Factors in the Eldercare Decision
Knowing that an elder requires care is one thing. Figuring out what sort of care arrangements can be made to address those care needs is another thing entirely. Learning answers to the following questions can aid your task of determining what care arrangements should be pursued:
A) What types of care are available?
B) What types of professional providers help to provide care?
C) What sort of care do elders need at a minimum in order to insure their safety?
D) What family attitudes and resources are available for providing (or not providing) care?
A) What Types of Eldercare Are Available?
The many different types of eldercare available to families in the United States may be broken down into two major categories: family-provided care and professionally-provided care. There are six types of professionally-provided care including: in-home licensed or unlicensed care, adult day programs, independent living facilities, assisted living facilities, continuum of care facilities, and dementia facilities. There are roughly two types of family-provided care, but multiple variations on the theme that are possible. Each care arrangement offers advantages and disadvantages and may be more or less appropriate depending on elders' needs and desires and the needs and constraints of the family.
- Family Provided and In-Home Care. Family provided care can occur in one of two ways: Either elders remains in their own home with family members providing them with assistance, or elders move into the home of a family member. In either situation, in-home professional health workers may still be needed to provide care during work hours or other times when responsible family members cannot be present.
There are three main categories of in-home workers: housekeepers and chore workers, homemakers, and health aides. Housekeeping and chore workers are hired to take care of basic household tasks, including getting the laundry done, dusting, cleaning, doing yard work, or running errands. Homemakers assist with more in-depth household management and may do tasks including meal preparation, personal care services (such as assisting with bathing or dressing), and making sure that medication gets taken at scheduled times. A homemaker may be employed directly by the elder or family or work for an agency.
The third type of in-home health worker may be a health aide, certified nursing assistant, nurse's aide or other form of visiting nurse. Health aides and nurses usually work for an agency, and the family negotiates with the agency for their services. However, a health aide can also be directly hired by the family if this is convenient. Health aides and nurses assist with personal care tasks, dispense medications, and report back to elders' primary nurse, therapist, or doctor regarding elders' health status. In some cases, costs for aide or in-home nurse services may be reimbursable via Medicare when ordered by a doctor.
There are advantages and disadvantages to hiring an in-home worker from an agency, rather than doing so independently. The first advantage of using an agency is that agency staff members are more likely to be fully trained and licensed than are independent workers. Being liable for the quality of care provided to elders, agencies will usually require their employees to undergo ongoing continuing education and performance monitoring. Agencies will also generally provide backup care should a primary aide or nurse become temporarily unavailable. Knowing that a backup aide is available should a primary aide become sick, go on vacation, or be otherwise unable to provide care can help set families' minds at ease and allow them to have a less interrupted lifestyle. A final advantage of using an agency to locate an in-home aide is that, as the employer of the aide, the agency handles payroll taxes and reports income as required by the government, saving the family the need to perform this work.
The major disadvantage of using an agency to locate an aide is that they are often for-profit businesses and the services they offer may be quite a bit more expensive than could be negotiated with an independent worker. Agencies are also more likely to be less flexible about service hours and duties than an independent worker who will generally be more open to negotiating care duties. For example, an independent home health aide may be willing to assist with meal preparation for the elder. With an agency, however, the aide will most likely only agree to provide basic medical and personal care services. The final disadvantage to using an agency is that the elder and family may not get to pick the particular worker who will provide services. This can become a problem if the elder and the aide do not get along.
- Adult Day Programs. As their name suggests, adult day programs offer elders supervision and care in a structured setting during daytime hours. More specifically, they offer elders the opportunity to participate in structured social and personal activities, receive basic medical and therapy services, or participate in educational programs. Adult day programs come in two varieties, which may or may not co-occur. There are programs that emphasize social interaction, and, separately, programs that exist to fulfill medical needs. Most all day programs are community-based and generally available only during regular business hours, Monday through Friday. Enrolled elders may attend programs one or more days each week.
Day programs are a good option for elders who do not require round-the-clock care, but who, for whatever reason, are also not safe remaining at home all day alone. They offer respite for families who have an elder living with them, but need to work during the day. Daily fees for day programming range from $30-$50 and up depending on the types of programming and services provided and the part of the country where services are offered. Generally program fees are paid out of pocket with private funds, although in some cases, Medicare may subsidize the expense. Due to cost, day programs may not be appropriate for all elders.
