Assisted Living Settings/Facilities and the ADA. Information Bulletin # 331 (4/2011)

by Steve Gold

CMS issued proposed rules regarding Medicaid’s Home and Community-Based waivers. 76 Federal Register 21311 (4/15/11). One part of the proposed rules focused on Assisted Living Settings and whether these qualify under Olmstead’s “the most integrated setting” mandate. CMS stated that “a State’s obligations under the ADA and Section 504 are not defined by, or limited to, the cope or requirements of the Medicaid program; however, the Medicaid program provides an opportunity to obtain partial Federal funding to assist in compliance with the ADA and 504 through the provision of Medicaid services.”

CMS noted that older Americans “ with and without disabilities” may wish to live together. Because so many nursing homes have “converted” to ALS by changing their names and repainting the facility, it is important that advocates for older Americans “with and without disabilities” hold your State Medicaid agency accountable to make sure that the following CMS criteria are really being applied. CMS will permit Medicaid waiver funding only if the ALS were really community-based settings. Advocates can make sure the following criteria are implemented.

Here are the CMS criteria. Unless they are complied with, a Medicaid funded ALS waiver does not comply with the ADA and 504.

1. “The individual has a lease.” Leases trigger tenant rights and the proprietors of the ALS take on landlord duties. They are written and enforceable. State tenant rights statutes provide legal requirements and recourse that residents in an ALS could use if the landlord, aka provider, tries illegally to evict the tenant or act contrary to the lease.

2. The “Setting is an apartment with individual living, sleeping, bathing and cooking areas.” These rights will prevent nursing home providers from just changing the name of their facilities. Each apartment must have an individual cooking area - like a kitchen or kitchenette. Individual bathing is more than a toilet, but includes a shower and/or bathtub. Wow, this is beginning to sound like a real apartment.

3. “Individuals can choose whether to share a living arrangement and with whom.” Hey, isn’t that like what nondisabled tenants do?

4. “Individuals have lockable access to and egress from their own apartments.” That’s fancy talk for a key and a lock. Yes, the person in an ALS has the right to lock the door to her/his own apartment. What next? Invite whomever they wish into thei apartment?

5. Yes. “Individuals are free to receive visitors.” Providers cannot screen of guests.

6. Individuals can also “leave the setting at times and for durations of their own choosing.” They can go out whenever they want. No night curfews.

7. “Aging in place, or allowing individuals to remain where they live as they age and/or support needs change.” Advocates better make sure this is explicitly spelled out in the lease!

8. “Leases may not reserve the right to assign apartments or change apartment assignments.” Make sure it’s explicitly in the lease so there is no doubt about this right.

9. “Access to the greater community is easily facilitated based on the individual’s needs and preferences.” This means that the ALS provider, i.e., landlord, cannot arbitrarily deny a person the right to leave the ALS. More affirmatively, does it suggest providing some assistance in gaining such access - i.e., “easily facilitated”?

10. If there is a “person-centered plan,” compliance with it is “not in and of itself a condition of the lease.” Although the intent of this one is good, we’re not sure why compliance should ever be a condition of a lease. People in ALS should be treated like adults.

If these points are not provided for, then the ALS are “not home and community-based because they are not integrated in the community. A setting that is integrated in the community is a setting that enables individuals with disabilities to interact with individuals without disabilities to the fullest extent possible.”

CMS wrote that “we are particularly interested in gaining comments on these aspects of the proposed rule.” Anyone want to wager that the ALS industry will be against these basic rights?

Advocates for the elderly and disabled Americans should let CMS know these rights are long, long overdue. If advocates do not respond, CMS will be swamped with ALS providers opposing the changes.

Please let CMS know what you think about ALS. You have only until June 14 to respond. If you do, refer to the file code CMS-2296-P.

Electronically - http://www.regualtions.gov and follow the instructions under the “more search options” tab.

