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Many families face the question of what is the best place for an aging family member to get the best care in their later years? In-home care? Nursing home? And, how do you pay for it?
For his series, “Getting Into Their Reality: Caring For Aging Parents,” News Director Eric Douglas spoke with Chris Braley, the owner of a memory care assisted living facility in Kanawha County.
This interview has been lightly edited for clarity.
Douglas: One of the things that I’ve dealt with — what other people I’ve talked to have dealt with — how do I, as a caregiver, make the decision that it’s time for mom or dad or my family member to go into a facility?
Braley: Yeah, that’s the million-dollar question. I have a lot of families that have come to me over the years, and they’ve asked when is it time? And I think it’s really an individual account based on the personal situation. What I counsel families on is looking at, “What’s the safety issues?” When you get to the point with an aging parent or spouse, what kind of safety issues are you dealing with? Are they ambulatory? If they are, are they forgetting where they are in their home and not recognizing that? And are they trying to get out and in their mind going to their home, maybe to their childhood home.
In the field, we call that an elopement risk. Obviously, that can be a very serious safety issue, because the individual with dementia in that moment, when they’re in their house, they may not realize it. For 23 of the 24 hours that day, they did recognize it, but then at that moment — that you can’t predict as a caregiver — it’s a strange place, and they’re trying to get out. That can be very challenging for the caregiver in that moment, whether it’s family or a private caregiver, trying to de-escalate that situation and redirect because in that person’s mind, they’re terrified. They don’t recognize it, they’re trying to get out and they’re going to do whatever they can to get out.
When they get a little more confused, when they get frustrated, are they becoming aggressive? How are they handling the behavioral strategies that the caregiver is trying to de-escalate the situation? Are they getting physical? That becomes very challenging, especially for an aging caregiver. Statistically, the caregiver that is providing care for someone with dementia can have a higher risk of mortality.
Douglas: Most caregivers are not trained in all those de-escalation techniques. I’ve definitely seen that.
Braley: We quite often see that they’re maintaining, and all of a sudden, for whatever reason, whether it’s a medical issue or something else with the disease progressing, it’s like they fall off that kind of cliff and now the parameters you had in place to care for them don’t work. It puts families in crisis.
Douglas: I’ve heard it said it’s easier for somebody to go into a nursing facility from a hospital, rather than just calling up and trying to get mom or dad in a facility, right. Explain that process for me.
Braley: Typically, if you have someone in the hospital, then there’s been a crisis. There’s been a situation that occurred, whether it was due to their dementia, and maybe they became a little more aggressive, and they had to go to the hospital to have behavioral health work with them and adjust medications. Or perhaps they fell, they harm themselves, and they’re in the hospital recovering from that. That crisis allows them to be able to transition from a hospital into whether it’s a nursing home or maybe rehab services, or into assisted living, because the family has realized it’s probably time for long-term care.
That can be a little easier than on the flip side where they’re at home and maybe there’s not a crisis, but the family sees what’s coming, and they want to try to be proactive. But the one with dementia is going to probably struggle a little more with that. And also, I think, when a family is not in crisis in that moment, that guilt just hammers so much more. And that’s a whole other aspect of dealing with talking about the grief that families go through in this.
Douglas: I think that’s an important thing, too. It’s a grief process, but it’s a really slow burn grief process.
Braley: When you dissect grief, there’s stages. And the other interesting aspect to this is, typically there’s more than one person in that family. You can have different family members in different grief stages. And that creates a whole other ball of wax. And in dealing with that, you could have someone who is in the anger stage, you could have somebody who’s in the denial stage, you could have someone reaching acceptance. A lot of times you’ll see the ones that are dealing with the person on a day-to-day basis, that are the primary caregivers, they’re going to be more likely to be closer to that understanding and acceptance than a family member who lives in another state and only talks to mom or dad on the phone and can’t quite recognize what’s going on.
Douglas: What are the differences, assisted living versus skilled nursing homes. What are the differences between those types of facilities?
Braley: A nursing home is going to be, is more geared toward a skilled need. And that’s the way that nursing homes were designed initially, that someone who just has a skilled medical issue, maybe they need a feeding tube, or they have a wound that is something that requires more nurses and doctors to be paying closer attention to it. Whereas assisted living will have nurses and can have a doctor come into the facility and has CNAs and caregivers, but it’s more geared toward helping that individual on their daily activities and needs.
But then when you take memory care, and look at assisted living, at least for me and my memory care, we’re focused on the dementia aspect. That’s what our staff are trained on, what we do every day. We’re a smaller facility so it allows us to have that one-on-one attention to give to the resident with dementia attention. In a larger facility, whether it’s a large assisted living or a large nursing home, they just can’t give that individual attention all the time.
Douglas: As I understand it, private pay facilities run anywhere from $5,000 to $10,000 a month. How do you pay for that?
Braley: Some people have prepared and they have what’s called Long-Term Care Insurance. But most people don’t have that. There are some VA benefits if the individual is a veteran, or their spouse is a veteran, that can help pay for long-term care and can help pay for in-home care. Of course assets, retirement, things of that nature that unfortunately people have to then tap into in order to pay for the care.
Douglas: I’ve heard many stories of people who’ve have to sell the family house and effectively watch any inheritance just kind of evaporate as they’ve had to pay for care.
Braley: I strongly encourage families to consult with an elder law attorney, that really can help. They can help the family weave through that, because that is the horror story. From my understanding, there are some aspects with Medicaid that you don’t necessarily have to sell your house and those kinds of things. So you definitely want to consult with an attorney in that area.
Douglas: When it comes to Medicaid and Medicare, for Medicaid to kick in, you have to have liquidated assets down to below $2,000, right?
Braley: This is kind of a soapbox of mine with Medicaid. The reality is, there are a lot of people in our country, and especially in our state, that can’t afford private care. And the only way they can get 24-hour care, because they don’t have the funds and they are eligible for Medicaid, is to access that Medicaid for a nursing home. But they don’t necessarily, maybe, have that skilled need. They could probably benefit better in a more focused memory care facility.
Right now, unfortunately, in West Virginia, Medicaid doesn’t pay for assisted living care, it only pays for nursing home care. But there are other states where it’s opened up a little more and Medicaid is trying to adjust more to assisted living care, because the reality is, assisted living care is less expensive than nursing care.
There is what’s called a DHHR supplement, which is closely connected to Medicaid that West Virginia will pay out but it doesn’t touch anything so no assisted living facility can accept that supplement. It’s just really not set up to be successful.
Douglas: What’s the process? Do you start making a whole bunch of phone calls? Where do you start?
Braley: That’s a great question. I think you want to be as proactive as possible. It’s best to start looking before you have to do it and start touring facilities, whether it’s a nursing home, or assisted living based on what you’re able to do. And start asking the questions. You’re interviewing them and taking tours and finding out how they did in their surveys with OHFLAC (Office of Health Facility Licensure and Certification) and things of that nature so you can make the best informed decision you can for your loved one. Also look for what in home services are available.