NURSING HOME CONSIDERATIONS

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How to Choose a Nursing Home: It's a book by Joanne Meshinsky, RN, Avon Books, 1991 that I will paraphrase from over the next couple issues because I think it has valuable insight to offer. (Good luck in finding the book- but it's probably worth the effort if you have someone going into a home. There's a tremendous amount of info from direct experience that is lacking in most other texts.) It's necessary since there were about 1.5 million nursing home residents in 1985 and they are expected to reach 3.1 million by 2025. That's because the number of elderly is growing so fast. It is estimated that the number or elderly over age 85 will be about 4.9 million by 2000 and up to 7.1 million by 2020. Admittedly, the odds of needing a home are fairly small when one is younger and less that 5% of the elderly end up in homes. From age 65 to 74, less that 1.5% are in a nursing home at any one time but over 20% of the elderly over age 85 receive nursing home care. Studies indicated that one in four will need nursing home care before they die. A key point for some of you is that if you live alone or in a cold weather state, the odds go up dramatically.

NURSING HOME INSPECTORS: (How to Choose a Nursing Home). This list is a brief rundown on what an inspector reviews at a nursing home. However, it seems to be an excellent list you can use yourself. You might have to dig deeply to check all of these, but since I'll assume a loved ones comfort is at stake.........

• Cleanliness and safety of building
• Good storage, preparation and service
• Emergency power supplies
• Proper functioning of call lights
• Accuracy of medication recording.
• Room and water temperature
• Fingernails, toenails, hair, teeth, and personal grooming of the residents
• Provision or rehabilitations services
• Activity programs
• Observations of resident's rights
• Availability of fire extinguisher
• Adequacy of lighting
• Medical records
• Physicians orders and nurses documentation

  
  
  
  
  

DIRECTORS OF NURSES RESPONSIBILITIES: (How to Choose a Nursing Home)

• Makes daily rounds to all units
• Supervises, schedules and evaluates all nurses and assistants
• Reviews the residents care
• Confers with private doctors and the medical doctor
• Handles complaints and problems
• Ensures adequate care
• Directs and supervises in service programs
• May help in developing a written plan of care for each resident
• Develops and implements the nursing policies
• Ensures the residents rights to fair treatment
• Maintains the privacy of each individual resident

Looks like the Director of Nurses may be the person you may want to talk to before signing any papers and admitting a loved one.

MURDER: Parents of Murdered Children, 100 East 8th St. B-41, Cincinnati, OH 45202, 513 721-5683 supports local chapters for parents of murdered children

FINANCIAL QUESTIONS TO ASK A NURSING HOME: (How to Choose a Nursing Home)

• What are the set fees and what services do they cover
• Are there extra charges. What for and how much
• If a resident leaves a home, does she receive a refund. How much and based on what schedule
• Does the home accept Medicare and Medicaid patients. (Not all homes want this but they should meet the same standards as Medicare. Maybe they have been turned down so you need to check).
• How are payments to be made. Any deduction for payments made in advance.
• What happens if the resident runs out of private funds.
• How often are the nursing home bills increased. You might also do the numbers to see if they are in line with inflation or greatly exceed it.
• Does private insurance pay any of the bill
• Are the charges higher on your unit for a resident with Alzheimers (senile dementia). Remember, there is's a lot more care required here and its even gets more extensive as the patient enters the final stages of Alzheimers.

  
  
  
  
  

I thought the last comment was extremely noteworthy. Alzheimer patients experience a continual loss of motor skills and thought processes and do take an increased amount of time by the staff to take care of.

NURSING HOME COSTS: (How to Choose a Nursing Home) Here is an interesting example of how the facts are not what they appear to be. Every article on nursing home care focuses on the monthly cost- let's say $3,000 per month. But the nursing home may add $40.00 for laundry and $15.00 for ironing. Total $3,055 per month. Another home is substantially cheaper at $2,300 per month. But they have daily costs of $3.00 for incontinence care; $4.00 for spoon feeding; $15.00 per dozen for incontinence pads; $2.00 for tissues and $30.00 for laundry and ironing. Added together, they total more than the first home. Additionally, many of the other costs you think are covered by you basic monthly fee are NOT. Enema supplies, catheters, rubber gloves, bandages, syringes, hand and skin lotions and urine testing materials are among those added to monthly bills. As are doctor, pharmacy and surgical company supplies. Then you still need to consider renting a wheelchair, walker, cane. Maybe add in speech or physical therapy. Be prepared.

