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Start-Up & Operations Manual U.S. Edition Copyright The Launch Company LLC All rights reserved. With the exception of the blank forms, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any other information storage and retrieval system.
Introduction A golden opportunity lies right before your eyes! If you have ever considered starting and operating a Home Care and Assisted Living Placement Business, conditions have never been better for success. The senior population is one of the fastest growing segments and, consequently, the demand for non-medical Home Care and Assisted Living Services is greatly expanding and will continue to expand well into the 21st Century. This means there is a business opportunity in the Senior Care industry open to you. Yet, the task of turning this opportunity into a reality remains as challenging as ever. The competition in the Senior Care field is stiff and will continue to increase, as baby-boomers age. Therefore, getting off on the right path is critical to your success. This manual, Launch Homecare - Start-Up Manual will help you along your journey by saving you time, money and by offering tips and guidelines in starting a successful Senior Care Business. Diligently researched and backed by many years of hands-on experience, the manual will put you on the fast track. It is generically presented and is tailored for the Non-Medical Home Care and Assisted Living Placement Business. It provides an introduction to Home Care, outlines the necessary steps for setting up a Senior Care Business. The Launch Company LLC - Start-Up & Operations Manual i P age
Cover & Introductory Pages Whether your intention is to operate a Senior Care Business by yourself or in partnership with another person or to establish a larger scale Senior Care Business, you will find the manual to be extremely helpful. While the manual is geared for the Non-Medical Home Care and Assisted Living Placement Business, the practices and tips it provides will also benefit a Medical Home Care Business. It is recommend that you start your business on a smaller scale and build from there, as it is easier to control and make modifications to a less complicated business than it is to a larger one, especially as you work through the learning curve. Icons Throughout the manual, various icons are used to make the document more user friendly. The icons used are illustrated below: Tip Tips to improve the effectiveness and efficiency of your business. Many of which have been learned from first hand experience. Web sites, which may be helpful on the subject being discussed. Suggestions for improving your chances of success. The Launch Company LLC - Start-Up Manual ii P age
Cover & Introductory Pages Additional information on a topic that the author feels is worth mentioning. Indicates certain material is provided in the Appendices. Advises of a value-added feature. Bonus Fictional Senior Care Business Also, throughout the document, a sample business Mystic Meadows Home Care Services - is used for illustrative purposes, which will assist the reader in relating theory to practice. The name is strictly fictional and does not represent a particular person, agency or other type of business. Form Usage For added value, the forms utilized and/or suggested throughout the manual are included in blank format in the Appendices. Although this document is Copyrighted, persons who purchase it may duplicate and use these blank forms, without obtaining permission from the author, providing they are used solely for the purchaser s own business and providing he/she does not sell them. Purchasers can use the forms as they are or they can modify them to suit their unique circumstances and desires. BEST OF LUCK IN YOUR ENDEAVORS!! The Launch Company LLC - Start-Up Manual iii P age
Cover & Introductory Pages Disclaimer Launch Homecare - Start-Up Manual is intended to provide general information and guidance only. Because legislative requirements for Home Care Standards, employment law and business operations vary, the information presented should not be interpreted as being universally applicable. Our manuals and training are sold with the understanding that they do not constitute legal, medical, accounting or other professional advice. Legal advice & other professional assistance should be sought prior to commencing your Senior Care Business in order to determine the impact of all levels of government legislation, rules and regulations, local laws, licenses, etc. upon the operation of your business. It is the user s responsibility to determine what is applicable in his/her area and to keep updated on changes in legislative and other criteria. The concepts, examples, and content should be used at the user s own discretion. The author shall not be held responsible for any losses, monetary or otherwise, which the user may incur. Neither shall the author be held responsible for any contracts resulting from the use of the sample forms or for the usage of various assessments, which are provided as a guide only. We have taken all necessary steps to ensure that our electronic products (downloads) virus free and will not accept liability for losses or damages as a result of viruses, worms etc., which may be transmitted through downloading, emails, copying and/or other means. The Launch Company LLC - Start-Up Manual iv P age
Cover & Introductory Pages Manual Site Map Chapters Chapter 1A - Homecare Overview Chapter 1B - Assisted Living Placement Overview Chapter 2 - Mission, Vision & Goals Chapter 3 - Feasibility Study Chapter 4 - Business Plan Chapter 5 - Financing Your Business Chapter 6 - Business Start-Up Requirements Table of Contents A Table of Contents can be found at the beginning of each Chapter. If you ve purchased the Launch Homecare Start-Up Package, you will have access to all of our manuals which, all together, will give you all of the information, tools, and resources needed to start your own home care and assisted living placement company. The Launch Company LLC - Start-Up Manual v P age
