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Information and assistance with Home Care, Home Health Care, Independent Living, Assisted Living, Nursing Homes, Dying With Dignity. |
Hospice is a lot more than you think
Hospice is more than escorting people at their life's end. Hospice offers a wide variety of services that can support you and your family before and after someone's death. First of all hospice service is covered by Medicare/MediCAL. Hospice provides care and support with social workers, nurses, home health aids, counselors, volunteers, and clergy. The main goal of the hospice work at home or in a facility is to make the patient comfortable, set up a pain management schedule and support friends and family members.
Hospice also offers a transition program for individuals with life-threatening illnesses and a prognosis of about one year of life. It covers emotional and practical support. Besides other services, these clients have a caseworker to assess his or her changing needs and make the necessary referrals to different community resources.
The End of Life Coalition is also a part of the wide hospice program. A few months ago this program received a grant, which it used to send some people for training to learn to teach others about expectations, common situations and how to handle them, and skills to help those who are dying. I attended this first class, and it more than exceeded my expectations. I have worked my whole life in the health field, and I have seen many people dying, but this class has given me a new perspective of life . . . and death. These classes offer much helpful information, and very often the most useful knowledge comes in the form of small hints that can mean so much to someone expecting his or her own death or the death of a loved one.
One of my class mates, Cherokee, lost her friend on a day during our five-week course. She told us, "This class is about love. It takes away the fear of the future and the fear of death. We are living and dying at the same time — if you will, life is a terminal illness." The next class, called Care Giving at Life's End, will start in April or May. For more information, see the phone numbers at the end of this article.
The End of Life Coalition is providing for the second time a stage reading to the Community about life, aging and dying. It called VESTA.
What is VESTA? VESTA (goddess of the hearth, identified with the Greek goddess Hestia) is a stage reading about life and death. There will be one performance April 18, 2004, starting at 1 pm at the First Congregational Church, 900 High Street in Santa Cruz and tickets are still available.
VESTA is about an elderly Lady going through the aging process. It portrays her relationship with her family, with her friends, her sometimes irrational behavior and how her surrounding responds to it. It is in down to earth language with often-humorous situations. After the performance the public has the one time opportunity to sit together with trained counselors and Community professionals and talk about the play but also their own situations, the fears und the expectations. There are special groups talking about: Living Will, Senior Care Options, and Grief and Loss. Everyone can make the decision whether they want to stay for the discussion or come only for the stage reading.
When we become aware that we, or a family member/friend, come close to the end of life we all deal with different kind of emotions: Denial, fear, impatience, and the greatest dread is for the unknown. We all have to go through and each one of us is dealing with it in very different ways.
Some people live in apprehensive life situations and consciously refuse to involve anyone in the own affairs. Searching for a last will, searching for life insurance, going trough all the collection of checkbooks and statements, figuring out where and with which bank the mom/dad did her/his business after a loved one passed on leads very often to conflicts in families and the split may go through the rest of their life. What a lot of people try to protect during a lifetime is suddenly exposed to every one. Where is the protection now? Wouldn’t it be better that at least one person, if not a family member then a friend, lawyer, or a trustful someone, has all the copies and knows at least where and with whom to deal. All this will be talked about in the performance and afterwards in groups with interested people. Every one can stay as long as they wish.
At the beginning of March this year Christa Martin (not related to me) wrote an article for the Good Times about her personal experience losing first her mom and then shortly after her dad. How she dealt with grief and who could help her and which kind of help she couldn’t accept. She really wrote from her heart and I hope we will see her on April 18 at the VESTA performance.
I personally learned through my professional life, working in hospitals and especially in the last 10 years with seniors, to listen and sometimes listen between the lines. Very often I was the one addressed by a partner during a drive or by a client when I was alone at home with them. a sometimes- emotional conversation gave my clients a peace of mind they rarely had before. I encouraged my clients to talk to someone they think is the right person, or to sit down with me and to write down last wishes . . . or sometimes what is not wished at all. Have a peaceful springtime.
