One of the most common questions posed in care coordination is how to decide between in-home care and facility placement. While there is no simple answer to this question, it is important to recognize the pros and cons of both choices. There are several factors involved in making the best choice: level of care/care needs, cost, and safety are just a few. Let’s look at home care first.
Typically, “home care” refers to services provided by a certified home health aide. These aides can provide assistance with bathing, dressing, meal prep, grocery shopping, and housekeeping. Home health aides can be private, but most are hired through agencies that provide home care services. It is very important to ensure that aides are fingerprinted and successfully a pass background check, as they are going into your home or that of a loved one. Some agencies will provide 24/7 caregivers at a higher cost. Typically, a schedule is based on need and the availability of the aides. Some individuals require an aide two times a day (morning and evening), while others have an aide only one or two times a week for assistance with groceries, laundry, or housekeeping. The most important thing to remember is that when someone is home and requiring 24/7 supervision and care, if an aide does not come for their shift, the main contact/caregiver for that person is the backup. Agencies will often try to have a substitute aide, but there are times when no one is available. It is then that the responsibility falls to family and friends to make sure that individual has the recommended 24/7 care.
Home care is paid through private pay, veterans benefits, a long-term care insurance policy, or Medicaid. Insurance, such as Medicare, only pays for skilled services like nursing, physical therapy, occupational therapy, and speech therapy. Often, these are provided through a plan of care and once the goal of the plan is reached, Medicare coverage ends.
The other option to consider is a facility. If a person requires significant care, does not have enough support and socialization, has too many environmental hazards, or resides in an unsafe neighborhood, a facility may be the best option. Facilities may have more of an “institutional” feel, but they can provide a lot of the services that are unreliable in the home setting. Long-term care facilities are categorized as Continuing Care Communities (consisting of independent living, assisted living, and nursing home levels of care), assisted living facilities, and skilled nursing facilities. Which setting is appropriate to meet your needs is determined by your level of care or how much care you need. Long-term planning is used to determine where your needs are at this time and what you will need in the future. Continuing care communities are one such planning method. Couples and individuals can meet with these communities, complete a financial assessment, and sign a contract that ensures their care throughout the various levels of care. For couples who need different levels of care, these are a popular option, since they remain on the same “campus,” even if they are residing in different buildings.
Assisted living facilities are often private pay only, but with the addition of the Assisted Living Waiver in Ohio, some assisted livings will take Medicaid after private paying for a set period of time (one, two, or even three years) and most have waiting lists for Medicaid beds. Assisted livings provide services starting with meals and medication reminders up to hands-on care provided by aides. Each facility is different in the care they can provide so it is important to get information about their levels of care, as well as staffing (e.g. is there a nurse available 24/7 or is the nurse on call?). It’s important to remember that assisted living facilities do not provide full care like that of a nursing facility.
Nursing homes provide two types of care–skilled care and long-term nursing care. Skilled care is what is provided by physical therapists, occupational therapists, speech therapists, and certain skilled nursing needs, like wound care. Skilled care is typically only paid for by Medicare and insurances for period of time. When the goals of care are met or a person is at their “baseline,” it will be determined what level of care is most appropriate for them. Do they return home? Do they need an assisted living? Or do they need to transfer to a long term care bed? If long-term care is determined to be the best fit to meet their needs, then cost is discussed. Long-term care can be private pay. It can also be partially paid for by a long-term care insurance benefit. Eventually, many people spend down their finances on their care, requiring them to apply for Medicaid. Medicaid will pay for long-term care beds in most settings.
The biggest complaints with nursing home care is lack of staffing, taste of the food provided, and lack of activities. Most nursing homes attempt to provide a variety of activities, but many residents feel they are bored or not receiving enough social stimulation. Nursing homes have to feed a large number of people with a variety of dietary restrictions (sugar fee, low sodium), which can have an adverse effect on the taste and variation in food choices. Nursing facilities have state standards for staffing, but are often staffed at this minimum number. This can lead to longer response times to call lights and a lack of individualized attention to residents’ needs.
It is helpful to plan ahead for any and all care needs. Talk with family and friends about your goals and wishes regarding your care. Speak with an elder law attorney who can help you protect your assets and coordinate your finances to provide a clear picture of what care options you can afford. Having a plan for care can lessen the burden of dealing with a crisis and preserve your preferences for care.