Chapter 1A Homecare Overview Chapter 1A HOMECARE OVERVIEW Table of Contents What Is Home Care?... 1! Non-Medical & Medical Home Care Services... 2! Is There A Need for Home Care?... 2! What Are The Goals of Home Care?... 3! What Are The Advantages And Disadvantages Of Home Care?... 3! What Are the Differences Between Medical & Non-Medical Personnel?... 5! Medical Personnel... 5! Non-Medical Personnel... 6! Who Purchases Home Care Services?... 7! What Types of Agencies/Organizations Provide Home Care Services?... 8! Home Health Agency... 8! Non-Medical Home Care Agency/Private Duty... 9! Registry/Staffing Agency... 9! Social Service Agency... 10! Companies... 10! Medical Equipment/Supplies... 10! Public Authorities... 10! Hospices... 11! Independent Contractor/Self-Employed Individual... 11! Who Pays for Home Care Services?... 11! Self /Private Pay... 13! Public Third Party-Payers... 13! The Launch Company LLC - Start-Up & Operations Manual i P age
Chapter 1A Homecare Overview Older Americans Act (OAA)... 13! Veterans Administration... 13! Social Services Block Grant Program... 13! Community Organizations... 14! Religious Associations... 14! Private Third-Party Payers... 14! Commercial Health Insurance Companies... 14! Medigap... 14! Long-term Care Insurance... 15! Health Insurance and Managed Care Organizations... 15! Civilian Health & Medical Program of the Uniformed Services (CHAMPUS)... 15! Health Maintenance Organization (HMO)... 15! Automobile Insurance Companies... 15! Workers Compensation... 15! Disease/Condition Focused Organizations... 16! Limited Government Payers... 16! Medicare... 16! Medicaid... 18! Medicaid Waiver... 18! Who Pays for Non Medical Home Care Services (i.e. Services You Provide)?... 19! Where Can Inquiries About Home Care Be Directed?... 20! The Launch Company LLC - Start-Up & Operations Manual ii P age
Chapter 1A HOMECARE OVERVIEW What Is Home Care? Home Care can mean different things to different people, so having a common understanding is an important first step in the planning and development of your Home Care Business. Home Care is a general term used to reflect a wide range of social, medical and non-medical support services that are conducted for purposes of enabling compromised individuals to live safely and independently in their own homes and communities. Home Care Services are provided by a number of different types of Home Care organizations/agencies and the skills and duties performed by Home Care personnel vary. Home Care that is not paid for by a governmental source (Medicare and/or Medicaid) is called Private Duty Home Care. Private Duty Home Care Agencies may provide highly skilled nursing services and/or non-medical support services. Private duty Home Care Services are usually paid for by the client and in some cases by third party payers as explained below. This segment of the Home Care market is vast and spending is expected to surpass Medicare spending in the not too distant future. The Launch Company LLC - Start-Up & Operations Manual 1 P age
Chapter 1A Homecare Overview Non-Medical & Medical Home Care Services Is There A Need for Home Care? There is a need for Home Care Services and that need is escalating and will become a factor to reckon with, as the elderly population numbers continue to increase. Part of this upsurge is due to: Senior citizens are living longer and baby-boomers are swiftly approaching their retirement years. The development of Health Care Teams and Health Care Providers enable people to be managed and monitored in their own homes and communities. Because of the high costs of health care in hospitals, patients are being discharged early. Many require short-term assistance at home, as they recuperate. Care in the home is more cost effective than care in hospitals/institutions. The quality of life improves for those people who are able to remain in their own homes. The burden on caregivers (family and/or friends who are providing direct care to someone) is increasing. Often this can result in caregiver burnout, which, in turn, leads to the need for outside support. The Launch Company LLC - Start-Up & Operations Manual 2 P age
Chapter 1A Homecare Overview There are global changes in health care needs, as a result of non-communicable diseases, mental illness, injuries and the continual growth of HIV and AIDS. Research is increasing the availability and effectiveness of treatments, medications and technology, which makes it possible for people to be cared for at home rather than being cared for in hospitals/institutions. These issues continue to place an increasing demand on the need for long-term care. Since health care costs will become even more staggering, the provision of effective in- Home Care continues to be a strong option. What Are The Goals of Home Care? The goals of Home Care include: assisting individuals to improve and maintain their health and quality of life; promoting the individual s independence; enabling individuals to receive care in their own home; enabling individuals to leave a facility to receive rehabilitation or palliative care at home; providing support to the family, which will help them handle an individual's need for care; and, providing informal caregivers with support to meet their own related needs. What Are The Advantages And Disadvantages Of Home Care? Advantages: Clients are happier when they are able to remain in their own homes and communities, as they can maintain their independence. Government subsidization costs are a mere fraction of what they would be if clients were hospitalized or institutionalized. Clients can choose the amount of care they receive (within established limits). Hospital stays can be shortened if the level of care they require can be delivered at home. The client s quality of life is enhanced when dignity, privacy and freedom are factored into the treatment program. The quality of care provided at home is often better than the care provided in institutions and hospitals. Terminally ill people can elect to spend their last days in their own homes, which provide a familiar and comforting environment. The Launch Company LLC - Start-Up & Operations Manual 3 P age
