Long term care includes a wide spectrum of services beginning with help with activities of daily living (called ADLs) such as bathing, grooming and dressing, all the way to skilled nursing home care. Long term care can be delivered in a wide range of settings from your own home to a traditional nursing home. The cost of long term care varies depending on the level of care and where it is delivered.

Even today, people who need long-term care rely almost exclusively on care provided by family and friends in their own home. Nearly 80% of adults receiving long-term care at home rely exclusively on unpaid help. When families cannot do the whole job, because continuous or intensive care is needed, or because caring has become too physically taxing, families turn to more formal arrangements for that care. This Chapter Two will help you identify the long term care options available to you, how to locate them in your area, and what government programs are available to help you pay for the care you choose. We also identify related Web sites and organizations that will help you understand and navigate the long term care delivery system.

It is well established that seniors prefer to remain in their own homes and communities as they age. In recent years, services and facilities have evolved to allow seniors to age in place. As you age and begin to require assistance with the activities of daily living, you will need to begin to examine your housing and long term care options. Initially, you may require only supplemental in-home health care and assistance with limited daily activities. The time may come, however, when you will require more intensive care and cannot live alone.

To accommodate the increasing demand for organized housing, a variety of options has sprung up in recent years which break down to three broad categories: independent living, assisted living, and nursing homes. The categories differ primarily in the amount of assistance and care they provide for residents. All three types can be combined in a fourth option – continuing care retirement communities (CCRCs). The discussion that follows takes you through your options starting with the least intrusive and ending with nursing home care. The following is a summary of your long term care options:

INDEPENDENT LIVING

Independent living includes senior apartments and retirement communities targeted to active seniors who are able to care for themselves independently. Some independent living facilities offer limited assistance with ADLs.

Retirement communities
Retirement communities are designed for independent seniors. Sometimes called congregate living, they offer an apartment-like setting with 24-hour on-site supervision. Services usually include meals, housekeeping and laundry. Numerous social activities help to keep the residents active and foster a sense of community. Only private pay is accepted; no government subsidy is available.

Senior Apartments
Senior apartments allow independent seniors – many of whom may even drive - to enjoy an active lifestyle among their peer group. Senior apartments offer amenities found in other rental communities such as a clubhouse, pool, tennis courts and even golf courses. Although senior apartments typically do not offer 24-hour on-site supervision, they do offer laundry facilities, access to meals, and local transportation on a fee basis. Only private pay is accepted; no government subsidy is available.

Subsidized Senior Housing
The federal government and most states subsidize housing costs for seniors with low or moderate incomes. To be eligible, your adjusted gross income (including interest and dividend income calculated at two percent of the value of your assets) must not exceed $39,150 (2005). Rent is 30% of your adjusted gross income (further reduced by your out-of-pocket medical costs including Medicare and medigap insurance premiums). Although there are no minimum health requirements, you should be able to live on your own without assistance or arrange for your own private-pay on-site assistance. Due to high demand and limited funding, most facilities tend to have lengthy waiting lists: two-years is not uncommon. Facilities usually have on-site do-it-yourself laundry, and occasional meals are available for a token fee. For more information, call the HUD housing counseling locator at 1-800-569-4287, or visit http://www.hud.gov/local/index.cfm. Application should be made in person at the subsidized senior housing location in which you wish to reside.

THE ACCESSMENT PROCESS

Assessing your ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) is key to selecting appropriate long term care and applying for benefits. ADLs include daily activities such as walking, toileting, continence, eating, bathing, dressing and transferring. You are graded in each activity using the following characterizations: independent, supervision, limited assistance, extensive assistance, and total dependence. IADLs are higher function tasks necessary to live independently such as managing money, shopping, cooking, cleaning, and taking medications. As with ADLs, you are graded on your ability to complete each function. ADL and IADL scores are used by clinicians to develop care plans and by insurers to determine eligibility for benefits and suitability for placement in the appropriate facility. For example, if you can independently perform all ADLs and IADLs, you would not be eligible for many of the programs described in this Chapter Two that require a higher level of functional need. Individuals with IADL difficulties who can perform ADLs independently would not qualify for third party or Medicaid and Medicare assistance, and instead would have to rely on family and community intervention.

