Assisted Living vs. Nursing Home Care

Monday, September 19th, 2016 by Cathy Cassata

As a family caregiver you may find yourself limited in the level of care you can offer your aging loved one. It’s not uncommon for caregivers to find at some point that they can no longer provide the emotional, physical or social support their loved one needs and deserves on a daily basis. But, deciding where the next best place for them to go is can be difficult. Here’s a few things to consider about assisted living facilities and nursing homes (also known as skilled nursing facilities).

Know What They Don’t Offer

While assisted living facilities are supervised communities that offer services such as meals, social activities, and assistance with activities of daily living (e.g. bathing and dressing), one focus at these communities is to provide a healthy social environment so that elders don’t become socially isolated.

“Assisted living by definition is a lesser level of care [than a nursing home] and typically a more home-like environment often looking like an apartment. It is for someone whose prior living arrangement is no longer adequate,” says Jan L. Welsh, an Aging Life Care Manager and owner of Special Care for Older Adults, in Cincinnati, Ohio.

Because assisted living communities are considered non-medical facilities and are not licensed by Medicare or Medicaid to provide skilled care, they are not required by law to have a licensed nurse on staff. Even if a nurse is employed by the assisted living facility, which is often the case, the nurse cannot give residents hands-on skilled nursing care, which is defined by the federal and state governments and includes dressing wounds, administering insulin and oxygen, and more.

Assisted living facilities do not have the same safety or administrative requirements as a skilled nursing facility, and they are prohibited from providing any types of care they are not licensed to give.

“Some assisted living programs offer enhanced services, so you can receive a similar level of care that a nursing home would offer, as long as the family can pay for the services in addition to the room and board,” says Nancy E. Avitabile, who, like Jan, is an Aging Life Care Manager and owner of Urban Eldercare, LLC​​​, a care management practice based in Manhattan. “With this option, as the person becomes more immobile and eventually bedbound he or she could continue living there.”

Is Skilled Care a Must?

Nursing homes are set up like hospitals and staffed with registered nurses, licensed practical nurses, and certified nursing assistants who are licensed to provide skilled care. Skilled nursing facilities are regulated by the Department of Health and can bill Medicare and Medicaid for skilled nursing care, so they must comply with many complex legal regulations and requirements. For elders who need round-the-clock supervision, or who may need that level of monitoring in the near future, a nursing home may be the best option.

“When a caretaker can no longer provide what’s needed for their loved one, for instance, if the person needs ongoing dialysis or is bed-bound or needs a ventilator, those are appropriate times to consider nursing home,” says Avitabile.

While a senior’s health will inevitably decline over time, knowing which type of care your loved one will need in the future is hard to predict, adds Avitabile.

One thought is that your loved one may choose an independent living community first, then assisted living and then move to a nursing home when more advanced care is needed.

“That order works well for some people, but some people don’t necessarily have to enter assisted living even if they’re chronically ill,” says Avitabile. “We get conditioned to think that ‘OK, now my parent is older and becoming more frail and they can’t fully take care of themselves so now let’s move to assisted living.’ That’s not always the next step. Sometimes it’s less expensive to have an elder stay in their home and provide services for them there.”

Welsh adds that sometimes a person’s health actually improves when they are placed into a facility because they are in a more stable or healthy environment and at other times it declines. If a person was missing medications or eating poorly, those things can be easily stabilized in a nursing (or assisted living) environment. On the other hand, if the facility care is less than the care the person was receiving at home, or the person has a difficult time adjusting, they can go downhill quickly, she notes.

Major Factors for Nursing Home Placement

Determining whether a loved one should move into a nursing home will be based on several factors unique to each individual. However, Welsh says the following are major indicators:

·         Increase in falls and wandering around dangerously

·         Medication management becomes complicated

·         Incontinence

·         Family fears the risks of being responsible for the aging loved one

·         When aging loved ones become victims of phone, mail or door-to-door scams

·         Sudden change in health (particularly diabetes, stroke, etc.) and independence of the aging person

·         Diagnosis of dementia or Alzheimer’s disease

The senior’s personal preferences, whether expressed in Healthcare Power of Attorney documents or based on prior life style

Think Long-Term

Before deciding on a long-term residence, think about the long run.

“Moving is stressful. Moving an older adult who then decides they don’t want to be there is incredibly stressful for them. If you’re interested in a place, after looking at several and meeting with staff, I’d suggest having your loved one stay for a weekend, or at the least a whole weekday to get a sense of how it is day to day,” notes Avitabile.

Besides the health and lifestyle care your loved one will need, Avitabile says consider the following before making a decision:

·         Cost

·         Flexibility

·         Proximity to family

·         How easily your loved one will acclimate in the environment

·         How easily your loved one connects with new faces and other people

No matter where your loved one lives, Avitabile says to keep the following in mind. “It’s very important that family finds ways to engage with the elder and arrange for visitors,” she says. “You can’t assume anything. Nursing homes have improved over the years, but the more present family members, aging care coordinator or caregivers are, the more the nursing home is aware that other people are looking out for your loved one.”

Reprinted from: https://www.seniorhomes.com/w/assisted-living-vs-nursing-home-care/

Who Will Care for the Caregivers?

By Dhruv Khullar  JAN. 19, 2017

I should have put his socks back on.

The thought kept nagging me as I finished my clinic notes, replaying the afternoon in my head. My final patient of the day — a man with dementia — was a late addition to the schedule, after his daughter, herself a patient of mine, called to report he hadn’t been himself lately. We scheduled him for the last appointment, so she could join after finishing work across town.

