Long-Term Care and Health Care Facilities

A health care facility is any place where health care professionals administer treatment or care to people with chronic or acute illnesses or injuries. This includes hospitals, nursing homes, assisted living facilities, residential homes for the aged, walk-in clinics, dialysis clinics, and more.

All health care facilities in Tennessee are licensed and regulated by the Tennessee Department of Health, Division of Health Care Facilities, or sometimes by the Centers for Medicare & Medicaid Services, to ensure that they comply with federal guidelines.

To determine a facility’s licensure status–and whether it is the kind of facility you need–call Health Care Facilities, (865) 594-9396, located at 7175 Strawberry Plains Pike, Suite 103, Knoxville, 37914. Information about all licensed facilities in the state, as well as other useful information, is on the agency’s website.

The Department of Health has a Complaint Hotline to report how a facility is operating or to inquire about licensure status. The number is 1-877-287-0010. Complaints can also be filed online.

Many older persons live independently throughout all or most of their lives and remain in their own homes. For older people who need assistance, families can often supply practical and emotional support. When an older person has no family available to help, requires more assistance than family can provide, wishes to downsize, or wants the social environment of a communal setting, he or she needs to move into a long-term care facility, such as assisted living or a nursing facility.

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 the decision. Having some sense of control and choice can ease adjustment to a move. Early planning allows time to look at available options and improves the chances of making a good decision.

Information about choosing a nursing facility is available from Senior Information & Referral, 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 available online. Six important factors to consider are type of care required, certification, financial resources, convenience of location, availability of a bed or room, and community atmosphere.

1 . Type 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 typically offer services such as meals, laundry, housekeeping, and some help with personal care, but usually cannot provide medical care unless they have 24- hour licensed nursing staff. If your loved one has dementia, you may need to consider facilities that have secure units to prevent wandering. However, some long-term care insurance policies will pay for housing with assistance and in some cases, CHOICES in Long-Term Services and Supports or VA Aid & Attendance might cover some costs.

Nursing homes provide medical care and often offer more than one level of care. A physician determines whether skilled or intermediate care is needed before a person can be admitted. Some nursing facilities have secured units for people with dementia. 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 caregiver.

Skilled care provides 24-hour-a-day nursing services for a person with serious health-care needs, up to and including high-level wound care, respirator, tube feeding, intravenous therapy, and more. Rehabilitation services also are available. The specific services offered in each skilled- care facility can vary, so ask when evaluating facilities.

Skilled care sometimes is offered in transitional care units in hospitals. Intermediate care provides less extensive health care than skilled care. Nursing and rehabilitation services are provided, but not around the clock. Intermediate care offers medical supervision and help with personal care, but not skilled nursing.

2. Certification

If ongoing long-term care is likely to be necessary, consider choosing a facility that is Medicare- and Medicaid-certified. Some facilities do not accept CHOICES (Medicaid) patients. In a dually certified nursing home, a move would not be necessary if the patient’s funds run out.

3. Analysis of financial status

Make a complete inventory of resources, including source and level of income, property owned, savings accounts, stocks and bonds, veterans’ benefits, pensions, insurance benefits, and any family assistance. If there is not enough money to pay for nursing home care, contact the East Tennessee Area Agency on Aging and Disability (the single point of entry) to start the application process for enrolling a person in CHOICES (Medicaid).

Original Medicare pays for a limited amount of skilled nursing facility care if it is medically necessary and the patient was admitted to a hospital for at least three days (not counting the day of discharge) for the medical reason for which facility care is sought. Some Medicare Advantage plans do not require the three-day hospital stay before paying for skilled care in a nursing facility.

Generally, traditional fee-for-service Medicare pays all costs for the first 20 days of skilled care. For the next (up to) 80 days, traditional Medicare pays all but 20% per day. Review your Medicare supplement insurance or Advantage plan to determine what your plan pays. After 100 days, Medicare pays nothing. Medicaid will pay the cost of medically necessary skilled or intermediate care for financially and medically eligible patients. Most, but not all, long-term care insurance covers nursing facility costs up to the policy’s per- day limit. Private funds pay the rest.

Most long-term care insurance policies include a waiting period, called an elimination period, before you can receive benefits. During the elimination period, you pay costs out of pocket.

Medicare does not pay for intermediate care. CHOICES for Long-Term Care will cover medically necessary intermediate care for financially and medically eligible patients. Some long-term care insurance policies cover intermediate care in a nursing home. Private funds pay the rest.

