicare Home Health is free but can only be accessed if ordered a physician. Medicare will only authorize the free home health services if specific events have happened such as a recent hospitalization lasting three or more days, or a recent change in health status, etc. Medicare will send a Registered Nurse to evaluate the elder and that nurse decides if other professionals such as physical therapists, social workers, dieticians, etc. should perform evaluations. Each professional will determine what services they will render and for how long. Medicare services are temporary in nature and are not offered on a full time basis. The average visit by the nurse, aide and therapist is less than one hour each. Even Medicare home health aides only stay long enough to bathe and dress the patient.

Private Duty Home Health can be arranged on a full time, part time or live-in basis. Many Long Term Care Insurance policies will pay for home health care. The amount of care one can get and the duration of the service varies depending upon which policy they purchased. If someone does not have insurance, they must pay out of pocket (or private pay) for any services. Typically a private home care agency will offer services at a minimum of four hours per day. Typical eight hour shifts are 7am-3pm, 3pm-11pm and 11pm – 7am. Many elders complain that an agency sends them a different caregiver each day. In order to avoid that as much as possible, order care every day for at least eight hours. This will allow the agency to schedule the same person for all your shifts. Because labor laws do apply and the agency would have to pay overtime for time, which exceeds 40 hours per week, you will most likely have at least two to three caregivers on a full time case. The average hourly rate is $14.00 per hour. A live-in will cost about $150.00 per day. A live-in lives in your home and drives your car (or theirs for a mileage fee) and you are expected to feed them as well, even if you go out to dinner. By law, a live-in is entitled to two hours per day of free time. They can do what ever they like, including leaving the house during their break. If this arrangement will not work for your situation, consider hiring an aide around the clock. Around the clock care is typically delivered in two twelve-hour shifts, which are done by two different caregivers. One aide comes to the home from 8am until 8pm and is relieved by the second caregiver at 8pm until 8am. Around the clock care can be delivered in many schedule formats. A live-in is expected to have their own private bedroom and bathroom although many agencies are flexible on this issue. The live-in is expected to be awake all day and have at least 7 hours of sleep at night. If the elder does not sleep at night, a live-in arrangement will not work. One option is to have the live in ($150/day) plus hire a caregiver to come to the house and stay up all night with the elder ($14.00. hour for eight nighttime hours). This costs $112 + $150= $262.00 per day. The only other alternative is to have around- the-clock care which will cost $14.00/hr X 24 hr=$336/day. Adding the eight-hour night shift to the live in saves about $3,000 per month. The Veterans Aid and Attendance Pension is available to qualified veterans who need a caregiver in their home on a regular basis. 

Types of Adult Housing and Facilities:

Independent Living Facilities usually offer small apartments with some meals included in the price. A person who lives in an Independent Living Facility is expected to manage their daily care needs on their own, but the staff would readily recognize if needs increased and assist the resident in obtaining the needed help. Some facilities have extra care services available for additional charge to help the resident “ age in place.” Others may ask a resident to move out if their needs exceed the scope of that particular facility. Limited transportation is usually provided although many residents are still driving when they enter an Independent Living Facility. These facilities may cost anywhere from less than $1,000 per month to over $5,000 per month depending upon the luxury amenities and location.

Assisted Living Facilities usually offer hotel size rooms with the option to share a room or pay extra for a private room. Three meals and snacks are usually provided as part of the price. Residents are expected to need some assistance with their daily care needs. Medication administration is strictly supervised. The State laws dictate who can live in an Assisted Living. The State does not want Assisted Living facilities to house nursing home candidates or Nursing Homes to admit people who could function just as well in an Assisted Living Facility. Assisted Living residents must be able to walk and transfer

(from bed to chair or chair to standing) with the assistance of only one other person. An Assisted Living resident can be left alone in their room for two hours or more. Nurses aides are on duty around the clock. Registered nurses or Licensed Practical Nurses are on duty at least during the daytime. Many medical services may make rounds and visit residents at least monthly. It is not uncommon for an Assisted Living resident to never have to leave the building for a medical or beauty appointment. Prices may range from under $1200/month to over $8,000/ month, once again depending upon the amenities. Medicaid has a program called the Medicaid Waiver, which can pay part of the cost of the Assisted Living. However, funds have been historically limited and waiting lists can be long. The Veteran Aide and Attendance Pension is designed to financially assist qualified veterans who need the services of an Assisted Living facility

Dementia Specific Facilities are designed especially for the memory impaired resident. The building, floor plan, furnishings, décor, activity program and even the lighting have been scientifically engineered to enhance the lifestyle of residents with dementia. Many Assisted Living Facilities and Nursing Homes offer a dementia program or dementia unit, but there are entire facilities that specialize in this unique population. Dementia Specific Facilities can be either Assisted Living Facilities or Nursing Homes. They are secure in order to prevent residents from wandering off the property and getting hurt or lost. The price for this extra level of care is usually about $1,000 to $2,000 more per month than a non-specialty building.

Nursing Homes are State regulated and are inspected at least annually. A person who needs a nursing home generally cannot live safely in an Assisted Living environment. A typical resident is either wheelchair bound or bed bound. Those who can walk around freely may need the nursing home environment because they need constant medical supervision. The medical component of this environment is similar to a hospital or hospice setting. The emphasis is on rehabilitation or custodial care rather than socialization and activities. The ICP Medicaid Program (institutional care program) will pay for the room, board and medical costs of those residents who meet the financial and medical criteria. It is possible to plan in advance to help an elder meet these strict criterions.

Financial Realities

Keeping an elder at home with a caregiver can be the most expensive option of all. Many families feel keeping their loved one in the comfort of their own home is priceless. If a paid caregiver cost $14.00/hour, eight hours per day is equal to $2,880.00 per month. Around the clock care exceeds $10,000 per month. Independent Living Facilities cost an average of $2,300.00/ month and provide no personal assistance. Assisted Living Facilities range from about $2,500/month to $5,000/month and provide limited care. A Nursing Home (without ICP Medicaid assistance) can cost from 5,000.00 to $7,000.00 per month and will provide total care.

Anyone considering hiring home health or moving an elder into a care facility of any type should have their elder’s current needs assessed by a qualified professional who can ascertain the elder’s current medical/psychological and financial needs and anticipate future needs/solutions. With careful, realistic planning, caring for an elder does not have to be a financial or emotional nightmare. Making the right choices for you and the elder you care about is easier when you enlist the help of people who know the eldercare community and all that it has to offer.