A Guide for Elders: Planning That Protects You and Your Assets, Chapter 5 WHEN SHOULD I CONSIDER GOING INTO A NURSING HOME? Are There Alternatives? WHEN SHOULD I CONSIDER GOING INTO A NURSING HOME? Usually, a person seeks nursing home care when it is no longer safe, even with help, to remain at home. If there ever was a time when people went into a nursing home just because of advanced age, those days are gone. Today, you must meet certain medical criteria, which show that nursing home care is a medical necessity, before a nursing home will admit you. Unless you can show that you need assistance with activities of daily living (like bathing, dressing, or getting in and out of bed), and that you need some skilled medical care (care only a nurse can provide), it is not likely that a nursing home would be willing to admit you. It is more likely that you will be encouraged to obtain help to remain at home. Only when it can be documented by your local Aging Services Access Point (ASAP — formerly, local home care corporation) that you are “qualified” for nursing home care, will you be a candidate for admission. IF I NEED HELP, WHAT ARE THE ALTERNATIVES TO NURSING HOME CARE? If you are having difficulty in attending to your daily needs (like dressing, cleaning your home, making meals, or purchasing groceries) because your medical problems are becoming more serious, your first move is to try to find someone who will come into your home and provide care in the areas where you need assistance. Most people prefer this kind of home care to nursing home care. The largest providers of home care in Massachusetts are the Aging Services Access Points, which serve all of the state's communities. Their primary reason for being is to help elders remain in their own home for as long as possible. So, the ASAPs receive federal and state funds to contract for the provision of a wide variety of nonmedical services to accomplish their mission. The types of services they offer include: Meals on wheels: If you have some difficulty preparing meals, they will arrange to deliver prepared meals to your home on a daily basis (weekend meals service may not be available). Companion services: If you need company, or occasional help with shopping, rides to the doctor’s office, or even a friendly telephone call so that you won’t feel isolated, the home care may provide you with companion services. Homemaker service: If you have difficulty keeping your home clean, or getting your laundry or shopping done, you may be able to get a homemaker service to come in several times a week to keep your living area clean and fresh. Transportation: If you need a ride to the doctor’s office, or to an elder meal site, or to a day care program, the ASAP may be able to arrange transportation for you. Respite care: If you require a great deal of care, and that care is provided by a family member, respite care may be available to provide occasional relief for your caregiver. For example, if your caregiver daughter has a chance to go on a vacation, the ASAP may be able to send someone into your home to replace her while she is away, or perhaps even put you up temporarily in a respite bed in a local hospital or nursing facility. If you need medical services, the local Visiting Nurses Association, or similar home health program, is available, on an as-needed basis. Remember that if your doctor certifies that you need skilled nursing care at home on a continuous basis, Medicare will cover the costs of the service for as long as the need exists. Unlike hospital stay coverage, there is no time limit on Medicare-covered home health care, as long as there is a medical necessity for the service, and the following conditions are met:  1. The care that you need includes intermittent skilled nursing care, physical therapy, or speech therapy. 2. You are homebound, that is, confined to your home. 3. You are under the care of a physician who certifies that you need home health care and has established a home health plan for you. 4. The home health agency that is serving you participates in the Medicare program. WHAT DO I DO IF I CANNOT GET SUFFICIENT HOME CARE SERVICES? If you are unable to get enough help to remain safely at home, or things are just not working out, you can look at other alternatives before opting for nursing home care. Some of these alternatives are: Congregate living or housing: These programs are springing up all across the Commonwealth, and there may be one in your community. A congregate-living program provides each resident with an individual private living area which is furnished by the resident, who also has access to common or shared areas, such as a kitchen, or living and dining rooms. This option affords you both privacy and the opportunity to socialize with other residents. There is usually a staff which provides services like food preparation and social services, and medical personnel are available, though not around the clock. In some congregate-living programs, the residents organize advisory councils, which can develop a very full schedule of shopping trips, movies, trips, speakers’ programs, and entertainment. The Massachusetts Executive Office of Elder Affairs can provide you with a booklet describing the congregate-living programs throughout the state. For more information, telephone them at 1-800-872-0166. Retirement communities: These are residential