Regular Mail: CMS, Dept of HHS, Attention: CMS-2296-P [yes, I know that is different but I do not know which is correct.], P.O Box 8016, Baltimore, MD 21244-1850.

Iowa Senior Care Advocate's Job Plan, Silence Are Questioned | The Des Moines Register | DesMoinesRegister.com

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Written by CLARK KAUFFMAN (ckauffman@dmreg.com)

Iowa's top advocate for seniors in nursing homes wants to have her job performance evaluated by the industry she oversees.

At the same time, the director of the Iowa Department on Aging is telling the state's eight local long-term care ombudsmen that they should not speak out about a recent dramatic cut in the number of state nursing home inspectors.

"That is unconscionable," said John Tapscott, a former state legislator who now advocates for the elderly. "You can't tell our ombudsmen not to speak out on the issues that affect their constituents."

According to federal law, each of the nation's long-term care ombudsmen is to advocate independently for the elderly residents of care facilities - a job that historically has put the ombudsmen at odds with both nursing homes and state regulators.

But new questions are being raised about whether Iowa's ombudsman, Jeanne Yordi, is working independently or advocating effectively for the elderly.

More

Related articles:
Seniors' advocate must be independent
Iowa long-term care ombudsman's tie to lawyer questioned

HUD Section 811 Listening Session - April 14th

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This past January, President Obama signed into law the Frank Melville Supportive Housing Investment Act, amending and updating the Section 811 Supportive Housing for Persons with Disabilities program.  Among other things, this bill provides a new authority to HUD to allocate long term operating assistance funds to states where a strong supportive housing plan exists to link services to mainstream affordable housing for persons with disabilities.

HUD will be holding a listening session on April 14^th from 1:00 – 3:00 pm to get stakeholder input and hear suggestions on how HUD might implement this new authority.  You are invited to attend.  However, participation is limited to 50 individuals so please RSVP by April 4^th, 2011 to Lisa Wimbush-Lathern at lisa.a.wimbushlathern@hud.gov.

The session will be held in the Brooke-Mondale Auditorium at HUD Headquarters in Washington , DC .  A conference call-in number will be provided for those unable to attend in person.

We look forward to your input and thank you in advance for your participation.

Carol J. Galante

Deputy Assistant Secretary

    for Multifamily Housing Programs

U.S. Department of HUD

451-7th Street, SW Room 6106

Washington, DC   20410

(202) 708-2495 (main line)

(202) 708-2583 (fax)

U.S. Senate Aging Committee Considers Assisted Living Issues

The federal government should take a more active role in oversight of assisted living facilities in light of current common practice that allows facilities to kick out or refuse to admit Medicaid-eligible residents even though the facilities themselves are approved to participate in Medicaid.

"Assisted living facilities are glad to accept money from Medicaid, but currently they don't live by the same rules as other Medicaid-certified providers," said National Senior Citizens Law Center Directing Attorney Eric Carlson during a roundtable discussion about assisted living issues today on Capitol Hill.

"If they agree to accept Medicaid, assisted living facilities should be held as accountable as other health care providers at both the federal and state levels," Carlson added. He also explained how, in the absence of consistent federal oversight, states have developed widely varying rules that do not protect consumers adequately.

When assisted living facilities stop accepting Medicaid, Carlson said the results can be devastating to residents. For example, after one 89-year-old Washington woman received an eviction notice when her facility stopped accepting Medicaid, she grew depressed, stopped eating and died within the month.

Carlson recommended that federal law be enforced to protect residents when a facility refuses Medicaid as in the tragic case above. It also calls on states to write rules to require Medicaid-certified facilities to accept residents regardless of their Medicaid status and prohibit facilities from penalizing current residents when a facility chooses to decertify.

In his remarks, Carlson also pointed to other problems and challenges related to the oversight of assisted living, basing his comments on a series of policy issue briefs and white papers that related to this and other legal issues developed with support from the Commonwealth Fund.

