Long Term Care. Chapter. In This Chapter

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1 Long Term Care It is estimated that approximately 70 percent of persons age 6 and older will need some form of long-term care at some point in their life. Long term care can occur in a person s home, in community based care, or a combination of both. Services are available for people who opt to stay in their home including In-Home Care and Adult Day Centers. The following information is a brief summary of the services offered in Oregon. Chapter In This Chapter Section -1 Living Options Section -2 Choosing a Senior Housing Community Section -3 The Resident s Bill of Rights Section -4 Paying for Long Term Care Section - Complaints

2 Chapter Long Term Care -1 Living Options Oregon has a unique range of residential communities for older adults who need help with activities of daily living or have medical concerns. Continuing care retirement communities, assisted living facilities, residential care facilities, adult foster care homes, and nursing facilities are options available to Oregonians who are considering relocating to a place they can receive help with their daily activities. Each community offers a different range of services. In-Home Care In-home Care and home health agencies provide assistance in your own home or other setting. The goal of in-home care is to provide enough help to allow you to stay in your current living situation. Services can include chores such as housekeeping and yard maintenance; personal care such as dressing, showering; and medication reminders. Home health is for rehabilitation services ordered by a medical provider. See Chapter 2, Medicare, for more information. It includes skilled care such as nurses, therapists, and health care providers. The length of service can be long term or on an as-needed basis for a short period of time. Medicare can pay for some home health visits and physical therapy under certain very limited conditions. Oregon Project Independence (OPI) can provide assistance to impaired seniors with daily activities, such as shopping, bathing, and housecleaning. Services such as Meals on Wheels can help you stay in your home longer. Adult day care is also available for people who need assistance and socialization during the day. 6 Legal Issues for Older Adults

3 Section -1 Living Options Continuing Care Retirement Community (CCRC) A CCRC provides a continuum of care from retirement through skilled nursing services on a single campus. There are about 1 of these communities throughout Oregon. There is an entrance fee and monthly fees. Generally there are income and asset requirements. Chapter Prospective residents must be provided information about how to cancel a contract and a copy of the community s last audited financial statement. If you sign a contract to live there, the community must provide you with a description of the services it offers and the fees required. Ask the following questions if you want to find out more about this type of community: 1. Are entrance fees refundable? 2. How does the community handle transfers to assisted or nursing care? 3. Is a transfer decision made by the staff only, or do I, my physician and my family control it? 4. How many nursing home beds are available?. What happens if no bed is available when I need it? 6. Are there memory care units available? 7. What happens if my spouse and I need different levels of care? 8. Can the community increase the monthly fees? 9. Am I required to have health insurance, and if so, would I be paying double? 10. What happens if I outlive my savings? 2012 Edition 7

4 Chapter Long Term Care Assisted Living Facility An Assisted Living Facility is licensed by the state and offers: Room and board in private apartments; Kitchenette; Housekeeping services; Medication and behavior management; 24-hour staff; Organized activities; and Help, if it is needed, with dressing, bathing, and personal hygiene. Residential Care Facility A Residential Care Facility is a state-licensed community serving six or more residents. It is similar to an Assisted Living Facility except the licensing does not require each apartment have private bathrooms or kitchenettes. Retirement Community A Retirement Community is a setting specifically for people age and older. These communities are not licensed and do not provide care to residents. These communities do provide: Room and board; Some offer meals or add meal programs or full service restaurant options; Organized activities; Security; and Limited housekeeping. 8 Legal Issues for Older Adults

5 Adult Care Home Section -1 Living Options Adult Care Homes are a living option with a smaller, homelike setting, often with a family, for five or fewer residents. There are three levels of Adult Care Homes in Oregon. The scope of care the Adult Care Home can provide is dependent on its level of care ("level three" homes can provide heavier care). The home may provide: Chapter Room and board; Medication management; Help with dressing, bathing and personal hygiene; Some nursing care; and Activities. Memory Care Community Communities that provide care to individuals with Alzheimer s or dementia are governed by additional regulations to ensure they provide appropriate care to their residents. These communities offer apartment style housing with a secure building and secure outdoor area. Some have alarms in addition to codes for entering and exiting the building. Rooms can be shared or private. In addition to the security of the building, Alzheimer s communities must provide programs to help residents with dementia including: Gross motor skills; Self care; Crafts and other appropriate activities. These units/communities are more expensive due to the extra care required for the residents Edition 9

