Where to Start & Who Can Help
A number of organizations and professionals can assist older adults and their families with the often difficult task of assessing what help is needed and in finding and arranging for the right living and care options. These include:
• Hospital social workers / discharge planners
• Long Term Care Ombudsman – offers consultation and guidance with nursing home placement and provides information about adult care homes (see Local Services and Information).
• Geriatric Assessment Programs – are usually affiliated with a hospital and utilize its resources to offer a multidisciplinary team approach in evaluating an older person’s physical, mental and social well-being and functioning. They help the client and family in making appropriate care plans.
• Care Management Organizations and private care managers – specialists in geriatric services assess the needs of older persons (usually in the older person’s home), arrange for and coordinate services and provide monitoring and follow-up for as long as needed or desired.
• Community Senior Programs – most offer health and wellness screening, classes and counseling, Medicare and insurance claims assistance, Information and Referral services, and discounts on services offered by the sponsoring organization or contact your local Area Agency on Aging
• Admission directors of independent living, assisted living and nursing homes
Home Care Services
Brought to you by:
Right at Home In-Home Care and Assistance Owner Shalom Plotkin
Many home health, personal care and social services are available in Cleveland and NE Ohio to assist temporarily disabled and frail people wherever they call home. These include:
Home-based Personal Care & Private-Duty Assistance
• Personal care aides and State Trained Nursing Assistants (STNA’s) provide assistance with bathing, hygiene, getting dressed, grooming, fall prevention, and daily health reminders
• Light-duty housekeeping, laundry and may provide pet care
• Enjoy conversation, help with socialization and may play memory games
• Serve Meals on Wheels or go grocery shopping, and may cook special diets
• Sitters jump in when someone cannot be left at home alone
• Escorts accompany seniors to appointments and shows in their vehicle or the client’s car
• Emergency alert monitors, safety bracelets, and medication dispensers are available
Most home care is provided by family members who suddenly find themselves in a caregiving situation. These services are often ordered by family members by the hour, or for a week of respite, but often times the relationships that develop with compassionate caregivers can last for years. You may expect your professional caregivers be screened, trained, tested, insured and supervised. Their supervisor will ensure that they have equally caring and reliable back-ups. Right at Home prides itself on reducing the hospital re-admission rate of our clients by an industry leading 57%.
Who pays for non-medical home based care?
That Depends. Unfortunately, the majority of private duty care is private pay. Medicare or Medicaid covers some home health care services but only under very specific and limited circumstances. Some are fortunate to have purchased long term medical coverage. The professional helping with assessment and care planning can guide you as to which services will be covered by insurance. If income is limited, one may be eligible for Ohio’s Passport Waiver program or the Veteran Administration’s Aide and Attendance program. Consider researching disease specific foundations, community grants, and reverse mortgages. Some drug manufacturers and charitable hospitals offer hardship programs for qualifying patients.
What types of covered Skilled Nursing and Instruction can be delivered in the home?
• In-home nursing, wound care and therapy
• Home infusion and laboratory services
• Pain management, palliative care, and hospice services
• Medical equipment, beds, commodes, and adaptive services
Among the services that health professionals provide in the home is teaching self-care to the patients and care-giving techniques to family members. Caregivers must take time to nurture themselves as well or may suffer from burnout and exhaustion.
Community based services are now also available, such as:
• Adult day care
• Municipal senior centers and transportation
• Congregate housing and meals
• Support groups (such as Alzheimer’s) or other disease specific organizations
• Home modifications such as grab bars, ramps, sensors, and chair lifts
• Geriatric assessment programs and care managers
• Your house of worship may have a sunshine team, Parish nurse, or chicken soup brigade
How to start getting help
Contact a doctor for help in evaluating the medical condition and the support needed in the home setting. Information about these services can be found in the “Home Care Services” category of the Resource Directory and the “Who Can Help” section of this Guide, or be calling the Information and Referral Services or the Agency on Aging in your county.
