ADLs (Activities of Daily Living) – ADLs are defined activities with which most elder care (or senior care) company caregivers provide assistance. Most companies that provide care define ADLs very broadly, describing them as any non-medical activity needed in the home. For example, a company may say they provide assistance with the ADLs cooking, cleaning, bathing, dressing, meal preparation, continence care, transportation, exercise assistance, medication reminders, light housekeeping and companionship.
Long-term care insurance companies define ADLs very specifically and include six or seven of the following activities:
- Feeding (being able to lift a fork or spoon from plate to mouth)
It is important that when you hear of ADLs you understand who is saying it and what specifically is meant.
APS (Adult Protective Services) – APSs are county or state departments where you and your staff will report all elder abuse (physical, emotional, sexual and verbal). If you have an elder care business, it is important to identify your state or county’s office, phone number and reporting procedure, to set a policy in place with your staff, and to train your caregivers on any mandatory reporting laws in your area.
Assisted Living Facility (AL) – ALs are elder care facilities that are licensed by the state to provide room/board, meals, medication management and care. Assisted living facilities are usually large, hotel-like buildings with many rooms and many common areas (dining room, game rooms, libraries, common activity areas). Many times AL facilities have a base rate per month for room/board/meals and then different levels or tiers of care. For example, Level One may be bathing three times per week and light housekeeping services one time per week. Level Two may include all of the Level One care in addition to transfer assistance to the dining room. Level Three care may include all of the Level One and Two services, in addition to assistance with continence care medication management.
Most of the time these levels of care are based on a point system that coincide with all ADLs or needed activities. Once they cross over certain thresholds, they fall into a different level with additional costs to the resident. AL facilities are usually a great fit for people who are very social by nature and need lower levels of care – staffing can sometimes be one caregiver to 12-15 residents. Usually lifestyle and activities are what draw people to AL facilities.
(SNF) “Sniff” Skilled Nursing Facility – A SNF is a facility that provides both short-term rehabilitation services and long-term custodial services. SNFs are also referred to as nursing homes or rehab centers. Medicare pays for SNF stays as long as it is preceded by a three-day hospitalization and the patient meets criteria for rehab. As soon as a senior patient stops meeting criteria for rehab (usually because they have either plateaued, met treatment goals or start to decline in function), they are no longer eligible for Medicare reimbursement and are discharged. Medicare regulations note this is up to 100 days, but that is not always the case. Most Medicare patients meet criteria to be discharged well before day 40 and, if a Medicare Part C patient is receiving care through an MCO, they usually are discharged around day 14.
Social worker – When you hear about a social worker it can mean very different things. Social workers who work at hospitals, home health and hospice companies are usually LCSWs (Licensed Clinical Social Worker) or MSWs (Master of Social Work). From these degrees, they have extensive training and experience. Social service departments are found in many SNFs, which may have “social workers” who do not hold a degree or a lot of training. In some cases, they may have worked in another area in the SNF and been promoted to the social worker position. Some large SNFs are required to have social worker with a degree depending on state regulations.
Case Manager – A Case Manager is usually a RN or LCSW who manages the patient’s stay in a hospital or SNF. Many Case Managers belong to Case Management Society of America (CMSA) and can also be certified as a Certified Case Manager (CCM). It may be valuable to build a relationship with your local chapter of CMSA and even consider sponsoring meetings.
Durable Medical Equipment (DME) – DME is equipment such as wheelchairs, walkers, hospital beds, oxygen and three-in-one commodes that patients need as they are recovering at home. Medicare pays for DME that is prescribed by a doctor and falls under Medicare’s covered benefits.
Three-in-One Commode – This piece of equipment is a commode/toilet that can be used as a bedside commode (1), shower chair (2) and raised toilet seat (3).
Hoyer Lift – A Hoyer lift is used to lift someone out of bed and then lowers him or her elsewhere, and vice versa. These are mainly used for those who are non-ambulatory and needs total assistance.
