Feature Article in the Southern California Physician Magazine (April 2011)
The Right Home?
Caring for the elderly means knowing what options in care homes are available.
by Jason Bloome
In 2011, 40 million citizens in the United States were 65 years old or older, 13% of the total population. By the year 2020 the U.S. Census Bureau predicts this number to grow to 53 million. America is graying and, as the number of seniors increases, costs for their care and services multiply. The impact this population will have on major metropolitan areas, such as Los Angeles, is profound. Sooner or later we must all deal with questions regarding what services are available to the elderly and who will pay for them.
Expecting all the answers from the government in an era of budget crunches and a reduction of services is fruitless. More and more the responsibility for shifting through the Byzantine maze of care resources and services available to the elderly will fall to caregivers. But even the best of players needs a coach from time to time - we all tend to look for advice and information from the experts. That is why it is especially important that physicians who care for the elderly be knowledgeable about the various eldercare issues. High at the top of this list is the issue of housing. Physicians should know what options are available for the elderly once they are unable to live at home.
With thousands of care homes in California, knowing about the different types of homes and the services they offer can be daunting. To add to the confusion, new laws are continually being passed governing the type of residents the homes can accept. Traditional care housing boundaries no longer exist. Alzheimer's patients who "wander" no longer need to be in locked, skilled nursing homes. Retirement homes with Alzheimer's wings and small residential board and care homes with alarms on the doors may be more hospitable. A senior who is wheelchair bound, or who has Parkinson's, or has a colostomy or catheter may not require 24-hour skilled nursing supervision. Other levels of care homes can meet these needs.
In California, there are four basic types of care homes:
· Retirement/ Assisted Living
· Residential Board and Care Homes
· Skilled Nursing Facilities
· Continuing Care/ Life Care
Depending on the type of home, these settings offer varying levels of care, from minimal services (e.g., meals and activities) to custodial care (e.g., help with dressing and bathing) to skilled nursing (e.g., tube feeding and completely immobile, bedridden residents).
Retirement/ Assisted Living
Both large (hotel-like) and small (home-like) custodial care settings are considered by the state of California to be Residential Care Facilities for the Elderly (RCFEs). The term "Retirement Home" or "Assisted Living" usually describes large settings that accommodate from 50 to 100-plus residents. Basic services include meals, activities and transportation to doctors. Assisted living services usually include help with medicine, dressing and bathing. Some assisted living settings also provide help for patients who are incontinent or wheelchair dependent.
Due to fire safety guidelines most retirement homes cannot accept patients with advanced dementia and/or Alzheimers. Those that can frequently have specialized wings in their buildings for residents who could "wander" or utilize "wanderguard bracelets" which trip an alarm when a resident leaves a desiginated area.
Most retirement homes offer a furnished room with a private bathroom (suites and two-bedroom accomodations may be possible as well). Although rooms usually do not have ovens and stoves; hot plates, microwaves and small refrigerators are usually permitted. Meals are provided in a large group dining room. A shared room typically costs between $1,200 and $1,800 per month; a private room costs between $2,200 and $4,000 per month, depending on the location of the home, size of the room and care provided.
Some retirement homes accept the Supplemental Social Security Income (SSI) rate for low-income participants as payment. The 2010 California (SSI) rate for a retirement home is $1086. For an SSI eligible participant the government pay the difference between a recipient's Social Security benefits and this amount to the retirement home. For instance, if a recipient receives a Social Security benefit of $300, SSI will pay the facility $1086 (the home keeps $961 and returns $125 to the resident for personal living expenses). Unfortunately, fewer and fewer retirement homes are willing to accept this low payment.
Community Care Licensing (CCL), a branch of the Department of Social Services, is responsible for licensing and visiting all assisted living and residential board and care homes at least once a year. CCL requires the homes to adhere to Title 22, mandatory guidelines which govern the type of care provided, staffing and overall physical environment of the home. A retirement home not licensed as an assisted living setting is not bound by Title 22 guidelines and, therefore, is not permitted to provide residents with custodial care assistance. Any such needs must be provided by an outside home health agency.
