- Email: [email protected]
The value of home care assistance
HOME CARE CEU: TOPIC
CEU
The Value of Home Care Assistance by Virginia Pinkerton, MA An analogy I find helpful to explain what home care aide (HCA) organizations do goes like this: if skilled medical services are the bricks of home care, HCA services are the mortar. HCA organizations hold the care structure together over a long period, filling in the gaps and preventing breakdowns that could threaten senior clients’ overall well-being. In short, we provide the services that allow seniors to stay independent, in control of their own lives, and in their own homes for as long as possible.
“
S
o what exactly is it that you do?”
Those of us who help provide home
care assistance to seniors hear that question a lot. It comes with the territory when you work in an industry segment that is both the fastest growing and the least understood in elder care today. TCM 42
January/February 2001
What Is an HCA Organization? Of course, more specific differences exist between home health agency services and those provided by HCA companies. The former’s services are primarily shortterm and medical in nature and must be ordered through a physician (eg, nursing and physical, occupational, and speech therapy). The primary goal is to help seniors through a crisis or acute episode, bring them to their maximum level of independence, and discharge them from service. This program generally is covered under the Medicare home health benefit. On the other hand, HCA organizations provide long-term supportive services, such as activities of daily living (ADLs) (eg, bathing, dressing, meals, and ambulation) and instrumental ADLs (IADLs) (eg, shopping, laundry, light housekeeping, and transportation). These costs generally are borne by seniors or their families. For an elderly person, however, these services are the difference between staying healthy and going into
An example is a San Diego, Calif., man who has been receiving HCA services from my company, AccentCare, for 6 years. In the beginning, we provided hourly care for John and his wife, who has since passed away. Caregivers shopped for them, prepared their meals, helped clean their house, and made sure the couple took their medications. Over the years, John has come to require 24-hour live-in assistance, but he remains alert and happy in his own home—at 105. The family is assured of his care through regular updates from our staff. The longevity of that case is unusual, but the gentleman’s needs are not. Surveys show that ADLs and IADLs are the types of services most people need as they age. According to a 1999 study prepared for the U.S. Department of Health and Human Services,1 only 5% of seniors who need care require the type of skilled care for which Medicare provides coverage. A whopping 95% of the rest need assistance with ADLs and IADLs.
standards of care for skilled nursing services and assisted living facilities. The good news is that many HCA organizations have recognized the problems that come with an unregulated industry and are beginning to implement voluntary standards. In California, I chaired a committee of providers who worked with the state Association for Health Services at Home to develop minimum voluntary standards of care. Our committee also worked with the Community Health Accreditation Program, a consumer-driven health care accreditation organization in New York, to develop an accreditation standard specific to the HCA industry. In addition, we identified other high-quality, HCA-specific accreditation programs, such as the Accreditation Commission for Home Care in North Carolina and Home Care University, an affiliate of the National Association for Home Care in Washington, D.C. However, because this segment of the industry is not regulated, many companies don’t see the need to be accredited. The resolution of this issue will be consumer- and payer-driven. Home Care Considerations Family members, discharge planners, and case managers searching for a quality home care provider must consider a number of issues and questions.
However, an awareness of the availability of HCA services remains low, mainly because the industry is so young. In the 1950s, “homemaker services” referred to child care in the home. In the 1960s, home care was formally recognized as including adults. In-home care began as an informal social model of care. Family, friends, and churches traditionally have provided needed support for seniors. Over time, however, families have changed and often are separated by distance, or both the husband and wife work, increasing the need for HCA services to fill the gap.
Who pays for home care? People wrongly assume that the government, Medicare in particular, will pay for long-term care (LTC), but the program does not cover assistance with ADLs or IADLs. Medicaid, known as Medi-Cal in California, pays for nursing home care for those whose assets are below a specified level. But in general, LTC is a private-pay market. Rates vary by region, but generally they range from $13 to $22 for hourly care and $130 to $200 per day for 24-hour live-in care.
Because the HCA industry is young, it is virtually unregulated in most states. Almost anyone can call himself or herself a caregiver. The lack of regulation in the industry inevitably leads to problems with poorly delivered services by unqualified staff. Stories of theft and abuse also have been noted in this segment. Contrast this to the other end of the care continuum where government regulation is firmly in place to maintain
Some seniors have LTC insurance policies that may include home care coverage. Those who do are forward thinkers who have planned for the inevitable, but they are in the minority. The first time most seniors and their families think about home care is during a crisis. A 1999 poll conducted by the Los Angeles Times2 found that 81% of respondents not currently providing elder care had no plans for dealing with it.