Nursing homes evaluate your level of competence in each ADL and IADL and enter their findings on a form called a Minimum Data Set (MDS). The MDS report is used by the nursing home for Medicare reimbursement purposes as well as to establish a care plan. The care plan outlines the recommended therapies and nutrition to allow you to attain the highest level of functioning in light of your disabilities. Care plans are revised monthly (or quarterly after Medicare has been exhausted) based on your progress. The more family involvement (and perhaps the advocacy of a private geriatric care manager) in the initial and periodic assessment process the better. No one knows you better than your own family and loved ones, and no one can better protect your interests.HOME CARE: AGING

IN PLACE

Historically, the bulk of long-term spending has been concentrated on institutional care; a phenomenon sometimes referred to as institutional bias. According to AARP, roughly two-thirds (67%) of Medicaid long term care funds go toward institutional care, despite the fact that consumers prefer to remain in their own homes and communities. Perhaps as a reflection of the wishes of our senior population, or because states are learning that home care is more cost effective than institutional care, spending on community based care has been increasing over the last twenty years as more people with long term care needs receive home and community based services. Spending on home and community based services has grown from $1.2 billion in 1990 to $16.4 billion in 2002, representing an average annual increase of almost 25% per year over the twelve-year period. And, spending on home and community based care is accelerating, increasing 83% between 1998 and 2003 alone.

Increasingly, older Americans are choosing to live independently, taking advantage of home care services. This process has come to be known as aging in place. The following categories of service, in combination, make in-home care possible:

• Home care includes checking blood pressure, monitoring vital signs (blood pressure, blood sugar, temperature) administering medications, changing dressings, and giving injections. Home care services can be provided by traveling physicians, dentists, podiatrists, wound care specialists, licensed nurses and therapists;
• Personal care services include help with activities of daily living provided by nurse aides or non-professionals;
• Custodial care includes assistance with IADLs like shopping, laundry and meals;
• Respite care is 24-hour care either in the home or at a facility that allows family members an opportunity to vacation or just take a break from the care of a loved one; and
• Adult day care is daytime care outside the home that allows family members to continue to hold jobs and take a break from the needs of the home care loved one.

If you need extensive daily care at home, you will probably have to pay for much of it yourself. With certain exceptions, government and insurance programs limit home care coverage to specified services on a part-time basis. Medicare and Medicaid will pay for in-home care if you pass the medical and financial eligibility requirements described below. Services such as meals-on-wheels, homemaker services, respite care, and care management, that are funded under the Older Americans and Older Michiganians Acts and administered by local organizations under contract with local Area Agencies on Aging, are more widely available but limited due to low funding. Most Older Americans and Older Michiganians Act services are free, but donations are requested and some services may have a fee schedule based on ability to pay.

CARE MANAGEMENT

The number of support organizations and providers of home care is dizzying. Your local Area Agency on Aging, senior center, visiting nurse association, hospice program, hospital, and county health department are all there to help. They, in turn, hook you up with other service providers and agencies, all with their own unique eligibility requirements, pricing structures and funding sources.

The problem is compounded when multiple services are needed. Fortunately, relief is available in the form of care management. Care management is a planning service, available through your local Area Agency on Aging or from a private geriatric care manager to help you identify and arrange needed long term care services.

Care management starts with a thorough assessment of your needs. A care plan is developed from the assessment. Then, using their professional background and knowledge of the long term care delivery system, the care manager implements the care plan by arranging needed services. The care plan and services are reviewed and revised periodically as appropriate.

ASSISTED LIVING FACILITIES

Assisted Living is the fastest growing type of senior housing, providing a combination of housing, support services and health care designed for the individual needs of its residents. Currently, there are no accreditation standards for assisted living facilities in Michigan. Assisted living has become a marketing term that refers to a group living arrangement with private or shared rooms for seniors who can no longer live alone, yet do not need professional nursing care. They offer protective oversight, social and recreational activities, and assistance with activities of daily living. Assisted living communities can be free standing or part of a continuing care retirement community. Licensed adult foster care homes and homes for the aged are also considered forms of assisted living.

Assisted living is significantly less expensive than nursing home care, but is not covered by Medicare or Medicaid. The cost of assisted living varies widely depending on the size of your living area and the services you require. The typical cost of an assisted living facility ranges from $1,500 to $4,000 per month.

