Alternatives to Nursing Care – Medicare and Medicaid Programs

Centers for Medicare and Medicaid Services (Me...
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by Rose Broyles

For the past few years, my sister and I have been at our wit’s end trying to find ways to ensure the stability of our parents’ financial, emotional and physical well being. We drive everyone crazy talking about the same problems and possible solutions! It was very difficult for us because had we had the choice, our parents would have stayed in their own home. But because they lived in a 2-story town home, it was physically impossible. So, on they went from home to an apartment, to assisted living to board-and-care, our mom to a nursing facility,  and then both reunited in  a rented home where they have been for the past year and a half. Is this their permanent residence? Probably not. But it’s been the most stable of all of the above. Unfortunately, a majority of their expenses are out-of-pocket because my dad still gets a pension which makes he and my mom ineligible for Medicaid.

Most of us familiar with Medicaid are under the assumption that it ONLY covers skilled nursing homes after the patient has exhausted all financial assets. Of course, this isn’t entirely true, but I’ll save that for another post specifically on Medicaid. However, there is a little glimmer of hope in alternatives which is offered with limited access through Medicare. There are two programs: PACE and Social Managed Care Plan. Unfortunately, for PACE, we do not live in the areas covered, but hopefully they will provide that service in San Diego soon. You may want to read below to see if you or your loved one lives in the covered area. 

PACE (Program of All-Inclusive Care for the Elderly

What is It

It is an optional benefit under both the Medicare and Medicaid programs that focuses entirely on older people, who are frail enough to meet their State’s standards for nursing home care. Medical and social services can be provided at an adult day care center, a facility or at the enrollee’s home. For most patients, the comprehensive  service packages enables them to continue living at home while receiving services.  PACE is only available to states who have chosen to include it under Medicaid. 

Eligibility

  • Must be 55 years of age or older
  • Live in the PACE service area
  • Submit to a screening by a team of healthcare professionals to assess eligibility
  • Be able to live safely in a community environment at time of enrollment. ** you may want to inquire about this one, because if the patient chooses to stay at home, this may be irrelevant.

Services

  • PACE offers and manages all of the services provided to enrollees to help maintain their independence. 
  • Health team maintains frequent contact with enrollee to adapt program to changes in health or needs
  • Services include: medical, social, rehabilitative, personal care, restorative services, etc.

Payment

  • PACE receives a fixed payment per enrollee from Medicare and Medicaid. The amounts remain the same throughout the year regardless of services provided.
  • Enrollees may have to pay a monthly minimum  depending on their eligibility for Medicare and Medicaid.

Find a Service provider

PACE Providers

Downloads

Download a PACE Fact Sheet here.

Social Managed Care Plan

This is an organization that provides a full range of Medicare benefits plus additional services such as: care coordination, chronic care benefits, prescription drugs, homemaker, personal care services, medical transportation, adult day care, and respite care. 

Unfortunately, there are only four available plans. 

Kaiser Permanente, Portland -Oregon

Requirements:

  • 65 years +
  • Have Medicare Parts: A and B ; continue to pay Part B premium
  • Live near KP service area
  • Cannot have end stage renal disease, or live in an institutional setting
  • Long-term care benefits require visit from resource coordinator to assess needs.

SCAN, Long Beach – California

Requirements:

  • 65 years + 
  • Have Medicare Parts: A and B ; continue to pay Part B premium and live near SCAN’s service area.
  • Cannot have end stage renal disease
  • Extended home services require a nursing home certificate which indicates that a member of an informal system like a relative is not sufficient to keep the patient out of a nursing facility.

Elderplan, Brooklyn- New York

Requirements

  • 65 years +
  • Have Medicare Parts: A and B ; continue to pay Part B premium and live near Elderplan’s service area.
  • Cannot have end stage renal disease
  • Enrollee must meet state requirements for nursing home certificate.

Health Plan of Nevada, Las Vegas- Nevada

  • 65 years + or younger of disabled
  • Have Medicare Parts: A and B ; continue to pay Part B premium and live near Health plan’s service area.
  • Cannot have end stage renal disease
  • Enrollee must meet medical, social, psychological and functional criteria as well as needing to be medically necessary.
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    Each plan has different requirements for premiums. Use the Medicare Options Compare Tool.

    Miscellaneous

    Download the Medicare and Home Healthcare Booklet here.


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    Playing catchup

    After 2 months of family activities, conventions, holidays, etc. I’m trying to catch up for lost time, relaxation, work.  I’m up watching old movies with the hubby right now while our little one is fast asleep. I had a pretty eventful day today, mostly running errands for my own personal needs as well as for my parents. I try to do their errands at the same time as mine so that I’m not pressed for time. Of course that doesn’t work because I feel like I never have time for anything! Anyway, so here I am at 1:15 AM trying to play catch up on this website as well as research more information to share to you and to help my sister and I out as well.

