Almost everyone I know is planning on aging in place. Let me be clear, there is really no other option but to age in place given the population bubble that Boomers represent. And almost everyone I talk with hasn’t really made a plan for how to do that.
Over my career as a consulting psychologist, I staffed nursing homes including those that provided care to Medicaid recipients and those that provided care to individuals with unlimited income. While I have some firmly held opinions about the overall delivery of services, I came away with a deep respect for the professionals who provide the care, especially the certified nursing assistants (CNAs) who deliver the bulk of services. These services are overseen by registered and licensed vocational nurses who monitor and care for a wide array of elders with unique challenges. And all of this is paid for by Medicare and Medicaid.
The image of debilitated men and women slumped in wheelchairs lined up in a hallway gives a very negative and false impression of what actually goes on in a skilled nursing facility (SNF). These facilities are highly regulated by states and provide medical care, as well as physical therapy, occupational therapy, meals and both short-term (post-acute) treatment and long-term care (LTC). Still, there is near 100% agreement that none of us want to end up in a nursing home. This is unrealistic, given that we are living longer and increasingly need support in different areas and different ways as we age.
Long-term Care Facilities
Terminology is sometimes confusing when exploring housing options as we age. SNFs are highly regulated and monitored. LTCs, on the other hand, include small, family-owned and operated homes as well as larger, corporate-run group facilities. Depending on the licensing requirements of your state, LTCs may receive little or no oversight or monitoring. These types of facilities experienced huge challenges during COVID. Several made the news in New York and Washington state for failure to care for their residents.
You will typically find aging adults who are unable to live independently, either due to physical challenges or cognitive impairment, in long-term care. The Biden Administration allocated $10 million dollars back in May, 2021 to safeguard the health and welfare of aging in adults in long-term care facilities. It is unlikely that this money will go directly to the facilities, rather it will be used by states to support and expand Ombudsman programs.
These programs assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences. Typically, ombudsmen are provided with training and supervision on how to investigate reports of abuse or neglect. Both individuals and families can file complaints, which are then investigated by the Office of the Ombudsman. Caseloads vary, and all too often there are not enough trained ombudsmen to handle the increasing numbers of complaints.
Ombudsmen are tasked with investigating complaints when resident’s rights or dignity are violated, when reports of physical, verbal, mental, or financial abuse are made, and where there are reports of poor quality of care, issues related to dietary concerns, medical care, therapy, and rehabilitation.
Other areas typically involving Ombudsmen include issues related to Medicare and Medicaid benefits, improper transfer or discharge of a resident, and inappropriate use of chemical or physical restraints. Chemical restraints have received additional scrutiny in the news lately noting the increased use of psychotropic medications to manage behavioral issues in residents with dementia.
Barriers to Aging in Place
The primary barrier as I see it, is how to deliver the necessary services to individuals living in their home. Necessary services change over time and include food, medicine, medical care, bathing and toileting care, as well as providing plans and facilities for evacuation, temporary stays in hospitals or SNF’s, and sufficient numbers of providers who are trained and qualified in delivering these services.
Then there is safety and security of the living space itself. At present, there are no national standards for what would qualify as “safe housing for elders”. At a minimum, these should include adequate heat and cooling, fall prevention, sufficient lighting, access to potable water, indoor plumbing, mold and toxin mitigation for asbestos and lead, adaptation for emergency evacuation, and WiFi.
Finding Care Givers
Without a doubt the most serious barrier to aging in place is the lack of qualified care givers. Family members have traditionally provided this care and have done so without compensation. The emotional, physical, and financial burden this represents is huge. Currently most care giving in the U.S. is provided by family members, many of whom have needs themselves that go unmet.
Unfortunately, care giving is considered an entry-level job. Even though it requires exceptional interpersonal and physical skills and capacities, it often pays minimum wage without a guarantee of regular employment. Sadly, there are instances where care givers have abused and taken advantage of those who are in their charge. Increasingly, there are instances where employers have taken advantage of the care giver by refusing to pay for services or requiring that additional services other than care giving be provided.
There are care giving agencies who oversee the hiring and training of care givers, as well as handling the necessary taxes and insurance. Your insurance may cover payment for this, or you may need to pay out of pocket.
If you are hiring a care giver on your own, you will need to recruit, interview, and then contract with the individual who will be caring for you or your loved one. You will need to know and understand employment law along with bookkeeping. You will also need to carry additional insurance should the care giver become injured while working for you. If your care giver calls in sick or is unable to come to work, you will need to find back-up personnel.
Because illness or disability isn’t planned, all these things are usually needing to be done while under a lot of stress. Taking the time to explore what is available and making connections now within your community will go a long way in smoothing the transition and actually achieving your goal of being able to age in place.
Long-Term Care Insurance
The promise of long-term care insurance is that it will cover costs associated with paying for the care you need whether you are in your home or another facility. It promises that you won’t need to sell off assets to pay for your care. It is essential that you be clear on what the process is for activating your benefits before you purchase this insurance. Remember, the company is in business to sell insurance, not to provide care.
The reality is that most people experience difficulty getting their claims paid or do not make it through the elimination period (typically 30, 60, or 90 days). Most (if not all) long-term insurance policies require a medical review of your situation before a claim will be authorized to be paid. If the review does not find that you meet criteria, your benefits will not be activated. Appeals may take months. By that time, you will have paid out of pocket for services you expected to be covered and you may never get reimbursed.
We are living longer and that means that we may need assistance in different areas of our life at different times. Most Americans have not saved enough money to pay for the services they rightfully are expecting will be available for them.
There is a constant battle in Congress to ensure that Medicare is fiscally sound. Medicare benefits, however, pay only 80% of costs, and are calculated based on outdated formulas that do not reflect the rapid changes associated with the cost of medical care we are now experiencing.
We must support increasing wages for all providers and ensure that care givers are seen as valued partners in health care. There is a growing movement to unionize care givers, which will go a long way to addressing the wage and working condition issues mentioned above.
Aging in place needs to change from an option to a certainty, with local health care systems participating in making decisions on how to deliver health care in the home. Insurance companies, including Medicare and Medicare Advantage plans must pay for in-home services. Communities must include plans for funding home and community-based services that can sustainably meet the changing needs of aging adults who are living longer. This includes adequate housing standards, adequate emergency services, and establishing and expanding partnerships with service providers in the community.
There is a lot of work to be done.