Q. We have been caring for my mother in our home for the past five years. We think she needs more help than we can provide. How do you know when a loved one is ready for a nursing home? Thanks for your help!
A. Caregivers and families often make a huge effort to keep their loved one at home for as long as possible. But there often comes a time when a nursing home is the best choice, or only choice, for a loved one. Please note that nursing homes are legally called “skilled nursing facilities,” and are often called “rehabilitation and healthcare centers,” or “health and rehab centers,” which are fancy terms that nursing homes give themselves to avoid using the term “nursing home” in their name because of it’s negative connotations.
When thinking about nursing home care, the first thing you need to understand is the difference between nursing homes and assisted living facilities. Please click here for our recent article explaining these differences. The second thing you need to understand is that nursing homes can accept Medicaid, and almost all of them do, whereas assisted living facilities cannot accept Medicaid, except for in very limited circumstances in some states through a waiver program that typically requires a person to have very low income. In Virginia, Maryland, and DC, the three jurisdictions that the Farr Law Firm serves, Medicaid is not available to pay for assisted living; however, all three jurisdictions do have state-funded assisted living supplements that apply to people with very low income.
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Virginia Assisted Living Supplement: In Virginia, assisted living facilities cannot accept Medicaid. Many people working in the admissions department of assisted living facilities will incorrectly tell prospective residents that they accept Medicaid, but this is completely inaccurate; many assisted living facilities have 2 Auxiliary Grant (AG) beds, which allow them to accept a state-funded assisted living supplement for people with very low income, typically after that person has lived in that assisted living facility for many years, paying privately, and has eventually run out of money. The Auxiliary Grant program has nothing to do with Medicaid, and is available for individuals even if they do not need the nursing home level of care.
DC Assisted Living Supplement:
DC is similar to Virginia in that DC assisted living facilities cannot accept Medicaid, but some DC assisted living facilities accept an assisted living supplement to people with very low income.
Maryland Assisted Living Supplement: Like Virginia and DC, Maryland Medicaid does not pay for care in an assisted living facility. Maryland does offer a state-funded supplement that will help some very low income people pay for a bed in an assisted living facility.
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Whether to put a loved one into nursing home care can be one of the hardest decisions to make in life. It is typically a very personal decision and there’s no “right” time for everyone. Going to a nursing home is about better meeting the needs of the person who needs care and giving that person the best quality of life possible. Please note that even though nursing homes are also technically known as skilled nursing facilities, most people in nursing homes are there for long-term care, also known as custodial care, and usually do not have any need for actual “skilled” nursing care.
If you are considering nursing home care for a loved one, these are some questions that can help determine if your loved one would benefit from the care they offer:
- Does Your Loved One Need Assistance with at least Four Activities of Daily Living?
Activities of Daily Living (ADLs) are common tasks we all do to live an independent life. ADLs cannot be avoided or skipped without affecting health and safety, and they directly tie to one’s independence and are essential for self-care.
Is your loved one having trouble with at least four ADLs? ADLs consist of six to eight essential self-care tasks:
- Bathing or Showering.
- Getting Dressed.
- Eating (being able to physically lift a fork or spoon to insert food into the mouth).
- Transferring, which means getting into/out of a bed or chair.
- Toileting, which means physically feeling the urge to use the toilet, using it appropriately, and cleaning oneself appropriately.
- Continence, meaning the ability to remain continent and to not have bowel or bladder “accidents,” or to properly clean up and change oneself after an occasional “accident.”
- Walking (or getting around independently by some means, such as a wheelchair) is sometimes viewed as an ADL.
- Being able to stay alone safely, and being able to respond properly to an emergency, such as a fire, is also typically viewed as an ADL. Needing assistance with this ADL is very typical and people with Alzheimer’s and other types of dementia.
Staff at skilled nursing facilities help with a wide variety of ADLs, often addressing more advanced needs than assisted living communities do. Nursing homes always offer skilled nursing care, 24-hour supervision, three meals a day, and assistance with everyday activities. Rehabilitation services, such as physical, occupational, and speech therapy, are also typically available.
- Does your loved one have severe dementia or another complex, progressive, or cognitive health condition?
