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Thread: CLASS Act and Aging in the Home

  1. #1
    Curmudgeon OtakuLoki's avatar
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    Default CLASS Act and Aging in the Home

    Warning: this is very much a TLDR type of post. It will get someplace, eventually, but it's a long trip.

    Actually - I've moved that long trip into a separate thread, here. I'm putting it into the IRL sub-forum because I just don't think it's really going to mean anything for people who aren't already members of our community. If there's a great hue and cry I won't object to seeing it moved, but as is, I think it would be TLDR for anyone not interested on a personal level.

    The reason I bring all this up, though is because of one of the portions of the recently passed health care act: The CLASS Act. Here's a quick look at it from the NYT.

    On the one hand, I think it's great, if it works the way it should: i.e. if enough people start buying into the premiums while they're young enough for it to be self-sustaining. By making it an opt-out program, I've got more hope for that than I would have otherwise. But either way, even a modest long term care insurance plan is going to seem expensive to anyone who hasn't had to deal with the realities of care costs for the aging. I've read at least one article where the author complains that he and his wife pay $5000 in annual premiums for their long term care insurance.

    Which seems a lot.

    Until you realize that my father's care last year, where half the year was in either Medicare covered rehab facilities or an assisted living facility, instead of a full long term care facility, cost almost $77,000. In that one year of benefits, my parents have already recouped everything my father put into his own long term care premiums. It's would even be a return of 15 years of premiums for the couple in the article I mentioned. It's very easy to see how that kind of premium would prove its worth.

    But that doesn't change the real perception of expense for that kind of insurance.

    The problem I have is that on the other hand, the pay out is going to be $50-$100 per day. Which, again, sounds like a lot. Until you start pricing care. And the people most pleased with this payment are talking about how it will allow more people to stay in their home longer. Which isn't a bad thing, but I think that already people are staying in the home longer than is safe and prudent. And this benefit is going to be large enough to provide for some accommodation, while not enough to really pay for a full support system for caretakers. A cheap home health aide here in Rochester was quoted to me at $75/hr, with a minimum 2 hour visit. Which is not a bad deal, really. But it will eat up that benefit like popcorn.

    I think that for the best health of everyone involved the current attitude that nursing homes are teh EVIL should be moderated. I have sometimes cursed my grandmother's example of keeping her husband home long past the point where he would have been best cared for in a nursing facility, because it provided an example for my mother that she cannot live up to, and that nearly killed her trying to. My mother still feels huge guilt for not being able to care for dad at home.

    I have now been involved, if only peripherally, with three close family members going into some level of eldercare facility. In each case, I believe, with the benefit of hindsight, that the transition to those facilities happened later than it should have, for the health of the patient, and the health of the caregivers.

    Keeping people at home is a nice goal, but I think that we already keep too many of our infirm at home too long, and this seems to be targeted to increase those numbers. Which worries me.

    I think that it would be really good if this insurance could be made available without adding to the burden on families by saying it's going to make it easier to keep people at home.

  2. #2
    Elephant artifex's avatar
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    It's something we talk about on occasion in school, because it's going to be part of the changing face of nursing. We're coming up on the baby boomers being senior, which is going to inflate the geriatric population considerably. And statistically, most people would prefer to age in place, and they tend to do better, health-wise, when they remain home. So yeah, I think for most people, "you can stay in your own home longer" IS going to be an attraction and a draw. Nursing has been shifting back toward home health, and I think this is going to be a big part of it. Hopefully the baby boomer generation en masse, and the changes just now going in to health care and insurance, will also be able to positively affect how financially possible it is to do this.

    When you say you think we keep our infirm at home too long, are you saying that it's inherently wrong to do this, or do you think the problem is the current context in which this is done? What if respite care and home health nursing were covered better and more affordable? To me, if it comes to a choice between care at home and care in a nursing home, if the amount and quality of care are equal (i.e. care from nurses, PTs, aides, etc. is freely available and affordable at home), the nursing home is rarely going to win as the optimal choice.