RESIDENTS BILL OF RIGHTS: (How to Choose a Nursing Home) Ms. Meshinsky has provided a concise review of the formal Bill of Rights for Nursing Home Patients. The Bill is for the patients safety, well being and privacy. They should be posted in the facility

• Every resident shall be treated with respect and full recognition of her dignity and individuality
• Every resident, prior to or at the time of admission, shall receive a written statement of the provided services at the facility and those that require extra charges (inclusive of Medicare and Medicaid non covered services)
• Every resident shall receive complete and current information concerning her health and medical condition, in terms she can understand, from her physician, unless the physician decides that informing the patient is medically contraindicated. She will participate in he planning of this treatment or may refuse medication and treatment
• Every resident shall be given privacy and respect during treatment and care of personal needs
• Every resident's medical record shall be treated in confidence and the written consent of the resident or family shall be obtained to release the records to any individual not otherwise authorized to receive it, except as needed in the case of the resident's transfer to another health facility or as required by law or third party payment contract.
• Every resident shall be free from mental and physical abuse and free from chemical and physical restraints except as authorized by a physician
• Every resident shall be encouraged to submit complaints and recommendations concerning the nursing home policies and services to the staff or outside representatives or the residents's choice, or both. Such complaints shall be submitted free from restraint, coercion, discrimination or reprisal.
• Every resident shall be informed of the relationship of this nursing home to any other health care facility insofar as the resident's care is concerned.
• Every resident shall be free to associate with persons and groups of her choice unless this infringes upon another resident's rights.
• Every resident shall be assured of sending and receiving unopened personal mail
• Every resident shall have the right to manage her financial affairs and may inspect her accounts an statements
• Every resident shall have the right to retain her personal possessions and clothing as space permits.
• Every resident shall have the right to remain in the facility and shall note be transferred or discharged, nor have her treatment altered radically, without prior consultation with the resident or, if the resident is incompetent, without prior notification of the next of kin or sponsor.
• Every married couple shall be afforded the right to privacy during their visits and, if both are residents of the facility, shall be offered the opportunity to share a room, unless medically contraindicated.
• Every resident shall the have the opportunity to perform services for her own benefit and not for the sole benefit of the facility.
• the administrator shall be responsible for the implementation of all the resident's rights
• The facility shall train the staff in the implementation of the residents' rights.

  
  
  
  
  

NURSING HOME THEFT: The Bluegrass Long Term Care Ombudsman Program, 1530 Nicholasville Rd., Lexington, KY 40503 has info on the precautions one should take to prevent theft in the nursing home. Ms. Meshinsky also says that you should label EVERYTHING. Use sew in labels, laundry markers, indelible pens to tape and put on EVERYTHING- even the removable parts such as the footrests on wheelchairs.

VIDEO TAPES: Here is yet another excellent suggestion by Ms. Meshinsky. Many elderly and partly senile patients can become highly agitated and aggressive, calling for past partners and relatives. She indicated that using a video tape with the family, children and married partner eased the stress considerably. She thought that this could ultimately reduce the amount of tranquilizers used for such stressful situations. If you have anything like this, bring them to the patient or nurse.

NURSING HOME ADMISSIONS DAY: Use the list below for the info you should bring on admissions day. And, according to Ms. Meshinsky , the best time to bring your relative in is mid morning.

• Relatives Height and weight (since medications are ordered according to weight
• Any hearing or visual disturbances
• any pain that is being experienced
• info on all medications or other substances used- lotions, vitamins, cough preparations
• info on any aids normally used- cane, wheelchair, crutches, etc.
• the ability to get in and out of bed and the bathroom
• any recent trauma
• any medical conditions that requires immediate attention- seizures, diabetes, epilepsy
• any allergies or adverse reactions to medications
• info on pacemakers, artificial limbs or eyes, including date of insertion and care reburied.
• Need for oxygen, catheter care or tube feedings
• skin or foot conditions that require special care
• use of dentures, eyeglasses or hearing aids.