The roundtable is convened by the U.S. Senate Special Committee on Aging, and is entitled "Assisted Living at the Dawn of America's 'Age Wave': What Have States Achieved and How Is the Federal Role Evolving?" The hearing starts at 1 p.m., March 15, in room 216 of the Hart Senate Office Building.

Source: National Senior Citizens Law Center
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Mather LifeWays Institute on Aging Identifies 10 Senior Living Trends | Aging In Action

by Linda Hollinger-Smith - Aging In Action blog

Mather LifeWays Institute on Aging derived 10 top senior living trends after surveying 600 senior living organizations representing more than 1,000 communities from 15 states. Trends indicate that older adult living communities and care providers must anticipate and cater to the personal needs and interests of residents by offering options beyond the basics and include more comprehensive provision for in-home care.

Trends are identified to allow developers and providers to address opportunities and create innovations to help shape the future of senior living relative to services, programs, amenities, and design. The ultimate goal is to create environments and lifestyles where people want to live, not where they need to live.

Based on survey results, the following are the top 10 emerging senior living trends.

1, Senior living residents are choosing to “age in place.”

2. Health and wellness programs and services are top priorities.

3. Technology will be key to promoting and sustaining independent lifestyles among senior living residents.

4. Resident programs must focus on meaningful activities and intellectual stimulation.

5. Senior living providers will provide services “beyond” their four walls.

6. Long-term care is transforming to support person-directed care and meaningful relationships.

7. Residents are demanding “customized services” driving the need for senior living providers to offer a customer-driven portfolio of services and programs.

8. Language, perceptions, and attitudes of care providers must be updated to reflect changing older adults’ needs and expectations.

9. Senior living industry may become a hotbed for job creation.

10. Above all, consumers want choices and value.
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Deaths from Acute Hepatitis B Virus Infection Associated with Assisted Blood Glucose Monitoring in an Assisted-Living Facility

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February 18, 2011 / 60(06);182

Sharing of blood glucose monitoring equipment in assisted-living facilities has resulted in at least 16 outbreaks of hepatitis B virus (HBV) infection in the United States since 2004 (1,2). On October 12, 2010, the North Carolina Division of Public Health (NCDPH) and the Wayne County Health Department were notified by a local hospital of four residents of a single assisted-living facility with suspected acute HBV infection. NCDPH requested HBV testing of all persons who had resided in the facility during January 1--October 13, 2010, and defined an outbreak-associated case as either 1) positive hepatitis B surface antigen and core immunoglobulin M (IgM) results or 2) clinical evidence of acute hepatitis (jaundice or serum aminotransferase levels twice the upper limit of normal) with onset ≥6 weeks after admission to the facility. Records were reviewed for potential health-care--associated exposures and HBV-related risk factors. Infection control practices were assessed through observations and interviews with facility staff.

The investigation identified unsafe practices, including sharing of reusable fingerstick lancing devices approved for single patient use only and shared use of blood glucose meters without cleaning and disinfection between patients. Of 87 persons who had resided in the facility during the study period, 47 were excluded from analysis because of HBV immunity (20 persons), chronic infection (one person), or unknown HBV status (26 persons). Of the remaining 40, eight met the case definition. Of these, all were hospitalized, and six died from hepatitis complications. All eight were among the 15 residents whom facility staff had assisted with blood glucose monitoring; none of 25 residents who had not been assisted with blood glucose monitoring were infected.

Despite long-standing and recently expanded infection control recommendations (2,3), HBV transmission continues to occur through sharing of fingerstick lancing devices and other blood glucose monitoring equipment. These practices put residents at risk for severe illness and death. In accordance with NCDPH recommendations, the facility now uses individually assigned blood glucose meters and single-use, autodisabling fingerstick lancing devices. The facility also offered HBV vaccine to all susceptible residents. NCDPH and the state licensing agency issued a notification to all health-care providers and licensed health-care facilities statewide warning of the potential for HBV transmission through unsafe diabetes-care practices. This outbreak underscores the need for increased efforts to promote compliance with infection-control guidelines in assisted-living facilities.