Chapter 1A Homecare Overview Relief can be provided to caregivers. Disadvantages: The client may have a number of caregivers, especially when an agency is utilized. Often there is a long-term expense required for in-home Care, especially when clients are not eligible for funding assistance. In addition to the costs of care, home maintenance and living expenses still must be met. Many people, especially pensioners, simply do not have sufficient financial resources for such extras. Staying at home can sometimes be lonely; consequently, social activities are often limited. The Launch Company LLC - Start-Up & Operations Manual 4 P age
Chapter 1A Homecare Overview What Are the Differences Between Medical & Non-Medical Personnel? Medical Personnel Medical Home Health services are delivered by medical personnel, which include: OCCUPATION Registered Nurses (RN) Licensed Practical Nurses (LPN) Physiotherapists Occupational Therapists Speech Therapists Social Assistants Dieticians DUTIES - provide skilled medical services including the insertion & monitoring of IV s, dispensing medications, giving injections, dressing wounds, monitoring vial signs and conducting catheterizations. - provide non medical and medical care, take vital signs, assist with personal care, ambulation, enemas, catheter care, range of motion exercises, tube feedings, and monitor/discontinue IV s. In some states, they may be permitted to administer medications and conduct other limited duties performed by an RN. - Work with people, who have disabilities or problems caused by disorder and accidents, to restore function and independence. - provide medical services such as training the client with disabilities or injuries on how to carry out his/her activities of daily living & determine if there is a need for special equipment, devices and/or home adaptations. - provide medical services such as assisting clients who have difficulty communicating as the result of stroke or other cause or have swallowing problems. - provide medical services such as assisting in the assessment of the social, emotional and environmental factors which affect the client & provide counseling & referrals. - provide medical services such as counseling on food choices & assist with developing diets specific to a client s medical conditions & individual likes & dislikes. The Launch Company LLC - Start-Up & Operations Manual 5 P age
Chapter 1A Homecare Overview Non-Medical Personnel Non Medical Home Care Services are delivered by Non Medical Personnel including: OCCUPATION Paraprofessionals such as: Certified Nurse s Aides/Assistants (CNA) & Home Health Aides (HHA) - Non Certified Assistants Homemakers Home Companions Chore Persons Volunteers DUTIES - are non medical assistants who are involved with the client s personal care & assist with activities of daily living such as transferring, mobility, dressing, grooming, bathing, toileting, doing exercises, taking vital signs, ensuring medications are taken and monitoring other activities. - provide non medical care such as custodial, personal care services housekeeping and homemaking. Note: A few states presently do not require that personnel, who perform personal care services, be certified. - deliver non medical services such meal preparation, housekeeping, laundry, shopping, general household, chores, running errands & accompanying clients to appointments. - provide non medical services such as companionship & social activities to housebound clients. Generally, they do not carry out any of the duties performed by homemakers and home health assistants, although they may help with minor chores. - deliver non medical services such as installing grab bars, railings on stairways, build wheelchair ramps, widen doors for wheelchair accessibility, lower cupboards and conduct a variety of minor renovations; - provide non medical services such as maintaining the grounds and ensuring safe access to the home through snow shoveling, shrub trimming, lawn cutting etc. - provide non medical services such as respite to the caregiver, errands, companionship, reading etc. The Launch Company LLC - Start-Up & Operations Manual 6 P age
Chapter 1A Homecare Overview Who Purchases Home Care Services? Home Care Services are purchased by a wide range of individuals and organizations. They include: the elderly; the housebound; the disabled; those with chronic illnesses; those with terminal illness; those who are recovering from acute illnesses or surgeries; those who are mentally or emotionally handicapped; family caregivers; accident victims; those requiring guidance with life skills; those seeking assistance with outdoor maintenance; those requiring transportation and errand running; and, those who require social outings. The Launch Company LLC - Start-Up & Operations Manual 7 P age
Chapter 1A Homecare Overview What Types of Agencies/Organizations Provide Home Care Services? Home Health Agency A Home Health Agency is a provider of home health services which include skilled nursing services, home health aides, and at least one other Home Care service such as medical social services, and therapies such as physical, occupational or speech therapy. It coordinates and provides health care services to individuals in their homes, rather than in an institutional setting. To be eligible for reimbursements from Medicare and Medicaid, these agencies need to be certified. Certification confirms that an agency has met the guidelines and criteria established by the federal government for patient care and management. These agencies must apply through the Centers for Medicare and Medicaid Services. The Launch Company LLC - Start-Up & Operations Manual 8 P age
