PODCAST: Nursing Home Care

Residents disproportionately affected by COVID-19

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New Covid-19 death data reveals 'hidden' crisis in care ...

BY JAMES BLUMENSTOCK MA

Residents of nursing homes have been disproportionately affected by COVID-19. The nature of this coronavirus—which is particularly harmful to older adults and people with multiple chronic conditions—has left residents vulnerable.

Additionally, the pandemic has exacerbated existing challenges in our fragmented long-term care system, which is financed, regulated, and administered by states, the federal government, and private care facilities.

During this webinar, panelists discussed policy options to support high quality care for nursing home residents during the COVID-19 pandemic.

NOTE: This webinar is a project of the Alliance for Health Policy and NIHCM Foundation, in collaboration with The Commonwealth Fund.

PODCAST: https://nihcm.org/publications/nursing-home-care

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Superannuation Demographics for Financial Advisors

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“Live Long and Prosper”

By Dr. David Edward Marcinko; MBA, CMP™

By Thomas A. Muldowney; MSFS, CLU, CFP®, CMP™

By Hope Rachel Hetico; RN, MHA, CMP™Senior Citizens

The words of Mr. Spock!

Recently, during my promotional speaking tour for the summer of 2009, I had the occasion to visit a few nursing and related homes for the elderly, sick, infirmed and aged. This harkened warm thoughts back to my time at Temple University in Philadelphia, PA as a young medical student. So, as a health economist and former certified financial planner, I recruited some folks and did some research on the domestic aging population to refresh my understanding of the facts and figures; especially in light of the current healthcare reform political debates [DEM].

Just the Facts  

According to the U.S. Bureau of the Census, there were almost 49 million people in the United States who were over age 60 in 2001. There are approximately 4 million people over the age of 85 living in the US and there are over 60,000 people older than age 100 estimated as of July 1st 2004. For every100 middle aged persons in the United States there are at present about 114 persons over the age of 65. This statistic will change as we move forward through time. In the year 2025, there will be about 253 people over age 65 for every 100 middle-aged people.

Enter the Baby Boomers

Beginning on January 1, 2006 at midnight and every 12 seconds thereafter for fifteen years, a baby boomer will have a birthday and cross over the age threshold of age 60. In the next 30 years, the 60+ age group will more than double, becoming 25% of the total population, and will have to be supported by a proportionately smaller workforce. Research published in June 2005 by AARP (based on data from 2002) estimates that: ‘‘In 2002, roughly $140 billion was spent on nursing home and home health care, with 24% of these costs being paid out of pocket” (O’Brien and Elias, 2004).

Aging Boomers

As the baby boom generation ages, the care needs will expand precipitously. Add to this, scientific and technological improvements in healthcare. These very same people will need more expensive healthcare and more expensive custodial care, and they will need it for an even longer period of time. Who will pay for this expanded need is not so clear. What is clear is that it will take money and lots of it to make these payments.

Money Preservation Variables

There are only three variables associated with the accumulation or preservation of money: ‘‘time, money and rate of return.’’ Time is reduced to the following two questions ‘‘How long until I will need my money?’’ and ‘‘How long will I live?’’ an uncertainty to be sure. Rate of return is either a function of the financial markets or the successful maintenance of a Long Term Care Insurance [LTCI] plan. Because of the volatility in the financial markets, the ‘‘money’’ question is equally as uncertain. In order to accumulate sufficient assets; an aging physician must ’tradeoff’ many other alternatives such as ’lifestyle.’

Assessment

What is certain is this—financial planning is important. More important is the implementation.

Conclusion

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Selecting an Assisted-Living Facility

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Checklist for Financial Planners

[By Staff Reporters]

Thousands of boarding homes cater to the elderly. Their operators promise to provide at least a place to sleep and food to eat. Beyond that, the services and assistance offered will vary from facility to facility. This checklist will help the financial planner or his or her client find a facility that is appropriate in all respects to the client’s resources and needs. Unlike nursing homes, assisted-living facilities often operate without any scrutiny from public agencies. Furthermore, Medicaid often will not be a source of funds.

The Checklist

The items the financial planner and client should consider when selecting a facility are listed below.

      1.   Determine the client’s willingness to live in a group environment.

      2.   Avoid unlicensed facilities, particularly if Medicaid-provided services may be needed in the future.

      3.   Review the facility’s inspection report.

      4.   Review the facility’s service contract and house rules. Look for answers to the following questions:

            a.         Where will the resident live?

                        Are there any types of ownership rights?

                        What flexibility is there with respect to furnishings?

                        Will the same unit be available after a hospital stay?

            b.         What meals are included?