6 Chapter Long Term Care Nursing Facility A Nursing Facility may be called a nursing home, care center, convalescent center or rehabilitation facility. Nursing facilities may offer: Room and board; 24-hour nursing; Personal care; Administration of medications; Management of chronic medical problems; Organized activities; Social services; and Discharge planning. A nursing facility also offers daily medical evaluation and rehabilitation services by physical, speech, and occupational therapists. Generally, people stay in nursing facilities only for a limited time unless their care needs require 24 hour nursing care or they are not appropriate for another setting. -2 Choosing a Senior Community It is important that the person who will be moving to a long term care setting makes the final decision about living in a senior community. Often, particularly in the middle of a crisis, communities turn to the spouse or adult children to make the decisions out of convenience. Family members and friends can offer advice, but the prospective resident should make the decisions, unless he or she is incapacitated. 60 Legal Issues for Older Adults

7 Section -2 Choosing a SeniorCommunity Social workers, referral agencies, and the Area Agency on Aging/Seniors and People with Disabilities office (AAA/SPD) can give information about arrangements that may be appropriate for you. If you are hospitalized, a preadmission screening is available to you. This service can help you make the decision about where you want to live based upon your particular needs and desires. For instance, if you need daily skilled care by licensed nurses, then you might want to choose a nursing home. If you need help with reminders to turn off the stove burners and take your prescribed medications, an adult foster care home or assisted living facility may be appropriate. Chapter When considering a specific living option, be sure the community and its administrator have current licenses as required by law. Consider whether you would get along with the people who live there. Inspect the home carefully. Make sure that they will provide the maximum opportunity for independence and mobility. Speak with the current residents about their lives. For example, ask about the quality of food, recreation, exercise, clubs, organizations, entertainment, and planned trips, as well as the freedom to have visitors and personal possessions such as furniture, bedspreads and curtains of your choice. Mealtimes are a good time to speak with current residents. Check on policies about visiting hours and phone calls (generally you will have your own phone line in assisted living, residential care, and retirement settings). Also, make sure that your personal doctor can care for you at the community. Ask the facility for a copy of its policies and procedures. An attractive exterior could be hiding a place that provides inadequate care. On the other hand, a floor that does not shine may mean that the community is making a safer environment for those with vision problems. Make sure the community you choose meets your needs. Visits from friends and relatives are very important so choose a living option near them, your place of worship or area you would like to live. To help you choose, you can ask family, friends, senior housing referral agencies, and doctors to participate in the decision process. Make sure the community you choose meets your needs Edition 61

8 Chapter Long Term Care Some Questions to Ask Consider asking the following questions. Note the answers, and learn the name and position of the staff members who answer your questions. See Chapter 14, Resources, for AAA information. 1. Is the community licensed? Is the license in danger of being revoked, suspended, or not renewed? (Independent Retirement Communities are not licensed but any community that provides care should be licensed). Ask the staff if you can see a recent inspection report. Check with the local AAA office and the state office of the Long Term Care Ombudsman, or senior housing referral agency for more information, such as possible abuse complaints from residents. (See Chapter 14, Resources.) 2. Do they have a contract with the state of Oregon to accept Medicaid? You may want to consider this even if Medicaid is only a distant option. Medicaid contracts are optional for communities and current contracts do not guarantee they will accept Medicaid payments in the future but is a good indication that they will continue the current contract. 3. What levels of care are provided? 4. Are organized activities and religious services available?. What rehabilitation and physical therapy communities and staff are available? 6. Are there any visitation restrictions? 7. Do staff members receive regular training and attend educational programs? 8. Are meals planned by a registered dietician or chef? Are special diet requests available? 9. Does the community have adequate safety features? Look for smoke detectors, alarms, sprinklers, hand rails, grab bars, and wide doors. 62 Legal Issues for Older Adults

