JOAN’S BLOG, MONDAY, AUGUST 11, 2014 – ASSISTED LIVING VS NURSING HOME- A PRIMER

This blog was prompted by a recent discussion – “Looking for Placement – Help” on the Message Boards concerning finding an appropriate placement for our spouses with Alzheimer’s Disease.

Let me begin by saying that this is a complicated matter. There are federal guidelines regulating nursing homes and assisted living facilities, but generally each State has different rules and regulations. You will have to find out the rules in your own State on your own or with the help of a Geriatric Care Manager (more about GCM’s later in the blog).

I am not an expert in this field, but I have had experience with nursing homes and Assisted Living Facilities in Rhode Island, Massachusetts, and Florida. I would like to offer you some basic information that is very important to understand before you look for placement.

ASSISTED LIVING FACILITIES:
Criteria for qualifying for Assisted Living:
Your spouse must be able to transfer with some assistance (no lifting) from the bed to the walker; from the chair to the walker or wheelchair. Some Assisted Living facilities have advanced licenses that allow them to be more flexible in their ability to accept less mobile residents, but you must find out EXACTLY what they are willing to do BEFORE you place your spouse or you are going to be called and told to remove them because they are too difficult for the staff to handle physically.
Violence and Running -No Assisted Living Facility will keep a violent or habitual “escaper”. Understand this in advance if your spouse has such tendencies. Many Alzheimer Spouses are so stressed, exhausted, and anxious by the time placement is upon them that they do not clearly understand the restrictions and are later surprised to be faced with eviction.
Diabetics -No Assisted Living Facility with which I have dealt will do daily blood monitoring of diabetics. Nor will they administer insulin. The reason for this is that a “skilled nurse” is required to take blood, even if it is only with a finger stick, and ALF’s do not have the staff for that type of work. ALF’s have what they term, “no stick” policy. If your spouse is a diabetic, you will be told that you have three options. The first is that the staff will “remind” your spouse to take his/her own blood at the designated times, and administer his/her own insulin. The second is to hire your own nurse to come in and take the blood and administer insulin if needed. The third is for you to come at the designated times to take the blood and administer insulin.
Doctor Visits – Although all facilities have vans with which to transport patients to doctors, YOU must choose your own primary care and specialists. No medication; no tests; no changes; nothing can be done to your spouse without the primary doctor’s approval. If there is a crisis, your spouse will be transported to the nearest ER at your expense.
Payment Responsibilities
No matter the outward appearance, from basic to ultra glamorous, the one most important fact to know about an ALF is that it is an APARTMENT that you MUST PAY FOR ON YOUR OWN. It is no different than moving your spouse from your home or apartment to a different apartment. Rents vary widely from State to State, from facility to facility. I have encountered rents as low as $2000 a month and as high as $10,000 a month. You must provide the furniture, every single personal item from toiletries to adult diapers to talcum powder. When your spouse runs out of toothpaste, deodorant, personal wipes and latex gloves (used by the staff to “assist” your spouse), YOU must provide replacements. It is possible that some of the more expensive ALF’s provide gloves for the staff, but I have not encountered one. Actually, these items may appear in the bathroom, and you may THINK they are being provided, but rest assured, they will appear on your monthly bill.
Level of Care: All Assisted Living Facilities have a payment schedule for level of care. There are usually four levels, and the fees are based upon the amount of care needed and the amount of medications dispensed. The following are examples. Amount of money and type of care provided are samples from what I have encountered, but it is VITAL that you find out what level on which your spouse is placed and the fee for that level. Check back often, because as your spouse declines, the level of care rises as does the price.
Level One - $250 per month IN ADDITION to the rent. Usually minimal to no transfer assistance and a minimum amount of medications – 2 or 3

The amount of money per month increases with each level. In the Assisted Livings I have dealt with for my parents, then my father alone, the maximum fee for the highest level of care (Level Four), was $1200. Remember, that is in ADDITON to the rent.
Example of monthly costs:
                         Rent - $3500
                         Level of care - $900
                         Personal Items (diapers, wipes, etc) -$250
                         Total: $4650

MEDICAID DOES NOT PAY FOR ASSISTED LIVING. DO NOT BE FOOLED INTO THINKING IT DOES. Medicaid will pay for a portion or all of “level of care” if you qualify, but WILL NOT PAY FOR RENT OR ANYTHING ELSE.   