For the Caregiving at Life's End class, call Joana deBelkadi at 477-0728; the class is free of charge.
Serving Santa Cruz County: Hospice of Santa Cruz County; phone 688-7684.
Serving Monterey, San Benito, and Santa Cruz Counties: Heartland Hospice: phone 373-8442.
Serving Monterey and San Benito Counties: VNA Hospice: phone 372-6688.
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This article originally appeared in Ruth F. Martin's column “Seniors' Choices” in the Register-Pajaronian newspaper. [March 2004]
To contact Ruth about consulting services, please call (831) 632-0603 or email her at info@healthandseniorcare.org.
©2004 Ruth F. Martin. All rights reserved.
Looking for Day Care for Adults and Seniors?
What is senior day care?
What do you do when your loved one becomes more dependent and needs more supervision, but is too healthy to move into an assisted living facility or nursing home? Or you, as a primary care giver, need a break? the adult/senior day care center is the best solution. Let me explain: A day care center is a place where adults and seniors with special needs gather together during day hours. In Monterey County there are day care centers, and in Santa Cruz County there is one day care center and one center for stroke patients._______________
This is part of an article that originally appeared in Ruth F. Martin's column “Seniors' Choices” in the Register-Pajaronian newspaper. [February 28, 2004]
To contact Ruth about consulting services, please call (831) 632-0603 or email her at info@healthandseniorcare.org.©2004 Ruth F. Martin. All rights reserved.
Seniors and AIDS
In July 2004 the World AIDS Conference met in Bangkok, and the current statistics show that AIDS among the heterosexual elderly is the fastest growing group not only in the United States, but also around the world.
If elderly people are alone after a partner has passed on or have gone through a divorce, eventually they may enjoy the company of a new partner. Besides going out and having fun, sexuality is still a part of life for seniors.
Many elderly people would not think to ask their partner to use a condom. I know most of us coming from an earlier generation are not used to using condoms for anything other than birth control.
A big part of successfully taking care of ourselves and elders in our care is getting education. In some cases this education involves learning not only how our bodies change, but also how the world has changed. Elder education about AIDS is an important part of health care and growing older.
A good place to start is going together, yes together, to get an AIDS test with a new partner. It's hard to know with whom your new partner has been sexually active before he or she met you, so an AIDS test is very important. Bringing up this discussion as you begin to think about intimacy can be the beginning to a trusting relationship. If your partner is appalled about doing this, think twice whether you want to be with someone who does not respect your health concerns. I wish every one with a new partner would have the strength and courage to stand up for their own health in this way. If you have no definite result from an AIDS test, condoms should always be used — at any age.
Sexual contact is the most common way to become infected with the AIDS virus. Another way is through a blood transfusion, although with current screening of donors and blood testing this is extremely rare: only 1:1 million. I think we can say that the United States blood supply is safe; nonetheless, if you plan a surgery, your doctor will probably recommend that you donate your own blood for your operation.
I don't want to bore you with numbers, but I do want to emphasize that elders are the fastest growing population exposed to HIV infection and AIDS. The difference between HIV infection and AIDS is that people with HIV infection have no AIDS symptoms, but they can develop full-blown AIDS at a later time. Magic Johnson, for example, has the HIV virus, but so far he has no signs of AIDS.
Today we have more and better medications with which to treat HIV infection. Medications for HIV infections are very effective, but they are most effective the earlier you are diagnosed and begin treatment. It is important to remember, however, that none of these drugs can cure HIV infection or AIDS. Once infected with the HIV virus, you will have the virus in your blood, in your body for the rest of your life. The only "cure" is prevention!
It is in your own hands and it is your own responsibility to protect yourself by practicing safe sex with condoms, talking openly with prospective partners, and getting tested. You have only one life, and I appeal to each one of you to take very good care of it.
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This article originally appeared in Ruth F. Martin's column “Seniors' Choices” in the Register-Pajaronian newspaper. [August 2004]
To contact Ruth about consulting services, please call (831) 632-0603 or email her at info@healthandseniorcare.org.
