Here at CareLink we understand that choosing the correct setting of care is a very important decision. Whether you are an individual seeking care, or a family member/caregiver looking for more information so you can decide with confidence what setting best supports the needs for your loved one, let this resource guide assist you. Created by our team of healthcare professionals, the purpose of this guide is to thoroughly highlight the different types of care available, help clarify the focus of each setting, and help you choose the best provider. This resource guide also explains payment and insurance options, additional questions to consider in your search, and provides you with our complete member listing.
CareLink's Resource Guide
1- DIFFERENT TYPES OF CARE SETTINGS. WHAT SERVICES ARE PROVIDED?
Home care provides health services conducted in the privacy of an individual’s home. This includes skilled nursing, social services, and physical, speech, and occupational therapy. There are also additional services available, such as providing a certified nursing assistant (CNA), a home companion, and homemaker care, which assists the client with activities in their daily life (ADLs).
A skilled nursing facility provides both long-term and short-term rehabilitation care for elders needing an in-patient stay.
Skilled services are utilized when a patient is in need of comprehensive care for a limited period of time. This includes daily acute medical therapy and/or rehabilitation therapy needs. For example, dressing changes after a post-operative hip replacement, as well as physical and occupational therapy. Upon completion of these rehabilitation services, patients are expected to return home.
Custodial care (also known as long-term care) most commonly describes the setting of a nursing home. This means that the client does not require a “skilled” service, but instead needs assistance with activities in their daily life, such as dressing, bathing, feeding, etc. These clients are generally not expected to return home, but could transition to another supportive setting in the community, such as PACE RI. Within custodial care, concierge and handyman services may also be available depending on the individual providers.
Assisted living is a healthcare residence where a senior adult can receive assistance with activities of daily living, which likely includes bathing, dressing, toileting, escorting, laundry, and taking medications, if required. Such assistance is not always necessary in this type of care, and depends on the individual’s needs. Most assisted living communities also offer memory care for residents in the early stages of dementia. Staff and at least one medical professional are typically on-call 24 hours a day, however intensive hands-on care or nursing care is not offered in this type setting. Details and policies vary per provider, and often include additional health services such as in-house rehabilitation.
Hospice is a type of healthcare that is dedicated to patients who are terminally ill and have a limited life expectancy. This type of care is provided in a home-like setting, focuses on maintaining the patient’s quality of life, while ensuring they remain as comfortable as possible, and provides palliative care as well as emotional support. Family members are welcomed to participate in the structure of care that best supports the needs and wishes of their loved ones, and grief support is always provided.
The role of palliative care is to:
- Treat the patient’s symptoms, including pain, depression, nausea, shortness of breath, loss of appetite, anxiety, and any other causes of distress or discomfort.
- Coordinate care that the patient might be receiving from various medical providers or community resources.
- Offer emotional support to the patient’s family, caregivers and loved ones, and help alleviate any feelings of distress or burden.
- Assist the patient and their family to clarify what matters most to them, and help convey those wishes and needs to their healthcare team.
Independent Living (more commonly referred to as senior housing) is designed for seniors who can still live independently. The goal of this type of housing is to minimize responsibilities of daily life, which includes landscaping, laundry and housekeeping services, as well on-site dining and security surveillance. A variety of activities and events are also typical offerings.
An adult day health center is designed to support families and caregivers by providing daytime care for their loved one in a secure, safe, and stimulating environment. Care is provided by certified professionals, and also includes transportation, nutritious meals, personal care assistance, and engaging daily activities. Participation is based on personal preference, anywhere from one to five days a week, and allows a sense of comfort and ease for families and caregivers to know that their loved one is being thoughtfully taken care of.
Memory care is available to any client with varying degrees of Alzheimer’s Disease and/or dementia. The focus of this type of care is to create an environment that is structured, organized, and most importantly safe, which therefore supports a stress-free lifestyle and helps promote and enrich cognitive skills.
Outpatient rehabilitation is an available service for clients who want to remain as independent as possible by living at home, yet seek to strengthen and regain ability in their daily lives. This type of therapy is offered in a variety of settings such as outpatient clinics or the client’s home, as well as participating adult day health programs. Clients receiving this type of care can also receive physical, occupational or speech therapy, based on their personal needs and goals. Wellness programs are also commonly offered.
2- HOW TO CHOOSE THE BEST PROVIDER
Gathering a list of potential home health agencies and then contacting each one to discuss their available services is a great first step in finding a home health agency. Doing online research and speaking to those in the client’s fellow community who might be familiar with these services is also helpful.