                        Will the facility provide appropriate meals and a special diet?

            c.         What form of transportation does the resident currently use?

                        What transportation is provided by the facility?

                        Can residents shop, dine, attend services or visit doctors?

            d.         What help does the facility provide during a medical emergency?

                        What type of staff training is provided or required? Is there 24-                        hour-a-day staffing?

            e.         What provisions are there for privacy? When are rooms cleaned and when can staff access the rooms?

            f.          What is the basic cost and what are the costs for extras?

                        What is included in each?

                        What provisions for fee increases are there?

            g.         Can a resident see his or her own doctor?

                        Does the facility offer transportation for appointments?

            h.         Who’s in charge of administering and scheduling medication?

                        Can medication and other supplies be purchased at the facility?

            i.          What happens if the resident’s health begins to fail?

                        Does the facility provide additional services to help with ADLs?

            j.          What is the procedure for transfers from one unit to another?

                        Does the resident have any opportunity to express an opinion?

            k.         What’s required if a contract is terminated by facility or resident?

                        What is the provision with respect to refunded fees?

                        Is there a required minimum stay?

Assessment

What have we missed?

Conclusion

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How to Select a Nursing Home

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Checklist for Financial Planners

[By Staff Reporters]fp-book6

The following will enable the financial planner to assist the client in choosing a nursing home.

The Checklist

1.   Review the client’s requirements. An assisted-living facility may suffice instead of a true nursing home, which is required by the frail and elderly needing daily medical care.

2.   Pick a location close to home and relatives. Frequent visits are crucial, not only to combat loneliness but also to ensure resident receives proper attention.

3.   Read inspection report (state survey). If the financial planner encounters difficulties in obtaining a current report, he or she should assume that the home has something to hide. Don’t expect perfection. Nursing homes provide a difficult service for difficult residents. If a home is unresponsive to inquiry regarding items in a report, assume a similar response to concerns about the quality of care being provided in the future.

4.   Tour the facility on an unannounced basis at different times on different days. Stroll through corridors and look and listen. Trust senses and instincts. Items to consider should include:

·         Appearance of residents’ rooms. Outward decor of facility can be misleading, so the planner should inspect the residents’ rooms. To what extent can the rooms be personalized? If rooms are shared, how are good roommate matches made?

·         Smells. High-quality homes have no lingering stench of urine or air freshener to cover up bad care and unusually high incidences of incontinence due to lack of attention by staff.

·         Safety hazards. Be especially aware of items in corridors that can be obstacles to those with unsteady gait and poor eyesight.

·         Sufficient staff members who are pleasant and respectful to residents. Are staff members responsive to residents’ needs? Are staff members warm in their interactions with all residents, even those requiring the heaviest supervision? Are aides helping residents with walking or exercise of their arms and legs?

·         Residents’ attitudes toward facility’s service. Talk with residents and staff to determine attitudes toward the facility’s service. Does the facility have a family counsel to provide it with input?

·         Grooming. A clear sign of neglect is failure to keep residents clean, well dressed, and well groomed.

·         Physical restraints. Nursing homes that have eliminated restraints also have improved quality of life and more social contact among residents. Ties, belts, vests, and high bed rails are an easy but unsatisfactory solution to managing residents. Count number of residents that are restrained; ask what percentage are restrained and why.

·         Food. Visit at meal time and sample the food to make sure it is palatable. The setting for meals should be attractive and pleasant, and food should be served at the proper temperature. Staff should be available to help residents who are not able to feed themselves. Review menus and determine the amount of concern for nutrition.

·         Activities. A wide variety of activities should be provided, and the participation level should be high. Bored residents in front of a television may be a sign of a home’s failure to stimulate its residents.

·         Dignity. Residents should be handled in ways that respect their dignity. For example, are residents properly clothed in public?

·         Bed sores. Bed sores are a sign of poor care. Review inspection reports and see if they are mentioned, or talk to residents or their families about this topic.

·         Special care units. Such units are often used as an expensive marketing device. The special care units may not be designed well and may indicate a lack of outdoor facilities.

5.   Review the facility’s policy on medical care. Will residents be seen by their personal doctors or by staff physicians? Does the home have good infection control and immunization plans? What sort of access to dentists and eye doctors is there?insurance-book9

6.   Perform financial analysis. The planner should gain a complete understanding of what the client’s and/or his or her family’s financial commitments are and how they will be met.

·         Determine the financial strength of the nursing home, particularly if client funds are to be advanced.

·         Consider a single lifetime payment in lieu of monthly rental payments.

·         Consider exclusions in contract. For example, nursing home insurance coverage should include loss of personal property and personal injury.

