Navigating the Long Term Care System

1. Navigating the Long Term Care System What you need to know

2. Things That You Need To Know • What is long term care • What services do facilities provide • What level of care can I receive • How much does it cost • How is it paid for • Resources to find care • Ways to evaluate the quality of care • Resources if home care is desired

3. Definition of a Skilled Nursing Facility (SNF) • A skilled nursing facility provides 24-hour skilled nursing care, related services, or rehabilitative services for the injured, disabled, or sick individuals. • The typical resident is a person who is chronically ill or recuperating from an illness, injury or surgery and needs regular nursing care and other health related services.

4. Skilled Nursing Facility • Considered to be a step down from the acute care hospital • Provide short term skilled/rehabilitative care and custodial long term care • Care provided by Licensed Professionals-RN’s, LVN’s CNA’s • Provide short term rehab services-physical, occupational and speech therapists • Licensed by the Department of Pubic Health-evaluated annually • The Nursing Home Reform Law 42 CFR Title 18 (Medicare) and Title 19 ( Medi-Cal) • California Code of Regulations, Title 22, Division 5, Chapter 3

5. Skilled vs Custodial Care • Skilled Care-Resident requires the services of licensed professionals for the treatment of acute conditions. • IV’s for anti-biotics • New tube feeding • Some wound care • Rehabilitative Therapies-Physical, Occupational or Speech Therapy • Custodial Care-Daily Routine Care -Dressing, grooming, toileting, feeding, ambulation/transfer assistance • The transition from skilled to custodial care is preceded by the discontinuance of Medicare coverage.

6. Primary Sources of Payment • Self-Pay • Managed care or other insurance • Medicare • Medi-Cal/Medicaid

7. How Does Medicare Pay for a SNF • Traditional Medicare • Requires prior hospitalization of 3 nights or longer for condition related to need for nursing home care • Must be admitted and not on observation • UP TO 100 days covered in SNF—skilled services only • 20 days covered at 100% • Day s 21-100 co-pay ($157.00) • Medicare Managed Plans-Kaiser/Sharp • HMO has to authorize all skilled nursing care • Determines length of rehabilitation stay

8. Medi-cal in Skilled Nursing Facilities • Does not pay for “acute” SNF stay unless noMedicare coverage. • Must be approved by Medi-Cal HMO • Will pay any co-pays that Medicare does not cover • Requires physicians order that long term placement in SNF is medically necessary. • Custodial resident will have to • apply for Long Term Medi-Cal • choose a Medi-Cal HMO • pay a share of cost to the facility—only able to keep $35 a month for personal spending. • Custodial stay has to be deemed medically necessary and authorized by the HMO • Not all skilled nursing facilities accept Medi-Cal

9. What is a Residential Care Facility for the Elderly (RCFE)? • RCFEs provide care, supervision and assistance with activities of daily living (ADL’s) • Ex. Bathing, grooming, and meal preparation. • They may also provide incidental medical services under special care plans. • Assistance with medication • Calling MD, lab, pharmacy • Treatment of minor skin issues • Transportation to medical appointments • Coordination with Hospice • RCFEs are non-medical care • Assisted Living and Board & Care are both considered RCFE’s • Licensed by Community Care Licensing-evaluated annually

10. How Much Does an RCFE Cost?

11. How Much Does an RCFE Cost? • $3,000- $10,000 per month! • Dementia care facilities $6,000-$10,000 • Costs must be specified in the admission agreement • Additional fees for special needs should be in admission agreements, such as • Bathing assistance • Incontinence • Walking to meals • Medication assistance—not able to administer • Assistance with dressing • Laundry • Transportation

12. Prohibited Conditions • Communicable tuberculosis • Stage 3 or 4 dermal ulcers • Gastrostomy care • Naso-gastric tubes • Tracheotomies • Full dependency for care-unable to perform any activity of daily living independently or with some assistance • Licensed professionals from Home Health or Hospice are required to monitor some conditions if the facility does not have an appropriate licensed professionals on staff • Stage 1 or 2 dermal ulcers are allowed but need to be managed by a licensed professional • Injections-insulin

13. How Do I Pay For Assisted Living • Private Pay • Private Long Term Health Care Insurance • Usually does not cover full expense • May have up to a 90 day waiting period • Medi-Cal waiver program • Extremely long waiting list and currently no beds available • Can’t make more than $1,400 a month even if on Medi-Cal • Facility has to be currently approved for the waiver program and willing to accept resident • May not be located in preferred area of town • Shared room • Only available in some counties in California • Veterans Aid & Attendance Benefit • Can take considerable time to apply and for benefits to start • Eligibility requirements

