Nursing Homes: The long and short of long term care
I entered nursing home life in college. I always knew I wanted to be part of the medical field but I didn’t Know where I fit. I don’t do well with with blood or bodily fluids, I’m more of a paperwork person. Billing didn’t suit me since I struggle with my own finances.
Eventually I found my niche in social work. I graduated college with my bachelor’s in social work in 2002 and started in a nursing home shortly after. I’ve been in nursing homes in multiple states until I fell ill in January and practically need one myself now.
Unable to continue my trained profession, I was forced to evaluate my skills and pursue a different life path. I searched countless work from home opportunities and found I wasn’t Able to fit them. One thing I’ve always done a decent job of is writing.
I’ve written various pieces, short stories and recently finished the rough draft of my first novel. I’ve found courses, read articles and done research on how to build a client base for writing and they all lead back to the same thing: people read what you write if you’re a good writer and you do best to write what you know. After 18 years a big part of what I know is nursing homes.
Now, before I start, some of this is fact, some is opinion and some is what I’ve found to be helpful to my patients and families along the way.
The overwhelming general consensus of the public is that nursing homes are bad places. Now I admit some of them are but the majority try very hard to satisfy their residents. Fact of the matter is no one ever says “woo hoo I’m going to live in a nursing home!” It’s true. 18 years, 5 centers, countless residents, not one woo hoo. Ever. While it’s not all fun and games long term care is in fact necessary. There comes a time in some people’s lives where they’re not able to take care of themselves anymore. Many depend on family to take on that role but no one can do a job 24/7/365. Don’t think You can, it’s not possible. There isn’t an insurance that pays for 24/7 caregivers and the cost of this is extremely high out of your own pocket. If you are independently wealthy, congratulations, I need to be adopted.
That isn’t most of us though so chances are nursing home care will come into play. So many of my families felt they were letting their loved one down admitting them into a nursing home but that’s not true. Providing care to someone does not always mean doing it yourself. Sometimes providing care means ensuring proper care is provided. The real let down is attempting to do a job that you are not capable of doing as you put yourself and your loved one at risk in the process. Families are still very much a part of the nursing home care team.
Since we talked about being independently wealthy and how not many people are, a big concern of long term care is how do I pay for it? Here are the biggest understandings I hear coming through the door: I have 20 days here, my insurance pays for 100 days, my insurance pays as long as I need it, nursing homes take all your money. They just take control of your money and keep it all. There is a bit of truth to all of that but not one is entirely true. Now, there are some long term care policies that do cover nursing home cost. I suggest you research them and learn all of what’s covered, what’s not, under what conditions and for how long. If that’s something that you can live with and afford, by all means go for it. For the rest of the world payment works like this: Medicare is a major insurance of the elderly population. Medicare has many parts but the main parts are A which covers hospitalizations and nursing home care, B which covers doctors, medical equipment and the like and D which covers your prescriptions. A rule of thumb is Medicare is meant to cover short term acute illnesses. In a nursing home, day 1–20 is covered at 100% day 21 up to day 100 is covered at about 80% with a sizable daily copay. Now all of those day time TV commercials you see about supplemental insurance, this is where that comes in handy. Your supplemental insurance generally picks up that co pay, as long as your Medicare is being used. None of this is a guarantee. Like anything else in life, in order to utilize the benefit you must qualify. To quality for your Medicare benefit you must require the daily care of a skilled professional be it a registered nurse or a member of the rehab department. Rehab being physical, occupational or speech therapy. So many people think they are entitled to 100 Medicare days and are shocked after encouraging them to participate in their rehab which they don’t want to do they are presented with a notice that Medicare will be ending. To get your benefit you must: stay 3 midnight admitted inpatient to a hospital within the last 30 days, have a need requiring a skilled professional and make progress toward feasible goals in fixing that need. If you do not meet that criteria, Medicare does not pay. If you do meet that criteria your benefit period is 100 days of Medicare paying some of your bill.
An alternative to Medicare is managed care or Medicare replacement. For some people, this financially makes sense for their budget. Just remember: managed care manages how much care they feel you should have. Under your managed care policy, you must receive authorization to enter the nursing home and then your care team must supply regular updates to your insurance company as to your progress. This part of “my insurance covers as long as I need it” is an understanding however what they don’t always tell you the insurance company is the one who decides how long you need it and that again is as long as you make progress toward feasible goals that a case manager can see for up to your allotted benefit time. Never indefinitely.