Private Duty – Private duty refers to private pay services. Most people who work in the elder care market refer to home care companies as private duty companies. It really refers to the fact that most home care/private duty services are paid for privately and out-of-pocket. Private duty is not limited to non-medical home care companies, as there are also some private duty skilled providers.
National Private Duty Association of America (NPDA) – The NPDA is one of the most well-known trade organizations for private duty home care (elder care) companies. It may be beneficial to join a chapter in your local marker to provide credibility.
Discharge Planners – Discharge Planners are usually either RNs or social workers (LCSWs and MSWs) responsible for discharging patients out of a hospital into either a SNF or the home environment. These discharge planners coordinate many types of goods and services including home health, DME, home care, hospice, and palliative care.
Medicare – Medicare is a Federal health insurance program run by the Federal government and primarily covers people over the age of 65 (some Medicare recipients are under 65, but are disabled). Medicare benefits are either administered through its own system called Fee For Service (FFS) Medicare or through a Medicare Advantage plan run by a Managed Care Organization (MCO). The best way to determine how a patient is covered is to ask if they have a Medicare card issued by Medicare or a card issued by their MCO who administers the benefit.
Medicare is broken into four sections:
- Medicare Part A – The first program instituted. Covers hospital stays.
- Medicare Part B – The second part of the program implement and covers doctor, SNF, home health and DME care.
- Medicare Part C or Medicare Advantage – This section of the Medicare program comes into play when a Managed Care Organization bundles all Part A and B services into one offering, and sells it as an all inclusive Medicare offering. The government instituted Part C as a way to try to control the rising costs that were occurring in a government run program. In Part C the Federal government pays a set amount per month to a MCO through a network of contracts with hospitals and doctors who manage that pool of money. Because MCO’s have been able to set up contracts with hospital groups and doctor groups, they have been able to manage the Medicare patients with cost savings.
- Medicare Part D – This section of the Medicare plane encompasses prescription drug coverage and can either be stand-alone drug coverage for Medicare Fee for Service (FFS) or combined with a Medicare Part C plan.
Medicare’s FFS is when Medicare beneficiaries choose to run their Medicare benefit directly through Medicare for Part A and B, and do not sign up for a MCO under Part C.
Managed Care Organization (MCO) – An MCO is an organization that sets up networks of contracts with doctors, hospitals, SNFs and home health agencies, and bundles those contracts together to provide a discounted bundled offering of health care services.
Medicaid – Medicaid is a Federal program run by each state and provides care for low income and certain disabled people. States usually set criteria for coverage and determine eligibility. Some states have Medicaid waiver programs that will reimburse for caregiver services and most also pay for long term patients to stay in SNF settings once they have no income to pay for other forms of care. It is important to find out if your state has a Medicaid waiver program that pays for elder care services or adult family home placement.
Independent Physicians Association (IPA) – An IPA is a group of doctors who have banded together to contract with hospitals or MCOs. In some cases, IPAs are now combining with hospitals, SNFs, and home health agencies to bolster their negotiating power with MCOs. In some mature markets, IPAs are even looking to contract and become direct providers with Medicare as ACOs (Accountable Care Organizations).
Dual Eligibles or Medi-Medis – These are patients that qualify for both Medicare and Medicaid programs. Many Dual Eligibles are paid for by the state Medicaid program in a Long-term Care setting and, in some states, can be reimbursed for caregiver services.
Hospitalists – Hospitalists are doctors who work exclusively in hospitals and manage patient care as they transition though the hospital. These are usually contracted groups of doctors who specialize in critical care hospital-based care situations.
Residential Care Facility for Elderly (RCFE) – RCFEs are licensed elder care facilities. In the state of California, this is a broad term used to cover any licensed elder care facility. Assisted living, board and care, memory care and, in some cases, independent living facilities fall under the RCFE classification.
Board and Care (B&C) and Adult Family Homes (AFH) – These are homes in residential neighborhoods that are retrofitted for elder care. Many times these homes have capacity and licensing through your state to care for up to six seniors. Most provide one caregiver per three residents (two for six). These homes usually have an all inclusive fee structure and include room, board, meals and care in the monthly cost.
