Why Lower Cost Home Care is Not a Bargain

I do a fair amount of public speaking on elder care issues in front of a variety of audiences, most of them professionals in various segments of the rapidly expanding elder care industry. On occasion though, I do speak to groups of elders on consumer awareness in the selection of care.

When speaking to this type of audience I always ask the rhetorical question, "If you need assistance with things like bathing, dressing, mobility, etc, and you have the choice of getting that care at home or in a nursing home what would be your preference?"

Not surprisingly, the preference for care at home is nearly unanimous. One of the greatest fears of older Americans is to be placed in a nursing home. They have visions of dreary environments and sub-standard care which is an issue we'll be discussing in future posts.

But there are misconceptions about care at home that should be closely examined. One is that "home care is cheaper than nursing home care", that is sometimes true and sometimes not true. If you were to need only a few hours each day to get you started and could then safely go about your day at home without supervision or support, a few hours of home care will be less expensive than 24 hours of care in a nursing home. But if you are severely disabled due to a stroke, or suffer from dementia and can't be left alone, 24 hours of home care is likely to be considerably more expensive than the daily cost of a nursing home.

Another misconception about home care is that "you don't have to pay the going rate for a licensed home care agency, there are independent caregivers that will charge you a much lower hourly rate." This is also true, sometimes these independent providers work through something called a "registry". Registry services are usually run by people who maintain a rolodex or data base of home care aides that would rather be employed directly by the familiy or the person neding care, than work for a licensed home care provider.


Preferable though it can be,the home care setting can be an undesirable place to be cared for if the elder needing care is left alone with an aide who is not well supervised or held accountable. Patients and families should be aware of their "Patients Rights" and ask for a written copy of these rights before services begin.

There have been numerous cases of both physical and financial abuse of frail elders at home just as there have been such reports in a nursing home.

The homebound elder should never be left without care when care is supposed to be provided. If the paid caregiver is unavailable due to illness or due to their own family problems, the elder or a member of the family should be assured that substitute caregivers are available on short notice.

While using home care personnel from an agency that acts as the responsible employer of the aides may be more expensive, using this alternative is safer and much less risky for the elder and their family.

Fortunately there is a national organization, known as the National Private Duty Association (NPDA) that works to set standards and to educate the public about both the risks and benefits of getting care at home.

Last year NPDA proposed model legislation that raises standards in the home based caregiving industry. The model bill and regulation represent the first comprehensive licensure framework produced for private duty home care and led by private duty providers.

Before you seek out the services of a home care provider I urge you to visit the web site of NPDA at http://www.privatedutyhomecare.org/displaycommon.cfm?an=1

At their site you can obtain a copy of the "Model Legislation Document" and the "In-Home Personal Care Services Code".

NPDA has targeted the widespread practice of registries placing workers in the home environment to provide home care services without clearly explaining (or sometimes even misleading) consumers and referral sources regarding the risks and responsibilities that consumers and workers have in these situations (i.e. making the consumer the employer of that worker without his/her knowledge).

Some of the other valuable consumer information available from the National Private Duty Association includes the following

Independent Contractors v. Employees: A Legal Challenge

Model Legislation (Act 999): Home Care Consumer and Worker Protection Act

Position Statement on Registries & Independent Contractors

The Accidental Employer

Elder Abuse Guidelines

NPDA Member Ethical Guidelines

ELDERCARE HELP FOR THOSE WHO DON'T QUALIFY FOR PUBLICLY FUNDED PROGRAMS-OR END UP ON WAITING LISTS WHEN THEY DO

I've now been in the professional practice of geriatric care management for more than 20 years. The profession of geriatric care management began in the late 1980's when a group of 100 highly trained professionals,predominantly nurses and social workers from 22 states gathered in New York City to talk about how we could better respond to 3 major issues.

1. A steadily growing population of elders-most of them in their 80's and 90's were in need of services such as modifications to their homes to allow them to continue to live there, and a range of social and health services such as assistance with bathing,dressing, feeding,mobility and incontinence issues, or simply standby protective supervision for those who might be physically healthy but suffered from progressive cognitive diseases such as Alzheimer's and dementia caused by strokes.

2. The combined trend of woman-who had traditionally been the primary caregivers to aging parent moving into the full time work force, and "adult children" (45-65 year olds with parents who were now over age 80, living, working and raising families far from where their now frail parents were living.

3.Limited services available to help family caregivers who were "over income" and not eligible for taxpayer subsidized services, or publicly funded agencies unable to provide the level of services needed by the aging parent.

In April of this year, the National Association of Professional Geriatric Care Managers held it's 20 aniversary conference here in Boston, and now has more than 2,000 members.