  
  
  
  
  

Also consider:

• is there help needed with dressing
• does she wash and bath herself
• does she prefer a bath or shower
• is she able to chew and swallow regular foods or should foods be ground up to facilitate swallowing without choking
• are there certain foods or preparations she likes
• is she allergic to any foods.
• is she oriented to persona, place and time
• is her memory for both long and short term good
• is she agreeable and compliant in daily care or does she become aggressive, agitated, hostile and argumentative, denying her needs for bathing and dressing
• does she become restless, or suffer from insomnia, lethargy or listlessness.

  
  
  
  
  

There's a lot more solid information that this book provides, so do try and check in out BEFORE you or a loved one needs to go into a home. At least keep this for reference.

DANGER!, DANGER!: (Nursing Homes) 5/96 There are many warning signs that foretell that an elderly relative may need a nursing home.

• Change in physical appearance. They tend to wear the same clothes- mismatched, let their personal hygiene deteriorate.
• Not eating correctly- lacking in nutrition. They may eat only what they have, not going out and buying good nutritious food. Might also not even be really aware of what they are buying.
• Financially confused. Not paying bills. And the worst- getting involved with the scams in the mail and hoping to win millions.
• Paranoia, hallucinations, and delusions. Remember, that may not necessarily represent senile dementia or anything really "bad" but a combination of prescribed drugs that have adverse reactions.
• Broken bones and bruises caused by falls. Seventy five percent of all fatal falls in the U.S. involved those over 65. Falls are the leadingcause of accidental deaths for those over age 75. Many are caused by medications and, mentioned previously, alcohol.
• Improper use of drugs- either misusing prescription drugs or overusing over the counter drugs. Could also be that they simply forget to take the medication altogether or take too much since they forgot they had taken it previously
• Fire Hazards. If the person smokes, they might forget to put one out. Or misusing the stove and burners and simply leave something on and completely forget about it.
• Depression. This has been identified repeatedly and will be mentioned again frequently. This is insidious and gets worse as one gets older- particularly when a loved one has died. Try to spot the signs and treat accordingly. Don't be judgmental if this has never happened to you. Just count yourself lucky.
• Incorrect responses to certain conditions. Confusion, memory losses are perhaps signs. Simply forgetting something is NOT a sign of senile dementia.

  
  
  
  
  

NURSING HOMES: Authors of the book on Nursing Homes suggest that each nursing home be approved by the Joint Commission of Accreditation of Hospitals (JCAH). While not absolutely necessary since many homes do not file for this accreditation because of the cost, it is a definite plus if one should have it. You may also look for homes that are Medicare and Medicaid approved since they must adhere to minimal federal standards. Such standards include rules for fire protection, the necessity for emergency power and standard nursing units with call bells. They also have standards for minimum requirements for patient rooms and toilet facilities. The book notes however that as much as the physical facilities may look good or bad, it is the nursing deficiencies that require the utmost attention. A lack of proper staffing and, in particular, bedsores, are an absolute indication of a poor home. They note that there is NO reason for bedsores of any kind and if they exist, there is something seriously wrong with the standard of care.

Talk to the staff since the answers may help to determine if this is the facility you want

• How much overtime do you work. Is it mandatory. How do you feel when you have to work overtime
• Do you like working here. Why,
• Why did you choose geriatric nursing.
• When do you restrain patients
• How would you characterize the nurse doctor relationship. The nurse patient relationship. The patient doctor relationship. The nurse staff relationship.
• How long have you been working here. Ask this of many if you can because you might get an idea of the turnover.
• What don't you like (or perhaps preferably) what would you like to see changed at the facility

  
  
  
  
  

URINE: Admittedly not the type of thing you'd expect in a newsletter, but I find certain elements in my reading that are so interesting, unique, require attention or should be known that I include them regardless of the subject matter. The authors of Nursing Homes have provided such commentary on several issues, and this is certainly one that I would have never thought of or discovered myself. "It is not unusual to be a smell of urine or feces in a nursing home. The important consideration is whether the odor is a stale smell of some duration or one of recent vintage." Nursing homes that have a strong smell of disinfectant might be using this to hide lingering odors. They further noted that timing is important. Testing the odors at 9:00 am or on a Monday morning is not necessarily fair. Patients are just getting up, bedding changed, a new work week beginning, etc. They suggest that checking the odors in the afternoon is a better indication.

