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Throughout the years, the long term care community has gone through a metamorphosis that has reflected the evolving needs of a changing society. Today, long term care encompasses a broad spectrum of care that includes ongoing skilled nursing care, subacute rehabilitative, hospice, respite or medical care, care for the developmentally disabled, adult day care, residential health care, assisted living, and home- and community-based care.
The providers of long term care serve the fastest growing segment of our population - the elderly, aged 65 and older. In 1999, 5.8 percent of that population was living in a nursing facility. The United States Census Bureau estimates that the elderly population of our country will continue to rise and exhibit dramatic increases from 2020 through 2030 as the "baby boomer" generation become senior citizens and life expectancy increases. It has been estimated that by the year 2050, one-fifth of the U.S. population will be over the age of 65 with 8.4 percent then being served by long term care providers.
Today's nursing facilities serve residents who require care under the supervision of a physician, whether they are expected to recover fully or to require extended long term care services. Specifically, subacute care centers have become the short term alternative for those residents requiring intensive rehabilitation following serious illness or injury. As people are discharged from hospitals after shorter stays, nursing facilities have evolved to provide extensive rehabilitation and post acute services such as ventilator care and complex wound care.
These facilities are licensed by the New Jersey Department of Health (DHSS) and are subject to annual, unannounced inspections. Rigorous standards regarding the qualifications of personnel, the construction of the facility, and the provision of residential and social services are enforced via these inspections. The facility Administrator must be licensed. In addition, the professional nurses must be licensed (RN or LPN) and therapeutic personnel are licensed or certified.
The DHSS also determines if nursing facilities meet at least minimum requirements for Medicaid reimbursements including facility and personnel requirements. The State Ombudsman has the authority to investigate and seek remedies for resident complaints and to assure residents' rights are maintained and nursing facility operations are conducted to serve the best interest of the public.
In order to provide a home-like atmosphere, the design of nursing facilities is usually a one story building with an average of 120 beds in semi-private quarters to accommodate two persons for sleeping (many facilities also offer a limited number of private rooms), personal needs and toilet facilities. Additionally, a common dining room, and recreational areas to meet and socialize are standard.
Nursing facility residents are those individuals who, by physician's order, require medically necessary nursing care on a regular basis. The primary diagnoses of these residents are those associated with chronic conditions such as, but not limited to, stroke, cancer, brain damage, metabolic disorders, Alzheimer's and dementias, arteriosclerosis, obstructive lung disease and infectious diseases. Chronic illness is one that is of a long duration or frequent occurrence; it is not an urgent or acute situation, but one that requires on-going medical attention.
The basic types of care offered by nursing facilities are:
Subacute care is a comprehensive inpatient program designed for an individual who has had an acute event as a result of an illness, injury or exacerbation of a disease process (i.e., a stroke, head trauma, knee/hip replacement, or kidney disease). Typically, the patient has a determined course of treatment and does not require intensive diagnostic and/or invasive procedures. A subacute patient may require this type of care for full recuperation or maintenance of his/her current health status in order to prevent regression.
Traditionally, subacute care took place in the hospital setting, however, today many nursing facilities are providing subacute care efficiently and cost-effectively in units within facilities designed to cater to the specialized needs of such patients. Examples include Ventilator Units, Head Trauma and Coma Units, Young Adult Units, IV Therapy Units, Rehabilitation Units, and Pediatric Units. Facilities have developed these services to meet the diverse and changing needs of patients. In many cases, subacute patients are rehabilitated and return home.
Assisted living is part of the continuum of long term care services that provides a combination of housing, personal care services and health care for those who need assistance with normal daily activities while promoting maximum independence. Many of the services offered in nursing facilities are also offered in assisted living residences. These services are provided in freestanding residences, near or within skilled nursing facilities or hospitals, or as components of continuing care retirement communities (CCRCs) or independent housing complexes.
In New Jersey, assisted living residences are also licensed by the Department of Health and subject to annual unannounced inspections in much the same manner as nursing facilities.
Assisted living residences provide a very home-like atmosphere in buildings of various designs. They may be single- or multi-story buildings with private and semi-private accommodations. Many residences also have two-room suites available for those wishing a more apartment-like living space. Rooms have kitchenette areas and private bathrooms. Common areas in these residences include dining rooms, recreation rooms and living room areas. Separate and secure Alzheimer's wings are often found in assisted living residences, as well, with special programs designed to serve those residents' unique needs.
The services and activities provided or arranged for in assisted living residences generally include:
The executive director or administrator of an assisted living facility must be licensed or certified by the New Jersey Department of Health.