Chapter 1A Homecare Overview The centers for Medicare and Medicaid Services can be accessed through: http://www.cms.hhs.gov/ Home Health Agencies are appropriate for clients who require skilled assistance. Care plans are closely scrutinized and managed and require a Physician s order. If a client requires care from more than one type of service provider, a multidisciplinary team often will be assembled to assess and develop simple and comprehensive care plans tailored to meet the individual s needs. The types of services that Home Health Agencies might deliver include nursing, physiotherapy, occupational therapy, speech therapy, medical supplies, social work, home health assistants and nutrition. These types of agencies may also provide nonmedical services as well. Non-Medical Home Care Agency/Private Duty A Private Duty Home Care Agency is generally an agency that provides Home Care Services that are not reimbursable under Medicare or Medicaid. This type of agency may provide skilled nursing skills or what is termed non-medical\custodial care or care that can be provided by a non-medical professional. The types of services available are wide ranged and can be provided by non-professional personnel and include activities such as personal care, respite, housekeeping, meal preparation, laundry, shopping, companionship, errand running, chores and transportation. The care is usually paid for privately by the client or, in some cases, by private insurances or other third party payers as outlined below. A physician s order is not mandatory to receive care and the type of care is determined by the client and the agency. These agencies may or may not be licensed and regulated, depending on each state s requirements and legislation. Most of these agencies hire the staff, conduct background checks, administer payroll and taxes and provide supervision. Registry/Staffing Agency Registry/Staffing Agencies assume the role of an employment service for Home Care nurses and Home Care Assistants. They refer individuals to the client, who makes the actual selection. A fee is levied for their efforts. The Launch Company LLC - Start-Up & Operations Manual 9 P age
Chapter 1A Homecare Overview Generally, these agencies do not have a Health Care License and they do not conform to government regulations. While not usually the case, some agencies hire nurses to determine care needs, to develop care plans, and to supervise assistants. When a client obtains the services of a registry provider, the person employing the assistant becomes responsible for supervising the care provided, for paying the assistant directly, and for ensuring all payroll tax requirements are met. Social Service Agency Non-profit, social service agencies (often religion affiliated) will, on occasion, provide Home Care. Initial assessments usually are conducted by a nurse or social assistant, who may also manage the client s care plan. Companies Pharmaceutical and Infusion Therapy Companies These companies deliver drugs, equipment and professional services for individuals receiving intravenous or nutritional therapies through tubes. Medical Equipment/Supplies Dealers provide clients with items such as respirators, wheelchairs, walkers, dressings, catheters etc. In most cases, these companies merely provide and service the product and do not deliver the actual care. Public Authorities Public Authorities for Home Care Services are sponsored by state or county governments. They are the employees of record for Home Care Assistants (HCAs) in a geographic area and serve as a clearing house for available assistants. These Home Care Assistants have the status of public employees. Acting as employees of record, the Public Authorities (PAs) are responsible for issuing paychecks, complying with state and federal health and safety laws, and for withholding taxes from the Home Care Assistant s pay (including Social Security payroll taxes). They also perform background checks and take on all liabilities for the HCA. Responsibilities such as these may be very difficult for frail, elderly clients to assume on their own. Public Authorities are a relatively new concept in Home Care. While they operate primarily in western states, such as California and Oregon, the concept is moving eastward. The Launch Company LLC - Start-Up & Operations Manual 10 P age
Chapter 1A Homecare Overview Hospices Hospice organizations provide care for terminally ill patients, either in their home or in special care facilities. Hospice care allows terminally ill individuals to live their final days in as natural and comfortable a setting as possible. This provides the family with an opportunity to participate in care giving. A professional team and volunteers work as a unit attending to the patient s medical, psychological and spiritual needs. Many hospice programs are certified by Medicare and are licensed according to the individual state s requirements. Independent Contractor/Self-Employed Individual Individuals may hire themselves out as independent contractors to perform Home Care Services. In this case the worker is responsible for their own payroll deductions, withholding taxes, Workers Compensation, bonding etc. The contractor is responsible for any liabilities. The client and/or family may become the employer and hire a Home Care worker as an employee. This process renders the client and/or family responsible for recruiting, hiring, and supervising. They also are responsible for paying for wages, unemployment taxes, social security, paying for Workers Compensation and withholding taxes. The client is also responsible for any liability issues such as injuries, which may arise, and assumes responsibility for training and supervising the Home Care worker. Who Pays for Home Care Services? Service providers may be funded by the federal government, state government, local cities, and private and non-profit organizations. Most people are not aware that an aging network exists throughout the USA. The Administration of Aging is the federal organization responsible for senior citizens. It supports state agencies on aging with resources and funding. All state departments on aging work with planning units or Area Agencies on Aging. They are responsible for coordinating senior services on a county level. The Launch Company LLC - Start-Up & Operations Manual 11 P age
