Long Term Care

Relationship Dynamics When a Spouse Becomes a Caregiver

March 18, 2020Filed Under: Long Term Care, Senior Health and Wellness

Caring for a seriously ill spouse can trigger relationship challenges. In the process of change, you can lose your best friend, your love, and your future as you both had imagined it. Promises will change from words spoken in oath on your wedding day to deeds of care in your mostly, but not exclusively, older years. The new caregiver morphs from a loving spouse into their new role, which is an entirely different sort of relationship of primary service. In more tragic cases, the caregiver can become distant to the marital bond, struggling with feelings of loss, fear, anger, resentment, or misunderstanding.

It’s a situation no spouse looks forward to on either side of the equation. A loving couple does not look forward to the day when they either must watch and tend to the mortal decline of their spouse or, conversely, be the spouse who feels wracked with guilt feelings knowing their health problems are placing a tremendous caregiving burden on their spouse. No matter the desire to avoid the experience, very few married couples will elude the complication that serious illness brings to their shared lives. Sadly, the needs of the caregiving spouse are often overlooked at a time when they need renewed strength to support their partner in new ways.

The caregiving pressures exerted on a spouse are significant. According to an analysis of 168 studies, while the caregiving spouse will protect their mate, they report more symptoms of depression, lower levels of psychological well-being, and more significant physical and financial burdens. To cope with the changes presents challenges, and sadly, the longer you have been married, the more difficult the process of rewriting the relationship’s rules and expectations become. Early on in the illness diagnosis, spouses are unclear as to how to handle the short-circuit in communication and productively process their feelings.

Many new spousal caregivers will feel the complications of isolation. Family members and close friends may not visit, not help, or even ignore the couple struggling to create new behavioral norms. Health Affairs reports that 55 percent of older spouses experience their end of life caregiving years without help from children, other family members, or even paid home health aides. The entirely new sort of relationship that becomes forged between husband and wife becomes defined by illness and lost emotional connections.

The need then becomes the focus on what to do to improve the situation. The first is the caregiving spouse needs an accurate understanding of the condition, treatment, prognosis, and needs of their ill spouse, whether they are diagnosed with dementia, cancer, heart failure, kidney dysfunction, or another serious illness. The information needs to come directly from attending physicians and health care providers. Caregivers need to participate in medical appointments and become an active participant in identifying health and wellness issues and potential fixes. Medical recommendations need to be prioritized so that the caregiver can be a positive, encouraging reinforcement rather than a nagging, stress-inducing reminder that can trigger frustrations on both sides.

If family and friends are willing to help lighten the load, it is imperative to accept help. Housekeeping, erranding, providing casseroles, transportation, visiting, anything that can reduce your workload as a caregiver is essential to accept graciously. Review your insurance plans as many give some level of coverage of home nursing services, occupational, and physical therapy. These services can improve your partner’s abilities and safety in your home.

Share as much time as reasonable with your spouse, listen to their thoughts, and spend time in quiet reflection. Follow routines that are established patterns in your life together. A Friday movie night at home with popcorn, walking the dog, or sharing morning coffee as a continued routine helps to keep a sense of continuity in the face of the unknown.

Recognize that you are not alone in your struggle. Authors Barbara Kivowitz and Roanne Weisman have written about their journeys as the caregiving spouse of a seriously ill mate in a book entitled Love in the Time of Chronic Illness: How to Fight the Sickness – Not Each Other. The most poignant recommendation describes shifting the notion of caregiving from a set of daily responsibilities to an act of expressing compassion. Kivowitz encourages couples to “Measure success by how well you connect, love and feel loved.” Don’t let a serious illness shake the foundation of your marriage. Identify your roles and set structure to address the issues at hand, and in the face of the unknown, you both will be better for it.

If you have questions or need guidance in your planning or planning for a loved one, please do not hesitate to contact our Cincinnati office by calling us at (513) 771-2444.

