Los Angeles County Medical Assoc. Physicians Magazine

The Right Home? Caring for the elderly means knowing what options in care homes are available.

by Jason Bloome

In 1993, 33 million citizens in the United States were 65 years old or older. By the year 2020 the U.S. Census Bureau predicts this number to grow to 53 million - a 40% increase in 30 years! America is graying and, as the number of seniors increases, costs for their care and services multiply. The impact this population will have on major metropolitan areas, such as Los Angeles, is profound. Sooner or later we must all deal with questions regarding what services are available to the elderly and who will pay for them.

Expecting all the answers from the government in an era of budget crunches and a reduction of services is fruitless. More and more the responsibility for shifting through the byzantine maze of care resources and services available to the elderly will fall to caregivers. But even the best of players needs a coach from time to time - we all tend to look for advice and information from the experts. That is why it is especially important that physicians who care for the elderly be knowledgeable about the various eldercare issues. High at the top of this list is the issue of housing. Physicians should know what options are available for the elderly once they are unable to live at home.

With over 1,500 care homes in Los Angeles, knowing about the different types of homes and the services they offer can be daunting. To add to the confusion, new laws are continually being passed governing the type of residents the homes can accept. Traditional care housing boundaries no longer exist. Alzheimer's patients who "wander" no longer need to be in locked, skilled nursing homes. Retirement homes with Alzheimer's wings and small residential board and care homes with alarms on the doors may be more hospitable. A senior who is wheelchair bound, or who has Parkinson's, or has a colostomy or catheter may not require 24-hour skilled nursing supervision. Other levels of care homes can meet these needs.
In Los Angeles there are four basic types of care homes:

· Retirement/ Board and Care
· Residential Care Home for the Elderly (RCFE)
· Skilled Nursing Facilities
· Continuing Care/ Life Care

Depending on the type of home, these settings offer varying levels of care, from minimal services (e.g., meals and activities) to custodial care (e.g., help with dressing and bathing) to skilled nursing (e.g., tube feeding and completely immobile, bedridden residents).

Retirement/ Board and Care Homes

Under the 2002 California Supplemental Security Income (SSI) plan, the government will make up the difference between a recipient’s Social Security benefits and the SSI subsidy limit of approximately $950. For instance, if a recipient receives a Social Security benefit of $300, the government would provide the additional $650 SSI benefit. For a Social Security recipient eligible for SSI benefits, retirement homes occasionally accept the SSI subsidy rate ($950) for a shared room and returns to the resident approximately $90 for living expenses.

Community Care Licensing (CCL), a branch of the Department of Social Services, is responsible for licensing and visiting all the board and care homes at least once a year. CCL requires the homes to adhere to Title 22, mandatory guidelines which govern the type of care provided, staffing and overall physical environment of the home. A retirement home not licensed as a board and care home is not bound by Title 22 guidelines and, therefore, is not permitted to provide residents with custodial care assistance. Any such needs must be provided by an outside home health agency.

Residential Board and Care Homes

Residential Board and Care Homes are small family homes in residential neighborhoods licensed by Community Care Licensing to provide 24-hour custodial care to four to six residents. All custodial care, meals, and activities are provided by live-infull-time staff. The administrator/ owner, who generally does not live at the home, normally picks up the medication, does the shopping and provides the transportation to the doctor. Most are licensed to accept non-ambulatory residents and have been constructed with these residents needs in mind (e.g., wheelchair accessible bathrooms and inside/ outside ramps).

Residential Board and Care homes are allowed to provide assistance to residents who need help transferring from bed to wheelchair, but they are not permitted to accept or provide care for residents who are completely immobile, bedridden or unable to turn in bed. The high staff-to-resident ratio (usually two staff to six residents) make this an ideal setting for residents who are incontinent, have advanced dementia, Parkinson’s disease, Alzheimer’s disease, or who have a high level of physical care needs. The homes can also accept "wanderers" as long as they are equipped with alarms on the doors and are gated. Normally, Residential Board and Care homes will also accept respite (short-term) clients if a room is available.

Although Residential Board and Care homes are not permitted to accept residents with skilled nursing needs, there are times, however, when Community Care Licensing will grant exemptions to this rule. Depending on the nature of the condition and care required, administrators can frequently obtain waivers for residents who need insulin shots, have catheters or colostomies, for instance. One example might be a catheter that needs to be cleaned once a week, a service that an outside home health agency can provide. Community Care Licensing evaluates each exemption request on a case-by-case basis. The administrator must be granted a waiver before the resident actually moves into the home.

Residential Board and Care homes range from $1,000 to $3,000 per month for a shared room; for a private room, the cost is between $1,900 and $4,000 per month, depending on the location of the home and the care provided. Most Residential Board and Care homes cannot afford to accept the SSI ($950) rate. Currently, California has no mechanism in place to provide funds for custodial care assistance. The innovative system that Oregon has adopted to pay for care homes by using a combination of SSI and Medi-Cal as funding sources might be an example worth investigating. (For more information about their program call Oregon's Senior and Disabled Services Division at (503) 945-6403. See Legislation for information about efforts in California to allow Medical to pay for assisted living homes.

Skilled Nursing Facilities

Skilled Nursing Facilities, which offer skilled nursing care in a hospital-type setting for 30 to 200-plus residents, are licensed by the Department of Health Services. They must adhere to Title 22 as well as Federal Omnibus Budget Reconciliation Act (OBRA) guidelines governing patients rights and quality of life issues.

The 24-hour skilled nursing care offered in these settings is provided by licensed, trained professionals such as registered nurses (RNs), licensed vocation nurses (LVNs), and certified nursing assistants (CNAs).

Services provided in this setting may include care for a resident who is completely bedridden or who has an IV or g-tube. Skilled Nursing Facilities also offer occupational, speech, respiratory and physical rehabilitation services. These services are usually provided by contracted companies that specialize in rehabilitation. Rehabilitation services are usually covered by Medicare Part A. Nursing homes offer private rooms (single bed), as well as shared rooms (two to four beds).
Private paid, nursing homes cost from $84 to $120 per day, depending on the number of beds in the room and the skilled nursing services required. Ancillary charges (including medicines, diapers, personal laundry, etc.), may also apply. Many Skilled Nursing Facilities accept Medi-Cal as payment. The 1996 governmental Medi-Cal reimbursement rate is $73.26 per day.
Each skilled nursing home must have posted (usually next to the main nursing station) its most recent evaluation report, which should reflect any deficiencies and violations as well as the home's plan of correction.

Continuing Care Communities/ Life Care Communities

Continuing Care Communities/ Life Care Communities are settings where all three levels of care (minimal services, custodial care and skilled nursing) are provided. These communities are attractive to residents who do not want to move as increased care needs develop. Some of these homes require a large entry fee for admittance. Others charge for services on a month-to-month basis. There are less than thirty Continuing Care Communities in the Los Angeles area.
Many seniors and their families reach the point when they need to look for a care home. Choosing a home depends on the location, the type and quality of the services provided, staffing and the budget. In Los Angeles, there is no lack of care homes available. Knowing the options beforehand simplifies the search for a good one.