communities for older adults. They offer housekeeping services, dining facilities, and leisure activities, as well as home health services and medical and nursing care, often located on, or near, the premises. Generally, a large down payment is required, and monthly fee payments can be expensive. Retirement communities vary significantly in terms of cost, and, since they usually amount to a major investment, you would be wise to seek professional, legal, and/or financial advice before entering into such an arrangement. Assisted living: There is much publicity these days about assisted living facilities (ALs), because the state is trying to encourage less expensive settings for elders who need some assistance, but may not need nursing home care. There will be much more discussion about these new developments, since the field is relatively new, even though assisted living may sound a lot like other kinds of housing for elders. Facilities are being designed to provide residents with staff to assist with activities of daily living, such as bathing, dressing, and grooming; three meals a day, and with medications. Caregivers may be available around the clock, and all household services — cleaning, laundry, and housekeeping — will be provided. You will furnish your apartment or unit with your own furniture, but unlike retirement communities, there will not be a high “up front” cost. Assisted-living facilities are expected to proliferate in the future (call Elder Affairs for more information). Rest homes: Sometimes referred to as Level IV Rest Homes, these facilities tend to be more institutional than the other alternatives already discussed. Rest homes are different from nursing homes, however, in that neither Medicare nor Medicaid pays for such care, because the care provided is “custodial,” that is, nonmedical, usually involving supervision of the activities of daily living, and some assistance with such activities and medications, rather than supervision. Rest homes are a great deal less expensive than nursing homes, and residents can receive Supplementary Security Income (SSI) or even welfare benefits, if they are eligible, to help pay for the costs of such care. IF I DO ENTER A NURSING HOME, WHAT SERVICES ARE PROVIDED? Nursing home facilities provide nursing and rehabilitative care, social services, and assistance with the activities of daily living (eating, dressing, bathing, toileting, and moving in and out of bed). Nursing homes are increasingly able to furnish more intensive medical care, as they move toward becoming medical facilities for care, versus a type of housing, such as rest homes, or assisted-living facilities. Some nursing homes specialize in certain types of care, like head injuries, Alzheimer’s disease, and some have aggressive rehabilitation programs. Nursing homes are supposed to work toward maximizing the health and well-being of each resident, so that each one can function at the highest level possible. There should be emphasis on each resident’s quality of life, since the facility is their home. HOW DO I CHOOSE THE RIGHT NURSING HOME FOR ME? It is best if you and other members of your family visit and compare a number of nursing homes before making a final decision. Look the place over, and get a sense of what services are provided and how the home will suit you. If you cannot get out to visit a facility, you or a family member can telephone the local Nursing Home Ombudsman, a volunteer who is not employed by the nursing home, but who visits usually on a weekly basis to answer questions, and resolve complaints that any resident may have. This person may be able to help answer some of your questions. Your local Council of Aging has the telephone number of the Nursing Home Ombudsman in your area. These are some questions that you may want to ask about a particular nursing home: 1. Does the nursing home participate in the Medicare and Medicaid program? 2. What is the staff-resident ratio during each work shift, that is, how many nurses’ aides and nurses per resident? 3. Does the nursing home have a rehabilitation program? 4. Does the local Nursing Home Ombudsman visit? 5. Are private rooms available? 6. How far away is the nursing home from family members and friends who will visit? In 1998, the Department of Public Health established a service that acts as a "report card" for nursing homes. It reports on the results of surveys of nursing homes by the Division of Health Care Quality of the Department of Public Health. You may call 1-800-CARE-FOR, or use the Internet at http://www.state.ma.us/dph/hcqskel.htm. WHAT ARE MY RIGHTS AS A NURSING HOME RESIDENT? When you are admitted, you should receive a copy of all of the nursing home’s policies that affect residents. You should be given a copy of the state Attorney General’s regulations governing nursing homes. You should receive answers to any questions you have about those policies and regulations. If you are Medicaid- eligible, you should not be treated discriminatorily, that is, any differently from anyone else. The nursing home may not solicit gifts from you, or impose any charges not permitted by Medicaid (if you are eligible for that program), nor may the nursing home ask you to waive your right to apply for Medicaid at any time. You are entitled to full use of your funds, including any personal needs allowance, to the use of a locked drawer, and