- Independent Living Facilities. Independent living facilities offer elders the opportunity to rent or purchase an apartment or condominium within a complex or campus offering recreational and social activities, and sometimes transportation services. Residents live independently while being part of a community of others in similar circumstances. The primary benefit of independent living facilities over conventional living situations are the recreational and social opportunities they offer residents, and the assistance such social opportunities may provide in preventing social isolation and depression. Generally, no special health care services or assistance with activities of daily living are offered.
The costs for living in an independent living facility will depend on local housing market conditions. Costs are generally similar or slightly more than rates paid to live in regular apartments, condominiums, or town homes of comparable quality. Rent or mortgage payments are generally funded out of pocket with private income, although Section 8 housing is sometimes available to supplement costs for low income elders. Medicare does not pay for independent living facility costs since no health services are rendered. Because they offer a completely independent living situation, such facilities are not subject to special governmental regulation.
- Assisted Living Facilities. Assisted living facilities are sometimes referred to as board and care, residential care, community-based retirement care, personal care, or adult foster care facilities. They offer residents comprehensive help with activities of daily living, but also feature an essentially independent living arrangement. Elders generally will occupy their own unit or apartment within the facility from which they can come and go as necessary. They will also have access to personal care workers as necessary to assist with their care needs. Skilled nursing services are not available on-site, by and large, but basic health services may be offered. Recreational and social activities are also made available to residents.
Costs for assisted living facilities reflect local market prices, and are adjusted up or down depending on the nature of services the facility agrees to provide. Monthly rates may vary from less than $1000 a month to over $3,000 a month. There is little financial assistance available for assisted living facilities. Payment is usually paid out of pocket using private funds. There are currently no federal regulations regarding assisted living facilities. Instead, licensing of such facilities occurs at the state level.
- Nursing Homes. Nursing homes provide care for elders requiring constant, "round the clock" care. Care is provided by licensed health professionals, including registered nurses (RNs), licensed practical nurses (LPNs), and nurses' aides. Elder nursing home residents will reside in a room within the facility that may or may not be private. Housekeeping and linen services, meals, and care from the medical staff and a social worker are included. Elders may also be offered on-site social and recreational activities.
There are three varieties of nursing homes: basic care, skilled care, and sub-acute care. Basic care nursing homes provide residents assistance with activities of daily living. An LPN or nurse's aide will often provide care. Skilled nursing care facilities are staffed by RNs. Additional therapists, including speech therapists, occupational therapists, and physical therapists are likely to be available as well. Sub-acute facilities offer the most comprehensive level of care, including daily or weekly medical treatments and care reviews performed by medical staff.
Costs for nursing home care vary based on the degree of care residents require, and on the area of the country the facility is located in. Nursing homes are federally regulated, and also licensed at the state level, often by state departments of public health. Residents may be Medicare eligible, and fees for nursing home services are often paid with funds provided by the elder, the elder's family, and Medicare or other third party insurers.
- Continuum of Care Facilities. Continuum of care facilities offer elder residents the widest range of care options. Private independent living arrangements are the basic feature of such facilities, with services added in a la carte fashion to assist residents as necessary, from basic assistance with daily living activities through skilled nursing services usually only available from sub-acute nursing homes. Assistance with activities of daily living, including cleaning and laundry services, meals served in a common area, grounds maintenance, and security services are offered, as are social and recreational programs. Available health services range from personal care to rehabilitation, hospice, or Alzheimer's services.
The wide range of services available in a continuum of care facility makes them particularly suited to elders with progressive conditions that will cause them to decline over time, require increasing levels of care. The continuum of care facility offers the most flexible combination of independent living and care as residents' care needs increase over time. By offering a full range of care in one place, these facilities lessen the total number of times elder residents must move as their care needs increase.
Regulation of continuum of care facilities occurs at the state level and is variable from state to state. Some states regulate such facilities heavily, while others provide only minimal oversight. Facilities may undergo a voluntary accreditation process through the Continuum of Care Accreditation Committee. A contract is generally required to be signed prior to moving in, and fees for services will vary based on need, contract length and local market conditions.
- Dementia Care (Alzheimer's) Facilities. The final type of eldercare facility to discuss specializes in the care of elders with Alzheimer's disease or other forms of dementia. This type of facility provides comprehensive assistance with activities of daily living, has skilled nursing available on site, and may offer a moderate range of social and community activities. Depending on state regulations, they may also administer medication. Elders are usually offered a private or semi-private room, meals, and laundry and housekeeping services. Fees are generally paid through a combination of private and Medicare funds.