Other Living Options
For the older person who cannot or does not wish to continue living at home and who does not need nursing home care there are an increasing number of other living options: (see also the Senior Living Facilities section of this Guide).
• Retirement communities: These are complexes that usually offer recreation and security, dining room meals and health screenings. They may include a variety of living accommodations: independent, congregate, assisted living and nursing care.
• Continuing care retirement communities (CCRC): Offer an older person a contract that provides independent living and various health care services for the balance of his or her life. Residents pay an entrance fee and monthly fees (some offer the rental option with no entrance fee) and can move from one level of care to another as needed
• Shared-living homes: offers a family-like setting for older persons who are ambulatory and able to care for themselves. The operator usually provides cleaning, shopping, cooking and other minor services (see Long Term Care Ombudsman).
• Adult Family Homes: provide adult foster care in private homes in which room, board and personal assistance and supervision are available for three to five unrelated persons. State licensed. (See Ombudsman)
• Adult Group Homes: or board and care homes, house 6 to 16 persons and provide room, board, and personal assistance. State licensed.
• Residential Care Facility (formerly Rest Home)
State licensed for 17 or more unrelated individuals who need care but who do not require full-time skilled nursing care. They are staffed 24 hours per day; provide special diets, assistance with self-administration of medication and help with walking, bathing, dressing, feeding, getting in and out of bed; not qualified for Medicare or Medicaid reimbursement. (See Ombudsman)
• Long Term Acute Care Hospitals (LTAC)
An LTAC is a long-term acute care hospital. They provide an acute hospital level of care and services for patients requiring a long hospitalization. The length of stay for an LTAC patient is typically 25-28 days. Services provided are in areas of: Ventilator weaning, 24-hour monitoring, IV therapy, Dialysis, medically complex-multi system failure, pulmonary disease, cardiac disease, stage III & IV wounds, neuromuscular disease, GI diseases, and post-op complications.
The increase in the over 65 population has resulted in a dramatic increase in the number and types of retirement communities geared to accommodate the needs of older adults.
Reasons for moving
Even though most older people would rather remain where they are, often circumstances make moving a serious consideration. Some of these factors are:
• Home is too big and difficult to maintain
• Need for cash from home equity
• The neighborhood has changed
• Family and friends are no longer nearby
• Health and social needs make the more secure and structured environment of senior housing appealing
If a move to a retirement community is being considered then it is best not to wait too long since there may be restrictive admittance requirements regarding health and finances. In general, facilities require that individuals be able to live rather independently upon entering and have sufficient income to pay the monthly fees for the time they expect to live there.
Planning for Moving
Design a floor plan of your new living space incorporating only the existing or new furniture that will fit safely and comfortably. Consider taking the opportunity to purchase a new mattress, box spring, or TV. Select small and keepsake items which will fit on or in the pieces of furniture being moved or on walls. If your meals will be provided by the retirement community, move only essential kitchenware.
Choosing a retirement community
Retirement communities offer one or more of the following types of living accommodations:
• Independent living
• Congregate living
• Assisted living
• Nursing care
Start by sending for information from the facilities in the locations of interest. Review the listing in the Senior Living Section and use the yellow “get-information” card in this Guide as a convenient way of requesting information. What do you want in a retirement community?
• City, suburban or country
• House, townhouse, apartment
• Low or high rise; one or two bedroom
• Ambience, lifestyle and the kind of social and recreational activities desired
The AARP guide to elderly housing communities advises:
• Learn the terminology to differentiate the kinds of care facilities that are available.
• Select retirement housing based on the services, amenities, location and ownership arrangements most suitable to current and future needs.
• Ask specific questions to determine the facility’s viability, such as history of the management and the sponsor.
• Carefully examine the occupancy contract. Contracts can vary widely from one facility to another.
Financial arrangements vary so widely depending upon the location, type of community, type of accommodations and services offered that it is almost meaningless to generalize about costs. Many facilities are strictly monthly rental or yearly lease, some require a substantial entrance fee with monthly maintenance fees, and others require an endowment of assets. These usually are not inexpensive since they provide substantial services tailored to the needs of the elderly. Monthly rentals generally start at around $1,000 and entrance fees or endowments can range from $30,000 to more than $100,000 plus monthly maintenance fees of $500 to $2,000 or more. About the only way to get an idea how much a facility will cost is to send for the information and carefully review the rates, preferably with an adviser.