She recounted the subtle changes she’d noticed in her father. He’d been eating less, sleeping more. He was less steady on his feet and seemed uninterested in playing with his grandchildren — an activity that normally filled him with irrepressible joy.

From her purse, she pulled out no fewer than eight pill bottles — each with a dose, time and frequency meticulously labeled. She handed me a handwritten transcript of his other recent appointments: an ophthalmologist, a neurologist, a cardiologist. As I examined him, her phone rang.

“Grandpa isn’t feeling well, sweetie,” she said. “There’s macaroni in the fridge. We’ll be home soon.”

She hung up and apologized for the interruption. Then she leaned over to pull his socks over his bare feet — socks I’d removed moments before and left on the exam table.

I should have put his socks back on.

There are some 40 million Americans like my patient’s daughter. Every day, they help a parent, grandparent, relative or neighbor with basic needs: dressing, bathing, cooking, medications or transportation. Often, they do some or all of this while working, parenting, or both. And we — as doctors, employers, friends and extended family — aren’t doing enough to help them.

According to AARP and the National Alliance for Caregiving, the typical family caregiver is a 49-year-old woman caring for an older relative — but nearly a quarter of caregivers are now millennials and are equally likely to be male or female. About one-third of caregivers have a full-time job, and 25 percent work part time. A third provide more than 21 hours of care per week. Family caregivers are, of course, generally unpaid, but the economic value of their care is estimated at $470 billion a year — roughly the annual American spending on Medicaid.

A recent report from the National Academies of Sciences, Engineering and Medicine suggests that society’s reliance on this “work force” — largely taken for granted — is unsustainable. While the demand for caregivers is growing because of longer life expectancies and more complex medical care, the supply is shrinking, a result of declining marriage rates, smaller family sizes and greater geographic separation. In 2015, there were seven potential family caregivers for every person over 80. By 2030, this ratio is expected to be four-to-one, and by 2050, there will be fewer than three potential caregivers for every older American.

This volunteer army is put at great financial risk. Sixty percent of those caring for older family members report having to reduce the number of hours they work, take a leave of absence or make other career changes. Half say they’ve gotten into work late, or had to leave early. One in five report significant financial strain. Family caregivers over 50 who leave the work force lose, on average, more than $300,000 in wages and benefits over their lifetimes.

Even worse, perhaps, is the physical and emotional toll of extended caregiving. Family caregivers are more likely to experience negative health effects like anxiety, depression and chronic disease. One study found that those who experienced mental or emotional stress while caring for a disabled spouse were 63 percent more likely to die within four years than noncaregivers who were also tracked. Another study found that long-term caregivers have disrupted immune systems even three years after their caregiving roles have ended. And caregivers of patients with long I.C.U. stays have high levels of depressive symptoms that can last for more than a year.

As overworked and underappreciated as family caregivers are, health systems, under pressure to reduce costs, increasingly rely on them to manage illness at home.

There’s more we medical professionals can do to improve the way we engage, support and educate them. Family caregivers aren’t always clearly listed in the medical record, and even when they are, we often fail to include them in important decisions about a patient’s treatment plan — despite expecting them to carry out that plan at home. We assume they’re able to perform complex medical tasks — administering injections, changing catheters, dressing wounds, starting tube feeds — but fewer than half of family caregivers receive the training to perform them.

The Academies’ report highlights several measures that could help. First, simply identify caregivers, assess their abilities and anticipate challenges they’re likely to encounter. The United Hospital Fund has developed a tool to understand caregivers’ existing home or work duties, as well as what training they’ll need to perform new caregiving tasks and any concerns they have about the treatment plan.

Having counseling and support services available to caregivers, as well as respite programs to temporarily relieve them of their responsibilities, could also help. And clinicians could be trained in how best to educate family caregivers, and to better meet their emotional and physical needs. A nurse might demonstrate how to turn a patient in bed without risking back strain. Or the right way to deliver an insulin injection — how to pinch the skin, what angle to insert the needle — and what signs to look out for if blood sugar levels get too low.

Policy makers can help caregivers, too. More than 30 states have passed versions of the Caregiver Advise, Record, Enable (CARE) Act. The act requires hospitals to identify family caregivers, inform them when patients are being discharged, and provide them with basic education on the tasks they’ll be expected to perform. Other policy changes might strengthen financial support for caregivers by increasing the amount of available paid leave and encouraging employers to offer more flexible work hours.

Caregivers should also feel comfortable speaking up about their needs, and asking for information on services available in their area. Increasingly, there are support groups available to those caring for patients with Alzheimer’s disease, cancer and other serious illnesses. The government’s Eldercare Locator is an online tool that allows older people and their caregivers to identify community organizations that can help with meals, transportation, home care, peer support and caregiving education.

Similarly, local Area Agencies on Aging can help connect patients and caregivers to the services they need. Employers might consider “time-banking” programs to share leave among employees. And, of course, we can all call to check in on a caregiver, and volunteer our time to give them a break.

If it’s a certainty that all of us will experience illness, it’s a near-certainty that most of us will care for someone with an illness. But our current conception of patient and disease seems too narrow. It may help to recognize that while patients’ needs come first, illness is often a family affair.

For many, caring for a loved one provides tremendous purpose and fulfillment. It can deepen relationships and offer the time and space for connection where it otherwise might not exist. It seems that the goal, then, should not be to reduce family caregiving, but to reduce its burdens.

About the Author:  Dhruv Khullar, M.D., M.P.P., is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter at @DhruvKhullar.

Reprinted from: https://www.nytimes.com/2017/01/19/upshot/who-will-care-for-the-caregivers.html?smid=nytcore-ipad-share&smprod=nytcore-ipad&_r=0