Long-Term-Care Facilities
(Nursing Homes, Assisted Living, Residential Homes for the Aged)
Most older persons continue to live independently throughout all or most of their lives and are able to remain in their own homes. For older people who need assistance, families can often supply the practical and emotional support required. In some cases, when family help is either not available or the amount or type of assistance needed is more than what a family can provide, an older person needs to move into a long-term-care facility such as an assisted living facility or a nursing home.
1. Choosing a Facility in Advance
If a move is necessary, think about how to choose and pay for an appropriate facility.
Whenever possible, an older person should participate in making the decision to move into a long-term-care facility. Having some sense of control and choice can ease adjustment to the new place. Early planning allows time to look at many or all of the senior housing facilities (see "Housing" and "Nursing Homes") in the area and improves the chances of making an appropriate decision.
You can get information about how to choose a nursing home from Senior Citizens Information & Referral Service, Long Term Care Ombudsman, medical and social work professionals, clergy, and friends who have relatives in long-term-care facilities. In addition, many publications offer advice. Medicare has Your Guide to Choosing a Nursing Home. AARP and Legal Aid Society of Middle Tennessee publish You Have Rights in a Nursing Home. You can get a copy from the Legal Aid of East Tennessee.
Five important factors influence the choice of a facility: the type of care required, certification, the financial resources available, convenience of location, and the availability of a bed or room.
A. The first consideration in selecting a facility is the kind of care needed.
The state licenses three levels of long-term care: Residential Homes for the Aged (RHAs), Assisted Care Living Facilities (ACLFs), and nursing homes. ACLFs and RHAs can offer services such as meals, laundry, and housekeeping, and some help with personal care, but usually cannot provide medical care unless they have 24-hour licensed nursing staff. Typically, no public dollars pay for staying in an ACLF or an RHA, and residents of these types of facilities pay the entire cost of their stay. However, some long-term-care insurance policies will pay for housing with assistance and in some cases, VA Aid & Attendance might cover some of the cost.
Nursing homes offer medical care; they often offer more than one level of care. A physician will do an evaluation that determines whether skilled or intermediate care is needed before a person can be admitted to a nursing home. Note: In the following descriptions, “skilled” is a term for a particular type of care and does not refer to the expertise or ability of the person giving the care.
Skilled Care provides 24-hour-a-day nursing services for a person who has serious health-care needs, up to and including high-level wound care, a respirator, tube feeding, intravenous therapy, and more. Rehabilitation services are also provided as needed. The specific services offered in each skilled-care facility may vary; ask about services when you are evaluating facilities. Skilled care is sometimes offered in transitional care units in hospitals
Intermediate Care provides less extensive health care than skilled care. Nursing and rehabilitation services are provided for patients in intermediate care, but not around the clock. Intermediate care is for persons who need medical supervision and help with personal care, but not skilled nursing.
B. The second factor in selecting a nursing home is certification. If ongoing long-term care will probably be necessary, choose a facility that is both Medicare- and Medicaid-certified. Some facilities do not accept Medicaid/TennCare patients. In a dually certified nursing home, a move would not be necessary if the patient’s funds run out.
C. The third factor in choosing a nursing home is a frank analysis of the older person’s financial status. Make a complete inventory of available resources, including source and level of income, property owned, savings accounts, stocks and bonds, veterans’ benefits, pensions, insurance benefits, and any family assistance available. If there is not enough money to pay for nursing home care, contact the Medicaid/TennCare office.
Original Medicare pays for only a limited amount of skilled nursing home care if skilled care is medically necessary and the patient has been in the hospital for at least three days (not counting the day of discharge) for the medical reason for which the nursing home care is needed. Some Medicare Advantage Plans do not require the three-day stay in a hospital before paying for skilled care in a nursing home. Generally, Medicare will pay all of the cost for the first 20 days. For the next 80 days Medicare will pay 80 percent of the cost per day. Review your Medicare supplement insurance or Advantage plan to determine what your plan pays for should you require skilled nursing home care. After 100 days, Medicare pays nothing. Medicaid will pay the cost of medically necessary skilled care for income-eligible patients. Most, but not all, long-term-care insurance covers nursing home costs up to the policy’s per-day limit. Private funds pay the rest.
Medicare does not pay for intermediate care. TennCare Medicaid for Long-Term Care will cover medically necessary intermediate care for income-eligible patients. Some long-term-care insurance policies cover intermediate care in a nursing home. Private funds pay the rest.