Professional Geriatric Care Managers (PGCMs) are health and human services specialists who help families care for older relatives, while encouraging as much independence as possible. The PGCM may be trained in any of a number of fields related to long-term care, including, but not limited to, nursing, gerontology, social work, or psychology, with a specialized focus on issues related to aging and elder care. The PGCM acts as a guide and advocate -- identifying problems and offering solutions.

If you are interested in finding a Professional Geriatric Care Manager to assist in creating a plan of care for someone you know, or are interested in learning more about the profession of geriatric care management or the National Association of Professional Geriatric Care Managers, I encourage you to visit the associations comprehensive web site at http://www.caremanager.org.

I also recommend a wonderful article complete with an informational photographic slide show slide show on this subject. at http://www.forbes.com/2007/07/25/geriatrics-medicare-medicaid-pf-retire-in_sm_0725retirement_inl.html

Written by Shannon Martin, A professional geriatric care manager based in Florida the article contains much of interest to family caregivers

"As people live longer with chronic illnesses and our population ages, we all face new dynamic issues in our lives." Shannon writes, "The issues we must deal with range from locating and managing in-home care to discussing a move to a care facility with a reluctant parent while navigating the maze of Medicare and Medicaid."

"Start Talking: Start discussions about these issues. Use this article or a friend's experience as a conversation starter. Ask loved ones what they would want if they needed help.

The direct link to the excellent slide show is at http://www.forbes.com/2007/07/25/geriatrics-medicare-medicaid-pf-retire-in_sm_0726retirement_inl_slide_4.html?thisSpeed=15000.

Bob O'Toole, the editor of this blog can be reached at bob@elderlifeplanning.com

Growing Number of Doctors Refuse to Serve Medicare and Medicaid Patients

Medical Progress Today is a newsletter published by the politically conservative Manhattan Institute. In their July 20 issue, Paul Howard wrote about the increasingly absurd pretense that programs funded jointly by states and the federal government such as Medicaid and Medicare are "expanding" to provide coverage to more uninsured or under insured Americans.

In fact, while these programs were originally intended to provide health insurance for those who are eligible, they have morphed in recent years to become political programs to manipulate the public into thinking that government funded health care coverage is expanding. In fact both of these programs are shrinking. Absent a major political shift, those who qualify for these "health insurance" programs(you're eligible for Medicare at 65 regardless of your income or assets. You're eligible for Medicaid if you meet certain poverty definitions-these vary from state to state-no matter how old you are)-will in fact only be eligible for "waiting lists" (i.e no care at all).

Howard quotes from a Wall Street Journal article that ran last week on the front page on "a phenomenon that has been long noted in the policy community: many doctors refuse to accept Medicaid patients because of the abysmally low reimbursement rates they receive from the program."


"On paper... Medicaid coverage is real insurance. the safety-net program is intended to provide comprehensive health-care coverage for more than 50 million Americans too poor or disabled to afford it elsewhere... But when Medicaid patients seek care, they often find themselves locked out of the medical system. In a 2006 report from the Center for Studying Health System Change, a nonprofit research group based in Washington, nearly half of all doctors polled said they had stopped accepting or limited the number of new Medicaid patients."(italics mine reo)

"That's because many Medicaid programs, straining under surging costs, are balancing their budgets by freezing or reducing payments to doctors. That in turn is driving many doctors, particularly specialists, out of the program."

Howard's commentary in Medical Progress today states "This problem is endemic to government funded health care problems. As the government expands services that appear to be free to the end-user, there is overuse of the system and rising costs. To contain those costs, government squeezes reimbursement to providers and rations access to more expensive, hi-tech care."

"Medicaid reimbursements are lower than Medicare reimbursements, which are in turn lower than what private insurers pay for their own patients. (Check out the helpful panel on fee disparities in the WSJ article.) Indeed, physicians refusing to accept new Medicare patients is a problem all its own."

"States that are rushing to expand eligibility for their own Medicaid programs (that claim to cover everything) to higher and higher income levels are basically trading expanded insurance coverage on paper with paper thin access to health care."

Howard, and the policy experts at the Manhattan Institute believe that the answer to this problem should be a free market one. Get rid of Medicare and Medicaid and use the funds to purchase private health insurance.

"Is there a better solution?" asks Howard. "For starters, give poor Medicaid participants vouchers to purchase their own health insurance on the open market, complete with a health saving account to roll-over any savings after premium payments. Florida and other states are currently experimenting with programs like these.

"Universal "free" health care may sound attractive in the abstract, but the rationing and restrictions that come with expanded government programs are often not what their advocates hoped for, particularly for the poorest and most vulnerable patients."