Reported by

Z Moore, MD, J-M Maillard, MD, M Davies, MD, North Carolina Dept of Health and Human Svcs; N Dailey, MD, EIS Officer, CDC.

References

1. CDC. Transmission of hepatitis B virus among persons undergoing blood glucose monitoring in long-term--care facilities---Mississippi, North Carolina, and Los Angeles County, California, 2003--2004. MMWR 2005;54;220--3.
2. CDC. Infection prevention during blood glucose monitoring and insulin administration. Atlanta, GA: US Department of Health and Human Services, CDC; 2010; Available at http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html. Accessed February 10, 2011.
3. Food and Drug Administration. Use of fingerstick devices on more than one person poses risk for transmitting bloodborne pathogens: initial communication: update 11/29/2010. Washington, DC: US Department of Health and Human Services, FDA; 2010; Available at http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm224025.htm. Accessed February 10, 2011.

Immigration Reform: A Key Retirement Issue - The Best Life (usnews.com)

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By Philip Moeller

With Social Security and Medicare programs facing deficit-cutting proposals in the new Congress, seniors and their advocacy groups already have big issues on their plates. Yet a good case can be made that immigration reform is another emerging issue for millions of seniors who need care. The shifting outlook has several components—rising demand for care due to a growing elderly population, a sustained effort to provide elder care in homes rather than institutions, a shrinking work force of Americans, and an economic recovery that will eventually reduce the supply of family members available to provide unpaid care.

Full Article

Moving Out of Nursing Home Care; Independent Assisted Living - AARP Bulletin

by: Cynthia Ramnarace | from: AARP Bulletin

For eight years, Thomas Smallwood got around relatively well for a man with no legs. Poor circulation had led Smallwood, 63 at the time, to a difficult choice: his legs or his life. He chose the latter. You don't need legs to be a man, he thought. The man makes the legs.

Smallwood was among as many as 12 percent of nursing home residents — 168,000 out of the 1.4 million — designated "low-need," meaning that the assistance that they do need could conceivably be delivered in their own homes or in assisted living. And according to a recent November 2010 pilot study by researchers at Cornell University, more than half of that low-need population could transition back into the community with the right social supports.

"People just assume that a nursing home is a one-way street," says Rhoda Meador, associate director of outreach and extension at Cornell's College of Human Ecologyand author of the study. "But many practitioners don't accept that."
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Managing the Transition to Post-Acute and Long Term Care | Aging In Action

by John Davy on January 31, 2011

Transitions to long-term care, assisted living, and other supportive living options are often made in difficult conditions, under the financial and time pressure that follows acute care and other crises. A recent article (Kane 2011) in the Journal of the American Medical Association’s “Care of the Aging Patient” series reviews transitional and long-term care options for older adult patients who are transitioning from acute care, and argues that physicians should familiarize themselves with such options and, when possible, be involved in the transition.

The article provides a review of the last two decades of research on transitional (post-acute) care, long-term care, rehabilitation and other assisted living options.
Full Article

Style Without End - NYTimes.com

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By PAULA SPAN

Ari Seth Cohen can probably blame his fascination with glam older women on his grandmothers.

His mother’s mother, whom he describes as “my best friend, growing up,” successfully lobbied for him to leave Seattle, where he’d been working in galleries and in a men’s store, and to move east. “She always told me New York was where everything is happening, and if I wanted to do something creative, I should be there,” he told me.

His father’s mother was a fashion plate who took him shopping at Escada. “She wore beautiful suits and jewelry, a very elegant woman,” Mr. Cohen recalled.