Organizing a tour with a facility’s admission staff is an important place to start when researching skilled nursing facilities. This allows the client and family members/caregivers to ask specific questions, get a sense of the atmosphere there, and to see firsthand how the residents of that facility are cared for. Clients should also be aware of the CMS Five-Star Rating System, which is designed to help measure the quality of nursing homes, and are based on assessments covering health inspections and staffing, as well as sixteen other physical and clinical measures to further highlight their success. This rating system is not definitive, however it is a great tool in clarifying information and assisting with decision making. Availability at skilled nursing facilities can be limited, and waitlists are common. More information can be found at Medicare.gov.
Conducting an online search is the first step in choosing an assisted living community that best meets the client’s needs medically, socially and financially. Once a list has been created of prospective options, it is important to take a personalized tour, and possibly even stay for lunch. This gives clients and their families/caregivers ample time to ask questions, interact with current residents, and to discover some of the offered activities that might be of interest. Some assisted living communities also offer in-house rehabilitation, wellness and other health services. Research can be done online. We recommend the following website: HealthRI.gov.
Choosing the right hospice is a very personal decision, and it is recommended that a family/caregiver does proper research on various facilities so they can understand what environment best suits the needs for their loved one. Hospice providers are located both in-state and nationwide, and can either be for-profit or non-profit. A helpful website for hospice ratings and additional information can be found at Medicare.gov.
Organizing a tour with a facility’s admission staff is a great place to start when researching independent living facilities. This allows time to ask questions, specifically to ensure that the client’s needs are being met medically, socially and financially. It is also important to find a facility where current residents look happy and comfortable. Suggesting lunch at the facility is also a great idea, as it gives extra time to interact with residents and get an overall feel of the facility’s atmosphere. Research can also be done online.
When researching adult day health centers, it’s important to first identify those that have the facilities and expertise that meet the participant’s specific medical and social needs. The next step is organizing a personalized tour to see the facility, talk to staff, and ask questions. It’s important to take notice how members of the day center interact with each other, and how comfortable and happy they are. Most adult day centers will allow new members to attend the center for a few days to ensure the setting is a good fit for them, and that it is somewhere they can envision themselves enjoying. (Refer to CareLink’s complete membership list at the end of this guide for more information.)
Memory care facilities are often connected with other forms of care, such as assisted living, skilled nursing facilities, and adult day health centers. An important first step in researching this type of care is to have a meeting or personalized tour of the centers in consideration. There are also some aspects to consider, such as the quality of care that is being provided in the memory care setting, what medical services are available, and how the facility is able to cater to a patient’s specific needs. Available activities for patients is also something to pay attention to, as well as the level of patient-staff interaction.
When a client is in need of outpatient rehabilitation services, they should first identify their personal health and independence goals. They should then decide which setting would be most appropriate and beneficial in meeting those goals, whether it is the high-quality equipment and resources at a direct outpatient clinic, or more personalized therapy in the comfort of their own home, or if it is coordinating services at their adult day health program. The client should also consider transportation needs, how often appointments are needed, and what works best for their daily schedule. It is helpful to call a variety of outpatient providers, explain the client’s specific goals and needs for therapy services, and request additional information in order to make an educated decision. Many outpatient clinics provide extensive information online.
3- FORMS OF PAYMENT FOR DIFFERENT SETTINGS OF CARE
*Please refer to the next section for descriptions of insurance options and eligibility.
- Commercial Insurance
- Private Pay
- Long-Term Care Insurance
- Medicaid (Custodial Care)
- Private pay — Applies to both short-term rehabilitation and long-term stays.
- Medicaid — Covers custodial care only.
- Medicare — Covers skilled care only, and often only covers the first 100 days of a patient’s stay.
- Managed Medicaid (UHC, NHP, Tufts) — This can cover both skilled and long-term, depending on the product.
- Commercial Insurance — Covers skilled care only.
- Long Term Care Insurance — Depending on the policy, the patient may have to pay privately first, and then will then be reimbursed by the insurance company. Usually these policies have a set monetary limit.
Assisted living is usually privately paid. However, in some cases, long-term care insurance will cover this type of care. Some facilities also have designated Medicaid waiver beds. It’s important to check with the specific provider to see if this type of waiver applies.
Hospice is a Medicare-covered benefit, and most insurance policies will cover the costs. Palliative care is provided in the individual’s home or at a facility, and is typically billed directly to the insurance company.
Medicaid does not cover the direct costs of independent living facilities, however some long-term care insurance policies do. Coverage can also be funded through private pay.