He's right on target when he says that government funded health care is not what their advocates hoped for,however, other policy analysts and health care providers say that the solution is a truly universal, government funded health insurance plan like most other developed countries already have. (See my previous post on Michael Moore's movie "Sicko" which is currently playing at a theater near you and breaking box office records for a documentary film.)

Bob O'Toole, Editor of this blog can be reached at bob@elderlifeplanning.com

Sources for this post:
http://www.manhattan-institute.org/html/about_mi.htm

http://www.medicalprogresstoday.com/blog/archives/2007/07/medicaid_covera.html

http://online.wsj.com/article/SB118480165648770935.html

Using Home Equity To Pay for Care:HUD Sponsored and Federally Insured Program Guarantees You Won't Lose Your Home

any older adults wish to remain in their homes, but find it hard to cover the costs that can come with a chronic health condition. For some, using home equity to pay for help at home can be an important option.

Whether you are a caregiver or a person needing care but determined to stay out of a nursing home, one of the biggest challenges is finding the resources to pay for needed care. Borrowers continue to own their homes and do not need to make any monthly payments. Instead, they can choose to receive the funds as a lump sum, line of credit, or as monthly payments (for up to life). The loan comes due only when the last borrower moves out, dies, or sells the home.

One of the biggest fears people have about reverse mortgages is that the bank takes the title of the house and can evict you once the equity is used up. That is NOT the case. Part of the Federal Housing and Urban Development(HUD) approved program is an insurance policy that protects both the lender and the homeowner from a loan default.

Reverse mortgages are loans that allow homeowners aged 62 and over to convert home equity into cash while living at home for as long as they want. Borrowers continue to own their homes and do not need to make any monthly payments. Instead, they can choose to receive the funds as a lump sum, line of credit, or as monthly payments (for up to life). The loan comes due only when the last borrower moves out, dies, or sells the home.

The number of people taking out reverse mortgages has grown significantly in recent years, climbing from a loan volume of fewer than 6,000 loans annually prior to fiscal year 2000 to over 48,000 just in 2005-still a tiny number compared with the millions who are eligible for the program.

One of the best objective sources of information on the subject of reverse mortgages is the non-profit National Council on Aging.(NCOA)

NCOA’s Use Your Home to Stay at Home™ initiative is a public-private partnership that encourages the appropriate use of home equity to help older people live at home.

A well established and highly respected organization,NCOA's work is guided by research, consumer surveys, and discussions with partners and experts.

According to NCOA's web site(http://www.ncoa.org), one of their studies shows that "more than 13 million Americans can use reverse mortgages to pay for long-term care expenses at home. In this way, many can stay independent and live in their homes longer."

"For example, a 75 year old with a home worth $100,000 could receive a reverse mortgage loan that could pay $500 a month for almost 12 years. The extra cash could go a long way to help with family caregiving and other long-term care expenses."

The Use Your Home to Stay at Home: Expanding the Use of Reverse Mortgages to Pay for Long Term Care report, funded by the Centers for Medicare and Medicaid Services and the Robert Wood Johnson Foundation, also shows how reverse mortgages can alleviate financial pressure for state Medicaid programs and the federal government.

A free copy is available for download in PDF format at http://ncoa.org/Downloads/ReverseMortgageReportPublications.pdf.

NCOA also provides 3 other highly useful and informative guides for consumers that are also available for download at https://www.ncoa.org/content.cfm?sectionID=321&detail=1795

The titles of these publications are:

Use Your Home to Stay at Home: A Planning Guide for Older Consumers is helpful if you are planning to live at home as you grow older. This booklet discusses the challenges of continuing to stay at home if you need help with everyday tasks, also known as “aging in place.”

The booklet shows how home equity can strengthen retirement plans and can help you manage your cash flow if your health declines. It shares some pros and cons of using a reverse mortgage in your retirement plans and dispels common myths about reverse mortgages. It also tells you where you can go for more information.

Use Your Home to Stay at Home: A Guide for Homeowners Who Need Help Now helps you decide if a reverse mortgage is right for you. It explains how home equity can help you pay the costs of living at home with a chronic health condition. This booklet will help you answer key questions:
Will staying at home work for me?

What resources do I have to help me stay at home?

What other housing options are available?

It discusses different long- and short-term financing options, and it tells you where you can go for more information.

Reverse Mortgage, a Smart Move for Seniors provides an in-depth study on the growth of reverse mortgage industry in the last few years and the different reverse mortgage products available for seniors.


Bob O'Toole, the editor of this blog can be reached at bob@elderlifeplanning.com