Housing Options and Long Term Care

In this module you will learn to Identify the need for intervention, and how to identify the appropriate intervention, to make the right housing choice & talk to your loved one about making a change.
Click on a topic below to go to that area of the page:
1 Free Community Information & Referral Service
2 Advance Care Planning
3 When is it time to intervene?
4 What are alternatives to Residential Settings?
5 Modifications which can be made to the home
6 Finding Resources
7 Can my loved one move in with me?
8 How do we make the decision to move?
9 Roadblocks
10 Common Losses
11 What has not been lost?
12 Talking about the move
13 Housing Options
14 How to involve your loved one
15 Do some research
16 What is the cost?
17 When is it time for the nursing home?
18 Nursing Home Quality Report System
19 How do I pay for this?

Free Community Information & Referral Service

  • Aging Information Line
    A service of the Area Agency on Aging that helps connect callers to services such as the following:

    • Financial assistance
    • Health resources
    • Counseling
    • In-home services
    • Housing options
    • Nutrition and meal programs
    • Educational opportunities
    • Transportation
    • Benefits counseling

Advance Care Planning

A good resource for helping you and your family plan appropriately is
www.oag.state.tx.us
Click on “Elder Texans” and go to “Advance Care Planning”.

Planning For The Future

  • Helps dispel fears about what will happen.
  • Helps avoid potential problems such as running out of money.
  • Ensures wishes are respected.
  • Identifies appropriate persons to assume specific roles.
  • Ensures personal business is in order.

Have a family meeting

Bring the family together, including spouse, children, and grandchildren. Any one who may be involved in providing support should be part of this meeting. Involve out-of-town relatives. Talk about the future, including fears, potential problems, wishes, individual roles and legal issues

Plan and Communicate

Discuss important documents and personal information. Make sure you fully understand the wishes of your loved one. You may want to discuss end-of-life issues with a physician, minister and other family members.

Does your loved have …?

  • A Directive to Physicians
  • Durable Power of Attorney for Healthcare
  • General Power of Attorney
  • A Will · A burial policy
  • Health insurance, Medicare
  • A log of financial information such as bank accounts, investments

Establish An Information Center

  • Identify a place for important information and documents.
  •  Make sure all family members, trusted neighbors, and/or friends can access this information in an emergency.
  • Distribute copies of important documents to family, physicians, attorneys, etc.

Visit the Doctor!!!!!!

  • Everyone should visit a physician at least yearly.
  • If your loved one does not have a physician, make an appointment immediately.
  • It is not uncommon for doctors to have waiting lists. It could be several weeks before your loved one is seen.

Before the visit

  • List all concerns and questions.
  • List all medications, including herbals, vitamins and over-the-counter medications.
  • List all known allergies.
  • Prepare a complete medical history including mental health issues.
  • Copy advanced directives as Directive to Physicians and Durable Power of Attorney for Healthcare.

During the appointment

  • Go with your loved one so that you can be his/her eyes and ears.
  • Let your loved one talk when asked questions, and interject if needed.
  • Tell the doctor about any specialists being seen.
  • Be respectful of the doctor`s time and don`t give frivolous information.
  • Get to know the nurse and office staff. Ask if you can contact the nurse directly with questions.
  • Find out if the physician will see patients in a nursing facility.
  • Find out how the doctor feels about end of life issues.

When is it time to intervene?

Warning Signs

  • Decline in ability to perform activities such as dressing, bathing, etc.
  • Change in appearance, looking unkempt.
  • Bills unpaid, mail unopened.
  • Leaving iron or stove turned on.
  • Problems with incontinence/odor.
  • Apathy and depression.
  • Ruined food in refrigerator.
  • Missing appointments/events.
  • Becoming paranoid or suspicious.
  • Not eating well.
  • Unable to take medication properly.
  • Social isolation.
  • Unexplained dents in car.
  • General safety concerns.
  • Change in behavior.

Analyze the Information

  • Listen to neighbors, friends, relatives.
  • What have they observed?
  • Observe for yourself, but be aware that your loved one may appear more oriented when you are present.
  • Make unannounced visits at different times of day.
  • Spend extended periods of time in the home to observe their ability to function independently.
  • Respond; don`t react.