EVALUATING A NURSING HOME: This is a rather extensive list taken and paraphrased from Nursing Homes. It's very long, but absolutely necessary if an elderly person needs to go into a nursing home.

EXTERIOR

Are there wheelchair access ramps and handrails

Are the grounds and walks well maintained without clutter

If the weather and time are appropriate are residents outside

Bird feeders and seasonal plantings would be thoughtful. Are there any

HALLS AND LOBBY

Are the halls well lit

Are there handrails in the corridors

Are the halls wide enough for two wheelchairs to pass

Is the housekeeping adequate

Are the furnishings well maintained an adequate

Are the exits well market and not locked

Are safety devices such as fire extinguishes visible

Are there sufficient elevators for the number of patients

Are the laundry and food carts in the halls covered

Are residents allowed free access throughout the facility

Are state licenses on display

Is there a bulletin board indicating recent and future events

Are safety precautions taken during mopping and waxing

Are the halls cluttered

Are old cooking smells evident

Are there other stale odors

Is there a cover-up smell of disinfectant

Are residents ambulating in the halls and common areas

Is any carpeting too thick for walkers and wheelchairs

RESIDENT ROOMS

Look at more than one room and more than one unit

Do semi-private accommodations have more than the two recommended beds

Other than the hospital bed, can residents provide their own furniture

Is there privacy curtain for each bed

Is each resident area at least 80 square feet

Is each bed at least four feet from another bed

Does the room have a dresser, mirror and closet space

Are a bedside table and overhead light provided

Is there a moisture proof mattress

If the call bell becomes disconnected, does it ring the nurse

Can a private phone be installed

Can pictures be hung on the walls

Is there one comfortable chair for each resident

Is there fresh drinking water with a glass by each bed

What is the policy for room transfers

Does each resident involved have to agree on room transfers

Do the televisions have earphones

Is there room for easy wheelchair access

Does each room have a thermostat set on 72 degrees

If the room does not have air conditioners, can you install your own

May residents smoke in their rooms. If not, are there designated smoking areas

Are smoking areas well maintained and supervised

Are ashtrays plentiful, clean and well placed

RESIDENTS BATH

The bath should not be shared by more than four persons

Are there call bells near the toilet, sink and tub

Are there grab bars at the toilet and tub/shower

Does the tub/shower have a non skid bottom

Is the bath large enough for easy wheelchair access

Are raised toilets seats available

Is the bathroom clean and odor free

Are there filled soap and paper towel dispensers

DINING FACILITIES

Is the menu rotated on at least a three week cycle

Does the posted menu agree with what is actually served

Are the dishes and utensils appropriate for the patients ability

(Dishes and utensils should not be paper or plastic unless the patient is on precaution because of contagion)

Is the dining room easily accessible by wheelchair

Are aides readily available to help those who have difficulty

Are dining room personnel trained in the Heimlich maneuver

Is adequate time given to those who need time with their meals

Are meals served at rational times or for staff's convenience

There should not be more than 14 hours between meals

Is care taken with seatmate assignments

FOOD

Is the food tasty, warm and attractively prepared

Is the food warm and covered when served in the patient's rooms

Is there an alternate entree for the main meal

Are snacks and beverages served between meals

Is care taken in the preparation of special diets

Are fresh fruits and vegetables served in season

Are the servings prepackaged or cooked from scratch

RESIDENT ACTIVITIES

Does the facility have a trained recreation director

Are there recreational areas of sufficient size

Is there a recreational calendar posted that seems adequate/ Do these events actually occur

Are the activities for residents of different abilities

Are there activities for residents of divergent interests

Are special events planed for the holidays

Are wheelchair patients transported to outside activities

Are religious services available

Are hobby and game equipment available (kilns, board games, etc.)