Hiring In-Home Health Care Services

March 5, 2020Filed Under: Long Term Care

in home care

There is a wide range of home health care services available from daily household tasks to medical care. Before identifying a health care service for information, get a clear idea of what you are in the market for, be it recovery from surgery or long-term care for a chronic illness. The first step is to determine what you need help with and how often you need that help. Then assess your budget to provide home health care services. Get the specific information together about the types of insurance you will be relying on for payment. Determine what your loved one’s comfort level is with the process. A non-compliant recipient of care is going to make for misery all around. Have open and non-threatening discussions with your loved one and listen to their concerns. They may give you refined information about what type of individual to look for in a home health aide such as a non-smoker, early riser, card player, fastidiously neat person, an aide with experience with a specific chronic disease, or a multi-lingual aide.

Once you have identified your needs, though they may change or need to be scaled back, the search for a provider begins. The Mayo Clinic recommends finding a qualified home care service agency. Only deal with properly licensed agencies. Most states require agencies to be licensed and regularly reviewed, so check with your state health department. Be sure the agency is Medicare-certified for federal health and safety requirements. If it is not, inquire as to why. Ask about employee screening and if the agency is willing to provide references and follow up on them. Request a list of the doctors, hospital discharge planners, and other medical and administrative workers who have experience with the agency.

The individual home health aide should have proper credentials. Check to see that they are appropriately licensed by directly checking with the licensing body itself. Does the aide have a track record, and can they provide references from at least two employers? Follow up on any references given. Also, check with your loved one’s medical team to see if they have specific individuals who would be qualified and a good fit as your home health aide. Check for the quality characteristics of the agency. How do they monitor and train caregivers? Are caregivers licensed, accredited, and insured through the agency and proper licensing bodies? Is continuing education provided to health aides? Does the overall attitude of your potential home health aide have a positive attitude and display patience? Can scheduled hours be consistent with the patient’s needs? Will the same aide reliably and routinely show up?

Once you have a few qualified home health care options available, it is time to identify which agencies are affordable to your budget in the area of your loved one. It makes no sense to learn about specific services that you cannot afford, so pricing is one of the first considerations beyond qualifications. Ask the agency how it handles billing and expenses and get literature that explains services and fees. What levels of care do they provide? It is important to get detailed, written information as to all of the costs associated with home care services. If it is not in writing, be wary and walk away.

Does the agency allow for fees to be covered by health insurance or Medicare? Talk with the agency’s billing personnel to ensure that your health insurance is accepted and be sure to understand the criteria that Medicare requires. Do not forget to ask about financial assistance or payment plans and again request that all the information is in writing. Once you understand the payment set-up, reconfirm what services are included in those fees. Often the sales pitch in the front office does not map out to the details of fee-for-service in the accounting department.

How much will the aide charge for providing home health services, and what services are included? Does this information mirror the data provided by the agency? Inquire about sick days and check for any scheduled vacations that might impact continuing service to your loved one. Who is responsible for payroll, social security, and other taxes associated with the aide? Does your aide receive standard holidays off as defined by federal guidelines; are they paid holidays, and who pays?

Before an aide enters into your loved one’s home, there should be a written care plan that includes details about medical equipment, specific care needs, and the responsibilities of the aide and the agency. This plan is usually in the form of a 3-ring binder where an aide denotes hours of care provided and can reference doctor input, which should be frequently updated. Also in the book should be a list of responsibilities and rights for everyone involved, which is often referred to as the patient’s bill of rights. This document varies widely, but Medicare.gov provides a detailed example of what they include.

Inquire if the agency will continue to work directly with you and other family members after the aide is identified and hired for service. What is the process for elevating concerns and complaints? If there are problems, what is the protocol to resolve them? What are the emergency plans in the event of power failure or a natural disaster that can create safety hazards, particularly with medical equipment? What are the response times during a medical emergency? Is your aide instructed to dial 911 first? Check for a back-up plan in the event the home health aide has an emergency come up or has car trouble, or inclement weather precludes them from showing up.

According to Homecare.com, the average agency health care worker has between 1 to 2 years of experience, so implement the 3 R’s and get resumes, references, and reviews. Ensure the credentialing process through your identified agency includes home health aide social security number and trace verification. Be sure it checks federal and state criminal records, sex offender registry, and valid driver’s license check through the licensing department in your state. The aide’s license and credential verification need to be vetted. Finally, there should be contact with the Fraud and Abuse Control Information Systems (FACIS), which checks for wrong actions by individuals and agencies in the health care field.