·         Determine what services the client will require, what is covered under the facility’s general fee, and what services are provided for an extra fee. Determine what the extra fee will be for each additional service that will be required. Family members should not agree to pay these charges because this could delay Medicaid funding.

·         Analyze pricing structure in general and what the pattern of increases in fees has been.

·         Determine residents’ rights in eviction proceedings for nonpayment of rent, in returning to nursing home after hospital stay, and in having Medicaid make payments on behalf of resident.

·         Determine residents’ rights to appeal decisions and what the appeal procedures are.

7.   Obtain and check references, including families of current residents, local hospitals, doctors, and government agencies, particularly the ombudsman at state departments for aging.

Assessment

What have we missed?

Conclusion

In any case, early planning is the key to supporting both your kids’ futures and your retirement. Making logical college funding decisions, rather than emotional ones, creates a win/win for everyone.

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Re-Examining Medical “Do Not Resuscitate” Orders

Information for Financial Planners and Advisors

By Dr. David Edward Marcinko; MBA, CPHQ, CMP™

By Hope Rachel Hetico; RN, MHA, CPQH, CMP™

[Publisher-in-Chief and Managing Editor]

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According to the Rev. Chuck Meyer, former Vice President of Operations and Chaplain at St. David’s Medical Center in Austin, Texas, a new designation for Allowing a Natural Death (“A.N.D.”) would eliminate confusion and suffering when patients are resuscitated against their wishes.

Defining Do Not Resuscitate [DNR] Orders

As medical professionals, we know that a Do Not Resuscitate [DNR] order does not mean that medical care has stopped. It simply means that the goal of treatment has been changed. But, to FAs, patients and family members who are emotionally involved in the situation, this truth may not be apparent www.HealthDictionarySeries.com

Terminal versus Healthy Patients

While a completed DNR tells physicians not to start Cardio Pulmonary Resuscitation [CPR] if the patient suddenly goes into cardiac arrest, the order does not differentiate between a terminally elderly ill patient; and a potentially healthy younger person who may die due to current circumstances. A non-terminal patient may be in a DNR category and continue to receive aggressive or supportive treatment aimed at a cure; or at supporting him through this medical crisis. If symptoms start to respond, then the DNR category might even be changed to a full code.

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Assessment

Should financial advisors become involved in this issue? If not, why not; and if so; to what extent? MD-CFP® subscribers please chime-in with your unique experiences.

Conclusion

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Healthcare Organizations [Financial Management Strategies]

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Assessment

Rest assured, Healthcare Organizations: [Financial Management Strategies] will become an important peer-reviewed vehicle for the advancement of working knowledge and the dissemination of research information and best practices in our field. In the years ahead, we trust these principles will enhance utility and add value to your subscription. Most importantly, we hope to increase your return on investment [ROI] by some small increment.

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Conclusion

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At-Home or Nursing-Home for Long Term Care [Part III]

Cost and Duration of Long-Term Care at Home

By Dr. David Edward Marcinko; FACFAS, M.B.A., CPHQ™, CMP™

By Thomas A. Muldowney; M.S.F.S., CLU, ChFC, CFP® CMP™

By Hope Rachel Hetico; R.N., M.H.A., CPHQ™, CMPdr-david-marcinko1

This is the third post, in an exclusive four part series for the ME-P titled: At-Home or Nursing Home Care for Long-Term.”

Average Nursing Home Stays

It is generally agreed that if short, recuperative stays are excluded, the average stay in a nursing home is about 21/2 years. Nursing home studies show that residents experience four types of stay before death: 12 percent remain for less than 90 days; 21 percent stay between 91 and 365 days; 43 percent stay for up to five years; and 24 percent stay longer than five years. It is not possible to know in advance which type of stay you or your family may experience. But, put in another way, two-thirds stay more than one year and one-quarter stay more than five years. Most seniors also have home care services before entering a nursing home.

Custodial Services 

Custodial nursing home services are paid from the elder’s savings or by Medicaid. The current estimated annual cost for a nursing home resident is about $35-40,000. However, the annual cost for a nursing home in metropolitan areas may be at least twice as much.

Assessment

In the past decade, nursing home charges increased 8 percent a year. At a minimum, these costs may be expected to climb at a 5 percent annual rate in the future.

Conclusion

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Nursing Home Perceptions & Realities [Part II]

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Cost and Duration of Long-Term Care at Home

By Dr. David Edward Marcinko; FACFAS, M.B.A., CPHQ™, CMP™

By Thomas A. Muldowney; M.S.F.S., CLU, ChFC, CFP® CMP™

By Hope Rachel Hetico; R.N., M.H.A., CPHQ™, CMPhetico

This is the second post, in an exclusive four part series for the ME-P titled: At-Home or Nursing Home Care for Long-Term.”