Is there a library with current books and periodicals

Are large print material available

Is newspaper delivery available

Does the local library have bookmobile service

Will volunteers obtain books for patients

Is there transportation to events outside the facility

NURSING CARE

Are the aides certified by the state

If the are not, is there an in house training program

Is here in service training for the nursing staff

Is a nursing care plan prepared for each patient on admission

Do the staff emphasize activities for daily living

Is a licensed nurse on duty for each unit 24 hours per day

Is the facility fully staffed or does the facility use pool (outside temporary help) nurses and aides

What the average job tenure for nurses and aides

Are nurses or aides allowed to turn off call bells at the nursing stations.

What is each unit's staffing for each shift

Are bedridden patients turned and repositioned every two hours

Are physical restraints checked every two hours and the patients checked for friction marks and toileted or changed

Is the staff attitude towards patients condescending or impatient

Does the staff seem to congregate constantly at the nurses stations or the employees lounge

Does the staff interact pleasantly with the patients

Does the staff do a complete change for an incontinent patients

Does the staff attempt bladder retraining

Is the staff truly interested in rehabilitation or does their attitude seem more custodial

MEDICAL SERVICES

Does the patient present doctor have privileges

If not, who will be the patient's doctor

What hospital does the home use in an emergency

Does the patient's doctor have privileges there

What ambulance service does the home use and what is the response time

Does the ambulance service have trained Emergency Medical Technicians

Is a doctor on call 24 hours per day

Are specialists available

Will the patient have a physical at the time of admission

Can you use you own pharmacy

If not, will the pharmacy the facility uses fill prescriptions generically

Will the doctor see the patient at least every 30 days for the first 90 days (a must)

Is a separate examination room available

Are suction machines, oxygen and other equipment available

What are the qualifications of the medical director

How many other facilities does he serve

Does the medical director have a financial interest in the facility

THE RESIDENTS

Are the residents neat and are their nails trimmed

Are the men shaved

Are the women neat and the hair well kept

Are confused patients up and dressed

Do an excessive number of patients seem physically restrained

Are many patients lethargic

Are most patients dressed in clothes rather than gowns

Are the patients hesitant to speak with you

Are the patients interacting with each other

Do they seem to like the nursing home

GENERAL

Is there a patient's resident council

Is there a patient's family council

Were you given a copy of the Patients Bill of Rights

Can a spouse of a patient or lovers have privacy if they wish

Are social workers available

Are visiting hours extensive

Are children allowed to visit

Are pets allowed to be brought in

Is alcohol permitted with a doctors orders

Does the facility have a problem with theft

OTHER SERVICES

Are hairdressing and haircuts available on a regular basis

How often is personal laundry picked up and delivered

Are the appropriate therapists available

Are therapy rooms fully equipped and utilized

Are there regular visits by an optometrist

Are the regular visits by a podiatrist

Is a dentist available

Can X-rays be taken at the facility

FINANCIAL QUESTIONS

Is a contract required and can you have a copy to study

How much deposit is required

When is the balance of the deposit returned on the patients discharge

What is the basic daily rates and exactly what does it include

How much are other services

Laundry

Beautician or barber

Podiatrist

Therapists

Pharmacy

Minor medical items such as laxatives, tissues, etc.

Does the facility charge extra for special nursing such as incontinence care, feeding or other services

How are the resident's valuables such as jewelry handled

What happens if the patient's funds should be depleted and it is necessary to apply for Medicaid

WAITING LIST (where applicable)

How long is the waiting list

What is the approximate wait

What is the EXACT procedure to get placed on a list

Does the facility give preference to hospital transfers or other medical conditions

Does the facility have any special units the potential patient might qualify for

If a bed is turned down, can the patient's name be retained high enough on the list and for what length of time

NURSING HOME CARE: 1996 Per John Hancock, these are the reason why people are in nursing homes

AILMENT %of Insurance Claims

Dementia/Alzheimers 36%

Bone/Joint Disease 17

Cancer 14

Stroke 13

Heart/Blood Conditions 10

Organ Disorders

(Stomach, liver) 4

Lung Disorders 3

Wounds/Injuries 2

Diabetes 1

NURSING HOMES: (1997) Want to provide better care for your loved one without added expense. George Hach, writing for ANSWERS magazine, says that you must maintain a good relationship with the nursing home staff. "....nothing substitutes for personal interaction and you need to get to know the names and interests of staff members." And "the most important staff relationship to establish is with the Certified Nursing Assistant (CNA)." These personal relationships will carry over to your parent. But don't offer them monetary gifts since that might violate many codes. Hach says an occasional gfift- not at holidays- is appropriate but only when it is fresh or dried fruit, nuts or flowers. He also states:

Clothes- Make sure your parent has enough clothes for a two week period. If your mother is incontinent, use house dresses that snap in front. Men should have shirts with buttons and pants with elastic bands. (I have heard that velcro snaps are even better- particulary for those with arthritis.) Both need two or three bathrobes.