Even though there appear to be many “retirement” communities available most are above the budget of low-income seniors. In this situation you may be eligible for federally subsidized private facilities and public housing. Contact your county Department of Human Services for detailed information.
Download a copy of the visiting checklist here
When visiting a community do the following:
• Evaluate the units based upon your space needs and their location.
• Walk through the entire complex and observe how the residents are using the services.
• Ask residents how they like living there. This is often best done at mealtime.
• If the facility has a respite or vacation program, consider spending some time at the facility in order to experience the normal living environment.
• Make sure you understand the requirements for admission to assisted living or nursing care, the policy for moving from one care level to another, any extra costs and if the facility has the appropriate certification.
• Get copies of all rental, lease and purchase forms and rules.
Assisted living is a broadly descriptive term for a level of care and support that ranges between independent living and nursing home care.
Assisted living facilities provide services for frail older people who are functionally and/or socially impaired and may need 24-hour supervision. Confusion often arises about another type of living and housing arrangement called “congregate living.”
Congregate living facilities generally provide supportive services such as a main meal, housekeeping, social activities and transportation but do not provide the degree of personal assistance offered in assisted living facilities.
Residential Care Facilities (RCFs) provide a level of care that is clearly defined by state licensure requirements. These include, in addition to assistance with personal care, the ability to prepare special diets and provide assistance with self-administration of medications. They have trained staff on duty 24 hours per day.
Assisted living is offered in a variety of settings from senior apartment complexes to multilevel retirement communities or nursing homes. Accommodations, usually a small studio apartment or a single room with bath, are physically designed to serve those who need some assistance with activities of daily living, such as dressing and bathing; or those who use a wheelchair or a walker to get around. Some facilities have licensed nursing personnel who monitor medications and provide a variety of health counseling and screening programs. Others simply offer reminders to take medications.
In addition to basic charges fees are generally based on how many services are needed.
Assessing Nursing Home needs
There are no uniform standards that define assisted living. Services offered under this name vary widely. It is, therefore, especially important to make a careful assessment of the prospective residents’ needs a part of the pre-planning before visiting facilities. This is the key to finding the assisted living facility that balances the needs of a physically and mentally frail older person and yet offers care and services based on choice and dignity in homelike surroundings.
Personal care needs
To determine needs, consider the following questions: Why is a change in residence being considered? With what aspects of daily life is help needed: dressing, bathing, toileting, getting in/out of bed or chair, walking, eating, medications, decision making? How much help is needed and how often?
What support can the older person expect from family, friends, others? Are they nearby? What financial resources are there to pay for care, now and for how long in the future? What plans are there if and when the resident needs more care than assisted living offers or funds are exhausted? Who will help the resident make decisions and plans if another move becomes necessary?
It is often difficult to make these determinations and decisions and to try to anticipate future needs. The prospective resident/family/friends will want to consult professionals such as the physician, private care managers and counselors, attorney, financial advisor and/or hospital discharge planner.
Choosing a senior living facility
Once the prospective resident’s needs are defined and financial resources evaluated the process of finding the “right” facility can be narrowed.
Review the list of senior facilities in the Senior Living Facilities section and select those in the geographic area and care level of choice.
Request more information from these facilities by completing the form on the Contact Us page or call us directly at (440) 338-5233 for assistance in your search.
Review the facility brochures with your list of essential needs in mind and ask questions that apply to your situation:
• How are medications and special diets monitored? Who does this?
• What other health services are available?
• In case of sickness are meals brought to the room?
• Who provides personal care, how are these services scheduled, how much do they cost?
• Are all parts of the building accessible to those using wheelchairs?
• What recreational activities are offered?