To hire the best home health care services possible for your loved one do your research thoroughly before moving forward. Once you are engaging agencies and individual aides ask questions, get literature, take notes and then follow up on references, license verifications and credentialing. The research and care you put into the process upfront can stave off unwanted complaints or problems with your home health aide selection. You will create the best outcome for the patient by identifying the most qualified and affordable candidate for your situation.

We help families create comprehensive estate plans for anyone who may need long term care. We discuss care needs, how care will be paid for, who will make decisions, and much more.

If you have questions or need guidance in your planning or planning for a loved one, please do not hesitate to contact our Cincinnati, Ohio office by calling us at (513) 771-2444.

Medicare Falling Short With Home Health Care

February 20, 2020Filed Under: Elder Law, Long Term Care

All across the US, there is a new refrain spoken by Medicare home health providers, including occupational, speech, and physical therapists, social services, as well as intermittent skilled nurses: “Your husband (or whomever) is not going to get better, so we will have to discontinue our services as Medicare will not pay for it.” Termination of care is swift, often within 48 hours of delivering the message, and the home health care chores fall to the family system or must be paid for out of family funds. So what changed?

PDGM Figure 1

Significant changes began on January 1, 2020, as to how Medicare pays for home health services. Medicare has altered its billing approach from a therapy delivered model (the more therapy you receive, the higher the payments billed to Medicare) and changed it into a reimbursement system known as the Patient-Driven Groupings Model, or PDGM. Medicare Advantage plans have separate rules and are not affected.

The Centers for Medicare and Medicaid Services (CMS) provide Figure 1 as an example of how a 30 day period becomes categorized into 432 case-mixed groups for adjusting payment purchases in the PDGM. These 30 day periods are further broken into the following subgroups: admission sources and timing, twelve clinical principal diagnosis subgroups, three functional impairment levels, and three levels of co-morbidity adjustments. During the 30 days, there is only an allowance for one chosen category under the larger color-coded categories. CMS deems this newer approach to be more holistic regarding patient need assessments.

In 2017, the most recent year for which the data is available, for-profit US home health care agencies (approximately 12,000) provided care to 3.4 million Medicare beneficiaries. Home health rates charged were based on the amount of therapy delivered. The more therapy a patient received, the higher the payout to the agency. Due to the change in payment structure, these agencies are cutting back on therapies provided and even reducing the number of therapists employed. They can’t bill enough to Medicare to remain profitable. These new payment conditions are based on a patient’s underlying diagnosis and other case-specific complicating medical factors. As a result, home health care agencies now have a stronger financial incentive to meet the needs of short-term therapy, post-hospital or rehab facility, as well as caring for patients requiring nursing care for complex situations like post-surgical wounds.

CMS believes this new way to assess payments will strike a balance between costs, efficiencies, needs, and outcomes. The members of the National Association for Home Care and Hospice (NAHC) disagree. Data culled by NAHC from home health agencies indicate there will be a substantial reduction of therapy services offered as a result of the PDGM. William Dombi, the association’s president, states that the cuts “may not be a good move” because medically, patients may deteriorate more rapidly without therapy and seek aid in emergency rooms or hospitals. He also notes the possibility that if more patients end up worse off and go to emergency rooms or hospitals, that this will reflect poorly on home health agencies and can affect their referrals.

Providing the right patient therapy at the right time by home health care agencies is critical to positive patient outcomes. CMS has done extensive analysis of historical data and, through the use of artificial intelligence tools, feel they can better predict what kind of services and how often a patient will need them through the PDGM. Clarifications are being posted online by CMS that deal with early errors in the program and the ensuing turmoil of therapy provision for patients within the new guidelines. It is the hope that more reviews and revisions to the PDGM will strike a better balance between cost and efficiency, patient therapy needs, and outcomes.

Understanding the role Medicare will play when it comes to long term care services can be confusing. We help families plan for the possibility of needing long term care, and how it could be paid for without causing the family to spend everything they have.

If you have questions or need guidance in your planning or planning for a loved one, please do not hesitate to contact our Cincinnati, Ohio office by calling us at (513) 771-2444.