In all of these circumstances, when someone else decides you no longer meet criteria for the benefit you always, Always ALWAYS have the right to appeal that decision. Your center staff, generally social work or the billing office will notify you with a notice of non coverage of benefits letter indicating your last covered day and your appeal rights. The purpose of the letter is not to say you agree with the decision, just that you’ve been made aware this decision has been made and are in receipt of your right to appeal and the process of doing so. In filing an appeal, your medical record is forwarded to an independent third party who does a thorough review and agrees or overturns the decision to end your coverage.
So you’ve come to the end of your rehab time. You’re not well enough to go home, your insurance isn’t going to pay anymore, now what? Well, you need another payment source. For some that is long term care insurance, for others that is being independently wealthy, for a majority that is applying for government financial assistance aka Medicaid.
While Medicare is a federal program that does not vary, Medicaid is run by individual states. Each has its own limits and criteria but essentially when you are below a certain asset limit and are in need of care you cannot afford the state will help you. Some may be over that asset limit but still unable to afford care. This is not an end all. Things can be done with the help of an elder attorney. I am not at liberty to discuss those things as that is considered giving law advice from someone who is not a lawyer. Doing that is a crime and well, county orange would make this chubby chick rather pumkinish so we’re not going to do that. With a few simple questions the nursing home billing office will be able to tell you if you need to seek an attorney or if they are able to assist you in the process.
Now, this is where that “nursing homes take all your money” and “I worked all my life to throw away my money to these people” bit comes in. Long term care is expensive, I won’t Lie about that. But you have three shifts of nurses to pay, three shifts of nursing assistants, your food, someone to make your food, someone to ensure the food you eat is healthy for your medical condition, supplies to take care of you and that’s before we get to the support staff and keeping the lights on. The cost of doing all that adds up. First, yes you are expected to pay for your own care just as you go to the grocery store and pay for your own food. Next when you apply for Medicaid, the state determines how much they feel you are able to pay. Generally that is your income minus a small dividend you’re allowed for yourself but literally almost everything is provided to you for that price. Certain things are taken into consideration and allowed such as your insurance payments, prepaid funeral planning and saving some money for a community spouse. Your wine of the month club membership however will need to come out of your allotted monthly spending. Or transfer to me, I like wine.
Applying for Medicaid requires A LOT of financial documentation. It’s best to be up front and supply everything you’re asked for. Your state appointed Medicaid caseworker will find the savings account you thought you closed in 1985. There is no hiding anything. You may feel that’s no one’s business however you are asking for the taxpayers to help pay for your care. The state is going to make absolute certain you need that help. Having the nursing home take control of your money is an option but not required. You are perfectly able to keep your finances as they are but it’s your responsibility to pay the bill every month. Having the nursing home do it endures your money comes to the facility, your part is paid and your allotment is placed into a resident trust fund, a bank account of sorts for your use where you can ask for some as needed.
Alright so we’ve covered how you get in and how to pay for it but what about selecting your nursing home? Often times the hospital will have a list of “preferred providers” or may even select it for you. DON’T LET THEM DO THAT. Where you live is your choice. Period. End of conversation. “They told me I had to come here” or “it was the only place my insurance allowed. Those may be true but you always have a choice. If you don’t like where the hospital picked, choose your own, you don’t like who your insurance contracts with change insurance but never settle on living somewhere because someone said you had to.
A great resource at evaluating local nursing homes is:
Here you can enter your zip code and see a variety of local nursing homes and what they offer. They are also rated on a star system based on their last inspection and you will see if they’ve had any allegations of abuse for which they have been investigated for.
Narrow down a few you’d like to select and then have a loved one go visit and take a tour. Things to look for: how quickly are you greeted to take a tour? Is the staff member friendly? Are they knowledgeable to answer your questions? How long did it take to find someone to help you? Did they offer to show you the whole facility? Or “just the highlights” now granted due to privacy and safety places like the kitchen and rehab gym with patients are off limits but you should be able to see all the halls, dining areas, activity rooms etc. Look up and down the halls. Are there a million call lights going off? Is there garbage, or worse, on the floor? What are the staff doing? Look at the residents. Are they clean? Is their hair combed? Do their socks match? What does the center smell like? If you’re there around meal times is the smell of appetizing food wafting through the halls? Now, some smells cannot be avoided. Someone who is ill and has just soiled themselves is going to have an odor around their room. The center however should not smell like urine. Old pee smells. New pee does not. Old pee should not be around. Look for a posted menu and activity calendar. Do they list things your loved one will enjoy? And if they’re available, meet the administrator. This person should be friendly, knowledgeable, approachable and interested in the day to day function in the home. Once you’re satisfied with the answers to all your questions it’s time to move forward on moving in.