Discussing these issues with aging relatives is difficult. And even when family members are ready to bring up the topic, parents are not always willing to discuss the possible need for LTC because they don’t want to be a burden. Those who have had the experience of caring for an elderly spouse, parent, or relative report that it requires a tremendous amount of physical and emotional stamina. A study published in the December 1999 Journal of the American Medical Association3 found that the stress of providing supportive care to a sick spouse could shorten a caregiver’s life. Families and their advisers must understand the options on the continuum of care. From the least to most restrictive, care options are home care, retirement communities, independent living facilities, assisted living facilities, board and care facilities, and skilled-nursing facilities. In short, most people do not understand what their options are. When a triggering event occurs, such as a fall, stroke, broken hip, diagnosis of Alzheimer disease, or a terminal illness, family members struggle to become educated quickly. It is not surprising that many poor choices are made in such situations. Determining a system to help coordinate care and assign responsibilities is important. Results of the 1999 study for the Department of Health and Human Services1 indicated that having both formal and informal caregiving in the home and a lack of coordination and consistency of that care caused the elderly’s needs to be inadequately met or not at all. Good providers will maintain consistency, coordinate care, and provide more highly trained and supervised caregiving staff. Families may benefit from using professional care coordination or case management services. Additional Questions The following questions and more than 25 others come from an evaluation tool I developed for home care providers intended to help consumers and referral sources, such as case managers and geriatric care managers, gain information about agencies to which they might refer patients. January/February 2001
TCM 43
CEU: HOME CARE
the hospital. Assisting seniors with light housekeeping, nutrition, and reminders to take medications consistently may make a significant difference in their quality of life.
CEU: HOME CARE
• Is the agency a member of a state or national home care association or other professional organization?
• Does a qualified individual conduct an assessment before services start?
and non-privately insured disabled elders living in the community. Washington (DC): the Department; 1999.
• What are the caregiver’s qualifications? • Will it provide a written plan outlining the caregiver’s duties? • What are its hiring practices? • Who employs the HCA? If the caregiver is employed by the agency, he or she should be covered for workers’ compensation insurance, Social Security, tax withholdings, EDD coverage, Medicare/Medicaid, and state disability. However, if the aide is an independent contractor, he or she should provide evidence of income-tax filing and payment of the additional taxes that an employer pays. Most importantly, the client or responsible party then becomes the employer and must not only have liability insurance and make the appropriate payroll deductions but also be capable of screening, checking references, and supervising.
• Will a supervisor visit the client’s home at regular intervals to make sure services are satisfactory or to reassess if conditions change? Will a written or verbal report of these visits be provided to the client’s family? The search for a high quality HCA agency may seem daunting. When the reward is finding a reliable organization that meets a client’s needs, however, the investments of time and energy seem small indeed. ❏ References 1. U.S. Department of Health and Human Services Office of Disability, Aging and Long-term Care Policy, LifePlans, Inc. A descriptive analysis of patterns of informal and formal caregiving among privately insured
2. National Survey: aging. Los Angeles Times 1999 April. 3. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the Caregiver Effects Health Study. JAMA 1999;282. Virginia Pinkerton, MA, former owner of a home care services organization, is the director of quality management and regulatory affairs for Irvine, Calif.-based AccentCare Inc., a 13-branch home care services company. She was the first representative of a home care aide organization to serve as chairwoman of the board of directors of the California Association for Health Services at Home. Freelance journalist Dennis Arp contributed to this article. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/112769 doi:10.1067/mcm.2001.112769
Mark your calendars now and plan to attend...