    Parental needs

    Earlier this week, we took our Dad to the doctor. He had swelling in his face, hands, legs and feet. Worried, our caregiver told us that she suspected something was wrong with his heart. My sister and I both suspected heart failure, but since we are not doctors we wanted to make sure. So, we took him to his doctor and he too, suspected heart failure. My poor dad now has to take 5 more medicines. He was only taking 2 before. It’s ok, because we want to prolong his life, we’ll do what we can. He goes back in 2 weeks for a follow up visit so we can see what his kidney tests indicate. I’m pretty optimistic. I try to be anyway. My dad is a trooper and so is my mom.  I’m praying that nothing abnormal will surface and that his doctor will just prescribe the necessary medicines (as he already has) and a good healthy regiment for my dad to follow.

    Some of the things on our agenda: 

    1. Re-start the Meals on Wheels Program. My dad should have a low-salt diet. So, no fatty Filipino food anymore!

    2. Have a Home Physician come visit him. It was so hard for us to get him out of his motorized chair into the car. He was in so much pain. He’s also over weight and so that made things all the more difficult. I don’t want him to suffer for each blood test (we have to do at least once a month blood draws to check his coumadin levels) and doctor appointments, so we will be working on a visiting doctor. I’ll be writing about this option soon so look out for it!

    3. Mail order pharmacy – Even though I live right next door to one,  I think it would be very convenient to have my parents’ meds delivered directly to their house. 

    Child Needs

    My poor daughter has a messed up sleeping schedule now because of all the craziness that has befallen us the last 2 months. Getting her back into a normal sleep schedule has been very hard. She’s at that stage where she wants to be a  ”grown up” and stay awake for as long as she can, argue with Mommy as long as she can, and be herself. Yes, as you can see it is very hard raising a toddler and playing co-caregiver to my 80 and 86 year old parents. 

    Anyway, back to work. I have a great addition to this site that I  will be launching in the very near future, so I’ll be posting the news here and also on the forums and recent news section. 

    –`@ Rose

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    Sleep Tips For All Ages

    Sunday afternoon nap
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    I don’t know about you, but I enjoy my sleep. If I’m tired, I don’t waste any time, I take a nap! Of course, I don’t nap everyday. My toddler does, but that’s part of her sleep cycle. What does it mean if I do take a nap? Is that practicing good sleep habits or compensating for bad sleep? Surprisingly, it’s the latter. Only the elderly , babies and toddlers need a nap as part of their rest regimen. What does that mean for the rest of us? It means, that we should be getting between 7-8 hours of sleep.

     

    For all ages, good healthy sleep habits include:

    1. Regular bedtime and waketime, seven days a week, all weeks of the year 
      Babies can be excused from this until they are three-to-six months old; after that they should start going to sleep on a regular basis and not wake up until the morning hours.
       
    2. Avoidance of naps or sleeping in on weekends. 
      Babiess, toddlers and the elderly are allowed naps as part of their normal sleep cycle. If you need to nap, either you need sleep or you not getting the right amount.
       
    3. Avoidance of caffeine, alcohol or nicotine, as all of these agents can disrupt sleep
       
    4. Regular exercise, but not too close to bedtime. Exercise is very good for sleep and even a small amount of exercise can be helpful, especially in the elderly.
       
    5. If you have trouble falling asleep, a calm, relaxing bedtime routine may be helpful. A hot bath prior to bedtime is an example.
       
    6. The sleep environment should be comfortable, have a cool temperature and be dark.
       
    7. Avoid stimulating activities such as reading, watching TV, doing homework or something from one’s own work in bed prior to sleeping.
       
    8. A small snack prior to sleep can be helpful for sleeping but a large meal can disrupt sleep.

     

    I’d like to add that  nice warm bath prior to bedtime is good. Nothing feels better than feeling fresh as you get under cool covers in your warm pajamas and fall into a deep slumber.  Some people  also suggest (if you are not lactose intolerant), a nice glass of warm milk. I usually don’t drink milk unless it’s with cupcakes or I have it in my cereal. Depending on the weather, a hot cup of chamomile tea helps me relax and get ready for bed. Finally, if you or your loved one is the type of person who doesn’t like complete silence when they are trying to sleep, I suggest buying an instrumental or environmental sounds CD from a store like Walmart.  When my daughter was first born, I not only played “Baby Einstein” for her but a piano instrumental with ocean sounds. I was surprised that I too fell asleep listening to the CD!

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