Services among assisted living facilities vary greatly, so make sure that the facility you choose meets your needs. The admission contract should be consistent with the facility’s stated aging in place philosophy. As you evaluate an assisted living facility, consider whether the facility is willing and able to adapt to your changing needs. Read the admission agreement/contract carefully and make sure that it correctly reflects your understanding of the costs, the services to be provided, and the reasons for being asked to leave. Pay special attention to the reasons for discharge; can you stay if you are incontinent or in a wheelchair?

The Assisted Living Federation of America (ALFA) provides an on-line directory of assisted living facilities and tips for consumers on what to look for when choosing a facility: http://www.alfa.org (Select “Consumers”). Also see http://www.michigan.gov/ltc for more information on all forms of long term care.

ADULT FOSTER CARE (AFC) HOMES AND HOMES FOR THE AGED (HFAs)

AFC homes and HFAs are long term care facilities licensed by the state. AFCs and HFAs provide room and board, supervision, and ADL services to residents who do not need continuous nursing care. The range of services offered by AFC and HFAs varies substantially, so it is important that the facility you choose matches your needs. HFAs tend to be larger facilities and are often part of a continuing care retirement community (CCRC). AFCs tend to be small facilities (from one to 20 residents) operated out of residential homes (often housing the home’s operator). Many AFC homes are dedicated to the developmentally disabled. As they do not provide skilled nursing care, Medicaid and Medicare tend to not cover AFC and HFAs. Whatever government assistance is available is likely to be very limited and subject to long waiting lists. Some help may be available from the Social Security Administration or the Department of Veterans Affairs.

There are over 4,700 adult foster care homes, and about 150 homes for the aged in Michigan. Be on the alert for unlicensed AFC and HFA facilities. Although unlicensed facilities aren’t necessarily bad, you do lose the benefit of state inspections and quality control. Additionally, your only recourse against violations of your agreement in an unlicensed facility are the courts, whereas in a licensed facility your state ombudsman will advocate for you.

As with any facility, it is important to review your written agreement, especially with respect to the provisions relating to discharge. You don’t want to be forced to leave the facility if your needs exceed the services provided.

You can call the Michigan Department of Consumer and Industry Services for more information about homes for the aged (517) 334-8404, and adult foster care homes (517) 373-8580, or visit the Department of Human Services (DHS) Web site http://www.michigan.gov/dhs. Information about AFCs and HFAs is also available from your local long term care ombudsman (see Chapter Four).

ADULT DAY CARE

Adult day care, when coupled with the traditional family support, has allowed a growing number of seniors to reside in their own home well beyond the point that they can care for themselves. Adult day care, where appropriate, is an extremely cost efficient method of caring for seniors who are unable to care for themselves but who do not require around the clock nursing home care. Adult day care provides needed respite for family members who are employed or otherwise need a break from the duties of caring for their dependent spouse or parent. Naturally, if you are bedridden, or do not have the stamina to function throughout the day, you are not a good candidate for adult day care. Adult day care allows for increased social contact in a supervised setting and includes a range of services including assistance with personal care and activities of daily living. A physician’s recommendation is required and applicants are screened to ensure that their needs do not exceed the services available. Other than Medicaid’s PACE program, neither Medicare nor Medicaid pays for adult day care.

The Program of All-inclusive Care for the Elderly (PACE), described in Chapter Three, is a federally funded adult day care program. Further information about adult day care can by obtained through the National Adult Day Services Association, c/o The National Counsel on the Aging, Inc. 409 Third Street, SW Washington, DC 20024 (202) 479-1200, Fax: (202) 479-0735, Website: http://www.ncoa.org

NURSING HOMES

The time may come when you cannot properly be cared for in your own home or an assisted living facility and will need the type of 24-hour skilled care only offered in a nursing home. Or, once your money runs out, you may find that as a result of Medicaid’s current institutional bias that government assistance is available to you only if you enter a nursing home. Choosing the right nursing home is critical. Not all nursing homes accept Medicaid, and those that do may have only a limited number of beds allocated to Medicaid patients.

Nursing homes provide a wide range of personal care and health services. For most people, the care generally is custodial, or basic in nature including room and board, personal care, protection supervision and medical care. Nursing home residents typically have severe physical or cognitive impairments: they tend to be over age 80, female, without a spouse in the community.

To be admitted to a Michigan nursing home, you must have a referral and recommendation from a licensed physician. To qualify for Medicaid, you must also pass the new medical eligibility requirements discussed in Chapter Three.