to the use of a telephone in complete privacy. You are entitled to have visitors, and to visit outside the nursing home as you please. You are entitled to have your mail delivered, unopened, to you. You have the right to be free from neglect, mistreatment, or abuse. You may not be treated any differently by the staff for insisting on or exercising your rights. If you have any questions about your rights as a nursing home resident, you may consult with the visiting Ombudsman. HOW WOULD MY NURSING HOME CARE BE PAID FOR? There are several different possible sources for payment of your bill: Medicare: Your Medicare insurance covers very little in the way of long-term care services. At most, Medicare will pay for the first 20 days of your stay, and a portion of the next 80 days, but under no circumstances does Medicare pay after 100 days. If you have a Medicare supplemental insurance plan, like Medex Gold, that insurance may pay the remainder of the costs for the 80 days when Medicare pays only part of the costs. There may also be a small daily payment or reimbursement after the first 100 days. Long-term Care Insurance: Some people have private insurance that includes coverage for long-term care. Such policies tend to be very expensive to the extent that they offer good coverage, and lack meaningful coverage to the extent that they are affordable. Some retirees have insurance plans that offer some long- term care coverage, and you would do well to explore whether you have any such coverage, or may be able to purchase such coverage, before the need arises. For example, Massachusetts state pensioners have $10,000 in annual coverage for skilled long-term care services in their retirees’ insurance. Department of Veterans Affairs: A military veteran who has been awarded service-connected disability may be eligible for payment by the VA for the costs of his or her nursing home care. If the nursing home placement is not related to the service- connected disability, the VA may pay for up to six months of such care. If the placement is related to the service-connected disability, the VA may pay indefinitely for the care. Private Pay: If you do not have any of the coverage just described, you are a “private-pay” resident, and pay a daily rate for your stay at the facility. Currently, the range of private-pay rates in Massachusetts is between $100 to $175 per day. If you are a private-pay resident, you pay your way usually on a monthly basis at the beginning of each month. There is no control over what a nursing home can charge as a daily rate, so you have to ask the daily rate at each facility you are interested in. In addition, the facility may charge for “ancillary services” above and beyond the daily rate. Medicaid: If you do not have any of the above coverage and your funds are spent down to an amount under $2,000, you are eligible for Medicaid coverage, and Medicaid will subsidize your care. Once you are Medicaid-eligible, you must pay a portion of your monthly income toward the costs of your care. You pay all of your monthly income over to the nursing home as your “patient paid amount,” except that you are allowed deductions for: 1. A personal needs allowance, currently set at $60 per month, so that you can buy clothing, slippers, a toothbrush, magazines, make telephone calls, or go out on visits or recreational trips, for example. 2. An allowance for payment of any Medicare supplemental insurance plan you have. Medicaid permits you to keep such insurance, because it may pay for services for which Medicaid will then not have to pay. 3. If you have a spouse living at home, there may be an allowance for your spouse to assure that there is sufficient income to maintain him or her at home.  After you contribute your patient paid amount every month, the Medicaid program, which has established a daily reimbursement rate, will pay the difference between what you have paid and what the bill is. For example, if the rate is $90 per day, the cost is $90 x 30 days = $2,700. If your patient paid amount is $1,000, then the nursing home bills Medicaid for the $1,700 balance. HOW IS NURSING HOME CARE PAID FOR GENERALLY? There are about 50,000 people in long-term care in Massachusetts. Medicare pays for the care of about 3% of these people, private pay plans cover the costs for about 18%, and Medicaid pays for the remainder. The current state budget of roughly $17 billion contains over $1 billion for Medicaid long-term care. This staggering expense accounts for the interest on the part of many people in developing less expensive alternatives to nursing home care. HOW CAN I LEARN MORE ABOUT NURSING HOME CARE AND RESIDENTS’ RIGHTS? The Patient’s “Bill of Rights” is found in Chapter 111 § 70E of the Massachusetts General Laws; nursing home residents’ rights are found in regulations promulgated by the Attorney General’s office and are published in the Code of Massachusetts Regulations (CMR) at 940 CFR 4.00. HOW CAN I GET ASSISTANCE?  For assistance, you can contact the Executive Office of Elder Affairs at 1-800-882-2003 (for the hearing-impaired, call 1-800-872-0166); they will have the name and number of your local nursing home ombudsman program and also the name and number of your Aging Services Access Point (formerly, local home care corporation).  Back to start of Chapter 5 Back to Table of Contents of A Guide for Elders On to Chapter 6