©2004 Ruth F. Martin. All rights reserved.
Have fun and do good work — Be a volunteer
I visited the Health Fair at the Watsonville Hospital on October 24, and I was impressed with how it was organized. I felt very welcome and was guided by confident helpers. When I expressed my gratitude to one of the people, I was told I should tell this to the president of the organization. That was the way I met Cindy Welch, the acting president of the Service League of the Watsonville Community Hospital. The Service League is a nonprofit organization, founded in 1969. Their mission statement reads: "... to serve the people, patients and staff in the hospital."
Through their untiring work, the Service League has supported the hospital for more than 30 years. And they are always looking for new members to serve as volunteers.
The Service League runs the coffee shop inside the hospital and is very successful with a paid cook in the kitchen and nice volunteers up front. People who work nearby come in for lunch. Who would voluntarily go inside a hospital to eat? It must be the food. And indeed the food is delicious and very affordable. I tried a salad with tuna, eggs, and cottage cheese; it was nutritionally balanced, I liked it very much.
The Service League has a teddy bear program. Each child staying in the hospital gets a teddy bear. This is not an ordinary teddy; it's hand-made by members of the League. It has a painted, smiling face and no buttons at all to be a danger to younger children. Cindy told me the story of a child who was wheeled to an x-ray with his teddy with him. On the x-rays the contours of the teddy were visible. How would you feel if that had been your child? Safe and loved.
Another program the Service League does is "cap knitting." Members and volunteers knit caps for newborn babies. Each mother goes home with the cap she received as a gift for her newborn. Isn't this remarkable?
Then there is the parking lot tram. The Service League purchased a golf cart, which is operated by volunteers as a service for the hospital. It transports people from the parking lot to the hospital and back.
A special treasure is the gift shop inside the hospital that contains all the nice, beautiful little things, including flowers, people can buy and bring to the bedside of a friend of loved one.
The "Old Spice team," is the group of people, volunteers from the Service League, who raise money every year performing the Relay of Life — a 24-hour walk-a-thon for the American Cancer Society.
The annual Halloween bake sale and sale of Easter baskets are fundraiser for the Service League. Employees can hardly wait to buy the outstanding homemade baked goods or the handmade treats inside the baskets.
The respectful and loving way the volunteers treat each other is remarkable. The whole atmosphere is so positive I could stay there for days.
The members of the League are looking for new volunteers. Interested people must be at least 18 years of age. Young people are also welcomed. The League is also looking for bilingual volunteers. Also, volunteers with only a little time are welcomed. The League is able to create a schedule tailored to the time you have available. There is no ate limit; the oldest volunteer is 94 years young. I was told that she is very sharp and forgets nothing.
The members gather together to socialize at the annual barbecue.
If you sign up to be a part of this wonderful program, I promise you will have a lot of fun. You will meet new people and perhaps new friends. The Service League asks for nothing, except your time. Whether you have a lot of a little of time, come forward and bring a friend. To make contact or for more information, write to: Service League, c/o Cindy Welch, Watsonville Hospital, 75 Nielson Road, Watsonville, CA 95078, or call 831-724-4741 ext. 1510. The Service League is accepting donations.
Giving and sharing is one of the messages the holiday season teaches us, regardless of our religious preferences. Service League members give and share, not only during the holidays, but all through the year. Try it. I wish all of you a peaceful holiday season.
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These articles originally appeared in Ruth F. Martin's column "Seniors' Choices" in the newspaper Register-Pajaronian (Watsonville, California).
To contact Ruth about consulting services, please call (831) 632-0603 or email her at info@healthandseniorcare.org.
©2003 by Ruth F. Martin. All rights reserved.
Medi-CAL
Should Medi-CAL pay for assisted living in California?
