There’s no place like home. That age-old adage is never truer than when discussing care for older or disabled adults, medically fragile children or anyone recovering from an accident or illness. Recent surveys have shown that most older adults want to stay in their homes, regardless of their health condition, and over the last decade, technological advances have allowed for increasingly advanced medical care to be provided in non-hospital settings. “Hospitals are discharging quicker … and patients need support when they come home,” said Bonnier Boyer, president of Comfort Care of Holy Spirit, which provides in-home medical care. Not only are people becoming more vocal about their desire to stay at home, but it’s considerably less expensive For the cost of every one person in a nursing home, nearly three could be cared for in their own home or community. “People are still unaware that for a year in a nursing home you’re looking at up to $80,000,” said Vicki Hoak, executive director of the Pennsylvania Homecare Association. “It’s much cheaper to care for someone in home because most of the time they don’t need that round-the-clock care that’s in a nursing home.” An average homecare visit costs $150, while the average hospital visit costs $1,500 a day, association figures show. One year of care provided in a person’s home would cost almost $13,000 while the state, through Medicaid, would have to pay $35,000 for the same care in a nursing home.
Pennsylvania Ranks High in the Nation
Pennsylvania already ranks third in the nation in the percentage of residents over 60, and that number is expected to climb by more than 1 million over the next 20 years. In response, Pennsylvania officials have been molding state programs and funding to ensure older residents and their families have a wide range of options to choose from in seeking health care. “Historically, Pennsylvania had been very biased toward nursing home care and the vast majority of money was poured into nursing home care,” said state Secretary of Aging John Michael Hall. The state’s recent mission has been to “bring more balance to how we spend our money and more evenly distribute it to home-based, community-based and nursing home care. “We think of long-term living as embracing both people who receive care in institutions and in home and community-based settings,” Hall said. “There ought to be more options … developed enough so each individual and family can see what is the best fit for them. “It’s one thing to say you have the right to receive care where you want it and another to be realistic,” he added. “We are doing much better. There are more options and choices.”
The use of home care is exploding in popularity both in Pennsylvania and the nation. Nationwide, Medicaid spending for home and community-based services skyrocketed by 81.5 percent between fiscal years 2001 and 2007, according to a new report from the National Center for Assisted Living. Just from the fourth quarter of 2007-08 to the fourth quarter of 2008-09, 8.3 percent more people on Medicaid in Pennsylvania were being cared for in their home as compared to the same period one year earlier, the state Department of Aging reported. While options are growing, one of the biggest questions facing consumers, regardless of the setting for their care, is how to pay for it. Depending on the services required and an individual’s income, the payment choices for long-term living options essentially are:
- Private health insurance
- Long-term care insurance
- Private pay
- Other programs
- Medicare Coverage
A common misconception is to think Medicare will cover their nursing home bill. “That is not true,” said Crystal Lowe, executive director of the Pennsylvania Association of Area Agencies on Aging. “It covers only a very short period of time.” Medicare pays only for medically necessary skilled care, generally available only for a short time after a qualified hospital stay. Skilled care, ordered by a doctor, might range from changing wound dressings to physical therapy. Lowe said nursing home patients essentially have two sources of payment: their own pocket and Medicaid through the state, although anyone with long-term care insurance may be able to use that for some coverage. Considering the cost, Hall noted that even those with a healthy nest egg “can run through that pretty quickly, so that over an extended period of time few people have the ability to pay for long-term care on their own.” Hall said those who meet income guidelines can access Medicaid nursing home benefits, while those who don’t must go through the “spend down” of depleting assets until they hit the income eligibility mark. “The reality is: Americans pay for long-term care through a government program called Medicaid,” he said. “It’s for the middle class and upper middle class.” While the goal may be to avoid nursing home care if possible, Medicare does not cover nonskilled personal care, such as help with activities like bathing, dressing, eating, using the bathroom or getting in and out of bed or a chair. “Medicare covers the medical in-home care on a brief and intermittent basis if it’s deemed medically necessary by a physician,” Hoak said. “Most people who are eligible for the medical care have the services covered, but a doctor must order home healthcare.”
Finding appropriate homecare help and determining how to pay can seem daunting for anyone trying to make this decision for the first time. Hall recommends first calling the county Area Agency on Aging. “The Area Agency on Aging is the gateway to help people access those services, help people navigate the system and get information on options,” he said. Pennsylvania’s 52 Area Agencies on Aging offer a wide array of services and information to older citizens ranging from Meals on Wheels and reduced-cost transportation to Medicare and insurance help to providing assessments for homecare and nursing home placements. “They work toward supporting older Pennsylvanians and maintaining the maximum level of independence that they can possibly achieve,” Lowe said. “Families often come to us and say, ‘I’m worried about my mom. I’m not sure she can stay home alone anymore.'” With that, the AAA kicks into action. Once determining the exact problem and its urgency, the agency “walks through a variety of supports that could help,” Lowe said. The answer may be as simple as tapping into the informal support network that already exists—family, friends, church groups. If the individual needs more formal help, an appointment for an assessment is arranged for those 60 or older through the state’s OPTIONS Program to determine what long-term living services best fit their needs. That could range anywhere from needing basic personal care services such as help around the home to being eligible for a nursing facility and anywhere in-between. The assessment covers health history, social and family support and finances—”an indepth look at their situation,” Lowe said. “We look at what their desires and needs are and how to achieve them. We find the best possible notch for the consumer’s situation, their desires and their financial capacity.”
There is no financial eligibility requirement for OPTIONS-based services. However, consumers may be required to make a co-payment for services based on income. “OPTIONS is a lottery-funded program that allows you to earn a little more but still requires assessments to be sure you need the services,” Hoak said. “It provides a significant amount of help for people who may have significant needs but don’t financially qualify for Medicaid.” Another possibility is the state’s 60+ Waiver or PDA Waiver, a Medicaid program that requires participants to meet income guidelines and certain medical diagnoses to receive medical services in the home. Other options for paying for homecare services could be a long-term care insurance policy or a reverse mortgage. Long-term care insurance policies are privately paid policies tailored to an individual’s needs that could help cover homecare or nursing home care. Reverse mortgages tap into the value of a senior citizen’s home to provide money for medical expenses or other needs.
Also available to help seniors understand their choices is APPRISE, the state’s free health insurance counseling program to help Pennsylvanians over 60. Counselors are specially trained volunteers who can answer Medicare questions and provide objective information about Medicare, Medicare supplemental insurance, Medicaid, long-term care insurance and prescription benefits. “It’s like stitching together a quilt,” Hall said. “Family feels it’s part of their responsibility to take care of their own and treat their parents and elders the way they want to be treated. The truth is the family can’t do it on their own.” The medical needs may be too complex or family lives too far away, he said. Nearby relatives may not be able to leave their jobs or families to provide proper support. “We try to make it possible for a family to figure out how to successfully honor the preference to stay in the home and have families be part of the solution,” Hall said.