Transitions: Moving Through the Healthcare Maze

Life is full of transitions. From a child’s first day of school to the launching of a young adult’s career to an older adult’s retirement party, these planned transitions can be filled with anticipation and excitement.

Life often delivers unexpected transitions, too. A natural disaster, a medical emergency, the loss of a job; these situations can bring about uncertainty and anxiety.

Healthcare transitions among older adults usually fall into the category of unexpected transitions. The parties responsible for handling these care transitions are then left with a complex maze of care options and are provided few resources to help navigate these options.

Research clearly shows that families are often ill-equipped to handle the sudden care transitions of an older loved one. A senior care cost index, for example, states that 60% of caregivers felt their caregiving duties had negatively affected their jobs. What’s more, 46% of family caregivers spent more than $5,000 a year in caregiving costs. These statistics reveal the reality that families lack support and resources to help them take an aging loved one’s care transitions in stride.

Medical Transitions

If your loved one needs to be admitted into a hospital, a number of options exist:

Acute Care

Acute care is a typical short-term stay in a hospital. Your loved one must meet medical necessity (having a severe injury or episode of illness, an urgent medical condition or recovering from a surgery) in order to remain in acute care. Insurance or Medicare will cover acute care. The patient will be responsible for any copays or out of pocket deductibles.

Long-Term Acute Care Hospital (LTAC)

An LTAC provides care for patients with serious medical problems that require intense, special treatment for an extended period of time—typically an average of 25 days or more. Insurance or Medicare covers stays in LTAC facilities.

Acute Care Rehabilitation provides intensive rehab for patients in a hospital setting. Rehabilitation typically lasts 3 hours per day for 5-7 days per week. The patient must meet medical necessity. Insurance or Medicare covers acute care rehabilitation, but insurance plans may require prior authorization.

Skilled nursing and rehab

Skilled nursing and rehab is often the next step for an aging loved one following hospitalization. A skilled nursing facility could be a nursing home, a stand-alone facility or even a unit within a hospital. To receive skilled nursing care, the patient must have medical need and have been admitted to a hospital for at least 3 midnights (skilled nursing is NOT nonmedical custodial care). Insurance or Medicare will cover the cost of skilled nursing, but copays and deductibles may apply.

After receiving skilled nursing services, your loved one may require any number of outpatient services. Outpatient services can include occupational therapy, physical therapy, radiology, lab testing and speech therapy based on your loved one’s needs. Insurance or Medicare covers most outpatient services, but copays and deductibles may apply.

Home health care is an alternative to a skilled nursing facility for patients wishing to receive care at home for an illness or injury. In order to receive home health care, a diagnosis must be provided explaining why home health is necessary. Home health care is meant for short-term care, not for chronic or long-term illnesses. Insurance or Medicare often covers home health care, but any out of pocket costs will vary by policy.

Hospice is a special end-of-life service that focuses on caring for loved ones in their final stages of life rather than curing them. Medicare requires that a patient requesting hospice has received a prognosis of six months or less, but the hospice services are not limited to six months (hospice will even keep in contact with families for a year following the loss of a loved one). Hospice services can be provided in-home or in a facility, but room and board in a facility is not covered under benefit. Insurance, Medicare and Medicaid will all cover hospice services.

Living Transitions

An independent living facility can also be known as a retirement home. Independent living facilities offer apartment-style living while incorporating community activities and amenities. Any care needed while in an independent living facility must be provided by an outside medical or non-medical provider. Staying in an independent living facility requires private pay, meaning your family must pay out-of-pocket.

Assisted living facilities allow your loved one to live as independently as possible, while offering a number of care options such as memory care. Residential care homes have become a popular choice among those needing assisted living services because they offer a smaller, homey atmosphere. Residential care homes can be located in neighborhoods just like yours! Assisted living facilities are NOT covered by insurance or Medicare. ALFs generally require private pay, but some long-term care insurance policies will cover ALFs. Medicaid might also cover ALF living through waiver programs, but financial criteria must be met and approved.

If your loved one is experiencing memory issues but can still live fairly independently, adult day services may be a good option. Adult day services offer day-time activities that provide social interaction and help stimulate your aging loved one’s memory during normal working hours. Adult day services are NOT covered by medical insurance or Medicare. Some ADS facilities accept VA benefits or Medicaid programs, but most adult day services will require private pay.

Nursing homes offer 24-hour nursing care for longer periods of time. Nursing homes assist your loved one with daily care needs (custodial care) such as dressing, grooming and eating. Nursing homes are NOT covered by medical insurance or Medicare. Medicaid will cover nursing home stays if financial and medical criteria are met and approved.

If your loved one simply needs help with independent activities of daily living such as doing laundry or cooking, non-medical home care (PAS) might be a good solution. Non-medical home care services provide workers who will visit your loved one in his or her home or in a facility. These workers are usually paid on an hourly basis. Non-medical home care is not covered by health insurance or Medicare. Some long-term care insurance policies may cover non-medical home care, otherwise the expenses must be covered out-of-pocket.

By Dane Roper