G-Tube – A G-tube is a feeding tube placed in the patient’s stomach to feed the patient liquid food. Often G-tubes are put in place when the elder care patient is having difficulty swallowing.
Foley Catheter – A Foley catheter is a tube placed in bladder and hooked to bag that voids urine.
Sundowning – This is a symptom of Alzheimer’s patients – behavior can dramatically change during a certain period of the day (usually the later afternoon). Symptoms of the Alzheimer’s are usually more severe during this time of day and can range from mild to combative.
Veterans Aid and Attendance Benefit – This benefit is a pension program for veterans who served during a time of war and need assistance paying for assisted living or home care services. This program is one of the key resource guides distributed to referral sources and will be covered thoroughly in training.
Hospital – Acute hospital care is defined as necessary treatment of a disease or injury requiring continuous management in a hospital setting. Medicare reimburses for an acute care hospitalization for both diagnosis and treatment.
Skilled Nursing Facility (SNF), Nursing Home or Rehabilitation center – Most skilled nursing facilities provide two types of services:
- Short-Term Rehab – Short-term rehab focuses on physical therapy, speech therapy, occupational therapy and nursing/skilled needs. After a consecutive three-day hospital stay, Medicare reimburses these services.
- Long-Term Custodial – Long-term custodial care focuses on the long-term care of seniors and includes bathing, dressing, feeding and other activities of daily living.
These services are not paid by Medicare, but can be paid by Medicaid if patient qualifies or can be paid for privately.
Home Health Agency – Physical Therapy (PT), speech therapy (ST), occupational therapy (OT), Social Worker (SW) or skilled nursing care are provided by home health agencies in the client’s home. To qualify, this requires a physicians order and medical reason, but does not require a three-day hospital stay.
Medicare pays for these services as long as the homebound patient has a medical need to be seen in the home.
Note: Home Health visits are anywhere from half an hour to one and a half hours, and are for a finite amount of time depending on diagnosis (i.e. two to three visits per week for three to five weeks). Home health visits are focused on medical need and do not cover a caregiver for heavy custodial care needs.
Hospice – Hospice focuses on managing the medical needs and comfort of those who have been diagnosed with life-threatening diagnosis such as cancer, dementia, COPD, CHF, end-stage heart or lung disease or even failure to thrive marked by progressive decline in nutritional intake, functions, weight loss or sudden disorientation.
Medicare pays for all hospice services rendered and can include the following resources to assist families:
- Social worker
- Hospice aide
To qualify, a physician must make clinical determination that life expectancy is less than six months.
Note: Hospice visits are usually intermittent and not intended to be used as main source of custodial or non-medical elder care. Families or hired caregivers are used to provide extended custodial care such as bathing, dressing, cooking, cleaning or companion services.
Palliative Care – This type of elder care focuses on the medical care for those diagnosed with life-threatening diseases, similar to hospice. The main difference of palliative care from hospice is that there is no definite life expectancy needed to enter into palliative care programs. Hospice requires less than six months life expectancy.
Most palliative care programs are reimbursed under the Hospice Medicare Reimbursement with little to no out-of-pocket costs to families who receive these medical services.
Non-Medical Home Care, Caregiver or Custodial Care Services – Caregiving services are focused on providing non-medical custodial services including cooking, cleaning, bathing, dressing, continence care, light housekeeping and companionship. This type of care is paid for out-of-pocket through long-term care insurance policies or through the Veterans Aid and Attendance Benefit.
Independent Living Facility (IL) – ILs are apartment complexes that allow seniors to live independently with structured activities they can choose to participate in with others their age. Usually there is no care provided. In some ILs meals are offered to residents and in others they are not. ILs are paid for out-of-pocket and are usually the least expensive of any private pay option, but have limited care options for those who need assistance.
Placement Services – This website provides complementary assistance to those looking for the best environment for their loved ones. Placement services refer people to different AL, IL, B&C homes or home care companies depending on their budget and care needs. It’s important to work with a placement company that actually drives you around and shows you the different places they recommend so you can make an educated decision.