Many people with mild to moderate physical and/or cognitive health condition can often live at home for years with good support from family and home health aides. The more assistance a person needs, the more necessary it becomes to start thinking about nursing home care. For example:
- People with Alzheimer’s or other forms of dementia who also have other serious and difficult to manage health complications — for example, uncontrolled diabetes or heart and lung issues that require support devices — may benefit from nursing home care.
- When a person is in the late stages of Alzheimer’s disease, feeding, changing, bathing, and moving them may require full-time access to medically-trained nursing home staff.
- When a loved one needs catheters, IV drips, a ventilator, a feeding tube, or other specialized medical care, nursing home care is likely the best option.
- Do they fall frequently, use a wheelchair, or are they confined to their bed?
Falls present a serious, sometimes fatal situation for seniors. If your loved one falls often, this can be a key indicator that they can no longer live safely at home. Nursing home staff have experience caring for older adults with mobility challenges and nursing home facilities are designed to minimize safety risks.
If your loved one is confined to their bed, or uses a wheelchair and can’t transfer to their bed or use the bathroom independently, they may also require the nursing home level of care.
- Can you no longer care for your loved one in your home?
These are some instances where caring for a loved one in your home may be too much to handle. For example:
- An older spouse may be having trouble managing the caregiving. Perhaps they are becoming too frail to cope with the physical demands of caregiving. Or they may have been diagnosed with their own serious illness.
- An adult child may be struggling with other responsibilities, including their own children to care for, a full-time job, and/or their own health issues.
- Perhaps you’re the only person able to care for your loved one. If you’re an older caregiver, providing all of the care yourself may take a toll on your own physical and mental health, frequently leading to a condition commonly known as “caregiver burnout.”
- Maybe you’re afraid for the health and safety of your loved one and feel incapable of caring for them anymore. If you can’t go to the bathroom or do household chores without worrying about their safety — that they’ll wander off or turn on the stovetop gas — it may be time to consider alternative care options.
- What if your mental health is suffering? Perhaps you are feeling angry at the person who is ill, socially withdrawn from friends and activities, depressed, exhausted, irritable, or anxious. Research suggests that the psychological effects of caregiving are often more intense than the physical effects. Perhaps it’s time to consider other alternatives.
- Perhaps you’re unable to hold down work responsibilities. You can’t sacrifice your job if it’s how you are financing your own needs and/or your loved one’s needs.
It isn’t easy to pinpoint the exact time your loved one should transition to a nursing home. But you should keep monitoring these signs and explore nursing home options well in advance of your loved one needing a higher level of care. Planning in advance can help you feel less pressured to choose a nursing home while in “crisis mode” – such as after a hospital visit, during an illness, or after a bad fall happens.
Making the Nursing Home Decision
It’s common to feel guilty and sad when moving a loved one to a nursing home, even if you made plans in advance. You may feel like you’re abandoning them or taking away a piece of their freedom. But it’s important to recognize when you’re making the best decision for their health and safety — and yours.
Your care can continue into their new living environment, too, by making sure your loved one is comfortable, happy, visited by loved ones, advocated for when needed, and getting the best possible care at the nursing home.
Paying for Nursing Home
When it comes to paying for nursing home care, Medicaid Asset Protection Planning can be started while your loved one is still able to make legal and financial decisions, or can be initiated by an adult child acting as agent under a properly-drafted Power of Attorney, even if your loved one is already in a nursing home or receiving other long-term care. In fact, the majority of our Lifecare Planning and Medicaid Asset Protection Planning clients come to us when nursing home care is already in place or is imminent. Generally, the earlier someone plans for long-term care needs, the better. But, fortunately, it is never too late to begin your planning.
To afford the catastrophic costs of long-term care without depleting all of your loved one’s hard-earned assets, you should begin Long-Term Care Planning as soon as possible. You should also do Incapacity Planning and Estate Planning, if you haven’t done so already. Contact the Farr Law Firm today to make an appointment for an initial consultation:
Elder Care Fairfax: 703-691-1888
Elder Care Fredericksburg: 540-479-1435
Elder Care Rockville: 301-519-8041
Elder Care DC: 202-587-2797
About Evan H Farr, CELA, CAP
