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"Continuum of elder care" supports variety of unique needs

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Todd Goldberg Todd Goldberg
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Dr. Todd Goldberg is medical director of Heartland of Charleston and Edgewood Summit Retirement Community. He is an associate professor at WVU School of Medicine, Charleston Division.

As a geriatrician, a physician specializing in the care of the elderly, one of the most interesting as well as difficult aspects is understanding all the different levels and types of care available for seniors. I have repeatedly noticed that not only the general public but even other physicians, both experienced and in training, don't understand the variety of care settings where seniors live and receive care.  Families need to understand what options are available for their loved ones, and health care providers need to understand what options are available for their patients.

The legal and political community also needs to understand different levels of care for seniors in order to help protect and advise clients and make appropriate public policies and resource allocations.  So I would like to summarize what professionals in the aging field call "the continuum of care."

We will start with the least intensive level of care and follow the trajectory of an aging individual down to the end.  Most seniors live at home, independently, alone or with loved ones, and are able to function for themselves, travel to medical appointments and keep track of their needs themselves.  Some live in private homes or apartments, and some live in "independent living" apartments for seniors.  Independent or "congregate" senior housing does not provide much, if any, in-home assistance.  Independent seniors are able to go to their own doctors' offices and other professionals for outpatient care, outpatient tests and therapies, and buy their own food and medicines at the store.

When needs for assistance are modest, seniors are often helped by their families, friends, or other informal nonpaid caregivers.  Professional home care agencies are also available.  Only skilled nursing care and rehab is covered by Medicare at home if there is an illness or hospitalization.  Basic assistance is usually not covered by any health insurance except in the case of special state programs, but there are many non-medical agencies and companion services available for a fee.

When an older person needs enough assistance in basic activities of daily living (bathing, dressing, traveling, getting food and medicine) that they are unsafe to live totally alone and don't have enough informal/family supports to survive at home, the next level of care is usually assisted living, also known as personal care, residential care, boarding or rest homes.  These facilities range from small homes to large institutional settings and are generally privately owned and operate on a cash fee basis.

Assisted living, like non-medical home care, is not usually covered by insurance unless the individual has purchased a private long-term care insurance policy for such a contingency.  Assisted living facilities are licensed and regulated by the state but not as tightly as nursing homes; they vary in their capabilities but usually have light duty nursing available 24 hours a day as well as outpatient therapy and activities and provide medicine and three meals a day.  They do not usually have medical care available onsite and cannot care for anyone with heavy needs.  Importantly, in most states including West Virginia, assisted livings cannot be responsible for individuals who are not ambulatory enough to vacate the building independently in case of an emergency.

When someone is too impaired to live in the modestly supervised assisted living setting, the next stop is usually a nursing home.  Nursing homes, also known as nursing facilities or skilled nursing facilities, are tightly regulated by the state and federal government and care for the sickest, neediest people in our society.  Sometimes people stay in a nursing home temporarily for rehabilitation and recuperation after a hospitalization (in which case Medicare pays for up to a few weeks/months), or long term for the rest of their lives (in which case Medicare does not pay for the nursing home but Medicaid does after personal assets have been spent down).

Regardless of setting, Medicare does pay for doctor's bills and outpatient testing and therapies.

When an individual gets to the final year of life due to a terminal illness, they are entitled to hospice care under Medicare and most other insurances.  The diagnosis to qualify for hospice is not only cancer but any terminal illness, including heart or lung disease or Alzheimer's.  Once certified by a doctor and hospice agency to be appropriate, extra nursing and supportive care is provided at home, in a nursing home or assisted living facility, or in an inpatient hospice facility (such as Hubbard House in Charleston).  People should be more aware of and accepting of hospice as they face death, as it is a wonderful service which people often don't accept and utilize until the very end, for too short a time.

Two other types of programs to be aware of, usually for patients who qualify for both Medicare and Medicaid and who otherwise would qualify to be in a nursing home, include the "Waiver" program and "PACE."  For such "dual-eligible" individuals, depending on state funds and regulations, extra social and nursing support may be available to keep people at home rather than being in a nursing home.  The state does offer this program to a limited number of individuals subject to the availability of state funds.

The Program of All Inclusive Care for the Elderly, or PACE, is a day-care based care management program also for nursing home-eligible dual-eligible individuals, modeled on the famous "ON LOK" day care program in Chinatown in San Francisco.  This program has spread to many other areas but is unfortunately not available in West Virginia due to a lack of state funding.

Ideally, as a person's needs change, he or she would move smoothly from care one setting to another as determined by their physicians, families, social workers and other professionals.  However, often both the public and professionals don't really know about all the different services available.  So unfortunately people often tend to bounce back from home to hospitals to nursing homes in an unplanned manner based on emergencies and other circumstances.  In some areas either state or local departments of aging or private geriatric care managers can help better monitor, plan and supervise safe and appropriate transitions of care.

So while conceptually there is a continuum of care ranging from outpatient to inpatient to home care to nursing home care to hospice, in reality all these components of the health care system operate in their own independent spheres with different funding streams and too little coordination and communication.  In the future it is hoped that electronic health records will follow the patient and assist communication from setting to setting.  But it all starts with people communicating, understanding each other, and knowing what is actually out there.

For  information on available facilities and services, some sources to consult include the Alzheimer's Association, the state or county aging department, social workers in the hospital or other facilities, and your own personal physician.  The WVU Geriatric Education Center website also posts a list of Caregiver Resources for Elder Care at http://www.wvgec.org/pages/Publications.