When he did move to New York, initially taking a job in a museum bookstore, he noticed a number of idiosyncratically chic older women on the streets. He took to carrying his Canon Rebel digital camera with him everywhere, snapping their photos. The result is the blog Advanced Style, launched in 2008, which declares itself “proof from the wise and silver-haired set that personal style advances with age.”

“Older people are comfortable in their own skin, and they wear their style with confidence,” Mr. Cohen explained, sounding a bit envious. He’s a mere 29.

That appearance matters, at least to a number of old people, is something lots of nursing home, assisted living and adult day staffers can testify to. There’s a reason so many of these facilities have beauty salons on site, a reason many women cling to their red lipstick and hair color when even walking becomes difficult.


I often hear complaints about the limited range of clothing designed for older women who disdain pastel velour tracksuits. You won’t see a lot of those on Advanced Style.

Full Article

New Research Demonstrates the Value of Social Connectedness for Older Adults

by Richard Shank on October 29, 2010

The research reported in this article is not directly about the move-in process into Long Term Care (LTC) or Senior Living (SL); however, it implies that competitive organizations will have to recreated the same sense of community within their residence that older adults feel they have left behind when they move in.

Researchers from University of South Carolina outlined the importance of salient social connections in the lives of older adults. “Salient connections…form the basis for all human existence and it is the phenomenon of connectedness that brings quality of life.” This seemingly commonsensical statement is far too often taken-for-granted and thus overlooked by many. Just as in the1980s when economists had to be reminded that market relationships are embedded in a web of social connections, today many service providers can stand to benefit from being reminded that the social connections their residents have help drive the satisfaction and quality of life of their residents. Additionally, these social connections help shape the decision to move into your residence. So paying attention to the social needs and relationships of residents or potential residents will help both program development and marketing.
Full Article

Aging's Challenges Amplified for Gays and Lesbians - NYTimes.com

Image via WikipediaBy PAULA SPAN

David and his partner, Paschal, together for more than 20 years, married during the brief period that same-sex marriages were legal in California. They’re in their 60s, in decent health and financial shape. Yet thinking about their future makes David uneasy.

With an eldercare system (if you can call it a system) that depends on younger family members shouldering responsibility for older ones, perhaps any childless and aging couple would share his concerns. But gay men and lesbians face particular challenges, as David pointed out to me in a recent e-mail.

Let him count the ways. “The guys who are 65 and older now generally came of age, and came out, when doing so meant alienation from your family,” David wrote. “Many of the older gays I know are still estranged.” They don’t feel they can rely on younger relatives for help.

David and Paschal (citing privacy concerns, they asked that their full names not be used) expect to have to care for themselves — not because they’re estranged from family members, but because their nieces and nephews live far away. So David is considering other options.

If the couple wanted to retire to Paschal’s home state in the South, where senior housing communities would be much less expensive, “we’d have a hard time finding a life care facility that would accept us as a married couple,” David wrote. “And I doubt the other residents would be too welcoming if we did get in. And church-sponsored places — often a good value for straight folks — are largely not available for open gays.”

A number of researchers have found that, for those reasons, older gay men and lesbians sometimes conceal their sexual orientation when they enter nursing homes or assisted living facilities, effectively recloseting themselves at one of life’s most vulnerable passages.


At older ages, too, a number of the federal policies that protect married couples come into force, leaving gay men and lesbians, even those who marry in their own states, at a comparative financial disadvantage. Paschal’s Social Security benefits, for instance, are considerably greater than David’s, but David won’t be eligible for the spousal and survivor benefits that other widowers receive should something happen to Paschal.
Full Article

Monitoring Elderly Parents - NYTimes.com

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It used to be that parents kept tabs on their children. But The Times reports this morning on new technology making it possible for adult children to monitor, to a stunningly precise degree, the daily movements and habits of their aging parents.