PART I
When Betty was unable to function without supervision, her family knew the time had come to look for a different environment. They decided on an assisted living facility, and Betty lived there for three years. Then due to financial losses in the stock market, the family was no longer able to pay for the facility. They met with Betty’s physician, and she was moved to a skilled nursing home after spending down her assets. For a short time Medi-CARE paid the skilled nursing home; then Medi-CAL provided reimbursement.Monthly costs for nursing homes is about 40 percent higher than costs for assisted living facilities; nonetheless, Medi-CARE/Medi-CAL is not paying for residents in assisted living facilities. Betty’s health would have allowed her to stay in assisted living, but lacking funds, she is now occupying an expensive bed in a nursing home.
What Is Assisted Living?
Assisted living has different names: board and care home, residential care home, residential care facility, community care facility or congregate home. Assisted living is defined by the Assisted Living coalition as "a congregate residential setting that provides or coordinates personal service, 24-hour supervision and assistance, activities and health-related services; designed to minimize the need to move; designed to accommodate individual residents' changing needs and preferences; designed to maximize residents' dignity, autonomy, privacy, independence and safety; and designed to encourage family and community involvement."When the Social Security Act passed in 1935 for seniors in the U.S., no one could foresee the changes we face today. When assisted living was developed it was exclusively for the private payer. In 1981, Oregon became the first state to receive a waiver to permit use of Medic-AID dollars to deliver care to people in community-based settings. With the growing population of seniors — currently 2.6 million in California — it us a controversial issue whether the government should spend Medic-AID assets for assisted living. Medi-CARE is a federal program that assists Americans 65 and older. It has two parts: Part A covers hospitalization and some bills for a limited stay in a skilled nursing home. Part B pays for doctors and outpatient medical care.
If you are 65 years or older and eligible for Social Security benefits, you are automatically enrolled in Part A, with a few exceptions. For a monthly premium, anyone over 65 can enroll in Part B, whether or not they are eligible for Part A.
Medi-CAL, as it is called in California (Medic-AID in the U.S.), is the health insurance for Americans without employer or private insurance should they become sick or disabled at any age. Medi-CAL is longterm health insurance coverage for Americans 65 years and older and also covers people who have a low income/SSI and few assets. Federal and state requirements regulate the eligibility for Medi-CAL with special rules for nursing home patients. Medi-CAL has a strict policy about the definition of assets and income.
Medi-CARE pays for service/care, room and board in a skilled nursing home for up to 100 days, if the patient was admitted after a hospitalization, with the required physician's order. If the patient needs further care in a nursing home and has assets, those assets must be spent down first before the recipient can apply for Medi-CAL. Medi-CAL will cover the costs of health-related services and room/board in a nursing home after the recipient has spent down his or her assets.
Medi-CAL pays for skilled nursing home residents only if they are low-income. If a particular resident could stay in an assisted living facility based on a medical assessment, Medi-CAL still could not pay under the current laws and regulations.
Currently (in 2003), a day in a nursing home costs approximately $140 in Santa Cruz County and $155 in Monterey County, which includes all services (room/board/care). A day in an average assisted living facility costs approximately $100 to $120 including room/board/care (on the Central Coast, costs can be up to $200 a day). Medi-CAL currently pays $115 per day/per patient in a skilled nursing home. A comparison between all assisted living and nursing homes is difficult because assisted living has no nursing care. Also, while some assisted living facilities are upscale retirement communities, others are more average facilities.
Should California join other states?
How can California receive federal Medic-AID reimbursement for residents in assisted living facilities? California could work on different models to spend Medi-CAL dollars for assisted living residents. One model California could follow would be to fund the services for assisted living through Medicaid Home and Community-Based Care Waivers. Another model could be the Medicaid State Plan Service.The services for assisted living may be reimbursed through Medic-AID Home and Community-Based Waiver or as State Plan Services, also called Personal Care. More states use the Waiver Program than the State Plan, but states using the State Plan have higher participation than states using the Waiver Program. The Waiver Program and the State Plan differ in three ways.
The Waiver Program: 1) Limited spending for services by state, 2) the level of care criteria for nursing homes must meet the state's criteria and 3) California must set up eligibility to 300 percent of the federal standard of SSI payment.
The State Plan: 1) State must provide services to all people who qualify for Medicaid, 2) a person must need the services covered and 3) a person must be on SSI or another eligibility for Medicaid.