If nursing home care needs to be paid for by CHOICES, an individual must be income eligible and medically eligible. The TennCare bureau in Nashville must decide–based on the physician’s description in the Pre-Admission Evaluation (PAE) of the level of care needed–if a person meets the standards for medically necessary skilled or intermediate care. Some PAEs are denied by the TennCare Bureau.

The standard can be strictly interpreted and is acuity based. This is a major change in the definition of medical necessity, making it more difficult to qualify for CHOICES. In general, eligibility is determined by an applicant’s need for assistance with the following Activities of Daily Living (ADLs): transferring, mobility, eating, and toileting.

Denials can be appealed, and the denial letter details the appeal procedure. Call the Long-Term Care Ombudsman or the facility social worker or admissions office for assistance or more information about the PAE or appeal process.

If nursing home placement is to follow hospitalization, the hospital discharge staff will seek pre-approval. Some facilities will complete and submit the paperwork. 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 depleted a person’s resources, and they need to apply for CHOICES, ask the nursing home staff for assistance. Apply before Medicare coverage or personal financial resources run out. Contact the East Tennessee Area Agency on Aging and Disability (page 117), which can assist with establishing financial eligibility. A PAE must be submitted for approval to the TennCare Bureau, even if someone is already in a nursing home. If approval is denied, be prepared to appeal, and follow directions in the denial letter. If you are denied on medical grounds, request an on-site visit from the TennCare Bureau. If denied on financial grounds, someone from the CHOICES program of the East TN Area Agency on Aging & Disability can advise the individual on how to file an appeal.

4 . Location

Choosing a facility that is convenient for family and friends makes visiting and monitoring easier.

5 . Availability

Some nursing homes have long waiting lists. Finding facilities that accept CHOICES can be difficult because some have opted out of the CHOICES system.

6. Community atmosphere

Nursing homes with special amenities create a more homelike, less institutional setting. Alternatives to traditional nursing homes include the “Green House” design and “Adult Care” home. The Green House is smaller, with a maximum of 10 patients in a homelike setting. The only Green House currently available in this area is the Jefferson Park at Dandridge. The Adult Care Home has a maximum of five patients in a private home in a residential neighborhood.

This option is available in Tennessee only for specific conditions. These options can be licensed for skilled and/ or intermediate level care, with more attention to individual needs than provided by larger institutions.

Another long-term care community option is the Eden Alternative. Nationwide, more nursing homes are incorporating parts of these concepts to create a cozier setting for residents and their families and visitors.

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 the issue. If immediate help is needed in locating a nursing home, contact the Long-Term Care Ombudsman.

If an older person is required to transfer from a hospital to a nursing home on short notice because of discharge date, 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 level of care needed must still be known, facilities’ certification by Medicare and Medicaid, funds needed to pay for care, convenience of location to family and friends, and availability.

Long-Term Care Ombudsman

The best way to support quality care for a nursing home resident is for family members and friends to visit frequently and establish and maintain communication with the staff.

Direct any questions or issues to the nursing staff or 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 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. There is no charge for these services. Call the Eldercare Locator at 1-800-677-1116 for information about ombudsmen in other states. Visit www.eldercare.acl.gov.

In East Tennessee, the names and contact information of ombudsmen are posted in a prominent place at each facility. When a loved one enters a nursing home, make a point of obtaining contact information for the ombudsman.

The Centers for Medicare & Medicaid Services (CMS) report information on the quality of care in nursing homes. Visit www.medicare.gov or call 1-800-633-4227.

Complaints about nursing homes can be filed with the Health Care Facilities Complaint Hotline, 1-877-287-0010. You can report abuses anonymously. Complaints can also be filed online.

Nursing homes that participate in the CHOICES and Medicare programs must have patients’ rights policies. Ask the nursing facility for a copy. Contact the district Long-Term Care Ombudsman for more information.

Families’ Rights

Questions about family responsibility for the cost of an older person’s health care and long-term care frequently arise, and legal advice may be needed. Contact an attorney or make an appointment with Legal Aid of East Tennessee for advice about responsibility and what to sign and/or not sign when arranging for care. A family member does not have to sign as a responsible party in order for their loved one 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. Do not “spend down” assets before obtaining competent counsel on Medicaid eligibility.