Assessing Care: Know Your Options

by Eileen Jordan

Your loved one’s need for care or assistance cannot be ignored.  Changes are required because the status quo is not working anymore.  Perhaps the need is gradually increasing, or a medical condition requires an immediate need for care.  Both situations can be overwhelming, particularly the latter.  How does one even begin to come up with solutions?  By learning what options are available.

If you are new to the world of senior caregiving, it may appear that the options are endless, but the type of care needed can be broken down into a handful of options.  As you look at the available options, there are usually only one or two that will apply to your situation.  So, the first step is to determine what type of care is needed.  It is important to become familiar with all the options because care changes over time.  Also, as you discuss care with different providers, you want to be sure you are speaking the same language. The main factors in determining care are needs and cost. 

Below is a brief summary of the options:

In-Home Care:  This is often the starting place for someone who is gradually needing more care and wants to stay in their home.  The most common options are help from family or friends, hiring a private caregiver, or hiring an agency. Volunteers from church or other organizations can help fill in the gaps, but usually cannot provide enough hours for a permanent solution.  The advantage is the loved one can remain at home with minimal change in routine compared to other care options and this is highly preferable to most people.  The disadvantage is that this is the most expensive type of care.  However, if the hours of assistance needed are not a lot, it may be the most cost effective as well as practical.  

Live-in care or moving in with a family member is also a common solution.  This falls under the in-home care category, but it has its own advantages and challenges.  Having the senior move in with a family member is the most cost-effective solution, but it can be very challenging for the senior and the host.  It is very upsetting for a senior to give up their own space and independence and live in someone else’s space, and it is difficult for the host to adjust to the changes a new person brings to the home, in addition to the caregiving requirements.  The caregiver will probably need help at some point, so it is a good idea to continue to research options. Having a family member move in with a loved one is complicated and has its own sets of challenges.  It is difficult for a senior to give up their routines and space to someone else, and difficult for the caregiver to live in a place where they may feel restricted and unwelcome.  This can be very beneficial to both parties if it is a good fit, but it is a niche that is very difficult to fill in a way that works.  WARNING:  Be very cautious before allowing someone to move in with a senior who wants care in exchange for free place to live.  If it does not work out, it is possible the live-in caregiver, even if a family member, will have to be evicted if they refuse to move out.  This process can take up to 3 months for the sheriff to evict them while they are living in the home of a vulnerable senior. 

Medicare or other medical insurance does not usually cover non-medical in-home care which includes meal preparation, help with hygiene and dressing, transportation, etc.  The only insurance that covers this type of care is long term care insurance which most people do not have because it is expensive.  Most in-home care is paid out of pocket.  There is financial assistance available through the Veterans Administration (VA) for qualifying veterans who meet the financial guidelines, but it can be difficult to qualify.  There are companies who can help a veteran with the qualification process with no cost to them.  Government assistance (called In-Home Supportive Services-IHSS in California) provides financial help for people with very low income and few assets.  When considering cost and hours needed, be aware that it is difficult to get a caregiver for less than four-hour shifts, and shorter shifts are usually more expensive than longer ones, especially with agencies.  Two hours in the morning and two hours in the evening are often requested but difficult to cover. 

Medical in-home care that is usually covered by medical insurance includes doctor prescribed home health visits which are usually for a limited time upon hospital discharge.  This will often include a weekly nurse visit for monitoring, physical therapy visits if appropriate, and a home health aide (HHA) to help with bathing two times a week.  They will not help with meals or care outside the medical realm and they are usually there only a short time.  Hospice or end-of-life care is covered by Medicare for people who are thought to be within the last six months of life, or longer for dementia and Parkinson’s patients.  This benefit can provide help with medications and medical supplies and equipment, as well as regular nurse and HHA visits and sometimes caregiving shifts when intense care is needed or volunteers available, but it does not provide regular caregiving.  Qualifications are complicated so it is wise to talk with a hospice provider to see if your loved one qualifies.  If going to the doctor is difficult but they do not qualify for hospice, they may qualify for palliative care which has much fewer benefits but can be helpful because it is in-home and eliminates many hospitalizations and trips to the emergency room. 

Independent Senior Living:  If a person is independent but caring for their home is burdensome and they are feeling isolated, a senior community may be a solution.  These are usually apartments, condos, or single-family homes where the grounds and shared areas are maintained but the resident will be responsible for the upkeep of their living space and their own care.  Care is not provided and a person is required to be able to live independently or to hire their own caregiver or domestic help to qualify to live in the community. There are usually planned activities and often a shuttle bus for residents who do not drive.  The advantage is the cost is low compared to the other options and there is often government help for low income seniors to cover rent.  The disadvantage is there is no actual care provided as opposed to assisted living and people often confuse the two.  Downsizing and simplifying one’s life can often be a solution to care, or at least minimize the need.