The purpose is to provide enough supervision to make it possible for elderly people to stay in their homes rather than move to an assisted-living facility or nursing home, and in truth many of the systems are godsends for families. But, as with any parent-child relationship, all loving intentions can be tempered by issues of control, role-reversal, guilt and a little deception — enough loaded stuff to fill a psychology syllabus.
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Michelle Singletary - Reading up on elder care

A Book Review By Michelle Singletary in the Washington Post
 
WHEN THE TIME COMES - Families With Aging Parents Share Their Struggles And Solutions
By Paula Span, Springboard Press 

Span's book, published last year, isn't a how-to manual as much as it's a how-to-get-through-the-years of caring for an elderly relative. Span writes that her work is a "support group in print." The book tells the stories of about a dozen families faced with becoming caregivers.

"We talk sometimes about a role reversal, the children become the parents, but it's a flawed analogy," Span writes. "Our elders are not children; they don't have to do what we think best. There's no T-shirt that proclaims, 'Because I'm the Daughter, That's Why.' And this passage, unlike child-rearing, will not result in eventual independence."

"When the Time Comes" is a beautifully written, heartfelt narrative filled with facts and advice from experts but also moving stories of care-giving. Span stretches the stories over five chapters that cover the living choices for the elderly -- home care, shared household, assisted living, nursing homes and hospice.

Read Review



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New Director of the AoA Office of Long Term Care Ombudsman Programs Announced

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Message from Assistant Secretary for Aging Kathy Greenlee congratulating the new Director of the AoA Office of Long-Term Care Ombudsman Programs.

It is my pleasure to announce that Becky Kurtz has agreed to join AoA as our new Director of the Office of Long Term Care Ombudsman Programs. Since 1994, Becky has served as the Georgia State Long Term Care Ombudsman in Atlanta. Prior to that position, Becky was the Advocacy Coordinator for the Senior Citizens Advocacy Project in the Atlanta Legal Aid Society as well as serving as Assistant Corporation Counsel for the City of New York Law Department. Becky has a Juris Doctorate from Columbia University School of Law and a B.S. from Emory & Henry College in Emory, Virginia.

I am very excited that Becky will be joining AoA. As the Older Americans Act statute states, "The Director shall serve as an effective and visible advocate on behalf of older individuals who reside in long term care facilities, within the Department of Health and Human Services and with other departments, agencies, and instrumentalities of the Federal government regarding all Federal policies affecting such individuals."

For many years I have considered her one of the most effective and committed state long term care ombudsmen. I look forward to working with her on behalf of the 1.6 million older people who live in nursing homes and other residential care settings. She is an exceptional advocate. Please join me in welcoming Becky to AoA.

A Danger to the Community? - The New Old Age Blog - NYTimes.com

By PAULA SPAN

So much for the stereotype of those nice, welcoming Minnesotans.

In Woodbury, Minn., a Twin Cities suburb, a proposed assisted living facility that would specialize in dementia care has run into angry opposition from some neighbors in a surrounding residential development called Stonemill Farms.

This is not, in itself, unheard of. Concerns about things like parking and traffic do sometimes surface when communities contemplate new assisted living projects. What’s unusual about Settler’s Pointe, a 45-unit facility that would replace a mostly empty retail strip, is that a number of its adversaries describe it as a potential threat to their children.

Here is Minneapolis Star Tribune columnist Jon Tevlin’s description of the controversy.

We’ll pause here for a moment to allow New Old Age readers, so many of whom have up-close experience with parents with dementia and with specialized dementia dwellings, to say: What?

We’ll also pause to acknowledge that only about 50 people signed the petition asking the city to reject the project, and about 75 showed up at a community meeting to oppose it. Stonemill Farms has close to 600 new homes, many clearly occupied by folks who don’t see the old and sick, even those in the 15 apartments slated for people who need “enhanced” care, as a danger to the elementary school across the street or the day care center next door (whose owner favors the new residence).