9 Section -2 Choosing a SeniorCommunity 10. What is the basic monthly rate, and what services does this rate include? How much do additional services cost? How often have the rates increased in the last five years? Chapter 11. Are any deposits required? (The community cannot require a deposit from Medicaid residents.) 12. Does the community use a particular pharmacy, and are the prices competitive with local pharmacy prices? 13. Does the community provide a safe place to keep valuables? Have there been any problems with theft? Senior community advocate organizations have helpful information for residents and their families. The Office of the Long Term Care Ombudsman and the Department of Human Services Facilities Licensing Office maintain a list of all of the communities in Oregon except retirement and independent living communities. Violations of state and federal laws are available to the public. Things to Observe Safety hazards, such as poor lighting, blocked fire doors, loose cords or torn carpets, etc; Cleanliness (check for dust, clean bathrooms, and deodorants used to cover up smells); Comforts such as flowers, art and seasonal decorations, working televisions and radios, pleasant public areas and accessible telephones; Involvement of residents; and The staff s attitude toward residents. Are residents treated with respect and dignity? How much privacy do residents have? 2012 Edition 63

10 Chapter Long Term Care -3 The Resident s Bill of Rights State and federal laws assure that each adult care community resident: Be treated as an adult with respect and dignity; Be informed of all resident rights and all house policies; Be encouraged and assisted to exercise constitutional and legal rights including the right to vote; Be informed of their medical condition and the right to consent or refuse treatment; Receive appropriate care and services and promptly; Be free from mental and physical abuse; Complete privacy when receiving treatment or personal care; Associate and communicate privately with any person of choice and send and receive personal mail unopened; Have access to and participate in activities of social, religious, and community groups; Have medical and personal information kept confidential; Keep and use reasonable amount of personal clothing and belongings, and to have a reasonable amount of private, secure storage space; Be free from chemical and physical restraints except as ordered by a physician or other qualified practitioner. Restraints are used only for medical reasons, to maximize a resident s physical functioning, and after other alternatives have been tried. Restraints are not used for discipline or convenience; Manage their own financial affairs unless legally restricted; 64 Legal Issues for Older Adults

11 Section -3 The Resident s Bill of Rights Be free from financial exploitation. The licensee must not charge or ask for application fees or non-refundable deposits or solicit, accept or receive money or property from a resident other than the amount agreed to for services; Chapter Be provided with a written agreement regarding rates and services. The licensee must provide 30 days written notice before any change in the rates or ownership of the home; Not to be transferred or moved out of the community without 30 days written notice and an opportunity for a hearing. A licensee may transfer a resident only for medical reasons, or for the welfare of the resident or other residents, or for nonpayment; Be provided a safe and secure living environment; Be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion; and Be able to offer suggestions or complaints without fear of retaliation. The bill of rights for a nursing facility resident: Be fully informed of all rules for resident conduct and responsibilities when the resident moves into the community; Be fully informed of services available in the community, related charges, charges not covered by Medicaid or the community s basic daily rate when the resident moves in; Be fully informed by a physician of his or her medical condition; Can participate in medical treatment planning; Can refuse to undergo any kind of medical treatment so long as the resident understands the consequences of refusing treatment; Can refuse to participate in experimental research; Is transferred or discharged only for medical reasons, the resident s best interests or non-payment; 2012 Edition 6

12 Chapter Long Term Care Is given reasonable advance notice for orderly transfer or discharge; Is encouraged to exercise all rights as a resident, voice grievances, and recommend changes in policies and services; Is free from restraint, interference, coercion, discrimination, or reprisal; Can manage personal financial affairs, or, if the community is handling the finances, be given a written report of financial transactions made on his or her behalf at least once a quarter or whenever the resident asks for a report; Is free from mental and physical abuse and from unnecessary chemical and physical restraint that are not prescribed by a doctor to treat symptoms; Is assured confidential treatment of personal and medical records, and may approve or refuse their release to any person outside the community (except if transferring to another health care institution); Is treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and care for personal needs; Is not required to perform services for the community that do not have therapeutic purposes in a plan of care; May communicate privately with persons of his or her choice and send or receive personal mail unopened; May keep personal clothing and possessions as space permits; If married, is assured privacy for visits by his or her spouse; and Is allowed to share a room with his or her spouse, if husband and wife are both residents in a community. 66 Legal Issues for Older Adults