Residential Board and Care Homes are small family homes in residential neighborhoods licensed by Community Care Licensing to provide 24-hour custodial care to four to six residents. All custodial care, meals, and activities are provided by live-infull-time staff. The administrator/ owner, who generally does not live at the home, normally picks up the medication, does the shopping and provides the transportation to the doctor. Most are licensed to accept non-ambulatory residents and have been constructed with these residents needs in mind (e.g., wheelchair accessible bathrooms and inside/ outside ramps).
Residential Board and Care homes are allowed to provide assistance to residents who need help transferring from bed to wheelchair, but they are not permitted to accept or provide care for residents who are completely immobile, bedridden or unable to turn in bed. The high staff-to-resident ratio (usually two staff to six residents) make this an ideal setting for residents who are incontinent, have advanced dementia, Parkinson’s disease, Alzheimer’s disease, or who have a high level of physical care needs. The homes can also accept "wanderers" as long as they are equipped with alarms on the doors and are gated. Normally, Residential Board and Care homes will also accept respite (short-term) clients if a room is available.
Although Residential Board and Care homes are not permitted to accept residents with skilled nursing needs, there are times, however, when Community Care Licensing will grant exemptions to this rule. Depending on the nature of the condition and care required, administrators can frequently obtain waivers for residents who need insulin shots, have catheters or colostomies, for instance. One example might be a catheter that needs to be cleaned once a week, a service that an outside home health agency can provide. Community Care Licensing evaluates each exemption request on a case-by-case basis. The administrator must be granted a waiver before the resident actually moves into the home.
Residential Board and Care homes range from $1,400 to $3,500 per month for a shared room; for a private room, the cost is between $2,000 and $5,000 per month, depending on the location of the home and the care provided. Most Residential Board and Care homes cannot afford to accept the SSI ($950) rate.
California has only a limited mechanism in place, called the Assisted Living Waiver (ALW), to allow medi-cal to pay for assisted living/board and care settings. Low-income patients with “skilled nursing needs” are eligible for the ALW for some assisted living settings that participate in the program (approximately 40 homes in Los Angeles) but this program is limited in scope (1,000- 1,500 patients state-wide) and is only available in certain counties: Los Angeles, Sacramento, San Joaquin, Sonoma, Fresno, San Bernardino and Riverside.
Skilled Nursing Facilities
Skilled Nursing Facilities, which offer skilled nursing care in a hospital-type setting for 30 to 200-plus residents, are licensed by the Department of Health Services. They must adhere to Title 22 as well as Federal Omnibus Budget Reconciliation Act (OBRA) guidelines governing patients rights and quality of life issues.
The 24-hour skilled nursing care offered in these settings is provided by licensed, trained professionals such as registered nurses (RNs), licensed vocation nurses (LVNs), and certified nursing assistants (CNAs).
Services provided in this setting may include care for a resident who is completely bedridden or who has an IV or g-tube. Skilled Nursing Facilities also offer occupational, speech, respiratory and physical rehabilitation services. These services are usually provided by contracted companies that specialize in rehabilitation. Rehabilitation services are usually covered by Medicare Part A. Nursing homes offer private rooms (single bed), as well as shared rooms (two to four beds).
Private paid, nursing homes cost from $140 to $200 per day, depending on the number of beds in the room and the skilled nursing services required. Ancillary charges (including medicines, diapers, personal laundry, etc.), may also apply. Many Skilled Nursing Facilities accept Medi-Cal as payment. The Medi-Cal reimbursement rate in California is $150-$250/day.
Each skilled nursing home must have posted (usually next to the main nursing station) its most recent evaluation report, which should reflect any deficiencies and violations as well as the home's plan of correction.
Continuing Care Communities/ Life Care Communities
Continuing Care Communities/ Life Care Communities are settings where all three levels of care (minimal services, custodial care and skilled nursing) are provided. These communities are attractive to residents who do not want to move as increased care needs develop. Some of these homes require a large entry fee for admittance. Others charge for services on a month-to-month basis. There are less than thirty Continuing Care Communities in the Los Angeles area.
Many seniors and their families reach the point when they need to look for a care home. Choosing a home depends on the location, the type and quality of the services provided, staffing and the budget.
In California, there is no lack of care homes available. Knowing the options beforehand simplifies the search for a good one.
Jason Bloome is the founder of Connections Referral Service, an agency which provides information and referral to care homes throughout Southern California. This article was published in the April 2011 edition of the Southern California Physician Magazine.