Nursing home eligibility is not required for beneficiaries using State Plan services. All people who meet the criteria must be served by the State Plan; the beneficiary must be on SSI or another form of eligibility of Medic-AID.
In the Waiver Program special requirements on the state level set limits on the number of people who can be served. These limits are defined as "expenditure caps" that are part of the cost neutrality formula required for approval.
The Waiver Program is available to people who meet the state's nursing home level-of-care criteria. They would be eligible for a nursing home stay if they apply (basically everyone after a hospital stay is eligible with a doctor's order). Under the Waiver Program, states may use a category that allows people with an income of less than 300 percent of the federal SSI benefit ($530 a month in 2001) to be eligible and receive all Medic-AID/Medi-CAL services. Using this program, states can pay for assisted living services. Fro example: If a prospective resident for an assisted living facility has less than 300 percent of the federal SSI benefit monthly income, he or she should be eligible for reimbursement.
Another benefit is that those who meet skilled nursing home criteria could be come eligible for Medi-CAL without spending down all their assets.
In assisted living, people may spend their assets for room and board and Medi-CAL covers the services. Currently, 30 states cover service (Waiver Program or State Plan) in assisted living facilities through Medic-AID. California passed a bill (A.B. 499) in 2002 approving a Medi-CAL Waiver for assisted living as a pilot project. The program itself has yet to begin.
A criterion for reimbursement for assisted living is room and board. Under a special section (1915 c) it is written that Medic-AID cannot pay for room and board outside a hospital or nursing home — except in limited circumstances as for respite care and meals that are served as part of a day care program and for hospice care at home and/or in assisted living facilities.
Medi-CAL pays the costs for services, meals and housing in skilled nursing homes in California.
If the Medi-CAL program will work for assisted living, housing should not be an issue. The whole program should be carefully analyzed and discussed, and it should not laterally request to receive equal reimbursement for assisted living.
Medi-CAL typically limits how much facilities may charge for room and board. This is tied to the state's SSI program for a single elderly person. Since Medi-CAL cannot pay for housing in assisted living, this needs not be addressed. This should be left to the resident and the facility to determine. The resident should pay the costs for room/board in assisted living and the service/care would be reimbursed by Medi-CAL.
I'm sure Betty, from the beginning of this article, would have had another year in assisted living. She would have been moved to a nursing home later, due to health and not financial reasons.
What part would a physician play in these changes? Would they have more work through the requirements of Medi-CAL? How is it dealt with in assisted living?
PART II
Voices from the assisted living community
When I went deeper into this subject, I contacted assisted living facility administrators and directors in Santa Cruz, Monterey and San Benito counties for their input. Almost all assisted living facilities owned by corporations and administrators are very concerned about overhead costs, when Medic-AID/Medi-CAL is involved. Sending monthly invoices to the Medi-CAL office and dealing with new requirements would dramatically increase the costs. It would not be long before more staff would be needed. The tenor from administrators and directors is that this would automatically raise monthly costs.Some assisted living facilities have one lump sum paid every month, covering room/board and services/care. To separate this sum into room/board on one side and services/care on the other should be an easy calculation. This should not be a criterion to be used against Medi-CAL reimbursements. Some voices are concerned that care will be less than it is currently; some facilities may save costs giving less care. I think care should not be different whether residents pay directly, privately to the facility, or Medi-CAL reimburses. We are talking about the hands-on care in the daily process of living and not the expensive or less expensive surroundings of a facility. Privately owned assisted living facilities welcome the program in general; these facilities, on average, have fewer beds and the clientele may be different. It is more a family-style environment and they are less concerned about the requirements for reimbursements.
The majority of the answers to my question, "Should Medi-CAL pay the full amount of the daily costs in assisted living" are "no. The answers would support an appropriate co-payment from the Medi-CAL office.
The question of whether every senior should be eligible for the Medi-CAL reimbursement split the administrators and directors (those who support the idea) into three answers: 1) Everyone should be eligible, 2) Only people who have spent their money and need the reimbursement to continue to stay in assisted living and 3) Only people who have no sources to pay for assisted living.