13 Section -4 Paying for Long Term Care -4 Paying for Long Term Care Chapter Planning ahead for long term care will provide more options and may help protect your assets. Many people will end up needing long term care but most don t plan until a life changing event occurs. The three main sources of funding for long term care are private funds, Medicaid, and long term care insurance. Medicare generally does not pay for long term care outside of 100 days of skilled nursing and some Home Health services. Certain veteran benefits may also be available for long term care. When searching for long term care first determine what the cost will be. The law requires long term care communities inform their residents of rates and services. See Chapter 3, Medicaid for more information. Get a copy of the admission agreement from a facility to review before signing as you may want to negotiate changes with the community. Life Insurance Accelerated Death Benefit Some life insurance policies offer an accelerated death payment which pays all or part of the policy s death benefit upon a terminal illness or permanent confinement. Review your policy or speak with your agent to see if your policy contains this clause or if one can be added to your current life insurance policy. Long Term Care Insurance Medicare and Medigap insurance do not cover the cost of long term care. Medicaid does cover all types of long term care. Long term care insurance is private insurance that can be purchased to cover the cost of nursing home care, home care, and other levels of service. Long term care policies are not standardized. There are a number of policies types and options; including riders, available in Oregon. Long term care policies are required to pay for covered services through a nursing home, See Chapter 2, Medicare, and Chapter 3, Medicaid, for more information Edition 67

14 Chapter Long Term Care assisted living community, home care, and adult foster home. Policies generally begin to pay for long term care when a certified healthcare provider confirms: The policy holder needs substantial supervision because of a lowered cognitive state or Section 4 The policy holder needs help with two or more Activities of Daily Living. Most policies provide a benefit up to a certain dollar amount per day, for a certain period of time. Generally, the larger the benefit and the longer that benefit is payable, the higher the cost of the policy. The cost increases with your age. After you have reached a certain age or have been diagnosed with a particular medical condition, you may not be able to buy long term care insurance. These limitations vary among policies, it is best to review multiple policies before deciding on one. Purchasers of long term care insurance policies have certain rights. For example: A policy is renewable as long as you pay your premiums on time. The company cannot end your policy due to changes in age or health. Your policy cannot limit its benefits to skilled nursing care only, but must offer home care, assisted living, and adult care home coverage (on policies purchased after 1992). Your policy cannot provide significantly better benefits for any single level of care. Your policy must pay for Alzheimer s disease and related illnesses. Your policy cannot require hospitalization before paying benefits for long term care. Your policy cannot require you to receive a higher level of care before paying benefits for a lower level of long term care. A new policy must cover pre-existing conditions after six months from the effective date of coverage. 68 Legal Issues for Older Adults

15 Section -4 Paying for Long Term Care There is a free look period of 30 days, during which you can cancel the policy for a full refund. Chapter In addition, companies selling long term care policies in Oregon may be required to: Provide alternatives if rates increase; Provide conversions or continuation programs for policy holders who lose group coverage; Offer inflation protection as an optional rider; and Include provisions to prevent unintentional lapses. Before You Buy Long Term Care Insurance: Read the Oregon Consumer Guide to Long Term Care Insurance, available from the Oregon Insurance Division. Determine if you or your spouse will qualify for Medicaid assistance. Know your insurance needs and budget before speaking with an insurance agent. You may not need long term care insurance if: You have limited assets or income; or You are currently on Medicaid. Ask for an explanation of the benefits if anything in the policy is unclear. See Chapter 14, Resources, for contact information for the Oregon Insurance Division. Request the policy in be writing and signed. Compare policies before you buy. Make sure the policy covers all the benefits you may need. Some policies cover unforeseeable care items. For example a new type of living arrangement that may not be known now. Ask how policies will plan for such things that may occur Edition 69