Residential Health Care facilities cater to residents who are able to get around on their own, are not in need of 24-hour skilled nursing care and are able to perform activities of daily living (i.e., bathing, dressing and grooming) with minimal assistance. The services offered are often very similar to those offered in assisted living residences. The facility provides 24-hour protective oversight, personal care services (i.e., laundry service), medication supervision and assistance, transportation and recreational activities. Health maintenance and monitoring services are provided under the direction of a registered professional nurse.
Residential Health Care Facilities promote maximum independence and offer semi-private and private rooms with or without private bathrooms, and common areas for dining and recreation. Three meals a day are served in the common dining room. Housekeeping and maintenance service is also provided. Staff are usually responsible for assisting in obtaining medical and social services. Some provide assistance for special needs, such as for those using oxygen and assistive devices, or with behavioral health or cognitive impairments. Residential health care facilities are regulated by the New Jersey Department of Health and the Department of Community Affairs. The are subject to unannounced annual inspections by these agencies.
The administrator of a residential health care facility must be licensed or certified by the New Jersey Department of Health.
As the name implies, CCRCs provide continuing care to people of retirement age in one location. CCRCs are designed to provide increasing levels of care as the needs of the resident change. For example, CCRCs provide independent housing (usually apartment-style living), personal care services in an assisted living setting and health care services in a nursing facility. All of these services are located on one campus, making for smooth transitions as the resident's needs increase.
CCRCs also offer a variety of recreational programs and often have separate facilities for amenities such as fitness centers and swimming pools.
Residents enter into a contract with CCRCs before admission that outlines the types of housing and services that will be provided.
CCRCs are regulated by the New Jersey Department of Community Affairs (Division of Housing and Development, Office of Planned Real Estate Development). Assisted living and nursing facilities on these campuses are licensed by the New Jersey Department of Health just as free-standing facilities are.
AFC is a community-based health program that offers services to frail elderly and physically impaired individuals who are seeking a long or short term alternative to facility-based care. Up to three persons receive room, board, personal care and other supportive health and social services in the home of an unrelated individual who has been carefully screened and approved by a Sponsor Agency and trained to provide the necessary care.
Participants must be New Jersey residents who are 18 years or older and have a medical condition or require a regimen of therapy that can adequately be provided by the caregiver in the home.
The program's registered nurse and social worker monitor the services provided on a regular and as-needed basis.
Home Health Care services are delivered in the home to individuals with medical problems by licensed home health agencies. These services are usually given on an intermittent basis and often substitute for or augment the skills of a family member caring for the individual. The decision whether or not to use home health services depends on both the scope of treatment needed and the home circumstances of the patient.
These programs provide daily nursing and nutritional services and medical monitoring in a comfortable non-residential environment. Adult day health care services allow the elderly to maintain residency at home as long as medically possible while providing supervised daily care. These programs offer relief to family caregivers that allows them to continue with daily routines and/or employment, knowing their loved one is safe and comfortable during the day. Most programs offer a full range of social activities and provide transportation services. Adult day health care programs are licensed by the New Jersey Department of Health and have specific standards of licensure they must meet.
Many people are unaware that the long term care profession is one of the most heavily regulated in the nation. The NJ State Department of Health licenses and inspects all long term care facilities. They are regulated by both the state and federal governments to be certain that they meet the requirements for participating in state and federal health care funding programs such as Medicaid and Medicare, where applicable, as well as to ensure that they adhere to established standards of operation. In addition, facilities must also meet local, state and federal fire and sanitation standards.
In order to maintain closeness with family, friends and community, long term care facilities are distributed throughout the state. Because of this, it is not easy to see the large and complex nature of long term care facilities as compared to hospitals, for instance. Each part of the state has its own unique culture and values. Facilities are designed to blend in with the community to further the home-like quality. They are kept small enough to fit in, but large enough to be cost efficient while offering the highest level of quality care. Locations of long term care facilities allow for community organizations to participate in social and recreational programs and local civic and church groups often provide daily life enhancements, such as visitation services, arts and crafts, adopt-a-grandparent activities and travel to local music or library events.
Observance of and adherence to the Bill of Residents' Rights are the guiding forces in the daily operations of today's long term care facilities. The statement of patient's rights is a lengthy document designed to promote and protect the rights of individuals in a facility.