However, Long Term Care Insurance DOES pay for Assisted Living. Not without a fight, of course. But they will eventually pay after many evaluations by their own “specialists”.

So what are you getting for your money? Assisted Living means exactly what it says – Assisted. The resident does not have to cook or clean. Usually 3 healthy meals are provided in the dining room each day. The apartment is cleaned weekly. The resident is given assistance with shaving, bathing, and dressing. But remember, the more assistance needed, the higher the level of care fee. Activities are provided during the day, and often there are “field trips” to restaurants, movies, theaters.

Memory Care Units in Assisted Living Facilities 
This is my personal opinion, based upon years of observation in a variety of facilities. I would NOT consider placing my spouse in an ALF that did not have a separate Memory Care Unit, no matter what the Sales Manager tries to tell you about how appropriate their regular facility is for Alzheimer patients. These memory units are locked and staffed by professionals who have had at least some training in dealing with Alzheimer patients. The activities are based upon research related to Alzheimer’s Disease, and are geared specifically to the needs of those with Alzheimer’s Disease. The staff knows the basic tenets of Alzheimer’s Disease – divert and distract, rather than argue.  The assistance provided is usually of a higher level than in the regular section of the ALF. You will be billed accordingly.

NURSING HOMES
This is a completely different animal, as the saying goes. In order to qualify for a nursing home, your spouse must be deemed by a physician to require around the clock “nursing care”. I cannot tell you with certainty what all of the criteria are, but I can give you probabilities. If your spouse is immobile, and needs lifting; is diabetic and unable to care for himself/herself; or has another debilitating medical condition, they may qualify for nursing home care.
Payment Responsibilities
Unlike an ALF, you do not have to provide ANYTHING, except clothes and whatever personal items you wish, such as pictures, a portable radio, magazines. All furniture, toiletries, diapers, wipes, gloves, and in our case, even a TV, are provided by the facility. The costs range from $6000 to $12,000 per month. MEDICAID DOES COVER NURSING HOME CARE, but they will fight it at every turn because of the cost. Usually, if your spouse’s physician writes a strong enough recommendation, Medicaid will cover it, minus your spouse’s social security check. (Spousal Diversion programs allow you to keep enough of that check to cover your shelter expenses).

If you are paying privately, the restrictions for admission are not as stringent as when Medicaid is involved. The simple fact of the matter is – Money talks. If you can pay, and the doctor says nursing home care is needed, your spouse is in. I speak from experience, as I know how I was treated at different facilities when I was looking for placement for my father, who was private pay, and how I was treated when looking for placement for my husband, who is on Medicaid.

The problem with most nursing homes is that they DO NOT have separate locked Alzheimer Units or specialized activities for Alzheimer patients. Every State and every facility is different, and this is beginning to change, but most generally, Alzheimer patients are placed within the general population of the Nursing Home. I was lucky to find one that was Medicaid Approved and had a separate locked Alzheimer Unit.
Doctors
When your spouse enters a nursing home, you must choose one of their staff doctors as his primary physician. These doctors assume all care for your spouse, and see them on a regular basis. In our case, the doctor sees Sid on the average of once a week, but often he checks on him when he is seeing other patients. All blood tests, x-rays, and other medical tests are done on the premises.

If you have the funds, I HIGHLY RECOMMEND hiring a Geriatric Care Manager to do the leg work for you. They are specialists in their field. If you understand the guidelines as I have written them, you will be equipped to ask the right questions, so he/she can find you the most appropriate placement for your spouse. As with hiring any professional, I would go with recommendations from people who have used that professional and been satisfied with their work.

What I have outlined is basic, simple, and different in every State, but it will give you a starting point and questions to ask when researching a facility for your spouse. One of the most important facts to keep in mind is that every State and every facility is different. I have given you my experiences and knowledge gained from three different States and 10 different facilities.

MESSAGE BOARD: Looking for Placement - Help

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