Mosby’s 13th Annual Medical Case Management Convention (MCMC XIII) September 22-25, 2001 Baltimore Convention Center Baltimore, Maryland Sponsored by:
To receive an MCMC XIII brochure as soon as it is available, call 800-826-1877. Visit Mosby’s Continuing Education and Training Department online at: www.mosby.com/CET TCM 44
January/February 2001
CEU: HOME CARE
CEU APPLICATION This article has been approved for 1 hour of CCM, CRC, and CDMS education credit by The Foundation for Rehabilitation Education and Research. To obtain your education credit, please do the following: 1. Read the “The Value of Home Care Assistance” article. 2. Make copies of this page for each person applying for credit. 3. Answer the following questions by selecting one statement. Four questions must be answered correctly to receive the educational credit. 4. Mail this completed form with a check for $10 to: Foundation for Rehabilitation Education and Research 1835 Rohlwing Rd., Ste. E, Rolling Meadows, IL 60008 Questions: For which educational credit (1 hour) are you applying? CCM ID#___________ CRC ID#___________
CDMS ID#__________
1. Which of the following statements describes issues in elder care today? _____A. Elders and their families typically do not plan ahead for potential crises and do not know how to find help when needed. _____B. Women are more likely to look after aging parents, making up 72.5% of all caregivers. _____C. Many adult children and their families are uncomfortable discussing long-term care needs. _____D. Caregiving can be stressful and, in fact, can shorten life expectancy. _____E. All of the above 2. The in-home custodial care provided by home care aide organizations differs from care provided by a home health agency in which way? _____A. Provides long-term supportive care that enables seniors to age in place as long as possible _____B. Provides skilled nursing care _____C. Administers medications _____D. Reimbursable by the government 3. Which of the following does NOT typically contribute to seniors’ unmet or undermet needs? _____A. Both formal and informal caregiving in the home _____B. Care management services _____C. Lack of coordination _____D. Lack of consistency 4. Which of the following statements is NOT true of home care aide organizations? _____A. Ninety-five percent of care needed by seniors is for ADLs and IADLs. _____B. Such services generally are not covered by the Medicare home health benefit. _____C. These organizations have been recognized as an established industry and are highly regulated in most states. _____D. The services are paid for out of pocket or through long-term care insurance. _____E. This care evolved from a social model of care. 5. Which question should be asked by someone looking for a company to provide in-home custodial care? _____A. Does the organization conduct an assessment before sending a caregiver into the home? _____B. What are the organization’s hiring practices (eg, does it conduct background checks before placing a caregiver in the home)? _____C. Is regular supervision conducted to ensure that proper care is provided? _____D. Who employs the caregiver? Is the client or the organization responsible for supervision, liability, and payroll deductions? _____E. All of the above Name ______________________________________________________________________________________________________ Address ____________________________________________________________________________________________________ City ___________________________________________________ State __________________ ZIP ________________________ Signature ___________________________________________________________________________________________________ An individual application and $10 payment must accompany each request. Applicants who do not score 80% or higher may reapply with another application and additional $10 payment. No refunds will be issued for the $10 processing fee, regardless of the certification an applicant holds. Documentation of credit and an approval number will be mailed from the foundation in 3 to 4 weeks. (Credit available from January 1 to March 31, 2001.)
January/February 2001
TCM 45
CEU
The Value of Home Care Assistance by Virginia Pinkerton, MA An analogy I find helpful to explain what home care aide (HCA) organizations do goes like this: if skilled medical services are the bricks of home care, HCA services are the mortar. HCA organizations hold the care structure together over a long period, filling in the gaps and preventing breakdowns that could threaten senior clients’ overall well-being. In short, we provide the services that allow seniors to stay independent, in control of their own lives, and in their own homes for as long as possible.
“
S
o what exactly is it that you do?”
Those of us who help provide home
care assistance to seniors hear that question a lot. It comes with the territory when you work in an industry segment that is both the fastest growing and the least understood in elder care today. TCM 42
January/February 2001
What Is an HCA Organization? Of course, more specific differences exist between home health agency services and those provided by HCA companies. The former’s services are primarily shortterm and medical in nature and must be ordered through a physician (eg, nursing and physical, occupational, and speech therapy). The primary goal is to help seniors through a crisis or acute episode, bring them to their maximum level of independence, and discharge them from service. This program generally is covered under the Medicare home health benefit. On the other hand, HCA organizations provide long-term supportive services, such as activities of daily living (ADLs) (eg, bathing, dressing, meals, and ambulation) and instrumental ADLs (IADLs) (eg, shopping, laundry, light housekeeping, and transportation). These costs generally are borne by seniors or their families. For an elderly person, however, these services are the difference between staying healthy and going into
An example is a San Diego, Calif., man who has been receiving HCA services from my company, AccentCare, for 6 years. In the beginning, we provided hourly care for John and his wife, who has since passed away. Caregivers shopped for them, prepared their meals, helped clean their house, and made sure the couple took their medications. Over the years, John has come to require 24-hour live-in assistance, but he remains alert and happy in his own home—at 105. The family is assured of his care through regular updates from our staff. The longevity of that case is unusual, but the gentleman’s needs are not. Surveys show that ADLs and IADLs are the types of services most people need as they age. According to a 1999 study prepared for the U.S. Department of Health and Human Services,1 only 5% of seniors who need care require the type of skilled care for which Medicare provides coverage. A whopping 95% of the rest need assistance with ADLs and IADLs.