Activity: Identify the real problem

  1. You pick Mom up for a visit to a local tearoom and her clothes are dirty. What might be the problem?
    1. Washing machine is broken
    2. Poor lighting in house
    3. Problems with eyesight
    4. Depression and/or apathy
  2. Uncle Joe doesn`t want to get out anymore. What might be the problem?
    1. Fear of falling
    2. Incontinence
    3. Can`t hear/enjoy activities
    4. Depression
  3. Aunt Mabel isn`t taking her medication properly. What might be the problem?
  1. Doctor`s orders are unclear
  2. Medication makes her feel worse
  3. She can`t remove cap from bottle
  4. She can`t read the label on medication
  5. She`s trying to save money by taking medications at a lesser dose and/or less frequently
  1. You visit Ms. Smith and notice a strong urine odor. What might be the problem?
  1. Incontinence
  2. Urinary tract infection
  3. Afraid to get in shower
  4. Unable to smell odors
  5. Not remembering to shower

How do you evaluate the situation?

  • What is the doctor`s opinion?
  • Is your loved one a hazard to him/herself or someone else?
  • Is the situation creating a burden for the spouse of your loved one?
  • Are you intervening too often?

Look at your own situation

  • Sleeping poorly?
  • Missing work or often late?
  • Feeling resentful toward your loved one?
  • Feeling overwhelmed?
  • Suffering from physical or emotional illness?
  • Being a caregiver is a balancing act. If the reason you are considering moving your loved one is your mental and physical health, don`t feel guilty. YOU CAN`T DO IT ALL!

Physical vs. emotional health

Consider the impact of the situation on you and your loved one.

What are alternatives to Residential Settings?

The choices:

  • In-home Services
  • Moving your loved one into your home
  • Residential properties

In-Home Services

  • What`s really out there?
  • There are multiple services that you can access in the home.
    • NOTE: It may be necessary to work with multiple service providers to meet the needs of your loved one

Home Care

Agency providing:

  • Personal assistance
  • Light housekeeping
  • Meal preparation
  • Transportation
    • NOTE: Some agencies are also licensed to provide hands-on care such as dressing, bathing and incontinent care.

Home Health

Medical service providing:

  • Therapies
  • Nursing services
  • Personal care
    • NOTE: Medicare will pay for some home health services if there is a need for skilled care. However, this is generally short-term.

Adult Day Care

  • Adult day care centers are classified as either “social” or “medical.” Both offer a secure setting for seniors who have physical or mental impairments, meal service, and activities. In addition, “medical” adult day care centers offer:
    • Meal service
    • Medication administration
    • Activities
    • Nursing supervision

Since adult day care centers are expensive to run, they are rarely found outside of urban areas.

Senior Centers

Centers that service active senior adults.

  • Nutritious meals
  • Activities
  • Games
  • Educational opportunities

Hospice

  • Medical service used when a person has been diagnosed with a terminal illness and, generally, has less than six months to live.
  • These agencies provide physical, emotional and spiritual support to the client and family.

Other Services

  • Transportation
  • Meals on wheels
  • Bill payer programs
  • Case management

Contact your local area agency on aging for information about these programs.

Questions to ask service providers

  • Does agency conduct criminal history checks and reference checks on employees and volunteers?
  • Does it have a drug testing policy?
  • Is the agency licensed? If licensed, what is its inspection history? · Is it bonded and insured?
  • How does it resolve complaints and concerns?

How will you pay?

  • Some in-home services are covered by Medicare, Medicaid and private insurance.
  • Ask questions before you sign any contracts.
    • Will the agency expect payment in advance?
    • Will it bill your insurance?
    • How often does it bill?

Modifications which can be made to the home

  • Add ramps.
  • Put grab bars in the shower.
  • Purchase an elevated toilet seat. .
  • Get a lift chair.
  • Remove safety hazards such as electric cords and area rugs.

Finding Resources

  • Ask a physician.
  • Ask a rehab specialist.
  • Ask a provider of medical equipment.
  • Access www.abledata.com, a web site with links to vendors who sell adaptive equipment.

Can my loved one move in with me?

  • Does your loved one want to live with you?
  • Is your home accessible?
  • Do you have the space?
  • What will the impact be on you, your family, and your loved one?
  • Do you have the stamina?
  • Will this move increase your stress?
  • What are you doing to take care of yourself NOW?
    • How will that change if your loved one moves in with you

How do we make the decision to move?

  • Put yourself in his/her shoes.
    • How would you feel if the tables were turned?
    • Fear, anger and embarrassment are all normal emotions.
    • Even the language we use to describe the move is often negative.
      • We sometimes say we had to “put” Mom in a home just like we “put” the cat out.

Roadblocks

Your loved one may not be in agreement and will likely put up roadblocks when you start to discuss making a change. Try to understand what is motivating him/her to put up these roadblocks.