16 Chapter Long Term Care Questions to Ask: Does the policy pay for all levels of care? How long will the benefits be paid? (The law requires a minimum of 24 months.) How does the premium compare with the maximum coverage provided? (How much coverage am I getting for the premiums?) Will premiums be waived while I am receiving care? Will premiums increase? What percentage of submitted claims get paid? How is the financial status of the insurer? How long have they been in business? What are the limitations and waiting periods for pre-existing conditions? What is the satisfaction level of policy holders with the provider? Medicaid Medicaid, also known as the Oregon Health Plan in the State of Oregon, is a needs-based financial assistance program. Medicaid will pay for care provided by a nursing home, adult foster home, assisted living facility, residential care facility, or in-home services for an unlimited time for persons who qualify under the income and assets guidelines. See Chapter 3, Medicaid, for more information. A person who can afford long term care when they first move to a community may eventually deplete their assets and become eligible for Medicaid. An attorney who is familiar with the Medicaid program can provide advice about how to qualify for Medicaid assistance. Not all senior living communities or in home care providers accept Medicaid payments. If you are likely to need Medicaid in the future, find a community that is contracted with Medicaid or you may need to move once your assets are depleted. The care provider must inform you of services and rates including any extra charges not covered under Medicare or Medicaid. 70 Legal Issues for Older Adults

17 Section -4 Paying for Long Term Care Facilities with Medicaid contracts cannot require the resident, their friends, or relatives to pay money in addition to the Medicaid rate for covered services. (See Chapter 3, Medicaid, for more information.) Chapter Medicare Medicare, like most health insurance plans, does not pay for most long term care costs. Medicare is a federal health insurance program for people age 6 and older and certain disabled people under age 6. Medicare will pay for a limited time of qualified skilled nursing and a limited amount of home health care. There are co-payment requirements. Reverse Mortgage See Chapter 2, Medicare, for more information. A reverse mortgage can be obtained by people who own their home with enough equity to qualify. In a reverse mortgage, the bank makes payments to the home owner, buying the property back from them. To qualify, you must be 62 years of age or older, own your home outright, or have a low mortgage balance that can be paid off at closing with proceeds from the reverse loan, and you must live in the home. Repayment on the loan is due upon your death or permanent move from the home. Generally the reverse mortgage holder will give the home owner or their descendents a specific amount of time to repay the loan or sell the home. If the balance is not tendered within that time, the reverse mortgage holder has the ability to take ownership of the property. There are fees associated with a reverse mortgage similar to a traditional home loan. The Veterans Administration The Veteran s Administration provides long term care for some United States Military Veterans. There are facilities for veterans in addition to programs such as Aid and Attendance and Home Bound Programs that are outlined in Chapter 4. See Chapter 4, Veterans Benefits, for more information Edition 71

18 Chapter Long Term Care. Complaints If you have a complaint about a nursing home or other community, you have a right to make your complaint known without fear of retaliation. You can report your complaint to: The nursing home administrator or resident manager; Oregon s Long Term Care Ombudsman. (See Chapter 14, Resources); See Chapter 14, Resources, for contact information. The Seniors and People with Disabilities Services Client Care Monitoring Unit. (See Chapter 14, Resources); A residents case manager at a local AAA office. (See Chapter 14, Resources); Your state and local elected representatives or your U.S. representative and senators; or A knowledgeable private lawyer or your local legal aid office. (See Chapter 14, Resources.) Complaints are public information. They can be reviewed before moving into a licensed community. If you work with a referral agency or social worker, they should check the complaints for you. Some complaints are available online, but to obtain a complete updated list, including unsubstantiated complaints, visit the AAA office in the county the community is located. See Chapter 11, Abuse, for more information. If you believe that a resident of long term care community is being abused, neglected, or exploited, call the Protective Services worker at your local AAA office or call the Long Term Care Ombudsman Program. The situation will be investigated, and help will be offered. (See chapter 11, Abuse, for more information.) 72 Legal Issues for Older Adults