Follow-up with phone calls and visits and if possible arrange for a trial stay to get a first-hand feel for the facility’s ambience and services. Talk to other residents at the facility about their experience. How and who on the facility staff (social service/recreation) will help the resident make the adjustment to the new setting and make the human connections which will make the facility truly a “home.”
For more information, call AARP at 1-800-424-3410 or send away to:
601 E. Street NW, 4th Floor
Washington, DC 20049
Types of Nursing Home Care
Government regulations have eliminated the distinction between intermediate and skilled facilities under the Medicaid program. Both are now classified as simply nursing facilities (NF). These level of care designations are still important, however, because they affect who pays for care. Medicare and most private insurance programs pay only for a skilled level of care. If payment under these programs is being considered it is important to clarify before admission to the nursing facility:
1. Level of care required
2. Verification that the nursing facility is certified for that level of care and that reimbursement will be approved.
Ask hospital discharge planners, the physician and nursing home staff to assist in clarifying these questions.
How to Pay for Long Term Care
Most seniors and their families start by paying for nursing home care out of their own resources. However, when care is needed for an extended period of time, the cost of nursing home care can quickly deplete life savings. You can expect to pay an average of over $90,000 a year for a quality nursing home.
Medicare has serious limitations when it comes to paying for nursing home care although it provides major benefits for other health care services. Its focus is on acute illness and “skilled” care in nursing homes. It does not pay for the non-skilled home care or intermediate nursing home care which is the level of care needed by most individuals. For the individual who cannot afford the needed care or who has depleted private resources in paying for care the Medicaid Program—not Medicare—can provide financial assistance for continued long term care.
Some nursing facilities are strictly “private pay” while others are certified to accept Medicare and/or Medicaid when an individual qualifies. If financial resources are limited, it is recommended that a Medicaid certified home be selected so it does not become necessary for the older person to relocate again when funds run out.
Medicare–What does it provide?
Medicare (Title XVIII) is a federal health insurance program which helps defray many of the medical expenses of most Americans over the age of 65. Medicare has four parts:
• Part A: Hospital Insurance: Helps pay the cost of inpatient hospital care. Under certain conditions, Part A helps pay for inpatient care in a skilled nursing facility, hospital related home health care and hospice care.
• Part B: Helps pay for necessary doctor’s services, outpatient hospital services, home health care and some preventive services, lab tests and physical therapy
• Part C: Offers coverage without the need for
• Part D: Helps pay for prescription medications the beneficiary requires.
Eligibility: Under the Medicare regulations to obtain
coverage in a NURSING HOME an individual must:
• Require daily acute skilled nursing care or rehabilitation services under a doctor’s care plan; 3 midnights of prior inpatient hospitalization required.
• Obtain care in a Medicare certified skilled nursing facility.
• Be approved by the facility’s Utilization Review Committee.
All of these conditions must be met. Eligibility is reviewed weekly. When it is determined by the review committee that the care is no longer needed at the facility, Medicare payment is stopped. Pursuant to “Jimmo”; improvement is no longer required.
What does Medicare pay?
• Pays all charges for the first 20 days
• For days 21-100 it pays for all covered services, except for a daily coinsurance amount
For 2020, the coinsurance is $176/day
• Beneficiary pays all expenses on and after the 101st day
• Pays unlimited days of hospice care for the terminally ill.
Detailed information about Medicare benefits can be obtained from the Social Security Administration (see reference section). Ask for Medicare 2017 handbook or go to www.medicare.gov.
Medicaid–What does it provide?
Medicaid (Title XIX) is a needs-based, means tested health care program cooperatively financed by Federal and State governments. Benefits cover both institutional and outpatient services. Medicaid will pay for skilled and intermediate nursing home care for as long as the individual is determined by a physician and the state Medicaid review department to need that level of care.
Eligibility: Ohio is now an Income Cap State. Eligibility for Nursing Home Care is based on age. Also, the amount of income you may have is subject to a capped Special Income Level ($2,349 in 2020). You may need to establish a special type of trust to continue your benefits in a nursing home OR waiver program. Certain assets that in prior years were exempt are now countable. In Ohio, the present requirements for a person to be eligible for nursing home care are:
• Total gross income per month from all sources may not exceed $2,349 for a nursing home resident unless a mQIT is in place.