Discuss each concern

  • Fear of running out of money
  • Fear of strangers
  • Fear of nursing homes
  • Fear of being forgotten
  • Fear of losing independence

Common Losses

  • Friends and family
  • Physical health
  • Roles such as spouse, employee
  • General feeling of independence
  • Identity
  • Car and home

What is a house?

  • Home
  • Memories, life history
  • Neighborhood, community
  • Sense of security

Consider this.  We spend most of our lives trying to create a space that represents who we are. We build a “house” and make it a “home”. We fix up, redo, add on and then we leave our castle for a 500 square foot apartment in a big apartment building.

What has not been lost?

  • Life history
  • Spirituality
  • Relationships with friends and family
  • Uniqueness
  • Peace and contentment
  • Wisdom
  • Treasures

Talking about the move

Talk to him/her with love and respect. Don’t treat him/her like a child. Involve him/her in the decision. Let him/her know that he/she is not a burden. Acknowledge that he/she will grieve this change.

Housing Options

  • Finding the right place can be a challenge.
  • There are multiple choices representing a continuum of care.
  • You will likely need to visit several properties to find the right fit.

Continuing Care Retirement Communities

  • Center with independent living, assisted living and nursing care on the same campus.
  • This is a good option for married couples who need different levels of care.
  • Some CCRCs will guarantee placement for the remainder of a person`s life even if the person runs out of money.

Affordable Housing

  • Properties that are federally funded for the aged and disabled.
  • Regulated by the Department of Housing and Urban Development to serve independent residents.
  • Additional services can be contracted such as health care, transportation, meals and housekeeping.

Independent Living

  • Private apartments or cottages.
  • Good option for people able to care for themselves.
  • Provide opportunities for socialization and a sense of security.
  • Properties generally provide housekeeping, laundry, meal service, and transportation.

Assisted Living

  • Assisted Living – Type A
    • Licensed facility.
    • Provide supportive services while allowing seniors to maintain their independence.
    • Type A facilities will accept residents who are able to leave the building unassisted in case of emergency.
  • Assisted Living – Type B
    • Licensed facility.
    • Type B properties can accept residents with more complex medical problems.
    • Services may include transfer assistance and incontinent care.
    • Residents who cannot leave the building unassisted in case of an emergency can be accepted.
  • Assisted Living – Special Care
    • Licensed facility.
    • Designed for people with dementia.
    • Generally locked units.
    • Special activity programming for people with dementia.
    • Daily personal assistance service.

Nursing Facilities

  • Nursing Facility
    • Licensed facility.
    • Provide therapy services, nursing care and custodial care.
    • Residents may be there for respite, rehabilitation or long-term care.
  • Special Care Unit – Nursing Facility
    • Licensed facility.
    • Providing specialized care for persons with Alzheimer`s disease and other types of dementia.
    • They may have locked units with special activity programs for the residents.

How to involve your loved one

  • Encourage him/her to be part of the process.
  • Ask if he/she has friends living in a community that is of interest.
  • Find out what is important to him/her and make these priorities your priorities.
  • Ask about specific services or amenities your loved one wants.

Do some research

  • What do friends, family, physician and clergy suggest?
  • Do you know people already living there?
  • What is the proximity to your house and work?
  • What is the proximity to your loved one`s neighborhood and church?
  • Did the property pass your prescreening?

What is the cost?

  • How much does it cost?
  • Is there a second person fee?
  • Is there a deposit? If so, is it refundable or non-refundable?
  • Is there an application fee?

Analyze long-term cost

  • Most properties will raise the rent at least yearly.
  • Ask about the history of rent increases.
  • When does the increase usually takes place?
  • Are you locked into a lease for a year?
  • What happens if your loved one gets ill and must move?
  • Annualize cost and plan for an increase of 5% or so per year.

Services and Amenities

Services and amenities may include:

  • Transportation
  • Fitness room
  • Resident garden
  • Meals
  • Laundry
  • Housekeeping

Before you go…

  • Make an appointment.
  • Make a list of all your questions.
  • Prepare the marketing representative by telling what is important to your loved one.
  • Go at a time when your loved one can see activity in the building such as meal time or game night.

While you`re there…

  • Make sure all questions are answered.
  • Get activity calendar and menu.
  • Get brochure with prices.
  • Get copy of lease agreement and other legal documents.
  • Observe staff and residents.
  • Talk to residents and their family members to see how satisfied they are.
  • Observe how people access the building for security purposes.

Get Organized

  • Once you tour several properties they will probably start to look a like.
  • Make a notebook with checklist and questions. Take notes during tours.
  • Keep brochures.
  • Once you have toured all the properties, you will need to narrow down your search.
  • Tour properties again.
    • You may want to go in the evening when management staff has left for the day.