standards of care for skilled nursing services and assisted living facilities. The good news is that many HCA organizations have recognized the problems that come with an unregulated industry and are beginning to implement voluntary standards. In California, I chaired a committee of providers who worked with the state Association for Health Services at Home to develop minimum voluntary standards of care. Our committee also worked with the Community Health Accreditation Program, a consumer-driven health care accreditation organization in New York, to develop an accreditation standard specific to the HCA industry. In addition, we identified other high-quality, HCA-specific accreditation programs, such as the Accreditation Commission for Home Care in North Carolina and Home Care University, an affiliate of the National Association for Home Care in Washington, D.C. However, because this segment of the industry is not regulated, many companies don’t see the need to be accredited. The resolution of this issue will be consumer- and payer-driven. Home Care Considerations Family members, discharge planners, and case managers searching for a quality home care provider must consider a number of issues and questions.
However, an awareness of the availability of HCA services remains low, mainly because the industry is so young. In the 1950s, “homemaker services” referred to child care in the home. In the 1960s, home care was formally recognized as including adults. In-home care began as an informal social model of care. Family, friends, and churches traditionally have provided needed support for seniors. Over time, however, families have changed and often are separated by distance, or both the husband and wife work, increasing the need for HCA services to fill the gap.
Who pays for home care? People wrongly assume that the government, Medicare in particular, will pay for long-term care (LTC), but the program does not cover assistance with ADLs or IADLs. Medicaid, known as Medi-Cal in California, pays for nursing home care for those whose assets are below a specified level. But in general, LTC is a private-pay market. Rates vary by region, but generally they range from $13 to $22 for hourly care and $130 to $200 per day for 24-hour live-in care.
Because the HCA industry is young, it is virtually unregulated in most states. Almost anyone can call himself or herself a caregiver. The lack of regulation in the industry inevitably leads to problems with poorly delivered services by unqualified staff. Stories of theft and abuse also have been noted in this segment. Contrast this to the other end of the care continuum where government regulation is firmly in place to maintain
Some seniors have LTC insurance policies that may include home care coverage. Those who do are forward thinkers who have planned for the inevitable, but they are in the minority. The first time most seniors and their families think about home care is during a crisis. A 1999 poll conducted by the Los Angeles Times2 found that 81% of respondents not currently providing elder care had no plans for dealing with it.
Discussing these issues with aging relatives is difficult. And even when family members are ready to bring up the topic, parents are not always willing to discuss the possible need for LTC because they don’t want to be a burden. Those who have had the experience of caring for an elderly spouse, parent, or relative report that it requires a tremendous amount of physical and emotional stamina. A study published in the December 1999 Journal of the American Medical Association3 found that the stress of providing supportive care to a sick spouse could shorten a caregiver’s life. Families and their advisers must understand the options on the continuum of care. From the least to most restrictive, care options are home care, retirement communities, independent living facilities, assisted living facilities, board and care facilities, and skilled-nursing facilities. In short, most people do not understand what their options are. When a triggering event occurs, such as a fall, stroke, broken hip, diagnosis of Alzheimer disease, or a terminal illness, family members struggle to become educated quickly. It is not surprising that many poor choices are made in such situations. Determining a system to help coordinate care and assign responsibilities is important. Results of the 1999 study for the Department of Health and Human Services1 indicated that having both formal and informal caregiving in the home and a lack of coordination and consistency of that care caused the elderly’s needs to be inadequately met or not at all. Good providers will maintain consistency, coordinate care, and provide more highly trained and supervised caregiving staff. Families may benefit from using professional care coordination or case management services. Additional Questions The following questions and more than 25 others come from an evaluation tool I developed for home care providers intended to help consumers and referral sources, such as case managers and geriatric care managers, gain information about agencies to which they might refer patients. January/February 2001
TCM 43
CEU: HOME CARE
the hospital. Assisting seniors with light housekeeping, nutrition, and reminders to take medications consistently may make a significant difference in their quality of life.
CEU: HOME CARE
• Is the agency a member of a state or national home care association or other professional organization?
• Does a qualified individual conduct an assessment before services start?
and non-privately insured disabled elders living in the community. Washington (DC): the Department; 1999.
• What are the caregiver’s qualifications? • Will it provide a written plan outlining the caregiver’s duties? • What are its hiring practices? • Who employs the HCA? If the caregiver is employed by the agency, he or she should be covered for workers’ compensation insurance, Social Security, tax withholdings, EDD coverage, Medicare/Medicaid, and state disability. However, if the aide is an independent contractor, he or she should provide evidence of income-tax filing and payment of the additional taxes that an employer pays. Most importantly, the client or responsible party then becomes the employer and must not only have liability insurance and make the appropriate payroll deductions but also be capable of screening, checking references, and supervising.