  3. #3
    Curmudgeon OtakuLoki's avatar
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    Quote Originally posted by artifex View post
    When you say you think we keep our infirm at home too long, are you saying that it's inherently wrong to do this, or do you think the problem is the current context in which this is done? What if respite care and home health nursing were covered better and more affordable?
    I don't think it's inherently wrong, in terms of keeping people in the home as long as possible, I just think that for emotional reasons people tend to keep their loved ones in the home a bit past their own personal line for possible. With costs for all involved that can end up being fatal. In an ideal world - sure, staying home til you die is better than being among strangers. But that ideal world, I hope, doesn't include sending your loved ones to the hospital.

    To me, if it comes to a choice between care at home and care in a nursing home, if the amount and quality of care are equal (i.e. care from nurses, PTs, aides, etc. is freely available and affordable at home), the nursing home is rarely going to win as the optimal choice.
    I agree almost completely here. There are some hazards that are damned hard to remove from a house, even with a generous remodeling budget - or at least often impractical. Putting in one ramp to get into the house from the drive or garage is usually doable, eliminating the hazard of all stairs within and around a dwelling is a lot harder. Similarly, for all the good work that's been done with making kits that convert the standard bath into a walk-in shower, they're still often a bit lacking from a safety point of view, from what I've read. And that doesn't begin to cover that many houses just do not have their doorways set to accommodate walkers. Let alone wheelchairs.

    Many of these problems can be worked around, and here's the bite, with sufficient money. Grab bars are just the beginning of the home remodeling tasks that can be done and should be considered - and are often the simplest things to arrange and cheapest, too. Some of the other work that I'd mentioned gets into serious remodeling territory. For people who are seriously counting on this benefit of up to $100/day, that can eat up the benefit damned quickly - and may even end up exceeding the value of the house.

    Then there's the current way that home health aides are supplied.

    What I am going to say next is going to sound like an attack, and I don't mean it that way. And if this act works the way the drafters are hoping it will, the current business models will be dramatically changed.

    Currently, however, home health aides are hugely expensive for what I found to be a limited utility. This is not the fault of the aides we got, nor even the agencies that supplied them. It's an inevitable consequence of their current business model. First off, the agencies providing home health aides here in Rochester were going to charge $75 an hour for their services, with a minimum two hour block1 for any home visit - which means that the most generous benefit I've seen associated with the CLASS Act will cover, at most, the costs of one two-hour visit every other day. Given the risks and needs and capabilities of the general public, I think that that level of care and time would best be used by letting the aide take care of bathing, and then dressing, the patient: It's both one of the most hazardous tasks for home care, and one that can often be flubbed by people without training. Not to mention that I don't think you can count on the public to be able to spot some of the trouble signs that even a minimally trained aide might be able to suggest need to be discussed at a higher level of care.

    Because of the nature of the home health aide business, now, it will be rare to get the same aide every visit. Scheduling is also currently problematic, with little opportunity to fine tune the aide's schedule with your own. And this, in particular, doesn't seem likely to change IMNSHO: There will always be more people needing aides than there will be aides, and there will always be certain peak hours for highest demand. Which means that a lucky few will get service then, but most will have less convenient timing. All of this had the effect, with my father, to annoy him, and make him put up his defenses with the aides we'd had. In particular, there's something that would bother many people in having to shower while being monitored by a different stranger every other day. The times we could get the aide at a time convenient for Dad's schedule, we did have him take a shower - but that was the sum total of all the aide had time for, between dealing with the difficulties of the task, the unfamiliarity of it, and the obstructionism from the patient.

    And, all things considered, I'm not comfortable saying that a two hour break is going to do all that much for a caretaker who is otherwise dealing with a difficult patient 22/7. Is it better than what most people would have available now? Hell yes! Will it be enough to extend that 'possible' I mentioned earlier? I don't know, but I'm afraid not.