When is it time for the nursing home?

  • Difficult question to answer.
  • Timing is generally not in your control.
  • Decision is driven by need.
  • Often, the physician or care provider such as home health agency will encourage the change.
  • Keep in mind that your loved one has the right to make decisions regarding his/her own care and where he/she will live, unless he/she is incapable of making these decisions and has had a guardian appointed by the Court.

Nursing Home Quality Report System

  • The Texas Department of Human Services has a web site designed to help you in the search for a nursing facility. It gives a comparison to other facilities in the county or zip code area.
    http://facilityquality.dhs.state.tx.us
  • NOTE: This report should not take the place of visiting a property.

The Long-Term Care Ombudsman may also be able to tell you about facilities’ complaint histories.

Touring the facility

  • Choosing a nursing home is much like choosing any residential setting.
  • You should ask many of the same questions you asked when touring a more independent setting.
  • What do your senses tell you?
  • Do residents appear well care for?
  • Do employees interact positively with residents?
  • Do employees interact positively with other staff?
  • Is the building clean and odor free?
  • Is the facility accessible by public transportation? If not, staff may have a hard time getting to the facility, and there may be more problems with short staffing.
  •  What is the facility`s staff turnover rate? This reflects how satisfied employees are with their work.

Once the move is made

  • Adjustment takes time
  • He/she may need to grieve the loss of the house, community, independence
  • Don`t sell the house immediately
  • Continue to visit with regularity but don`t hover
  • Plan times to visit when you can share a meal or attend an activity
  • Make sure he/she doesn`t feel abandoned

Visiting in the facility

  • Visit often.
  • Take things to discuss such as pictures, books, church bulletins.
  • Discuss your daily activities.
  • Encourage participation in activities.
  • Join them for activities.
  • Bring small gifts such as flowers or plants.

Building relationship with staff

  • Attend care plan meetings.
  • Be realistic.
  • Pick your battles.
  • Catch staff doing things right.
  • Learn chain of command.
  • Get to know staff by name.
  • Seek to understand staff.

Resolving problems with the facility

  • Talk to the person who can resolve the problem.
  • Follow chain of command.
  • Contact the Ombudsman. His/her phone number should be posted in clear sight.
  • As a last resort, file a formal complaint with Texas Department of Human Services.
    • NOTE: Write down concerns and give them to appropriate staff. It is also good to keep a record of your efforts

How do I pay for this?

  • Medicare
  • Medicaid
  • Private Insurance
  • Private Pay

Medicare

  • Medicare Part A – pays hospital and nursing home costs. Eligibility is automatic for most people when they turn 65.
  • Medicare Part B – pays physicians, labs, ambulance costs, etc. It does require you to enroll and pay premiums, unless your income is very low and you qualify for assistance through the State.
  • Part A covers …
    • Inpatient hospital care.
    • Skilled nursing facility care.
    • Home health care.
    • Hospice care.

     

  • Criteria for Skilled Nursing Facility Care.
    • Three day hospital stay.
    • Skilled need must exist.
    • Need inpatient facility.
    • Access services within 30 days of discharge from the hospital.
  • Misconceptions about Medicare:
    • AA person can be covered for up to 100 days provided if he/she has a skilled need and continues to improve.
    • If a person plateaus or stops improving, Medicare will cease.
    • Many people think they will automatically get 100 days of nursing facility care. However, this is not true.

Medicaid

  • Assistance program administered by State.
    • Eligibility is based on financial and medical necessity.
    • Different component of this program.
  • Medicaid – Community Based Alternatives.
    • Purpose is to direct Medicaid funds into community based care to allow people to stay at home.
    • Services include but are not limited to: personal care and attendant services, therapies, medical supplies and adaptive equipment.
  • Medicaid – Nursing Facility Benefit.
    This benefit covers:

    • Nursing services
    • Room and board
    • Medications
    • Medical supplies
      • NOTE: A person must meet certain income requirements and “spend down” to a specific level of assets. Currently, Medicaid recipients who are singly are allowed no more than $2,000 in assets (excluding the homestead).

Private Insurance

  • Supplemental Insurance – also known as “Medigap” functions as a supplement to Medicare Part A and covers most co-pays.
  • Long-term Care Insurance – covers people who may have chronic illness such as strokes, dementia, and arthritis.
    • The coverage is generally a daily rate and may cover home care, assisted living and nursing home care.

Private Pay

  • Many services and residential settings are not covered by any type of insurance or entitlement program.
  • Some of these services will require you to pay up front or at the time service is delivered.