Caregiving Support: What are the options if my loved one needs a higher level of care?

Is More Care Needed? 

There is no shame in coming to the realization that your loved one needs a higher level of care than can be provided on your own. In keeping with the theme that there is a hierarchy of needs, safety always comes first. Moving your loved one to a location where they will be safe and cared for can be the appropriate next step. 

Let’s review and define some of the alternate places where care can be provided: 

Continuing Care Retirement Community (CCRC): A community where a variety of care options are available all on one campus. Residents sign a contract and usually choose to reside at a CCRC while they are more healthy and independent. They will have top priority in the Assisted Living Facility or Skilled Nursing Unit on campus should their health decline. A CCRC is frequently a good choice for couples. If one spouse needs the higher level of care of the Skilled Nursing Unit, they are still nearby, which makes it easier for the well spouse to visit. Independent private homes or apartments are available, and the resident chooses a Tier designating how much assistance is provided, ranging from various meal plans or Medication Management, to housekeeping and laundry services. Each tier has a different fee associated with it. These communities are only for those who have sufficient funds to pay privately. Also, be sure to read the fine print, some contracts require a one year financial commitment, even if the resident passes away in less than one year of residence. 

Senior Housing: An apartment building for those 65 and over with limited income, which is often rent subsidized by the State or local government. There are very limited services provided, however, there is usually a security guard 24/7, and there may be a caseworker M-F that can assist with accessing basic information. If a resident requires assistance with personal care needs, they will pay for it privately, or utilize Medicaid benefits to pay for a home health aide. 

Assisted Living Facility (ALF): A facility with independent apartments and shared community areas. Assisted Living Facilities can be a very good option for those who are more independent, and have limited to moderate care needs. Perhaps the resident needs assistance with cooking, laundry service, housekeeping and medication management. An ALF is a very good fit. The ALF Memory Care Unit can be appropriate for those who need to be monitored for safety 24 hours a day due to memory impairment. If the resident becomes incontinent, or wheelchair bound and requires assistance to transfer into the wheelchair, they begin to push the boundaries of comfortably living in the ALF, as Assisted Living Facilities have very limited home health aide staffing. In addition, residents that need to be fed are often prohibited from eating in the main dining room. If a resident needs two caregivers to provide care, they are no longer appropriate for most ALFs. Lastly, there is frequently no nurse on duty over nights, so emerging needs after hours can lead to a crisis. Assisted Living Facilities do not provide social worker support, but they do offer a full range of activities and entertainment.

Assisted Living Facilities are costly, ranging from $7,000 to $12,000 a month. In addition, ALFs usually require the resident to sign a contract stating that they will be able to pay privately for 2 years before the resident needs to apply for Medicaid. Long-term care insurance may cover the cost, depending on your plan. Medicare does not pay for room and board at an ALF. 

Skilled Nursing Facility (SNF): A facility for those who require a higher level of medical attention, often referred to as a Nursing Home or Long-term Care. Skilled Nursing Facilities provide the highest level of care available. SNFs usually have a variety of units including:

• Subacute Unit: where rehab (PT OT or Speech Therapy) are provided, often to those recently discharged from the hospital. 

• Memory Care Unit: a separate locked unit for those with memory loss to help keep them secure from wandering. 

• Other units will be for the general population of individuals with care needs including assistance with feeding, bathing, dressing, mobility, and who may be incontinent or bed-bound.

All medications are dispensed by a nurse. Nurses provide wound care, and can manage respiratory needs, as well as catheters or colostomies. There are nurses and home health aides in the facility 24 hours a day. SNFs provide a social worker to assist with creating and maintaining the Plan of Care, and the social worker supports both the resident and family. SNFs also maintain an Activity Department with activities geared toward a variety of cognitive abilities. Skilled Nursing Facilities generally cost upwards of $12,000 a month. Most, (but not all), accept Medicaid as payment provided the facility has a bed available. Long-term care insurance may cover the cost, depending on your plan. Medicare will pay for rehab, but it does not cover the cost of room and board for long-term care placement. 

Both ALFs and SNFs treat all residents equally regardless if they are private pay or on Medicaid, most of the staff do not even know how the room and board is being paid.

If you need support through this decision making process, licensed clinical social workers with care planning expertise can help guide you through the process. NeuroCog Solutions offers these care planning services which is often reimbursed by insurance.