    I'm not faulting any of the care we got - for the level of care that it was, it was as good an example as I could have expected. But it's not quite what I'd have called an unmixed blessing, either. And that level of care did not include any supervision by LPNs, let alone RNs, PAs or even MDs.

    I have a very difficult time imagining any kind of progress where the patient is going to been by an RN more than once a week, a PA more than once every two or three weeks, or an MD more than once every two to three months. Which is not what I'd consider comparable care to that in a long term care facility.

    Bah, insomnia last night - I'm starting to fade here. I'll have to check this out later and see whether it's as complete or comprehensible. I hope I've managed, in my rambling way, to answer at least some of your questions.

  4. #4
    Elephant artifex's avatar
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    Quote Originally posted by OtakuLoki View post
    There are some hazards that are damned hard to remove from a house, even with a generous remodeling budget - or at least often impractical.
    Not everyone will need this level of modification to allow them to remain in their home, but true, once you start looking at basically turning a private residence into a fully-equipped assisted living facility then yes, I'd be doing some cost/benefit analysis too.

    The thing that sends most people into a nursing home, though? Is not exorbitant costs and effort required to make their homes safe for them. It's incontinence. (And lots of people go into a hospital for acute care continent, and leave incontinent.) If we can keep people out of the acute care hospital setting, if we can keep them continent, it'll make a big difference in keeping them home longer. And that doesn't seem like quite as much of a daunting prospect - except that it is, in our current crisis model of health care, where it's hard to get a nurse to come to your house until after you've experienced a debilitating health breakdown.

    Quote Originally posted by OtakuLoki View post
    What I am going to say next is going to sound like an attack, and I don't mean it that way.
    If you mean an attack against the current system, then I would say that it's not at all unjustified!

    Quote Originally posted by OtakuLoki View post
    Given the risks and needs and capabilities of the general public, I think that that level of care and time would best be used by letting the aide take care of bathing, and then dressing, the patient: It's both one of the most hazardous tasks for home care, and one that can often be flubbed by people without training.
    Oh, absolutely. I had ADL (activities of daily living) assistance training labs at the very beginning of nursing school (it's not really what we do, but we need to be able to do it or at least assist with doing it). My first clinical rotation was nothing but bed baths, diaper changes, and making occupied beds, all day. So I know that there's skill and technique involved, and I'll tell ya, just about every time I help a tech with doing one of these things even now, I still learn something.

    (OTOH, a basic seminar on how to give a bed bath, help people safely move from bed to chair or ambulate, etc., might be a really good idea for people planning to do home caregiving for family members...)

    Quote Originally posted by OtakuLoki View post
    All of this had the effect, with my father, to annoy him, and make him put up his defenses with the aides we'd had. In particular, there's something that would bother many people in having to shower while being monitored by a different stranger every other day.
    I completely understand this. It seems like there's very little, if any, continuity of care, and this is something that needs to be worked on. And short breaks aren't going to do it, either - respite care should involve a block of time that actually gives caregivers some respite from their work!

    Quote Originally posted by OtakuLoki View post
    And that level of care did not include any supervision by LPNs, let alone RNs, PAs or even MDs.
    And that sucks, because that's home assistance - but it's not home health care. Where are the people who can do capable assessments? They should have been there.