Confidential financial screenings are available to applicants of adult day health centers, and there are several programs that also help cover these costs. Medicaid covers 100% of the cost for individuals with assets below $4000 (single) and $6000 (married). State Co-Pay program pays for a portion of adult day health services for a person age 65 and over, and requires assistance with personal care, if income is below $25,520 (single) and $34,480 (married). Respite services are covered for income-eligible individuals, age 55 years and over. Veterans Administration benefits cover adult day health services, and private assistance offers reduced fees for individuals with low to moderate incomes.
Medicaid will cover the payment for memory care services in specific settings, while Medicare will often only cover the first 100 days. There are other payment options for memory care, such as respite services and benefits for veterans, however many people choose to use private pay. It is important to discuss these payment options with a member of staff during your facility tour.
- Commercial Insurance
- Private Pay
- Medicaid (Custodial Care)
INSURANCE INFORMATION (MEDICARE, MEDICAID AND LONG-TERM CARE INSURANCE)
Medicare is an insurance program. Medical bills are paid from trust funds which have been paid into by the individual being covered. Medicare is provided for adults over 65 years-old, regardless of their income, and is also available to those who are younger than 65 and are disabled or on dialysis. Patients pay part of their costs through deductibles for hospital stays, and small monthly premiums are required for non-hospital coverage. Medicare is run by CMS, an agency of the federal government, and services are universal throughout the United States.
Medicare is split up into various parts:
- Medicare Part A: To qualify for premium-free Medicare Part A, the patient or their spouse needs to have worked at least ten years and have paid Medicare payroll taxes during employment. Generally, Part A covers hospital care, skilled nursing facility care, nursing home care (custodial care exempt), hospice care, and home health services.
- Medicare Part B: Generally, Part B covers services that the government defines as “medically necessary” and “preventive.” This includes skilled services and rehab therapy, but does not include room and board at skilled nursing facilities, if necessary. Part B has a premium that most people pay per month.
Medicaid is an assistance program. It serves low-income individuals at all ages. Patients usually pay zero costs for covered medical expenses. A small co-payment is sometimes required. Medicaid is a federally funded program run by state governments in accordance with federal guidelines. If a patient seeks long-term services and wants to use state funding to finance that, a physician is required to complete a state-approved assessment. That assessment will then be submitted to state-employed nurses who will then confirm a clinical level of need to determine what services that individual may access. State funding is unavailable if a patient is denied a clinical level of care.
Long-Term Care Insurance is a type of policy created to help pay the costs of long-term care. Policies and costs can vary, depending on the provider.
OTHER IMPORTANT QUESTIONS TO CONSIDER
A resident can stay in an assisted living community until they no longer meet the criteria for care, which is often dictated by the Department of Health Regulations. This usually occurs when a resident requires a higher level of care, such as requiring assistance from more than one person to help transfer in and out of bed or a chair. However, different communities have different levels of care, so it is important for the resident to ask questions that are specific to their needs.
An alternative option is 24-hour home care. This is when a caregiver is present and awake in the client’s home 24-hours a day so they can assist with whatever specific needs are required. Home care is often considered an alternative for assisted living, however this kind of one-on-one care is often expensive, as it is usually charged at an hourly rate.
The cost of long-term care can vary:
- Skilled nursing could approximately cost between $9,000-$15,000 per month.
- Assisted living could approximately cost between $5,000-$12,000 per month.
- Long term care at home, if 24-hour care is needed, could cost upwards of $20,000 per month.
If the patient is a veteran and is currently enrolled in the VA program, then hospice care is part of the VHA Standard Medical Benefits Package. Veterans are eligible for hospice only if they meet the clinical need that is required for such service. In this case, there would be no copay necessary, regardless if hospice care was provided by the VA or a separate organization with a VA contract.
Private duty care (often known as custodial care) offers a broad range of long-term services to assist senior adults in their daily lives. This often includes non-invasive medical and nursing care, bill-paying, transportation services, meal preparation, and companionship. The goal of a private duty caregiver is to provide whatever support a senior adult needs to remain independent for as long as possible in the comfort of their own home.
Home health skilled care, on the other hand, is a medically-driven service that helps adults and seniors recovering after a hospital or facility stay, or are in need of additional support to remain safely at home and avoid unnecessary hospitalization. These Medicare-certified services may include short-term nursing, as well as rehabilitative, therapeutic, and assistive home health care. This care is provided by registered nurses, physical and occupational therapists, home health aides, and medical social workers.
Respite care provides temporary relief to unpaid caregivers (usually members of a patient’s family). Respite care is similar to hospice care and can take place at the individual’s home or a preferred health care facility, allowing caregivers some personal time off to rest and recuperate. Time restraints for this type of care are common, and can vary amongst providers. Respite care is typically covered by Medicare.