Chapter 1A Homecare Overview Most states require that Home Care Agencies be licensed to assure that care is provided within health and safety standards. Each state can establish its own licensing criteria and regulations. Consequently, the requirements will often vary depending on the state. The exception is that agencies, which have been certified by Medicare, must conform to federal regulations. Home Care Services can be obtained from various sources. Clients or their families can purchase services directly from the service provider or they can purchase services from an assortment of public and private sources. Usually, hospice care is provided whether or not clients and/or their families have the required finances to purchase the care. Funding payers include: Self-funding or private source payers. Public third-party payers. e.g.: the Older Americans Act; the Veterans Administration; Social Services Block Grant Program; Community Organizations; and, Religious Associations. Private third-party payers. e.g.: commercial health insurance companies; Medigap; long-term care insurance; health insurance and managed care organizations; Civilian Health & Medical Program of the Uniformed Services (CHAMPUS); Health Maintenance Organization (HMO); automobile insurance companies; Workers Compensation; and, Disease/condition focused organizations. e.g.: local chapters of the American Cancer Society; the Alzheimer s Association; and, the National Easter Seal Society, Limited Government Payers Medicare Medicaid Medicaid Waiver The Launch Company LLC - Start-Up & Operations Manual 12 P age
Chapter 1A Homecare Overview Self /Private Pay Individuals who do not meet the eligibility requirements for financial assistance from the government must pay for the service either themselves or obtain the assistance of another contributor. In these scenarios, the client and the service provider negotiate the fees. Most of your clients will be paying for services directly from their own funds. Public Third Party-Payers Older Americans Act (OAA) The Older Americans Act makes federal funds available for state and local social service programs. The purpose is to enable frail and disabled people, who are 60 years or older, to remain independent in their communities. Service covers Home Care Aids (HCA), personal care, chores, escort, meal delivery and shopping services to individuals with the greatest social and financial need. Those who can afford to pay for some of the services are charged in proportion to their income. Service is often requested by contacting an Area Agency on Aging. This agency either provides the services directly or in cooperation with local organizations. Veterans Administration The Veterans Administration supplies funds to veterans who have a disability classed at 50% or more due to a service-related condition. The services must be authorized by a Physician and must be delivered via the VA s system of hospital-based Home Care units. Veterans Administration does not cover non-medical services provided by HCAs. Social Services Block Grant Program Based on state analysis, states receive annual federal social services block grants. Allotment is determined on federal limits and population stats. Some of the funding is often directed into programs which provide HCA and homemaker or chore services. Additional information can be obtained from the state health department and/or local offices on aging. The Launch Company LLC - Start-Up & Operations Manual 13 P age
Chapter 1A Homecare Overview Community Organizations In conjunction with state and local governments, some community organizations provide funds for home health and supportive care. They may pay for all or a portion of the services, depending on the person s financial status and eligibility. For more information, contact hospital discharge planners, social workers, local offices on aging and the United Way. Religious Associations Many religious groups and organizations are supportive in supplying funds to assist persons requiring Home Care Services. Contact the local religious organizations in your area to determine if assistance is available. e.g. Churches, synagogues, kingdom halls, temples, mosques, etc. Private Third-Party Payers Commercial Health Insurance Companies Basically, commercial health insurance policies cover some Home Care Services for acute needs, but benefits for long-term services may from differ plan to plan. Commercial insurers, such as Blue Cross and Blue Shield, generally pay for skilled professional Home Care Services with a cost-sharing provision. These policies sometimes cover personal care services. Most commercial and private insurance plans will cover comprehensive hospice services, including nursing, social work, therapies, personal care, medications, and medical supplies/equipment. Cost sharing varies with individual policies, but often is not required. If additional Home Care coverage is wanted, clients may need to purchase Medigap insurance or long-term care insurance policies. Medigap Medigap is an insurance policy offered by private insurance companies to fill the gaps in coverage for original Medicare. The purpose of Medigap is to compensate for some of the shortfalls in Medicare coverage. Some Medigap policies offer benefits to facilitate athome recovery, which pay for some personal care services when the policyholder is receiving Medicare-covered skilled home health services. The policyholder s physician must order this personal care in conjunction with the skilled services. It is most beneficial to people recovering from an acute illness, an injury or from surgery. It is not meant for extended long-term care. The Launch Company LLC - Start-Up & Operations Manual 14 P age
Chapter 1A Homecare Overview Long-term Care Insurance Initially, long-term care insurance was meant to help people with the costs of facility care. However, as the needs and wants for Home Care grew, these policies have been extended to cover personal care, companionship and other in-home services. These policies are quite diversified and the provider should check with their client to see if they have such a policy. Health Insurance and Managed Care Organizations Some health insurance and managed care plans might cover Home Care Services. The eligibility and qualifying criteria vary according to the plan. Usually the assistance is medically necessary and/or requires skilled workers. Sometimes personal care is covered, other times it is not. Some plans require pre-approval of services. Managed Care Organizations, which are contracting with Medicare, must provide the full range of Medicare-covered home health services available in a particular geographic area. Only pre-approved services will be paid for by these organizations. Civilian Health & Medical Program of the Uniformed Services (CHAMPUS) CHAMPUS provides for skilled nursing care and other professional medical Home Care Services for dependents of active military personnel/military retirees and their dependents/survivors. It does so on a cost sharing basis. Health Maintenance Organization (HMO) HMO, usually a legal entity, arranges payment for the provision of basic and supplemental health services to its members from a network of independently contracted providers (e.g. physicians & other health professionals) and facilities on a prepaid or reduced fee basis. It offers consumers a comprehensive range of benefits at one annual fee but they can only see providers in the network. Individuals are assigned to a primary care doctor or nurse who decides what health services are needed and when. Automobile Insurance Companies An individual s auto insurance policy may cover the cost of Home Care Services if an individual was involved in a motor vehicle accident. Workers Compensation Workers Compensation will provide medically necessary homemaking services to those who were injured while working on the job. The Launch Company LLC - Start-Up & Operations Manual 15 P age
