Perspective Matters
November is Long-Term Care Awareness Month (or Long-Term Care Insurance Awareness Month, take your pick.) Either way it's a good time to talk about a subject that makes many of us uncomfortable - the increasing need for help we all face as we age.
I've previously written about generally being aware of options for aging in place safely and with dignity as well as defining activities of daily living (ADLs) and instrumental activities of daily living (IADLs.) Today I'm going to write about different categories of care and some terminology.
First let's talk about some terminology. The first thing you should be aware of is what's called a Geriatric Case Manager, or GCM. GCMs can help with assessing what help you or an aging person you care about needs, and help you find the right services. Often, they charge by the hour, and while it may seem expensive, you could spend tens of hours doing research and only learn half of what they know. There are many GCMs with a background in social work who are passionate about providing care focused on aging-in-place. Ideally, they are independent (they don’t provide care themselves and are not employed by a provider) and have networks of people positioned to provide everything from part time homemaker services to live-in companionship and nursing supervision.
This is a good point to also define the difference between Custodial Care and Skilled Care. Click here for the definition provided by the government (Dept. of Health and Human Services: Center for Medical and Medicaid Services.) For insurance coverage purposes, the difference is largely based on what type of care or services you receive, not where it takes place. Whether the insurance in question is Medicare, Medicaid, private health insurance or private long-term care insurance, Skilled Care refers to medically necessary care and must be provided by (or supervised by) properly licensed medical professionals. This can include everything from physical therapy to wound care and more. It will not include assistance with ADLs/IADLs. Medicare and private health insurance insure only Skilled Care, and may have limits, so you need to review your policy. They do not cover custodial care. Medicaid may cover custodial care services received in a nursing home setting, and some states have programs that will cover custodial care provided at home under certain circumstances. A GCM will help you navigate the various insurance programs available in your state.
Next is Home Health Care. No surprise, this is care that is provided at home, and generally includes Homemaker Services and/or Home Health Aide Services, (both of which are considered as Custodial Care as defined in the previous paragraph.) Getting both from the same source would be from a Homemaker Health Aide. Think about the ADLs and IADLs I described earlier. Generally, Homemaker Services would provide assistance at home with IADLs, and Home Health Aide Services would provide assistance at home with ADLs. A Homemaker Health Aide would provide both. The average cost nationally for any of these services is around $5000 per month based on Genworth’s most data. (Click here for more details.)
As we get older, we can also see our social circle shrink for various reasons. Adult Day Health Care programs may be a way to get both social activities and some health and therapeutic services. Think about a specialized sort of Community Center for people who need help with ADLs. Programs usually include transportation to and from the Center, social activities, and even physical, occupational and speech therapy onsite. There are also programs that offer more specialized services for people with dementia or developmental disabilities. In addition to the socialization these programs can provide, they also tend to be much less expensive than care at home, averaging about $1700 per month. *
So, we’ve talked about options for aging-in-place that focus on staying in your home. Sometimes, though, that’s not the best choice. Your home may be on multiple levels, and carrying laundry to the basement may no longer be safe or practical. There may not be a Senior Center or Adult Day Health Care program nearby that meets your needs, especially social ones. If you don’t have family nearby, you may want to plan ahead for the time you may need some help and put down roots in a place you can stay as your needs change.
These are all examples of situations in which Assisted Living is something to consider. This is actually a very broad category, with many types of living arrangements. One that is growing in popularity is what is known as a Continuing Care Community (CCC). They aren’t usually called that, but you’ll know them from the choices they offer. In a CCC, you typically can choose to move into an Independent Living, Assisted Living, or a Custodial Care situation (think nursing home) initially. With a CCC most people buy or rent an apartment or townhouse that’s defined as Independent Living. If you buy, there are often restrictions on selling or what your estate will receive, and you’ll also pay a monthly fee. I’ll go into more details on the financial side of CCCs in another article, so for now think about them as places that offer three levels of living, and as your needs change you don’t need to move again because they are set up to provide progressively higher levels of care.
When you first move in, they will assess your needs. You may need help managing your medications, or just want to be able to take your meals in a community setting. You may have a monthly fee that stays the same regardless of what services you access, or you may pay based on how many hours of help you get. Even in the hours-of-service model you are usually paying much less than receiving care at home. Often, at least one meal each day is included even in Independent Living.
Assisted Living generally refers to having staff members involved in your day-to-day life in some clear way. That can include helping you shower and dress, escorting you to meals and activities, and sometimes even accompanying you to medical appointments. To stay at the Assisted Living level, you generally must be able to function on your own up to a point, and need help, not complete care.
Many CCCs and even those that just offer the medium level of care known as Assisted Living also have specific Memory Units. These units are generally locked, which helps keep you safe from wandering and getting lost. People working in these units are specially trained to work with people with dementia and provide care that is compassionate, safe, and appropriate for the resident’s needs. There are a limited number of spaces in these units, and if you are already living in the Independent or Assisted Living unit in the community you may be more likely to get one of these spaces if you need it. Although there can be a wide range in the cost of Assisted Living based on the amenities of the community and level of assistance you need, the national average for private one bedroom accommodations in an Assisted Living facility is $4500 per month. *
When we reach the point of needing full time custodial care, there are a couple of options, and not all of them are available in every area. They can range from small residential group-home types of facilities (typically 4 – 7 residents) to what we think of as nursing homes (or retirement homes.) Nursing Homes usually offer both Private and Semi-private rooms, and the average cost nationally is about $9000 and $7900 per month respectively. *
The physical structure of many nursing homes, including full-time custodial services as part of a CCC, is focused on allowing the staff to care for multiple residents. They may resemble hospitals, with a “hub and spoke” configuration of staffing stations and resident's rooms. Facilities may be run by community based non-profit agencies or for-profit companies and deciding on a full-time residential facility for a loved one can be a difficult and emotionally wrought decision. Choosing a CCC while still living independently can alleviate some of the burden other family members may face regarding your care as you age. For more information about choosing the right type of facility, and a checklist you can use when it’s time to consider a nursing home, click here.
One thing I believe is that with each passing year there are more and more Americans that need more assistance with living as dignified older adults. There are many things about our current system of addressing the needs of our aging population that feel inadequate and even broken. This will change, because it must, as thousands of Baby Boomers turn 80 every day. Take the time to think about how you want to plan to age-in-place and consider the resources available.
Next time I will focus on planning financially for your own future as a mature and wise septuagenarian and octogenarian. In the meantime, remember that I believe financial planning is about making sure the right person in your life has the right cash to do the right thing at the right time. I also believe that effective planning allows us to preserve as many choices as possible for as long as possible, so consider working with a Certified Financial Planner to have the best chance of being prepared for the challenges of aging.
*Genworth Annual Cost of Care Survey, https://www.genworth.com/aging-and-you/finances/cost-of-care.html/?18,4
Certified Financial Planner Board of Standards, Inc. (CFP Board) owns the certification marks CFP®, CERTIFIED FINANCIAL PLANNER™, and CFP® (with plaque design) in the United States, which it authorizes use of by individuals who successfully complete CFP Board’s initial and ongoing certification requirements.