Everyone wants to age at home. It is possible to live and die at home just as you wish. However, doing so irresponsibly will prevent you from staying at home and will greatly increase your chances of being admitted to a nursing home. Your irresponsible nature will stubbornly refuse to acknowledge that the human condition is fragile, that your memory is not what it used to be, your balance, agility and strength is failing. You begin to have minor falls. You sometimes forget to turn off the burner on the stove and taking medications when you should. Humans are driven by primary drives. In older age, these drives are “activities of daily living”. The industry calls these activities “ADLs”. ADL has legal significance as the inability to perform them, the activities that a person normally performs daily, signifies the type of care you might need and also the type of long-term care benefits you are entitled to receive from insurance or a government benefits program such as Medicaid.
Depending on the situation, common ADLs are eating, bathing, dressing, eating or even preparing your own meals, transferring from a wheelchair to a toilet, walking and, in some cases, managing your own medicine. The degree to which you are unable to perform these ADLs determines the level of care that is appropriate and even the community that is best: home, assisted living facility, adult family home or nursing home.
Other factors should be considered by Medicaid and insurance companies but are not. Depression, risk of falling and hospitalization comes to mind. Falling is the number one cause of injury death if you are over 65 years old. The chances of falling in home is greater than in a quality assisted living facility. Picture in your mind a grid. “ADLs” on one axis and on the other the degree to which you are unable to perform ADLs, i.e., mildly, substantially or severely impaired when trying to : walk, bathe, eat, transfer from wheel chair to toilet, manage ones medicine,
The grid is my invention and is more art than science. It does illustrate that there are “levels of care” that correspond with impairment and levels of care are better provided in different residential settings. It is possible to provide all levels of care by simply modifying the home and paying for care providers, nurses and even doctors to visit you in your home and to pay for the necessary medical equipment to accommodate you. However, at an average cost of $26.00 per hour, it is unaffordable to most. Assume that your version of dementia is that you become confused as to your surroundings. That you are home but do not recognize your home. You do not recognize your family members. All you know is that you are not where you should be and so you seek to leave, to find home. You seek and find exits and, once out, wonder into the great big world out there. To protect you at home, it is necessary that a care worker be present 24 hours per day. Or suppose that you simply fall a lot. You also have to use the toilet at night from time to time. Most times when you get up at night to go, you are fine. But, from time to time you fall. Remember that falls are the number one cause of injury death in the United States. A full time care provider would be necessary simply to help you at night at a rate of $26.00 per hour simply to ensure you don’t fall. If you think that is a bad investment, think again. Following a hip facture, the 30-day mortality rate after hip fracture is about nine percent (9%). However, if patient has heart failure while being treated for a hip fracture, the 30-day mortality increases to sixty five percent (65%) and, if pneumonia sets in, the 30-day mortality rate increases to 43 percent. (Read more about mortality rates here.) Even if you don’t break a hip, falls often result in an ambulance ride to a hospital and, from there, discharge to a rehabilitation facility and, too often, permanent placement in a nursing home. That, by the way, was exactly what you did not want.
Few can afford home care 24 hour per day. The cost of such is exactly why Independent and Assisted Living Faciltities came into existence. Imagine an apartment building similar to any, even those in which your sons and daughters reside. The difference is that the apartments that are called Independent or Assisted are so called “protective environments”. These apartments simply acknowledge that you might need to hold a handrail in the shower, bath or hallway. When you were twenty, you didn’t need a handrail in the hall. You do now. Oversimplified, an Independent Living Facility (ILF) is the exact same type of building and in some cases the exact same actual building as an Assisted Living Facility (ALF) except that the ALF has care workers and perhaps a nurse on staff and care is provided for the resident in addition to the rent and an ILF does not.
An ALF is able to accommodate a higher level of care and an affordable price compared to Home Care (HC). Paying for one care worker for you is expensive. Paying for one care worker for you and nine people like you who live on your floor is less expensive. Where home care for a high level of care might cost $150,000 to $220,000, the average cost for ALF care in Washington state is $43,000 annually.
ALFs have limitations. The limitation is, generally, whether you need skilled care or not. The distinction is the same when receiving care at home. While you need help with ADLs, you may hire a home care worker to help you with these ADLs. But, suppose you need care for a bed sore or a surgical wound, or, heaven forbid, need intraveneous feeding or injections. These types of services may only be provided pursuant to a doctor’s orders and then only by certain licensed professionals, usually a nurse. Many ALFs draw the line there. In fact, many ALFs have a business model of light to medium assistance only. If you need higher care, you are literally asked to leave.
If you require and receive these “skilled services” at home, i.e., services ordered by a physician and provided by certain licensed professionals, it is called home health care (HHC). This is in contrast to home care (HC), care workers who are not medically licensed and help you with ADLs only such as cooking, light chores, bathing, walking etc.
If you are in an ALF and need skilled care, it might be necessary for you to either hire your own licensed professional to help you or, more likely, you will be required to relocate to a different type of community such as an Adult Family Home or a Skilled Nursing Facility.
Adult Family Homes are private homes in which housing and care is provided. Typically, the homes are licensed to have up to six residents. Adult Family Homes have developed as an alternative to more expensive skilled nursing facilities. As such, the number of Adult Family Homes has risen dramatically. Regulations have lagged. The turnover is stunning. * Stats on new yearly AFHs and closed homes.
Washington state is touted as leading the way in regulating AFHs. According to Washington law, a care provider, entity representative and resident manager must meet the following requirements in order to work in an AFH. First, be over twenty-one years of age, have a high school diploma or its equivalent, have had twelve hours of “continuing education” courses per year, have good moral character and be literate. WAC 388-76-10130.
Notice that the manager need not have any medical training. The state of Washington does not put out a proposed curriculum. For example, one of the greater risks to you when you are over eighty is poor nutrition. This is confounded when you also have dementia and become depressed. You literally forget to eat or when you remember about food, you do not have an appetite. Many Adult Family Homes have very qualified persons on staff who are trained and educated. They understand the importance of nutrition but no government agency is managing whether the twelve hours of education per year includes nutrition. It is possible that an Adult Family Home simply puts out bowls of Cheerios every morning and there is requirement that they also, heaven forbid, include a green leafy vegetable. But, who wants broccoli with Cheerios?
|# of Impaired ADLs||5||HC/HHC/IL||HC/ ALF||AFH/SNF|
Avg. National Cost
|Home Care (HC)||Care providers help you around the house with ADLs, e.g., preparing 8meals, bathing, etc||$20.00 per hour|
|Home Health Care (HHC)||You need more than just help, you also need a nurse to provide medical services such as an injection.||$20.00 per hour|
|Independent Living (IL)||As much as you want to stay at home, sometimes it is not possible. Imagine an apartment building but with certain features to make it a safer environment such as hand rails in the halls and bathroom|
|Assisted Living||Residential arrangements providing personal care and health services. The level of care may not be as extensive as that of a nursing home. Assisted living is often an alternative to a nursing home, or an intermediate level of long term care.|
|Adult Family Home|
|Nursing Home||These facilities often provide a higher level of supervision and care than Assisted Living Facilities. They offer residents personal care assistance, room and board, supervision, medication, therapies and rehabilitation, and on-site nursing care 24 hours a day.||$220.00 daily rate|
 Genworth 2015 Long Term Care Cost Survey