Statistics show that one 1 of every 2 elderly Americans will need long term care at some point in their lives, and many Americans assume that the government will provide this care. Some have purchased long term care insurance to cover the unexpected costs of caregiving.
As more than 76 million baby boomers approach retirement and become aware that Medicare is not the answer to the non-medical long term care needs of the elderly, more boomers will want to purchase insurance rather than be placed in a nursing facility. Studies also show that an overwhelming number of people would prefer to age at home, cared for by a family member or a home health care provider, rather than in a facility.
There are risks and benefits to each. Medicare is the only model with a national standard and certification process. According to the National Association for Home Care, more than 2.2 million Americans receive Medicare-reimbursed home health services, and more than 8 million receive some sort of home health care. There is no set national licensure or accreditation that governs non-Medicare agencies. The laws vary from state to state, and roughly 30 states have some form of licensure for in-home care that is not reimbursed by Medicare.
Depending on the state and its regulations, there are various types of in-home care agencies: licensed (if the state has licensure for non-Medicare providers), private duty non-licensed (if the state does not regulate the non-Medicare providers), registry, and certified. Understanding the models in your locale and how they function is an important tool.
The licensed agency
In New Jersey, for instance, private-duty home care agencies must be licensed, and those agencies are regulated and mon-itored by the state and can adapt their services to meet changing care needs. In the licensed agency model, the agency hires individuals after a careful screening process, including background checks. Additionally, direct care employees are supervised in the home by a registered nurse. Licensed agencies also provide additional training to their caregiving staff members, who are considered employees and to whom the agency pays taxes and other employer-withholding responsibilities. Most importantly, the agency supervises and monitors the care that's given, based on a plan created and agreed upon at the beginning of care, which is revised as needed and followed by all parties. The licensed agency is also responsible for providing backup in the event that a care provider is unavailable. The agency usually guarantees staffing for critical care cases.
The clients' risk level is relatively low with this model, and it offers a level of quality assurance because it gathers information, monitors its staff, and requires a modicum of public accountability from its agencies. The licensed agency model works well for clients who may not feel comfortable performing the duties of an employer, such as conducting background checks or withholding taxes.
In the states where there is no licensure, a private duty agency that employs its direct care providers would closely fit under this model, even without the licensure requirements.
The registry
In almost all areas of the U.S., the placement agency, or registry model (sometimes called the nursing registry), uses caregivers who are presented as independent contractors. In the registry model, the company recruits workers and places them in the clients' homes. They do not hire, train, or supervise these workers, and they are not considered agency employees. The registry essentially serves as a matchmaker, facilitating the coordination between client and caregiver.
In the registry model, the biggest question is, "Who actually employs the caregivers?" Based on the purpose of a worker in the home and how that worker is paid, you could determine that an employee-employer re-lationship is established between the worker and the client. But does the agency responsible for placing the worker have any accountability? At any rate, an individual entering into this type of situation should review and understand the IRS rules and labor legislation relative to the employment of caregivers placed through a registry.
This model poses potential risks and liabilities to the client's family and the employee. For example, if an injury occurs on the job, who is responsible for the medical bills? Most home-owners' policies strictly forbid employees in the home being covered for injuries. If the worker is not covered by their own workers' compensation policy, then the client would most likely be responsible for the resulting costs of the injury. Also, the client may be responsible for serving in the role of the employer with regard to hiring, payment, and tax issues.
The certified agency
This is the only model with national certification. The most complicated of the three models, certified agencies have benefits and drawbacks that should be closely examined. Medicare services are provided to qualified individuals through a Medicare-certified agency. Medicare, un-fortunately, is not a long term care option. Since its enactment in 1965, it is most associated with home care, despite the fact that coverage under Medicare is intermittent. Medicare coverage is very limited and primarily consists of skilled nursing and therapy for the elderly, and, since 1973, is also available to certain younger and disabled Americans. Some home health aide services are available in addition to skilled services, but the skilled need must first be present and require a physician's orders.
Medicare does not cover the needs of most people who need care, such as assistance with their activities of daily living (ADL), which include bathing, dressing, eating, or grooming. The most common form of assistance required from those who need long-term home care is from a non-medical homemaker or companion who provides services such as companionship, house-keeping, transportation, standby assistance with some ADLs, or medication reminders.
None of these services are provided by the certified agency under Medicare as these services fall under the heading of "non-medical," such as dressing, walking, eating, and grooming. All of these long term care needs must be met with some form of private duty home care that falls outside of a certified agency.
Geriatric care management
Many LTC policies require a geriatric care manager or nurse to evaluate a client for needs prior to starting and reimbursing for services. LTC policies that pay for care management make the decision about which model is best much easier. Care management provides such services as initial and ongoing client/patient assessments. Geriatric care managers are professionals with specialized knowledge about and expertise in senior care issues. Ideally, they hold an advanced degree in gerontology, social work, psychology, nursing, or a related health and human services field. This is critical because care managers will evaluate the client and their situation, identifying solutions that include designing a plan that maximizes the client's independence and well-being.
Geriatric care management is a sensible solution to determining the specific needs that allow the provision of customized and personalized home care and ancillary support services. The care manager creates a plan that is the outcome of a geriatric assessment and is essentially an action plan for current as well as future care. It identifies the client's current problems and needs and lists specific recommendations for care based on income, available support systems, and medical prognosis. The plan may or may not include home care, as it is based on the best interests of the client or patient, their payment and support resources, and their condition.
Choosing an appropriate model
Each model has its pros and cons, and it's up to the LTC agent to learn as much as possible about each option or to systematically use geriatric care managers in order to effectively communicate with the client on such issues. Geriatric care managers can be found at www.caremember.org, the Web site of the National Association of Professional Geriatric Care Managers Inc.
The shifting elderly population, the evolution of health care man-agement, and legislative changes mean that educated LTC agents will be key in the home health process.
Steven Nerayoff LLM, is president of Freedom Eldercare in Hackensack, NJ. He can be reached at 866-737-3336.