• Countable assets may not exceed $2,000 for an individual and $3,000 per couple. The family house may be exempt as long as the spouse or qualified relative lives in it, and the value is less than $595,000 for a single person. A community spouse or disabled child is not subject to the cap.
There are provisions to protect the spouses of nursing home residents. Spouses of Medicaid nursing home residents may keep:
• At least $2,113.75 up to $3,216/month income
• $25,728 or half of the couple’s combined assets, whichever is greater, up to $128,640.
The determination of income and assets can be complicated when a spouse is living. If substantial assets are present, it would be wise to contact an attorney or advocate for advice before an application is filed. See Legal/Estate/Financial Planning in the Resource Directory for information regarding local Medicaid attorneys.
What does Medicaid pay?
To determine this, an interview is required which may be conducted by telephone. If the application is approved, the nursing home resident must contribute all monthly income (except for a “personal and/or spousal allowance”) from the approval date and Medicaid will pay the balance up to the Medicaid per diem rate. Further detailed information is available from your local county Human Services Department (see reference section).
Other Considerations: Some Nursing Homes do not accept Medicaid as payment, or some may limit the number of beds for this program. However, in Ohio most Nursing Homes are dual certified. There are adequate Medicaid beds available. In order to insure an appropriate facility in the geographic area you require, it may be advisable to pay from the individual’s funds for at least one month. In this circumstance, an individual can continue to reside in the same facility. Private pay residents may choose to “spend down” assets before becoming eligible for Medicaid in Medicaid certified facilities. You may experience a delay in placement if the Nursing Home you choose offers Rehabilitation and is experiencing higher than normal admissions.
Other Programs: For low-income persons, in-home nursing care and care in custodial facilities may be paid for under Ohio’s PASSPORT program (1-800-626-7277) and the Optional State Supplement Program respectively. There are also beds available under the new Assisted Living Waiver thru Medicaid. Medicaid Eligibility is required. Ask the Area Agency on Aging in your county about these programs.
Managed-Care Health Plans and HMO’s: These plans supplement Medicare insurance. They focus on illness prevention with a comprehensive system of health services. Benefits may include: not having to buy Medigap insurance; dental, prescription and vision care. HMO’s save costs by keeping patients in their system and typically restrict the choice of physicians.
Hospice is a philosophy of care whose goal it is to help the terminally ill person die free of pain and surrounded by family and or caregivers who understand and can respond to their special needs. Hospice services can be provided at home or in a free-standing independent facility or nursing home. Hospice services are covered by Medicare with some cost sharing, by Medicaid and private insurance. See the Hospice Services page for local facilities that can walk you through what hospice means, and how to prepare.
Choosing a Nursing Home/Facility
It is important that the older person participate in the decision-making process as much as possible. Choosing a home that provides the kind of care and environment that meets the individual’s physical, social, emotional and spiritual needs will significantly help the older person make the adjustment to the new surroundings. Primary factors affecting the choice of a nursing home are:
1. The type of care required: The facility should be able to provide the level of care needed. If you are unclear about how “level of care” is defined, the physician, hospital discharge planner or nursing home admissions director can help define.
2. The financial resources available: Families need to determine what funds are available to pay for care, such as Social Security, retirement plans, veteran benefits, long term care insurance, equity in a home, Certificate of Deposits (CDs) and Individual Retirement Accounts (IRAs) as well as any assistance from family members. If the older person is unable to pay for nursing home care, the choice of a nursing home is limited to a facility which accepts Medicaid and has an opening.
3. Location: The best choice is a facility convenient to family, friends and physician.
What to do? Where to start?
• Use the list in this guide to locate nursing homes in the desired area and check whether they are certified for Medicare/Medicaid if this is a requirement
• Choose a number of suitable homes
• Call the facility’s admissions director
Things to ask on the phone
• Before making any visits, ask about particular services that will be needed. If the needed services are not available there is no point in making a visit.