• Will a supervisor visit the client’s home at regular intervals to make sure services are satisfactory or to reassess if conditions change? Will a written or verbal report of these visits be provided to the client’s family? The search for a high quality HCA agency may seem daunting. When the reward is finding a reliable organization that meets a client’s needs, however, the investments of time and energy seem small indeed. ❏ References 1. U.S. Department of Health and Human Services Office of Disability, Aging and Long-term Care Policy, LifePlans, Inc. A descriptive analysis of patterns of informal and formal caregiving among privately insured
2. National Survey: aging. Los Angeles Times 1999 April. 3. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the Caregiver Effects Health Study. JAMA 1999;282. Virginia Pinkerton, MA, former owner of a home care services organization, is the director of quality management and regulatory affairs for Irvine, Calif.-based AccentCare Inc., a 13-branch home care services company. She was the first representative of a home care aide organization to serve as chairwoman of the board of directors of the California Association for Health Services at Home. Freelance journalist Dennis Arp contributed to this article. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/112769 doi:10.1067/mcm.2001.112769
Mark your calendars now and plan to attend...
Mosby’s 13th Annual Medical Case Management Convention (MCMC XIII) September 22-25, 2001 Baltimore Convention Center Baltimore, Maryland Sponsored by:
To receive an MCMC XIII brochure as soon as it is available, call 800-826-1877. Visit Mosby’s Continuing Education and Training Department online at: www.mosby.com/CET TCM 44
January/February 2001
CEU: HOME CARE
CEU APPLICATION This article has been approved for 1 hour of CCM, CRC, and CDMS education credit by The Foundation for Rehabilitation Education and Research. To obtain your education credit, please do the following: 1. Read the “The Value of Home Care Assistance” article. 2. Make copies of this page for each person applying for credit. 3. Answer the following questions by selecting one statement. Four questions must be answered correctly to receive the educational credit. 4. Mail this completed form with a check for $10 to: Foundation for Rehabilitation Education and Research 1835 Rohlwing Rd., Ste. E, Rolling Meadows, IL 60008 Questions: For which educational credit (1 hour) are you applying? CCM ID#___________ CRC ID#___________
CDMS ID#__________
1. Which of the following statements describes issues in elder care today? _____A. Elders and their families typically do not plan ahead for potential crises and do not know how to find help when needed. _____B. Women are more likely to look after aging parents, making up 72.5% of all caregivers. _____C. Many adult children and their families are uncomfortable discussing long-term care needs. _____D. Caregiving can be stressful and, in fact, can shorten life expectancy. _____E. All of the above 2. The in-home custodial care provided by home care aide organizations differs from care provided by a home health agency in which way? _____A. Provides long-term supportive care that enables seniors to age in place as long as possible _____B. Provides skilled nursing care _____C. Administers medications _____D. Reimbursable by the government 3. Which of the following does NOT typically contribute to seniors’ unmet or undermet needs? _____A. Both formal and informal caregiving in the home _____B. Care management services _____C. Lack of coordination _____D. Lack of consistency 4. Which of the following statements is NOT true of home care aide organizations? _____A. Ninety-five percent of care needed by seniors is for ADLs and IADLs. _____B. Such services generally are not covered by the Medicare home health benefit. _____C. These organizations have been recognized as an established industry and are highly regulated in most states. _____D. The services are paid for out of pocket or through long-term care insurance. _____E. This care evolved from a social model of care. 5. Which question should be asked by someone looking for a company to provide in-home custodial care? _____A. Does the organization conduct an assessment before sending a caregiver into the home? _____B. What are the organization’s hiring practices (eg, does it conduct background checks before placing a caregiver in the home)? _____C. Is regular supervision conducted to ensure that proper care is provided? _____D. Who employs the caregiver? Is the client or the organization responsible for supervision, liability, and payroll deductions? _____E. All of the above Name ______________________________________________________________________________________________________ Address ____________________________________________________________________________________________________ City ___________________________________________________ State __________________ ZIP ________________________ Signature ___________________________________________________________________________________________________ An individual application and $10 payment must accompany each request. Applicants who do not score 80% or higher may reapply with another application and additional $10 payment. No refunds will be issued for the $10 processing fee, regardless of the certification an applicant holds. Documentation of credit and an approval number will be mailed from the foundation in 3 to 4 weeks. (Credit available from January 1 to March 31, 2001.)
January/February 2001
TCM 45