What to bring along: nursing homes are different than hospitals. There’s no gowns all day. Residents get up and they get dressed. They will need several complete outfits as well as good supportive non slip shoes. A small TV if one is not provided, perhaps a favorite blanket for their bed. Keep in mind, storage space is extremely limited and staff have to be able to maneuver in the room to care for both a resident and their roommate. Everything needs to be labeled with the residents name. Do not use a room number as the room they’re in may not be permanent. One white sock when loose in laundry will never find its way home with no name on it.
Things not to bring: baby powder, aerosol cans, oil, plug in air fresheners, medications, anything that can be used as a weapon such as scissors, letter openers etc. snacks must be in airtight containers labeled and dated. Do not bring anything of significant value. Over the course of 18 years I’ve seen a lot go missing. That’s not to say nursing home staff are thieves. Nursing homes are public buildings. That means staff, visitors, vendors and other residents come and go in and out of rooms. Things go missing. A lot. That’s a constant.
Anything else, just ask. One of my duties was always to write the “it’s time to clean out the closets and here’s a reminder of what’s contraband” quarterly letter. Things build up, wear out, need replacing and clearing out. Keep that done regularly to avoid a disaster later.
Now the tough part: what happens when you have a complaint. It happens. At some point someone had a bad day and cross words were said, there was a miscommunication of break time and a call might went off for an hour, whatever the case may be nursing homes do not please 100% of the people 100% of the time. It’s impossible. If you have a concern, speak up. It can’t be fixed if the staff doesn’t know about it. Start with the management team. Go to the social worker and fill out a grievance form. Let the staff try to fix it. Don’t be afraid to speak up. Too often I heard “I don’t Want to say anything it won’t end well for me if I do.” Staff retaliation is abuse. Abuse is a crime. Period. End of story. Speak up.
If the facility does not fix your concern, call your local ombudsman. The ombudsman program provides an outside resident advocate to work with the facility on the resident’s behalf to solve problems. Contact info for this group is required to be posted in the center. You should also be given a copy of nursing home resident rights in your admission packet with this information on it. The ombudsman make regular visits to nursing homes to check things out.
If these options do not suit you, file a complaint with the state. Contact information to do that is also required to be posted in the center. A surveyor will look into your complaint and decipher if any wrong doing was done with potential of or causing harm. In addition to surprise complaint visits, nursing homes undergo an annual state survey conducted by trained state surveyors. They will ask questions. Be honest. Depending on severity of problems, nursing homes may find themselves in deep financial doo-doo. Those results are what’s posted on the Medicare site.
Alright, so we’ve learned what qualifies nursing home entry, how you pay for it, how to pick one and what to do if you’re not happy. Time for the nitty gritty: what actually happens there? Shortly after admission you and your family should be meeting with your care team. This is where you learn who everyone is and what they do. They will also learn about you and they ask A LOT of questions. Why do they do that? Well because nursing homes don’t Just treat problems, they take care of people. In order to take care of people they need to know who the people are. Nursing homes explore every aspect of a person living there. That’s why nursing home’s inhabitants are called residents, not patients. They want to know who you are, where you’re from, how far did you go in school, your occupation, your spiritual beliefs, what you like to do, your mental health, psycho-social issues, what you like to eat, what you feel is wrong and what your goals are. Then they evaluate and find things for themselves. Then care plans are put into place. The care plan addresses a problem, gives a measurable goal for that problem and interventions on how to reach that goal. The actual care is then going through those interventions. Every three months or as needed those care plans are reassessed and a review is done to which patient responsible party or both is invited to attend and the plans are changed, cancelled or new ones added. Every department has their own and some have several. Nursing takes care of your medical, rehab takes care of therapy goals, dietary takes care of food, activities takes care of keeping your entertained, your mind strong and your spiritual needs met and social work chimes in with advanced directives, cognition, mood and behavior, psychosocial needs and discharge planning plus anything else that doesn’t fit in another department.
So what happens if you sign up for long term care but then you improve? Too bad you’re stuck. Just kidding. Nursing homes are not prison. You can leave with your treating doctor’s order and a safe plan. Not ready to go home? You can still go for an outing with family with an order and safe plan and advance notice to staff to prepare your meds etc.
So there you have it, the basics of nursing home care. Questions or requests for more info are always welcome. Stay safe and be healthy.