    Quote Originally posted by OtakuLoki View post
    I have a very difficult time imagining any kind of progress where the patient is going to been by an RN more than once a week, a PA more than once every two or three weeks, or an MD more than once every two to three months. Which is not what I'd consider comparable care to that in a long term care facility.
    Once or twice a week visits are about what you'd expect from home health nurses, I think, yeah. But the thing is - I feel like if we start doing a better job managing health - preferably without those hospital stays that are often really detrimental to health, especially mental status and continence - maybe more people would stay healthy that intermittent visits would be enough. :smile:

  5. #5
    Curmudgeon OtakuLoki's avatar
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    Quote Originally posted by artifex View post
    The thing that sends most people into a nursing home, though? Is not exorbitant costs and effort required to make their homes safe for them. It's incontinence.
    I hadn't realized. I mean dealing with the effects of chronic incontinence is a PITA. No question. Been there, done that, got the merit badge. It's not pleasant, it's not without its own stresses, but it's generally straightforward, and there are levels to it, too. If you can control the effects of incontinence with absorbent underwear, which seems to be what is the general run of incontinence, then I don't think there's any need to consider upgrading the level of care for that.

    Of course, there's a world of difference between urinary incontinence and bowel incontinence. I think that dealing with bowel incontinence is a lot more overwhelming, and more of a health hazard than urinary incontinence. But I'd never advocate nursing home care for a patient on the basis of a single incident of bowel incontinence, either.

    But while incontinence was a factor in at least two of the cases I've been involved with, it was never the driving consideration for getting into a higher level of care. My grandfather and father both had their judgment so impaired that the hazards in a normal house combined with their physical decline created a situation where simple things that most people take for granted were a real risk.

    One of the most frustrating, for example, was that the door into the master bathroom in my parent's house was narrow enough that it could only barely pass my father's walker through it.

    His solution was to leave the walker behind when he went staggering off to the bathroom. Of course, he'd do this without letting anyone know what he was doing. This lead to caretaking becoming almost an adversarial exercise.

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    Curmudgeon OtakuLoki's avatar
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    One more thought that I think is significant: people who aren't doing the caretaking often have such negative views of nursing homes that they completely minimize the stresses and hazards for those family members who are doing the caretaking. Which adds another stress on the caretaker: If they admit that things have gotten beyond where they can safely care for their loved one, they may be branded in the eyes of the rest of their family as selfish, lazy, uncaring, etc. etc.

    In my case, this happened both with my grandfather, when my uncle refused to acknowledge, for years, what was going on; and again with my father, when my sister couldn't understand just how much stress caring for Dad was putting on us. Even after that stress put my mom in the ICU!

    ETA: I want to add: I don't think that my experience is necessarily going to be mirrored in every experience out there. Each case will have to be judged on its own merits. In many ways, while I do have problems with my father, if he'd acknowledged his limitations and adjusted his behavior accordingly, I suspect that my mother and could have adapted and kept caring for him for at least another nine months. (The effects of his meningitis would have been the trigger to get him out of the house, in that eventuality.) The direct physical symptoms alone aren't all that need to be considered. And those attitudes are going to vary a lot.

    OTOH, I believe my family experience is also going to be one of the the more informed ones out there: My mother is an RN, with a Master's in teaching to go with it - she may not have practiced much as an adult, but there's still a firm grounding in medical care, there; I may not be medically trained, but I have had several first aid certificates, and a very firm grounding in both general physio and biology; my sister, even, is a highly educated professional in her own right, with experience with various cognitive impairments. And we were still doing things that I figure are stereotypical stupidities, because emotions were overriding good sense and education.
    Last edited by OtakuLoki; 28 Mar 2010 at 10:20 AM.

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    Elephant artifex's avatar
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    Incontinence - whether it be bowel or bladder - is something that can often be addressed, with training. (Which boils down to basically the same thing you do with a toddler who's toilet-training - every couple hours, it's time to sit on the toilet.) It's not so easy when there's neuro issues, though! But it's really difficult and demoralizing for caregivers, I guess, and the bladder/bowel training does require extra attention, time, and patience. But yeah, that's statistically the #1 reason.

    I agree that nursing homes don't have to be the end of the world. For one thing, there's a wide range of assisted living out there! There's the down side of losing your home, but on the other hand, there's constant skilled care, and a social group. Right now, that level of skilled care in the home is mostly only available to the very wealthy.

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