Chapter 1A Homecare Overview Disease/Condition Focused Organizations Organizations such as the American Cancer Society, Multiple Sclerosis Society or Alzheimer s Association may sometimes assist with funding. A quick way to find out what is available in your area, is to contact the National Association of Area Agencies which has a list of 655 Area Agencies on Aging: Tip http://www.aoa.gov/aoa_programs/oaa/how_to_find/agencies/ find_agencies.aspx Limited Government Payers Medicare and Medicaid programs are government programs created by the Social Security Act of 1965. Medicare Medicare is one of the primary public payers in the United States. It is available to retired individuals who are over 65 and who have worked for at least 10 years in a position, which contributed to Medicare. To qualify for Medicare there are four main conditions that a person must meet: The home health care agency must be certified by Medicare. i.e. Medicare only covers Home Care provided by home health care agencies, which have been approved by Medicare. Unfortunately, this leaves out registry nurses, private therapists and independent caregivers. The client must be pretty well confined to his home, with the exception of going out for medical appointments or for religious purposes. The client must require nursing, physiotherapist or speech pathologist services at least on an intermittent basis. The client s doctor has assessed the client s condition as warranting in home support and he has developed a care plan for the provision of these services. Additionally, the client s doctor and the Home Care Agency must evaluate his care plan at least every 60 days. The Launch Company LLC - Start-Up & Operations Manual 16 P age
Chapter 1A Homecare Overview The services qualified people may obtain from Medicare include: skilled nursing services on a part-time or intermittent basis by a licensed nurse; home health aid services such as personal care on an intermittent or part-time basis; physical therapy as often and for as long as it is medically necessary and reasonable to restore physical movement and strength; speech language therapy designed to restore speech; occupational therapy as long as it is medically necessary and reasonable to achieve independence in carrying out the activities of daily living; medical social services to assess any social and emotional factors and to provide counseling and referrals to community resources; medical supplies such as wound dressings; and, some types of medical equipment such as walkers, wheelchairs and oxygen. (Medicare will pay 80% of the approved amount while the client pays the other 20 %.) Medicare s definition of intermittent or part-time care is that the combination of skilled nursing care or home health aide services is less than 8 hours per day or 28 hours per week. Medicare does not cover: 24 hour in-home Care; prescription drugs; meals delivered to the home; homemaker services such as shopping cleaning and laundry except that some home health aides will do a few chores when they are in the home for covered services; and, personal care provided by home health aides such as bathing, toileting, dressing, unless the patient is also getting skilled care such as nursing or therapy and the personal care is required because of the illness or injury. i.e. If personal care is the only care needed, Medicare does not cover the costs. The Launch Company LLC - Start-Up & Operations Manual 17 P age
Chapter 1A Homecare Overview Medicaid Medicaid is a joint federal and state assistance program that helps with medical costs for some people with low income and limited resources who do not have the money or insurance to pay for health care. To qualify for Medicaid, the applicant must have a low income and few savings or other assets. Medicaid coverage varies from state to state. Each state sets it own guidelines, subject to federal rules and regulations. Certain services must be covered by the states in order to receive federal funds. Other services are optional and are elected by the states. In all states, Medicaid pays for basic home health care and medical equipment. It may pay for homemaker, personal care and other services that are not covered by Medicare. Medicaid has programs that pay some or all of Medicare s premiums and may also pay Medicare deductibles and co-insurance for certain people who are entitled to Medicare and have low income. To determine if Medicaid covers any Home Care Services in the state wherein your business is established, contact the State Department of Health. Before some health care plans, including Medicare and Medicaid, will pay for covered home health services they will require agencies be certified. This means the agencies must meet defined federal requirements for patient care and are able to provide services to those who are covered by Medicare or Medicaid. These agencies are supervised, controlled and assume liability for all care. Periodic assessments are conducted to ensure that standards are being met. To determine what the requirements in an area are, check with the local Department of Health. Medicaid Waiver Medicaid waiver funds are federal and/or state joint programs. The purpose of the Medicaid Waiver is to enable individuals who require long-term care services to remain in a community setting even though their advanced age or disability would warrant placement in a long term care facility. The Waiver allows services that are typically covered by Medicaid only in a nursing facility, to be provided to eligible persons in their own homes or in assisted living facilities The Launch Company LLC - Start-Up & Operations Manual 18 P age