14. Overwhelmed?

16. What You Can Do • General • Complete your Health Care and Financial Power of Attorney’s • Ensure family and MD have copy and understand your wishes • Keep in mind that all facilities are businesses first • Skilled Nursing • Understand your Medicare/HMO coverage • Co-Pay’s for hospital and skilled nursing • Visit potential facilities ahead of time-facility checklist • Visit at different times • Talk to friends who have had someone at a facility • Know if they accept Medi-Cal-not all do • Compare Nursing homes-www.medicare.gov/nursinghomecompare/search.html • 5-star rating • Read the facility survey results-www.Medicare.gov • Contact the Ombudsman’s Office 800-640-4661 or 858-560-2507 • Can provide general information and resources

17. What You Can Do Cont/ • Assisted Living • Tour the facilities and discuss pricing and services provided • Ask about additional care fee’s • Community Fee’s • Read the Contract before you sign—it is there to protect the facility • www.ChoosewellSanDiego.org • www.rcfereform.org • Prepare for costs beyond initial move in-more care usually equals more money • Placement Agencies • Can be very helpful • Usually free of cost-paid by the facility when room rented • Often provide facilities at the max end of your budget—the higher the room rate the higher their fee • Thoroughly evaluate a facility before renting

18. Resources for Help • HICAP/ Elder Law & Advocacy • 858-565-8772 • http://cahealthadvocates.org/HICAP/sandiego.html • Medi-Cal • 1-800-541-5555 • Cal Medi-Connect Ombudsman • 1-855-501-3077 • Long Term Care Ombudsman • 1800-640-4661 or 858-560-2507 • California Department of Public Health Licensing and Certification (Skilled Nursing Facilities) • www.cdph.ca.gov • (800) 824-0613

19. Resources Cont • Community Care Licensing-Assisted Living Facilities • www.CCLD.ca.gov • (844) 538-8766 • Consumer Advocates for RCFE Reform • www.rcfereform.org • Choose Well San Diego • www.Choosewellsandiego.org • Medicare.gov • HICAP-Health Insurance Counseling & Advocacy Program www.seniorlaw-sd.org (858) 565-8772 • Elder Law and Advocacywww.seniorlaw-sd.org(858) 565-1392 • Consumer Advocates for Nursing Home Reform • www.CANHR.org • Provides excellent information for skilled nursing and assisted living resident rights, facility regulations and general information regarding topics related to facilities

20. Long Term Care Ombudsman

21. Long Term Care Ombudsman Program • A federally-mandated program through the Older Americans Act (OAA). • Advocates for residents in Skilled Nursing Facilities (SNFs) and in Residential Care Facilities for the Elderly (RCFEs) • Assisted Living • Board & Care Homes • Investigates complaints and reports of abuse and neglect in SNFs, RCFE’s and ARF’s as well as Adult day programs & Adult day healthcare programs for individuals 18-59

22. Our Volunteers LoLo • Volunteers are the foundation of our program • Initial requirements to be certified as a Long-Term Care Ombudsman volunteer include: • Pass background check and medical clearance • Complete a minimum of 36 hours of state-mandated training and 10 hours of field monitoring to be certified • Volunteers must complete 12 hours of state-mandated training each year to maintain certification • 86 current certified Ombudsman

23. What are some of the things Ombudsman Look for during a facility visit? • Facility poster & license is clearly displayed • Safety hazards, broken furnishings or equipment • Temperature of facility • Clean and odor free • Medications are locked/stored safely • Resident’s are clean and well groomed • Visible injuries (i.e. bruising, sores) • Adequate food supply • Emergency disaster plan

24. Common Problems and Complaints • Discharge/Eviction-SNF & RCFE’s • Inadequate supervision/staffing • Poor or lack of appropriate care • Resident Rights violations • Call light/staff response time • Food quality/selection • Poor Communication

25. Reporting • Reports can be received 24-hours a day. • Ombudsman office hours are Monday-Friday 8-5pm • Phone number to Crisis line is provided for after hours and weekends when reports are needed to be made. If there is an immediate need to speak with an Ombudsman someone is available 24/7. All reports made to the Ombudsman office are confidential 800-640-4661 858-560-2507