Nursing Homes Less Desirable

Most agree that nursing homes are regarded as the least desirable LTC choice. Some people enter a nursing home after a hospital stay with a need for skilled care or for short-term respite care. Many people who are admitted to a nursing home remain there for the rest of their lives.

The Only Answer for Some

Nursing home care may be the only answer for single people requiring LTC or people with Alzheimer’s disease. However, nursing home care is not always available when needed. Many of the better nursing homes have substantial financial requirements, and have long waiting lists, some lasting months or years.

Assessment

Unfortunately, some people will have difficulty being admitted to these nursing homes without a reservation. Many nursing homes will not accept Medicaid at the outset from a prospective resident; therefore, having funds available (which may be spent down) or LTCI may make a difference in getting into a nursing home.

Conclusion

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At-Home or Nursing-Home for Long Term Care [Part I]

Cost and Duration of Long-Term Care at Home

By Dr. David Edward Marcinko; FACFAS, M.B.A., CPHQ™, CMP™

By Thomas A. Muldowney; M.S.F.S., CLU, ChFC, CFP® CMP™

By Hope Rachel Hetico; R.N., M.H.A., CPHQ™, CMPdr-david-marcinko

This is the first post in an exclusive four part series for the ME-P titled: At-Home or Nursing Home Care for Long-Term Care.”

Remaining at Home

It is not surprisingly, eighty-five percent of married elders prefer to remain at home instead of moving to a nursing home or some other senior care facility. Staying at home is easier, more comfortable, and less traumatic. Home care statistics are limited, but three years is the estimated average number of years that elders will require custodial care services. This estimate also may combine home care followed by nursing home care. And, the anecdotal healthcare experience of two authors [DEM and HRH] confirms this period length.

Incremental LT Cost Approach

Quantifying the annual incremental costs of LTC home custodial services is difficult. Today, a high percentage of home care services are provided by unpaid family members, friends, or volunteer organizations. In the future, however, there will be fewer available unpaid caregivers, and more elders will have to pay for home custodial care.

Because of this potential shortage of caregivers, new business opportunities are springing up and, as usual, let the buyer beware. Many of these new businesses, for a fee, contract with a family that needs home LTC for a family member.  Upon contract, the new LTC business owner begins a search for a candidate caregiver who will live in your house and care for your parent or spouse. Often the in-home caregivers have difficulty speaking the language or may not be familiar with local customs.

Furthermore, many of them wish to be paid in cash rather than by check. As you might imagine, background checks, tax compliance and other legal considerations are of utmost importance.  Career education and career experience are also very important. Be sure that if you look for such a caregiver, you must exercise thorough due diligence so that your loved one will be cared for properly.

LTC Costs Vary Widely

LTC home care cost estimates vary widely by location and type of service. At present, the average annual cost for a live-in, full-time aide in the United States (especially if part-time help to relieve a full-time aide is added) is estimated at $40,000, the same as the estimated cost of staying at a nursing home for a year. If living expenses are added to costs for custodial aides, LTC home care costs can be more expensive than nursing home costs.

For three shifts of paid LTC custodial services, home care costs may exceed $100,000 annually; more than triple the current estimated cost for nursing home care. These numbers should not be surprising.  In a nursing home environment, one caregiver may be able to provide care for multiple patient/residents. This reduces the cost per patient. In your private home, your personal caregiver can give only care to a single patient.

Custodial Aide Costs

Costs for custodial aides in the fragmented, rapidly expanding, competitive home care industry may increase at a faster rate than the Consumer Price Index [CPI]. Employed aides will replace family caregivers. The Bureau of Labor Statistics [BLS] indicates that jobs for home health aides, human service workers, and personal and home care aides are expected to grow faster than any other industry in terms of total jobs.

In the next decade, there will be more than 2 million home care jobs, and they will become a larger component of total gross domestic product expenditures. Using an estimated three-year home care requirement and current estimated costs, and allowing for 15 years of inflation at 5 percent, $225,000 per person is a reasonable estimate to use for financial planning purposes.

Assessment

However, in some metropolitan or suburban areas, such as New York City, the cost should be increased by at least 100 percent. Of course, three years of required care is an estimate. About one-third of the people who require nursing home care will need it for more than three years. Presumably, nursing home care will be preceded by home care. Moreover, only one full-time aide was assumed. Some elders also will require additional part-time help.

And so, your thoughts and comments on this Medical Executive-Post, which represents the first in a series of four parts on: At Home or Nursing Home Care for Long Term Care, are appreciated. Comments from physicians and LTC insurance agents are especially valued.

Conclusion

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