A Guide to Continuing Care Retirement Communities

February 7, 2020Filed Under: Elder Law, Long Term Care, Senior Health and Wellness

continuing care

There are three distinct living phases associated with a continuing care retirement community (CCRC). The first is independent living when a resident enters into the community with few if any disabilities requiring limited assistance. In this phase of independent living, community residents typically take advantage of the broad range of social, physical, and intellectual offerings. The second phase is assisted living, which includes long-term personal senior care support services that include help with activities of daily living like medication management, bathing, meals, dressing, and transportation. The third phase is nursing home care, also known as a skilled nursing facility. This third phase addresses a resident’s requirement for 24-hour monitoring and medical assistance in the case of serious injury or severe illness. Nursing home care locations within the CCRC are usually located near an associated hospital if the need arises for acute care or hospitalization. The linked three phases of a CCRC provide a continuum of care so that a resident can spend the rest of their days moving between the levels of care as needed.

These residencies are also referred to as life plan communities, active adult community homes, and lifetime communities. CCRC’s vary from state to state and have no licensing by one oversight entity. There is no reliable data as to how many seniors are living in CCRC’s, but it is evident that continuing care within one inclusive community is gaining popularity. One way to distinguish a well maintained and safe CCRC is through the Commission on Accreditation of Rehabilitation Facilities (CARF). This organization is America’s only accrediting body for these types of communities and is an independent, non-profit organization focusing on advancing the quality of services to meet the residents’ needs and provide the best possible outcome. The Continuing Care Accreditation Commission, also known as CARF-CCAC, is a valuable reference when researching a move into a CCRC.

Opting to live in a CCRC is a costly senior housing option and requires due diligence and careful financial planning optimizing the experience. Payment plan specifics are different at each CCRC; however, an entrance fee is required. These entrance fees can be as little as $10,000 and as expensive as $500,000. Most CCRC’s do not allow ownership of the residence; however, a monthly maintenance fee requires additional monies ranging between $200 and $2,000. The residence is just one part of the contract negotiation. Health care coverage and costs are typically broken down into three fee schedule options. The first is an extensive contract, which is the most expensive. It provides the resident with unlimited access to healthcare with little or no monthly maintenance fee increases. The second is a modified contract that offers a resident unlimited access to healthcare, but health care is paid for as needed, and monthly maintenance fee increases offset this pay for health care as needed approach. The third is a fee-for-service contract, and while it seems like a conservative spending approach if the aging resident eventually requires extensive healthcare, it is costly. This fee schedule option allows residents to pay for all health care costs separately.

Websites that offer advice on senior living options like aPlaceforMom suggest that the admission agreement for a CCRC should cover

The three residence phases
Fee schedule options
Health care coverage
Cancellations and refunds
Services
Insurance requirements
Conditions for transfer within the community to other levels of care
What the CCRC’s responsibility is if a resident becomes unable to pay fees.

A contract review by a trusted lawyer or financial advisor is of the utmost importance. Contracts should include a clause that addresses refunds in the event a resident leaves the CCRC and, like the fee for service health care options, most CCRC’s have multiple agreement choices that offer varying degrees of refundability. In the past, most continuing care retirement communities were non-profit organizations, but today, many CCRC’s are a for-profit business. Check into the possibility that the business entity of your retirement living arrangement may one day be sold and understand how that would affect a residential contract.

It is essential to ask relevant questions when researching a particular continuing care retirement community, such as:

What if assisted living and nursing home facilities that are part of the CCRC are full when I need them?
Is there a reciprocal agreement between the CCRC and nearby communities?
What type of background checks are done for staff members?
What is the staff-to-patient ratio in each phase of living?
How can a resident participate in the organization’s decision making?
What type of memory impairment (or dementia) services are available?

The above questions are good starting points to learn everything possible about a particular CCRC. Some items will be specific to your health, financial situation, and family relationships. We often help families with determining the right type of living situation for senior family members.

If you have any questions or need guidance in your planning or planning for a loved one, please don’t hesitate to contact our Cincinnati office by calling us at (513) 771-2444.

Relationship Dynamics When a Spouse Becomes a Caregiver

Hiring In-Home Health Care Services

Medicare Falling Short With Home Health Care

A Guide to Continuing Care Retirement Communities

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