Visits- The best times to visit are from 9:30 to 11:30 am or 2:30 to 4:30pm. Do this often since he says the staff will pay more attention to those that get attention. (This is not a reflection against staff in regards to care for other patients- it's just a fact of life.)

What to bring- sugarless candy, dried fruit, reading material, pictures, children and, once again, pets. Do NOT bring aspirin, sugar/salt based candy, chocolate or snacks.

One comment from another previous source said that videos of family gatherings are very good.

Nurses (Spooner2002) Nearly 60% of the RN work force is over 40 years of age and the percentage of nurses under 30 has fallen 40% since 1980. 10% of falls occur in health care institutions (undoubtedly more since they go unreported) and it is due in large measure to the lack of trained aides and nurses. The understaffing of hospitals occurs in an environment where, according to the 199 National Hospital Discharge Survey, patients over 65 years of age accounted for 48% of discharges and 48% of hospital care days.

Weekends and, evenings and holidays are particularly hazardous. Increasingly, family and friends are staying in hospitals to ensure that the patient is accompanied when out of bed or in the bathroom.

Nursing homes- The Centers for Medicare & Medicaid Services said May 13, 2002 it has placed the results of complaint investigations on its Web site. Individuals looking into nursing home care will find on the site a list of health deficiencies for nursing homes that have been filed, examined and confirmed due to complaints. The complaint is confirmed through an on-site investigation before it is posted on the Web, CMS said. In addition, state nursing home surveys are conducted every 10-15 months.

Washington Post Profiles Nursing Homes Using New Ways To Boost Resident Satisfaction

Nursing Home Groups Pledge Improvement in Quality of Care (2002) Three of the nation's largest long-term care organizations, together representing the majority of the nation's 17,000 nursing facilities, as well as several thousand housing, assisted living and community services providers, announced a broad program of voluntary changes that officials said were designed to promote ethical conduct by elder care facilities and to reestablish the public's faith in the nation's long-term care system. The initiative is called "Quality First: A Covenant for Healthy, Affordable and Ethical Long-Term Care." The American Health Care Association, the American Association of Homes and Services for the Aging, and the Alliance for Quality Nursing Home Care have signed "Quality First" covenants committing to seven principles: continuous quality assurance and quality improvement, public disclosure and accountability, resident and family rights, workforce excellence, public input and community involvement, ethical practices, and financial stewardship.

Evaluation of the Wellspring Model for Improving Nursing Home Quality: (2002) Despite the passage of major reforms in 1987, serious quality-of-life problems are endemic throughout many of the nation's 17,000 nursing homes. However, the Wellspring model of nursing home care, which relies on a team approach to care, demonstrates that high quality can in fact be achieved. Wellspring, an Alliance of 11 nonprofit nursing homes in Wisconsin, has so far managed to stabilize staff turnover in its member facilities--a major problem for all nursing homes--and eliminate serious quality deficiencies on state inspections, according to an evaluation of the program conducted by Robyn I. Stone and colleagues at the Institute for the Future of Aging Services, for the Commonwealth Fund.

Into the Hands of Strangers: Placing A Loved One Into A Nursing Home  (2003)

Other Options for Long-Term Care  by Sandy Lieberman (2003)

Leaving the home can be difficult for a senior, particularly when failing health forces the issue. However, even a relatively healthy senior alone in a single family dwelling may become isolated and lonely, unable to manage a large home and yard, and may no longer feel safe. This may be the time to consider an Independent Living Retirement Community. Also known as senior housing, these homes are designed to accommodate the needs and preferences of older persons. They appeal to people who prefer to live independently and may not need the degree of personal care or health care associated with assisted living or nursing homes.