But the Stonemill Farmers opposed to this project sound scared. In a raft of e-mail messages to the city’s planning department, which made them available to me, they express their shock at finding a “high-density,” “locked-down facility” in their new residential development — perhaps not grasping that such buildings are secured not to protect neighborhoods from marauding old people, but to keep wandering dementia patients from endangering themselves. And maybe the neighbors don’t understand that 45 units, with one staff person for each five residents in the “enhanced” apartments and one to 10 in the others, constitutes a fairly modest size for an assisted living facility, not to mention a high level of supervision.
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When Foreclosure Threatens Elder-Care Homes - NYTimes.com

By LAURIE UDESKY
In September 2009, Sgt. Rick Turini of the Santa Clara County Sheriff’s Office drove to a house in San Jose to carry out a court-ordered eviction.

With foreclosures in Bay Area counties near all-time highs, the office had been routinely evicting 35 to 40 households a week. But this property was different: It was a board-and-care home for the elderly.

Neither the residents nor their families had been warned about an eviction, said Sergeant Turini, who does not recall the home’s exact address.
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Patient Money - Stressful but Vital - Choosing a Nursing Home - NYTimes.com

By WALECIA KONRAD

The decision is one of the hardest you will ever make. Your spouse, parent or another loved one needs care that assisted living or home health care simply cannot provide. You need to choose a nursing home.

It’s a difficult and emotional task. The horror stories are well documented, and even in the best nursing homes the transition can be wrenching for the entire family.

Finding a good nursing home takes research and perseverance. You want a safe, engaging and pleasant environment with caring staff and solid medical practices.

“You can actually get all of that in a nursing home — if you know what to look for and how to search,” said Larry Minnix, chief executive of the American Association of Homes and Services for the Aging, a trade group for nonprofit nursing homes and other organizations for the elderly.

Unfortunately, the typical search for a nursing home is made under duress. More than 60 percent of admissions come from hospitals. The patient may have broken a hip or had a stroke and now needs rehabilitative care. The hospital is in a hurry to discharge and may move quickly to get the patient moved to an available nursing home bed, regardless of the operator’s quality or reputation.
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Patient Money - Finding the Right Care for the Elderly - NYTimes.com

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By LESLEY ALDERMAN

TWO years ago my father, then 83, became very ill. Until then, he had been living alone in a pleasant one-bedroom apartment on the Hudson River, an hour’s drive from my home in Brooklyn.

After a couple of months in the hospital it became clear that my dad, Harvey Alderman, could not return to solo living. He was fragile and forgetful, and there was no way he could keep track of the 14 or so pills he had to take each day.

But where would he go — and how would we pay for it? Could he stay in his apartment if he had regular visits from an aide? Or should he go to an assisted-living facility where there would be more services available for him?

So began my family’s crash course in caring for an aging parent in declining health.

If you’re in this predicament, you know already there is no simple answer. Older people each have unique medical and emotional needs. And finances often dictate how far you can go in creating the ideal situation for them.
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Long-Term Care Financing Reform: Lessons from the U.S. and Abroad - The Commonwealth Fund

Broad health care reform legislation being considered by Congress would effect a major change in the way the United States finances long-term care. The Community Living Assistance Services and Supports (CLASS) Act would create a voluntary national long-term care insurance program. As lawmakers debate the potentially far-reaching proposal, they may learn from the experiences of other developed nations and from recent experiments in the U.S.

Long-term care is the personal assistance that the frail elderly and other adults with disabilities require to maintain the best possible quality of life. The assistance may be delivered at home or in a nursing facility or other congregant care setting. In the U.S., most long-term care is provided by family members, and some by paid aides. The cost of formal care is quite high, averaging $75,000 per year for residence in a skilled nursing facility and $20 per hour for home health aides.

In Japan and much of Europe, public benefits for long-term care of the frail elderly have become a pillar of social policy, along with retirement and health care. While many nations have enacted major reforms over the past two decades, they have taken somewhat different approaches.
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