The administrators and directors of exclusively assisted living facilities have shown less familiarity and experience in general about Medi-CARE and Medi-CAL, especially about reimbursement, than those experienced with skilled nursing homes. Very few would prefer to remain with the current private payment of residents. An interesting thought is that assisted living is a social program and if Medi-CAL is involved it could change to a health program. Nearly 100 percent of the answers assumed between one and 10 states have a contract for Medic-AID reimbursement, but the majority had never heard of it.
Voices from seniors and their families
Through my lecturing at the Adult School in Watsonville and the Adult School in Santa Cruz, I have been in contact with a variety of people. I have submitted these same questionnaires to seniors and children of the elderly. The answers are not surprisingly the opposite from the answers of administrators of assisted living facilities. All, old and young, would support a change of the current system. The financial "help" of reimbursement from Medi-CAL would allow more seniors to stay longer in assisted living facilities. Some would even consider moving sooner to an assisted living facility if they could have help paying the bills. Their own savings/assets would be stretched and the majority would support a reimbursement for the care/services and would be willing to pay for room and board.Summary
I opened a small window in the large house of Medi-CARE, Medic-AID (Medi-CAL). I addressed the most important issues about reimbursements for services in assisted living facilities. We have no federal requirements for assisted living and each state has its own rules and laws. Today, there are nearly 30,000 assisted living facilities in the U.S. with more than 1.15 million residents. by the year 2025, there will be more than 2.1 million residents; an increase of 70 percent. But, with all the Medi-CAL requirements, is California able to come up with a plan allowing coverage for services in assisted living (or a different program) without changing the requirements given by the Social Services Department of California for assisted living facilities?We cannot close our eyes to the fact that despite the ever-increasing population of seniors, in some states the rates for the Medic-AID reimbursement are too low to allow facilities to serve residents who meet the waiver requirements. That is, residents must meet the state's criteria to enter a nursing home.
I think each assisted living facility must make its own policy whether it wants to participate in the Medi-CAL program or not. At the moment — with more requests than beds — it will not be an issue. But if needs change and facilities struggle to maintain occupancy rates, they may be more likely to sign a contract with Medi-CAL to retain residents who have spent their resources and cannot afford the monthly fee.
But we all know the poorest of our seniors, the elders on SSI, could never participate in this achievement of our society. If it turns out a senior on SSI can no longer safely live at home, the only way to receive necessary care is a bed in a skilled nursing home, whether the level of health requires it or not. Medi-CAL is the only source of payments and so far it pays exclusively for skilled nursing home stays. The total costs for assisted living would be by far much less than the total costs in a nursing home. But as long as Medi-CAL is not covering room and board costs in assisted living facilities, those seniors have no choice but to go to a skilled nursing home.
I am aware that we are going through difficult times in our economy. I am also aware the government and the state are reducing spending dramatically. But whatever decision is made, it will have an impact on our increasing senior population today, tomorrow and for the next 20 to 30 years — maybe longer.
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Sources
- Assisted Living Quality Coalition, 1988: Assisted Living Quality Initiative: Building a Structure that Promotes Quality. Washington, DC.
The Coalition is a group representing the Alzheimer Association, the AARP, the American Association of Homes and Services for the Aging, the Assisted Living Federation of America, the America Senior Housing Association, and the American Health-Care Association — National Center for Assisted Living. - Senate Hearings 1999: Special Committee on Aging. United States Senate, April 26, 1999.
- Senate Hearings 2002: Special Committee on Aging. United States Senate, April 16, 2002.
- Zimmerman, Sloane, Eckert, (Mollica): Assisted Living: Needs, Practices, and Policies in Residential Care for the Elderly. The Johns Hopkins University Press, Baltimore and London, 2001.
These articles originally appeared in Ruth F. Martin's column "Seniors' Choices" in the newspaper Register-Pajaronian (Watsonville, California).
©2002 by Ruth F. Martin. All rights reserved.
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