Many retirement communities offer an opportunity to live among others with similar interests and needs, along with security and supportive services. Look for a community that is architecturally designed to alleviate some of the physical challenges that growing older may bring. For example, bathrooms may be equipped with handrails and grab bars or electrical outlets placed higher on the wall. Many accommodations are equipped for 24-hour emergency call service.

Senior Housing sometimes offers restaurant style meals, laundry service, house cleaning and limited transportation. The array of supportive services and amenities will vary from one community to another, but ideally the home you choose will offer the opportunity to live in dignity among others in a secure environment.

Monthly rents or purchase prices vary, depending on the community, the size of the apartment and services offered. Low cost, federally subsidized communities are available, but the Federal Division of Aging cautions that there can be up to a two-three year waiting list.

Assisted Living Facilities

Also known as personal care homes, this popular choice among families, requires licensing by the state. The American Association of Homes and Services for the Aging (AAHSA) calls this the most rapidly growing segment of all the senior living choices. Assisted living facilities (ALFs) are generally warm, friendly places best suited to the older person who needs assistance with daily activities.

ALFs allow their residents to be as independent as they are capable of being, while providing care services in the areas where they need help. Services include baths, dressing, oral hygiene, ambulation, help with meals, hair styling, transportation and recreation. Assisted living facilities provide a 24-hour staff, meals in a common dining hall, and are specially designed to allow access by the handicapped. An ALF should be designed with bathroom guardrails, sit-down showers, emergency pull cords, elevators, and other safety features.

Many assisted living facilities allow seniors to move in for several days to even a month or more, offering respite for the caregiver, a kind of vacation, for all involved. This can be an excellent way to try out a home to decide if this option is right for your loved one.

Cost can certainly be a major issue in the selection of appropriate housing. ALFs are all private pay, and, according to AAHSA, can range from less than $1,000 a month to more than $3,000. For the most part, assisted living costs are not eligible for Medicare or Medicaid reimbursement, although some states are beginning to provide some funding, either from state funds or through Medicaid. The fee structure of most ALFs changes as the needs of the resident increases and he or she requires a higher level of care.

Because the concept of assisted living is relatively new, and is not regulated by the federal government, the definition of "assisted living" often differs from state to state, even facility to facility. In some states assisted living facilities are allowed to provide some nursing care for residents, thereby qualifying to receive some payment assistance from Medicaid, the state-federal program for medical services to the poor. But this varies from state to state. Check with your local Area Agency on Aging to find out what services your state might pay for and how you may qualify.

Continuing Care Retirement Communities (CCRC’s)

The modern thought in residential housing is to offer a “continuum of care.” This latest catch phrase simply means that individuals can move to different levels of housing as age and health concerns require additional support. This is particularly important to those with progressive, dementia-related disorders such as Alzheimer’s disease.

CCRC’s may offer choices such as: independent living, assisted living, Alzheimer’s centers, and skilled nursing and rehabilitation services. Many progressive facilities are strictly designed for people with Alzheimer’s disease allowing residents in the early-to-middle stages of the disease to benefit from living in a more residential setting. Their programs go on to offer skilled nursing for Alzheimer’s patients as the need presents itself. These facilities offer a home-like, warm, friendly and safe environment exclusively for people with memory impairments.

Like Assisted Living Facilities, CCRC’s offer more care than traditional retirement communities. They were established to provide care when needed, leaving the healthy residents to live as independently as possible while simultaneously providing nursing care to residents who require it. The level of care ranges from minimal to a skilled nursing facility and is provided on the same campus, allowing residents to remain a part of the community. The basic premise of Continuing Care is that older people in reasonably good health may first enjoy independent living in the retirement section while having the security of nursing care, if necessary, in an adjacent section of the same facility.

This can be a good option for married couples in which one spouse has dementia. They may be well served in the retirement section for a long time into the disease as long as the well spouse can manage day-to-day needs of care. Although the retirement home section offers minimal services, additional services such as personal care can typically be purchased on a fee-for-service basis with an outside agency. Some facilities require that all residents be relatively independent at the time of admission while others may accept those with different levels of need.