Chapter 1A Homecare Overview To obtain a telephone number for information in your state, call: 1-800-633-4277 TTY/TDD or 1-877-486-2048 (for the hearing and speech impaired). Who Pays for Non Medical Home Care Services (i.e. Services You Provide)? The Launch Company LLC - Start-Up & Operations Manual 19 P age
Chapter 1A Homecare Overview Where Can Inquiries About Home Care Be Directed? National Association for Home Care and Hospice http://www.nahc.org or 1-202-547-7424 Centers for Medicare and Medicaid Services (CMS) http://www.cms.gov The National Association of Area Agencies on Aging www.n4a.org or 1-202-872-0888, Local Area on Aging List of local areas can be found at: http://www.aoa.gov/aoa_programs/oaa/how_to_find/agenci es/find_agencies.aspx Eldercare Locator at 1-800-677-1116 or www.eldercare.gov Local Legal Network (LSN) attorney. A list of LSN attorneys can be obtained by phoning 1-866-330-0753 or accessing website www.aarp.org/lsn National Alliance for Caregiving (NAC) www.caregiving.org or Email: info@caregiving.org Local Seniors Centers (Check your local postings for details.) Learn all you can about the Home Care industry and the various organizations/agencies that are responsible for providing & paying for Home Care Services in your area. The Launch Company LLC - Start-Up & Operations Manual 20 P age
Chapter 1B Assisted Living Placement Overview Chapter 1B ASSISTED LIVING PLACEMENT OVERVIEW Table of Contents What Is Assisted Living?... 2! Assisted & Independent Living Facilities... 3! Is There A Need for Assisted Living?... 3! What Are The Goals of Assisted Living?... 4! What Are The Advantages And Disadvantages Of Assisted Living?... 4! What Are the Differences Between Independent & Assisted Living?... 6! Independent Living... 6! Assisted Living... 7! Who Purchases Assisted Living Services?... 8! Who Pays for Assisted Living Services?... 9! Self /Private Pay... 10! Public Third Party-Payers... 10! Veterans Administration... 10! Religious Associations... 11! Private Third-Party Payers... 11! Long-term Care Insurance... 11! Automobile Insurance Companies... 11! Workers Compensation... 11! Disease/Condition Focused Organizations... 11! Limited Government Payers... 12! Medicare... 12! Medicaid... 13! Where Can Inquiries About Assisted Living Be Directed?... 14! The Launch Company LLC - Start-Up & Operations Manual i P age
Chapter 1B Assisted Living Placement Overview Chapter 1B ASSISTED LIVING PLACEMENT OVERVIEW What Is Assisted Living? Assisted Living can mean a lot of things to a lot of people. It really has evolved greatly over the years. There was a time in history when we did not have the resources and options available to seniors that are available today. At one point in time, assisted living was perceived to be nothing more than a nursing home where those too frail and sick to care for themselves were given medical attention, a place to sleep, and little to nothing else. Today, there are many options for seniors beginning with Independent living, The Launch Company LLC - Start-Up & Operations Manual ii P age
Chapter 1B Assisted Living Placement Overview facilities designed to provide very minimal services but giving the senior the peace of mind that they no longer need to cook or clean and can still remain independent. In addition, there are assisted living facilities providing greater levels of care, memory care units attending to those with mental challenges, and care homes providing a more residential environment while also maintaining a high level of care. Assisted & Independent Living Facilities Independent! Living! Memory! Care! Care!Homes! Skilled! Nursing! Assisted! Living! Facili3es! Senior! Living! Board!&!Care! Is There A Need for Assisted Living? There is a need for Assisted Living Services and that need is escalating and will become a factor to reckon with, as the elderly population numbers continue to increase. Part of this upsurge is due to: Senior citizens are living longer and baby-boomers are swiftly approaching their retirement years. The options have increased in number and variety providing seniors with incentive to utilize these types of services earlier in their aging process. The Launch Company LLC - Start-Up & Operations Manual 3 P age
Chapter 1B Assisted Living Placement Overview Because hospitals are looking to lower their re-admission rates, they are becoming increasingly careful how a patient is discharged. Often times, placement is a requirement for the patient to be successfully discharged. Assisted Living can be more affordable than homecare if the patient requires a high level of care. Living in an assisted living facility or home provides interaction with other people in a similar stage of life. This can increase the client s morale. It is becoming increasingly difficult for the children of elderly parents to provide the care as the cost of living rises. Statistically, people are living longer yet this doesn t mean that the need for care is decreasing. It is actually the opposite. For many people, life-sustaining medical treatment is allowing them to live longer but they are fully dependent on receiving care to do so. These issues continue to place an increasing demand on the need for long-term care. Since health care costs will become even more staggering, the provision of effective assisted living continues to become a more viable option. What Are The Goals of Assisted Living? The goals of Assisted Living include: assisting individuals to improve and maintain their health and quality of life; promoting the individual s independence; assisting individuals with all activities of daily living to ensure safety; preventing individuals from being readmitted to the hospital by managing the preventative and care maintenance plans established by the individual s primary care physician; providing support to the family, which will help them handle an individual's need for care; and, providing informal caregivers with support to meet their own related needs. What Are The Advantages And Disadvantages Of Assisted Living? Advantages: Clients are living around other people in a similar stage of life and can find friendship, support, and camaraderie. The Launch Company LLC - Start-Up & Operations Manual 4 P age