EVALUATING THE FACILITY

A tremendous amount of information is available to help you evaluate nursing homes. State surveyors make unannounced visits to nursing homes every 9 to 15 months to review charts, observe the care being given, and to check sanitary conditions.

Their reports (known as state survey reports or Form 2567) list each nursing home’s deficiencies, and are available to the public. Consumes Reports in their Complete Guide to Health Services for Seniors (2000) calls the state survey reports “the best piece of consumer information that exists anywhere for any product or service.” State survey reports must be posted in each nursing home in a conspicuous place.

You can find the surveys on the Nursing Home Compare database on the Health Care Financing Administration’s (HCFA) website: http://www.medicare.gov.

Michigan ranks very high (in recent years, first) in the country in assessing nursing home deficiencies, so if the facility you are investigating has relatively few violations you can be sure that it is a good facility. The state ombudsman (see Chapter Four) also provides valuable information as to the safety and quality of Michigan nursing homes and can recommend nursing homes in your area.

When choosing a nursing home, there is no substitute for visiting the facility and quite literally “sniffing around.” Call your local ombudsman and have them give you the names of three nursing homes in your area. Location is important. You want a nursing home close to family so that they can monitor your care and stay involved. Visit the recommended homes and talk to the staff, watch the staff interact with each other and the residents, and talk to other families visiting their loved ones.

FORMS OF PAYMENT

All nursing homes accept private payment and Medicare, but not all accept Medicaid. Those that accept Medicaid may limit the number of beds in their facilities which are certified as Medicaid beds.
Some of the higher end nursing homes are private pay only (accepting Medicare for residents who have come from the hospital), and do not accept Medicaid. You would be asked to leave a private pay nursing home once your Medicare benefits (up to 100 days) and money ran out.

If you have limited assets and income, or if you intend to employ the Medicaid eligibility techniques described in Chapter Six, you should choose a facility that accepts both private pay and Medicaid patients.

The key is to enter the facility as a private pay resident and then convert to Medicaid after you have spent down your assets. Government programs recognize two types of nursing home care: basic and skilled.

• Basic Care – Required to maintain activities of daily living, ambulation, medication management, supervision and safety.
• Skilled Care – Requires the services of a registered nurse,on a regular basis, for treatments and procedures.

Most nursing homes offer both skilled and basic care. Medicaid pays for both kinds of care, but Medicare pays only for skilled care. Medicare pays for skilled nursing facility care for a limited period of time if you meet certain conditions described in Chapters Three and Five. For more information, see Medicare Coverage of Skilled Nursing Facility Care (CMS Pub. No. 10153), or contact MMAP (see Chapter Four).

THE NURSING HOME CONTRACT

Despite the fact that nursing homes may not discriminate on the basis of health needs or financial status, they often do. Nursing homes are motivated by the fact that they are compensated at a substantially higher rate for private pay and Medicare patients than for Medicaid patients. They often practice a subtle form of discrimination in the admission process by requesting detailed income and asset information. From the information you supply, they can determine how long you can afford to private pay before applying for Medicaid. Although this practice is technically prohibited, it is commonplace. If you refuse to provide the requested information, you will typically not be rejected, but will be placed on an interminable “waiting list.” If you have minimal or no countable assets, and thus are a Medicaid patient on the day of your admission, you are likely to have difficulty finding a Medicaid bed.

You will be told that there is a waiting list for the limited number of Medicaid beds in their facility. Although true, the reason for the waiting list is that the beds are being held for their private pay patients who will convert to Medicaid. Nursing homes will often keep a bed empty waiting for a private pay patient to come along rather than give it to a new applicant with no countable assets. The simple reality is that private pay residents are more profitable to nursing homes and consequently are usually given admission preference. If you are able to find a Medicaid bed as a day one Medicaid patient, it may not be in a facility of your liking. Medicaid facilities simply do not have the revenue to hire the best staff and maintain the best facilities.

Technically, you cannot be asked to private pay for a pre-agreed period of time before applying for Medicaid, nor can homes require a third party guarantee of payment as a condition of admission. The nursing home cannot require a security deposit or other form of pre-admission payment if your care is covered by Medicare or Medicaid. Unfortunately, such practices persist, as laws against such discrimination are not well enforced. If you are signing a nursing home contract as an agent under a power of attorney or as a conservator, be sure to clearly indicate that fact by using words such as “under power of attorney dated ____” to avoid any appearance that you are personally liable under the contract. Although it is extremely unlikely that such a contract would be enforceable against you as a third party, it is best to avoid any potential legal conflict with the facility. Surely caring for your loved one is enough of a undertaking without having to extricate yourself from a sticky legal situation.