If you need to have nursing home care paid for by TennCare Medicaid for Long-Term Care you must be both income eligible and medically eligible. The TennCare Bureau in Nashville must decide, based on your physician’s description in the Pre-Admission Evaluation (PAE) of the level of care you need, whether you meet their standards for medically necessary skilled or intermediate care. Some PAEs are denied by the TennCare Bureau. The standards for medical necessity can be very strictly interpreted. The cost of providing TennCare Medicaid for Long-Term Care nursing home care has increased dramatically in the past several years. Curtailing admissions is one method of cost control. Denials can be appealed. The denial letter spells out the appeal procedure. Call the Long Term Care Ombudsman, MAPS, or the facility social worker or admissions office for assistance or for more information about the PAE or appeal process.
If nursing home placement is to follow hospitalization, the hospital discharge staff will try to get pre-approval from the TennCare Bureau. TennCare Bureau action on the PAE for nursing home placement for a person who is being cared for at home may take considerably longer than for care after hospitalization and may not be approved. Some facilities will complete the paperwork and submit it. The medical provider must complete a PAE, and mail or fax it to TennCare to verify medical eligibility. The “designated correspondent” will receive notice of approval or denial.
If paying for nursing home care has used up your money, and you need to apply for TennCare Medicaid for Long-Term Care, tell the nursing home staff and ask their assistance. Apply before Medicare coverage or personal financial resources run out. Apply at the Knox County Department of Human Services to establish financial eligibility. You must submit a Pre-Admission Evaluation (PAE) for approval to the TennCare Bureau, even though you are already in the nursing home. Approval can be, and has been, denied. Be prepared to appeal if you are turned down. Directions for doing so are included with the denial letter. If you are denied on medical grounds, you can request an onsite visit from the TennCare Bureau. The Knox County Department of Human Services Medicaid/TennCare staff will work with you.
D. The fourth factor is location. Choosing a facility that is convenient to family and friends makes visiting and monitoring easier.
E. The fifth factor is availability of a bed. Many nursing homes have long waiting lists. Finding a bed in a facility that accepts Medicaid/TennCare patients can sometimes be difficult, since some facilities have opted out of the Medicaid/TennCare system.
2. Choosing a Facility in an Emergency
Many older persons and their families avoid discussions and decisions about nursing home placement until a medical crisis forces an immediate decision. If immediate help is needed in locating a nursing home, contact the sources referred to in "Nursing Homes."
If an older person is required to transfer from the hospital to a nursing home on short notice because the doctor is ready to discharge him or her, emergency placement in a nursing home may be unavoidable. Even then, timing and arrangements for the transfer should be discussed with the physician and hospital personnel. You must still know what level of care is needed, whether the certification is by both Medicare and Medicaid, what funds are available to pay for care, consider the convenience of a facility’s location to family and friends of the patient, and find an available bed.
3. Long Term Care Ombudsman
The best way to ensure quality care for an elderly relative in a nursing home is for family members and friends to visit frequently and to establish and maintain good communication with the nursing home staff. To ask a question or resolve a problem regarding care of the nursing home resident, first talk to the nursing staff or the social worker. If the problem continues, talk to the nursing home administrator. If these steps do not resolve the issue, contact the district Long Term Care Ombudsman.
All states have an ombudsman program that is responsible for investigating, mediating, and trying to resolve complaints made by or on behalf of residents in long-term-care facilities (nursing homes, ACLFs, and RHAs). In Tennessee, the state, regional, or volunteer ombudsmen monitor and ensure the implementation of federal, state, and local laws governing resident rights and quality of care in long-term-care facilities. There is no charge for ombudsman services. You can find out about the ombudsman in another state by calling the Eldercare Locator.
In East Tennessee, the names and contact information of a facility’s ombudsmen are posted in a prominent place at each facility. When a loved one enters a nursing home, arrange to meet the ombudsman and acquaint him or her with your relative. The ombudsman can keep an eye on your patient and help resolve problems that may arise.
The Centers for Medicare and Medicaid Services (CMS) report information on the quality of care in nursing homes to help you choose high-quality health care. Visit www.medicare.gov or call 1-800-633-4227.
Complaints about nursing homes can also be filed with Health Care Facilities. To file a complaint, call the Complaint Hotline at 1-877-287-0010. You can report abuses anonymously.
4. Patients’ Rights
Nursing homes that participate in the Medicaid/ TennCare and Medicare programs must have established patients’ rights policies. Ask the nursing home for a copy of its patients’ rights policy. Contact the district Long Term Care Ombudsman for more information.
5. Families’ Rights
Questions about family responsibility for the cost of an older person’s health care and long-term care frequently arise. Families may need to seek legal advice about what their financial obligations are, if any. See your attorney or make an appointment with a Legal Aid of East Tennessee representative for advice about responsibility for the costs of nursing home care and, specifically, about what to sign and not sign when arranging for a relative to enter a nursing home. You do not have to sign as a responsible party in order for the elder to be admitted.
The spouse of a nursing home resident who is on Medicaid has the right to a certain minimum income and a maximum amount of assets.
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