Chapter 1B Assisted Living Placement Overview The cost of assisted living is far less than hospitalization or acute care. Maintaining health inside of an assisted living facility drives down the client s overall healthcare accost. Clients can choose the amount of care they receive (within established limits). Rehabilitation and outpatient care can be provided inside of an assisted living facility or home. The client s quality of life is enhanced when dignity, privacy and freedom are factored into the treatment program. Family members can visit their loved ones living in assisted living giving the family and the client the dignity of having their own place while still being close. Disadvantages: The client may not be given as much attention as he/she would if receiving homecare, as, within a facility, the client-to-caregiver ratio is often 15-1 and up to 30-1 as opposed to homecare where the ratio is 1-1. Assisted Living costs generally rise as the level of care rises. This often times causes clients to have to move as their level of need increases. Living in an Assisted Living facility or home is never really home and can be challenging for some people to adjust. The Launch Company LLC - Start-Up & Operations Manual 5 P age
Chapter 1B Assisted Living Placement Overview What Are the Differences Between Independent & Assisted Living? Independent Living Independent Living facilities do not provide hands-on care to their clients. They assist with cooking, cleaning, laundry, transportation, and many provide activities as well. The purpose of independent living is to provide a place for seniors who are beginning to feel the affects of age but are not ready for complete hands-on care. Below are some of the types of independent living: Facility Low-Income or Subsidized Senior Housing Senior Apartments (the more traditional independent living model) Retirement Homes/Retirement Communities Continuing Care Retirement Communities (CCRCs) Description In the U.S., there are senior housing complexes subsidized by the U.S. Department of Housing and Urban Development (HUD) for low-income seniors. These are apartment complexes restricted by age, usually 55 and older. Rent may include community services such as recreational programs, transportation services, and meals served in a communal dining room. Laundry services and community activities are also provided. Retirement communities are groups of housing units restricted for those over a certain age, often 55 or 62 and older. These housing units can be single-family homes, duplexes, mobile homes, townhouses, or condominiums. If you decide to buy a unit, additional monthly fees may cover services such as outside maintenance, recreation centers, or clubhouses. These facilities offer a spectrum of care from independent living to nursing home care in the same community. If residents begin to need help with activities of daily living, for example, they can transfer from independent living to an assisted living or skilled nursing facility on the same site. The main benefit of a CCRC is that you only need to relocate once to a new environment and can maintain your independence for as long as possible. Descriptions provided by HelpGuide.org The Launch Company LLC - Start-Up & Operations Manual 6 P age
Chapter 1B Assisted Living Placement Overview Assisted Living Below are some of the types of Assisted Living: Facility Assisted Living Facility Care Home Memory Care Skilled Nursing Description This type of facility typically is licensed for more than 10 beds and is designed to provide all levels of handson care. This would include assistance with all activities of daily living including bathing, dressing assistance, medication management, transportation, ambulation assistance, transferring, toileting assistance, etc. A Care Home provides the same level of assistance that a facility provides but the environment is where the greatest change lies. Instead of a large building, a care home is a residential home in a residential neighborhood. This gives the client the perception that they are home instead of in a facility. The caregiver to client ratio is also much lower. Because a care home typically does not have more than 10 licensed beds, you will typically find a 5-1 client to caregiver ratio. Memory Care facilities are similar to assisted living facilities except that they focus on caring for clients who have mental illness typically from Alzheimer s, Parkinson s, or some other form of dementia. Often times, these units are locked from the inside which prevents clients from wandering outside and getting lost or hurt. Skilled Nursing facilities are typically for short-term stays (30-90 days) and provide intense medical care 24/7 while a client is recovering from an injury or acute illness. Medicare will pay for these short-term stays for a set amount of days/year. Very rarely, a client is prescribed a long-term stay in a skill nursing facility due to severe medical treatment needs. In most circumstances, long-term stays at a skilled nursing facility require the client to pay privately. The rates at a skilled nursing facility are much higher than assisted living and it is always preferred to keep these stays short-term with a plan to move to assisted living after recovery. The Launch Company LLC - Start-Up & Operations Manual 7 P age
Chapter 1B Assisted Living Placement Overview Who Purchases Assisted Living Services? Assisted Living Services are purchased by a wide range of individuals and organizations. They include: the elderly; the housebound; the disabled; those with chronic illnesses; those with terminal illness; those who are recovering from acute illnesses or surgeries; those who are mentally or emotionally handicapped; family caregivers; accident victims; those requiring guidance with life skills; those seeking assistance with outdoor maintenance; those requiring transportation and errand running; and, those who require social outings. The Launch Company LLC - Start-Up & Operations Manual 8 P age