Medicaid, the largest payer for nursing home care, has the lowest payment rates:

Nursing Home Care Reimbursement per Day (2005):
MEDICAID: $116.00 | MEDICARE: $268.00 | Average Private Pay Rate per day*: $200.00
* This figure is based on our informal survey of Michigan private geriatric care managers and differs somewhat from the state’s posted daily rate of $11010.

Once admitted, you may be evicted only for the following reasons: nonpayment; for medical reasons (you need more or less care than the home can provide); for the physical safety of the staff or the other residents; or because the home closes. You may not be evicted if the assets you disclosed upon admission have been depleted faster than anticipated as a result of employment of the techniques described in Chapter Six.

As with any contract, nursing home contracts should be carefully reviewed to ensure that they are consistent with your understanding of the services to be provided and the costs for those services. You may wish to use the following checklist provided courtesy of Citizens for Better Care in its 1998 publication The Michigan Long Term Companion. NURSING HOME CONTRACT CHECKLIST

CONTINUING CARE RETIREMENT COMMUNITIES (CCRC)

Continuing care retirement communities (CCRCs) are residential campuses that provide a continuum of care all in one location. Residents, who must meet financial and health requirements, move from private units to assisted living and then skilled nursing care as they age and require more assistance. Individual condominiums or apartments are available for residents who are still able to live independently; assisted living facilities for residents who need help with daily care; and a nursing home for those who require basic or skilled nursing home care. The principal benefit of CCRCs is that you are guaranteed a lifelong residence, permanently avoiding the emotional and physical stress of moving. CCRCs allow a married couple to live in close proximity where one spouse requires a higher level of care than the other.

CCRCs tend to be high-end facilities for healthy people. They tend to charge a large entry fee as well as an ongoing monthly fee. Some offer the purchase of a condominium or cooperative unit in lieu of the entrance fee. In 2001, entry fees nationally ranged from $60,000 to $400,000 (depending on the type and size on your residential unit), with monthly fees ranging from $700 to $2,500 (depending on the services required). Most entry fees are refundable at death but do not accrue interest during the period held by the CCRC.

Many of the questions that you might ask when investigating a nursing home apply to a CCRC. Information about the CCRC’s nursing home should also be available from your local Area Agency on Aging or ombudsman. No federal law specifically regulates CCRCs, but Michigan’s Living Care Disclosure Act regulates the terms of their contracts, cancellation of memberships, and membership refunds. Nursing homes within a CCRC are subject to the same state and federal laws that govern freestanding nursing homes. (Because it is a private pay nursing home facility, you may not be able to employ some of the Medicaid planning techniques described in Chapter Six).

You must take into consideration the financial risks of choosing a CCRC. What happens if you don’t like the facility, your children move to a different city, the facility goes bankrupt, or the facility declines and you no longer want to live there? The contract terms among CCRCs vary widely, so it is extremely important that you read the agreement carefully - perhaps retaining the services of a qualified elder law attorney familiar with CCRCs.

You can get more information about CCRC from the Office of Financial and Insurance Services at (877) 999-6442, or email your questions to This e-mail address is being protected from spambots. You need JavaScript enabled to view it . Also see http://www.retirementliving.com/michigan.html for information about CCRCs in Michigan.

HOSPICE

Hospice is special care designed to provide compassion and support for individuals in the final phase of a terminal illness. Hospice care seeks to enable patients to spend their last days with dignity and comfort, and as pain-free as possible. Hospice care can be delivered in a number of settings: in the privacy of your home, in a hospice facility or in a nursing home. To locate hospice services in your area see the Michigan Hospice and Palliative Care Organization Web site: http://www.mihospice.org or the National Hospice and Palliative Care Organization (NHPC) website: http://www.hospiceinfo.org.

The vast majority of hospices are certified to participate in Medicare. Medicare Part A, private insurance and Medicaid all cover hospice. See Lost and Found: Finding Self-Reliance After the Loss of a Spouse (Collinwood Press, 2001)