• Is there a waiting list? How long is the waiting period if you need immediate care?
• What are the home’s admission qualifications? Some require that residents be able to care for themselves to a certain extent. Some require proof or assurance in writing that bills can be paid. Some will not accept patients with mental disorders.
• Ask about basic costs, extra charges and anticipated increases.
Schedule visits and use the checklist
• Make an appointment to visit several of the facilities that sound appropriate. If possible, take the prospective resident with you.
• Arrange to meet several of the key staff people such as the nursing and activities director.
• Observe the living environment and staff relationships with residents.
Nursing homes bill for two types of charges:
1. Daily rates for room, care and some nursing services
2. Extra charges for any services not included in the basic rate such as therapies, pharmacy, wheelchairs, dental care, hand-feeding or care for incontinence.
If you are a cosigner, ask what your obligations are. Ask what the transfer policy is if the older person will need to convert to Medicaid after all funds are exhausted.
After the visits, the list of appropriate homes can be narrowed. Further elimination can be made by talking to those acquainted with the nursing homes in the area – physicians, clergy, relatives, friends and the local nursing home ombudsman.
After you have identified a facility make a second visit to discuss final admissions procedures. However, you may find there is no vacancy. In that case, put your name on the waiting list. In the meantime, check other care alternatives that may be used to meet immediate needs (see Home Care Services section).
You may find yourself responsible for managing your older relative’s personal and business affairs and for deciding about particular medical treatments. Difficult choices and complex issues may be involved. Advance planning and discussion with your relative is extremely important. Some legal issues that older persons and their families need to consider include:
• Joint ownership
• Representative payee
• Power of attorney
• Springing power of attorney
• Durable power of attorney
• Medical power of attorney
• Trusts, wills and possibly living wills
Consult with your attorney for appropriate legal assistance or contact ombudsman.
Federal regulations require that all health facilities participating in the Medicare or Medicaid programs such as hospitals, nursing facilities, hospice and home-care programs and health maintenance organizations, ask patients when they are admitted whether they have advance directives. The law also requires that patients be informed of two important rights. The first is the right, under state law, to make decisions about their medical care—including the right to refuse or select medical treatment and of their right to prepare legally binding advance directives.
These are documents, usually a living will and/or durable power of attorney for health care, that reflect in writing, the individual’s wishes regarding life-sustaining medical treatment if the individual becomes incapacitated.
A living will is a document in which the individual can specify in advance his or her wishes regarding withdrawing or withholding life-sustaining medical care in the event the patient becomes terminally ill and can’t express those preferences to doctors or relatives. In Ohio, these decisions must be in writing, must be signed and witnessed by two people not related by blood, marriage or adoption, or must be notarized.
A durable power of attorney for health care is a document in which a patient designates another individual, usually a family member, close friend or counselor, to make decisions if the patient is unable to do so. The patient may also give specific directions about treatments wanted.
See the Legal/Estate Planning/Financial page for local services and attorneys that can help.
Information about these documents is available in healthcare facilities, through attorneys or can be obtained in a packet by writing to the LeadingAge Ohio (formerly Midwest Care Alliance):
2233 North Bank Drive
Columbus, OH 43220
Enclose $4.00 for the Advanced Directive booklet which includes living will and power of attorney for healthcare. Call or visit their website for more info.
Either of these documents may be revoked at any time. You do not have to consult an attorney to complete these forms but they are important legal documents and you may wish to do so. You may also want to consult your physician and discuss with family members your wishes in these regards.
Legal Hotline for Older Ohioans:
A toll-free call to Pro Seniors offers free legal advice for Ohio residents age 60 or older. This nonprofit service is sponsored by the United Way and private donations and is endorsed by AARP. This free service can help with questions relating to Medicare, Medicaid, health insurance, nursing homes, retirement benefits and consumer issues. Contact Pro Seniors at 1-800-488-6070 or visit proseniors.org.