Assisted Living:  This is often the next step when a senior can no longer be in their home.  They range from luxurious with many amenities to less desirable with fewer amenities, and the pricing to match.  There are also different levels of care or care packages that a resident pays for and this needs to be fully understood when comparing pricing and determining cost.  Some have apartments with kitchenettes and others have a bedroom and private bath.  Some have memory care units for residents with dementia at an added cost.  The best way to find a good fit for your loved one is to visit unannounced and talk to the staff and residents in the main living areas, and if it looks promising you can arrange a formal tour and meal in the dining room.  The advantage is full care and social activities, and the disadvantage is the cost, especially for a couple.  It is far less costly than 24/7 home care.

Board and Care:  For seniors with medical needs that require more care than assisted living can provide a board and care is an option.  A board and care is a licensed 24-hour care property, often within someone’s personal home.  The costs and quality of care vary so it will require some research.  They can be less costly than a skilled nursing facility (SNF), and they are often smaller and more personal.  The quality of care depends on the management and staff, as with a SNF.

Note: There are senior placement services that can help place a senior in appropriate assisted living or board and care at no cost to the senior.  This can be by a company or by an individual.  The service provider is paid by the residence or facility where the senior ends up moving into in the form of a referral fee.  It is important to keep in mind they are working from their list of contacts, so you want to be active in the search as well, like working with a Realtor.  Your questions about facilities you have seen or heard about can help them get more contacts and save you legwork if you have a good working relationship. 

Skilled Nursing Facility (SNF):  Also known as a convalescent hospital, nursing home, rehab facility and the place that most elderly people dread going into.  Like any facility, the quality of care depends on management and staff so there are good and bad.  Often people are discharged from a hospital to a SNF before returning home if the level of care needed is too high for home care.  The cost is usually covered by Medicare or other insurance for a certain number of days and anything beyond that requires private pay or government assistance for those qualified.  Only those with very limited assets and income qualify for government assistance.  Some board and care facilities would also be an option for hospital discharge.  The disadvantage is the hospital environment and limited staff.  Patients are often required to stay in their hospital beds unless a staff member can assist them, and the wait can be long.  The advantage is a full range of medical services and physical therapy during recovery.  For long term care, a board and care may be preferable.  Medical facilities often have social workers on staff that can assist with financial aid for those who need it and qualify for it.  The quality of care in a medical facility or assisted living is often related to how often family and friends visit.  Accountability is critical and family can help with this by being on top of their loved one’s care.  Sometimes private caregivers are hired to help with this.

Important:  Before having the hospital discharge a loved one needing a high level of care to home, be sure you will be able to provide that type of care and the equipment needed. Skilled home care and equipment rental is available to those who can afford it, but the cost is very high, often more than double the cost of a SNF, and usually not covered by medical insurance or Medicare.  Family members are often willing but not trained or physically strong enough or available for the care needed.  Once a patient is discharged, it is difficult to get them into a rehab facility without a hospital readmission.  For long term care, it may be prudent to discharge the loved one to a board and care while arranging for home care.  Facilities usually require payment for 30 days and that can relieve pressure, so mistakes are not made by planning in panic mode.

Once you know your options and have some idea of cost, then you can assess the care needs and come up with a plan.  Care needs are fluid and always changing, whether the change is gradual or sudden, and you should be prepared for next steps. Like many things in life, care can be determined by finances.  Doing your research and educating yourself about care options and available resources can save a lot of money and improve care.  Plus, the more you learn the less overwhelming it all seems.  Another resource is technology.  Emergency call buttons that can be worn around the neck or on the wrist, cameras in the home that can be monitored on cell phones, lift chairs and other equipment that can cut down on the need for hands-on care should also be considered. Yes, care is expensive, but there are more care options and assistance available than ever before.

Not to be forgotten in all the work and research and sometimes fear involved in trying to come up with a workable plan, is the tremendous opportunity for love to be on display.  This is a real hands-on opportunity to return love and care that was received in early years, and to show God’s love in action.  Even caring for a parent who may not have been the perfect caregiver to their child is an opportunity for testimony to God’s love and grace.  Our greatest testimony is allowing God to love others through us.  Ask God for wisdom and guidance and He will walk you through this journey.

I will bring the blind by a way they did not know; I will lead them in paths they have not known.  I will make darkness light before them, and crooked places straight. These things I will do for them, and I will not forsake them.  Isaiah 42:16

About Eileen Jordan: Eileen has been in the caregiving field for fourteen years, both as caregiver and care manager