Most CCRC’s require an entrance fee plus a set monthly fee with the guarantee that care will be provided indefinitely. Such an arrangement offers lifetime security for a fixed cost. Other facilities base their fees on the level of care a resident requires; in other words, residents who need more health care will have a higher fee than those who require less care. Some facilities accept Medicaid when residents deplete their assets, while others accept private payment only.

Nursing Homes

Thinking about whether to put your loved one in a nursing home is often a decision full of emotional conflict. It is often seen as a last resort or a sign of failure on the part of the caregiver or their family. While the decision should not be made carelessly, in many situations nursing home care is clearly the best option for both the caregiver and the loved one. A skilled nursing facility provides comprehensive care for those with medical needs requiring day-to-day, 24-hour supervision and medical care. A nursing home stay may be only temporary or may be a long-term living arrangement.

All nursing homes are government-licensed facilities with round-the-clock care supervised by registered nurses and certified nursing assistants. Although nursing homes offer rehabilitation services such as physical, occupational and speech therapy, most services are custodial in nature because many of the residents live there due to chronic conditions that may not respond to therapy.

In assessing whether a nursing home is the best option, you will also need to consider your financial and personal resources. Under certain limited conditions, Medicare will pay some nursing home costs for Medicare beneficiaries who require skilled nursing or rehabilitation services that have been ordered by a physician. To be covered, you must enter the nursing home directly after a qualifying hospital stay, which is at least three days.

According to the Health Care Financing Authority (HCFA) about half of all nursing home residents pay nursing home costs out of their own savings. After these savings and other resources are spent, many people who stay in nursing homes for long periods eventually become eligible for Medicaid once they have depleted their personal assets. If you have any questions about how you will pay for nursing home care, what coverage you may already have, or whether there are any government programs that will help with your expenses, there are people who can help. Your State's Insurance Counseling and Assistance (ICA) program has counselors ready to help you figure out how you can finance your long-term care. Some nursing homes accept residents on a private payment basis only and do not accept Medicaid reimbursement.

Lastly, include your loved one to the fullest extent possible in the decision-making process. This will help to alleviate fears and make the transition easier.

NURSING HOMES (2004) Every certified nursing home in the United States is surveyed every year, or at least every 15 months. in 1996, 22% of nursing home residents were independently ambulatory (able to walk without assistance). By 2002, that number had dropped to less than 15%. By all measures of acuity, nursing homes are serving a much "sicker" category of residents than in the past.

The increase in acuity between 1996 and 2002 has occurred in every state. Some states had very high acuity in 1996, so the incremental increase in acuity was modest, such as in Hawaii. Others, such as Iowa, have seen a dramatic increase in acuity since 1996.

There has been a steady decrease in the total number of certified (participating in Medicare or Medicaid), nursing homes in the U.S. since a peak in 1998. The total number of certified homes has dropped from a high of 17,259 that year, to 16,491 in 2002. This is a decrease of 4.4%, and is especially interesting when considered with the fact that the numbers of the very elderly (the most likely users of nursing homes) is currently growing rapidly. The drop in the number of nursing homes between 1998 and 2002 flies in the face of most demography-based predictions that anticipated steady and dramatic increases in the number of nursing homes.

Two trends seem to be working against this expected growth. First, the elderly are experiencing much greater health and lower rates of disability that allow more of them to avoid nursing home stays, or reduce the lengths of their stays. Secondly, assisted living and other options are serving many of the more independent frail elderly that in the past would have had no option other than nursing home care.

the four and a half percent fall in the number of nursing homes between 1998 and 2002 has been uneven across the States. The decline in the total number of certified nursing homes has been most dramatic in Arizona (18%), Texas and Massachusetts (12 % each), Oregon (11%), and Nevada (10%).

Not only is the number of nursing homes not growing, but the occupancy rate of nursing homes across the country continues to decline. Although individual states' occupancy rates vary dramatically, the overall trend has been down since 1998. While the occupancy rates range from over 92% in states like New York, Minnesota and North Dakota, to just over 70% in Oregon and Texas, the national occupancy rate in 2002 is 82.45%. This is down from 83.48% in 1998. The overall occupancy rate for nursing homes has never exceeded 85% in the years from 1995 to the present.