These are just a few of the many areas addressed by the statement of rights:
Residents have the right to:
Upon admission, long term care facilities are required to give residents and/or their guardians a copy of the statement of resident rights. In addition, facilities must give a copy to the resident's next of kin, all facility staff and must post these rights prominently in a public place within the facility.
Today's facilities are providing a variety of services for both short- and long-term patient stays. Many people are under the misconception that once a person enters a long term care facility, he or she is there for life. This is not the case today. For example, a primary goal of the nursing facility is to rehabilitate residents so that they can return home. In fact, approximately 30 percent of all nursing facility residents nationwide are discharged to home-like living arrangements. Those who cannot return to their homes permanently may make therapeutic home visits, health permitting. Facilities also encourage day trips and often provide transportation services so that residents may continue to participate actively in their communities.
Many facilities also offer what is known as respite care, which is short term care designed to give the primary caregiver of an individual temporary relief from his/her responsibilities.
In addition to providing skilled nursing and/or personal care, long term care facilities aim to restore residents' health and help them live as independently as possible. This has translated into shorter stays. Today's nursing facilities offer many rehabilitative services to a variety of individuals.
Gone are the days when nursing facilities provided services exclusively to elderly patients with chronic debilitating illnesses. People of all ages — younger adults, children and even infants are turning to nursing facilities due to chronic illnesses or accidents. In fact, many are choosing nursing facilities as an affordable alternative to extended acute care hospital stays.
There are several major sources of payment for long term care. These include: Medicare, Medicaid, Supplemental Security Income, a group of sources which are considered third party payers, & private funds.
Medicare is the federal health insurance program for people 65 and older and is administered by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS). The Social Security Administration offices handle applications for Medicare and provide general information about the program.
Medicare covers the nursing facility expenses of those who have recently been hospitalized for three or more days and require daily skilled nursing care or rehabilitation services for a relatively short period of time. Only a small percentage of nursing facility residents in New Jersey receives financial assistance from Medicare.
To be eligible for Medicare benefits, the primary physician must certify that skilled nursing care or rehabilitation services are needed on a daily basis. Once admitted into a nursing facility as a Medicare funded resident, medical needs are evaluated frequently. At the point that skilled or rehabilitative care is no longer needed every day, Medicare benefits cease. The maximum amount of time that Medicare will cover nursing facility costs is 100 days and there is a co-pay after the 20th day.
Depending on how an assisted living facility provides health care services, Medicare Home Health benefits may be available to facility residents. Check with the facility regarding this benefit.
More than half of New Jersey's nursing facility residents receive financial assistance from Medicaid, the health care program for low-income individuals that is funded by the federal and state governments. Many people confuse Medicaid with Medicare. Medicare is the national health insurance program for the elderly and disabled. Medicare benefits are not based on income.
In New Jersey, the financial eligibility for the Medicaid program is administered by the State Department of Human Services in conjunction with the county welfare agencies. The information about financial resources and assets provided here is intended to be general information. Each person's circumstances are different. The county welfare agency or social services board will make a determination of financial eligibility after all the necessary information has been supplied.
The welfare agencies (which are called social services boards in some counties) determine if a prospective long term care facility resident is financially eligible for Medicaid benefits. There are specific income maximums that determine financial eligibility. If the income is higher than that, it is possible that financial help may be available through the Medically Needy Program. There are also limitations on the amount of assets an eligible individual may have. For more information on this program, call the County Board of Social Services (welfare agency) in your home county.
Among the frequent concerns of individuals applying for Medicaid are questions about the financial obligations of a spouse and other family members, and the status of the person's home. For a married individual whose spouse will continue to reside in the home, the home and furnishings are not counted in the eligibility determination. The other assets of the spouse in the community are counted but the community spouse is allowed to keep a certain amount of assets. The asset allowance for the spouse remaining in the community is determined at the time of entry into the nursing facility. Even if not eligible for Medicaid at the time, a couple can receive a resource assessment from the county welfare agency/board of social services at the time of nursing facility admission. This assessment will allow the couple to know how much of their assets must be spent before Medicaid eligibility can be established. (These eligibility guidelines and requirements change periodically. The best way to obtain present or future Medicaid eligibility is to contact the county welfare agency/board of social services in your home county for further information.)
If the individual is applying to enter a Medicaid certified facility, a health care professional will conduct a Pre-Admission Screening to assess whether placement outside the home is appropriate and will determine with the individual what kind of care and setting is appropriate. This evaluation is performed by one of the Long Term Care Field Offices throughout the state.
Once a person is deemed eligible for Medicaid (a process that may take several weeks or months), his/her benefits include full coverage of basic expenses in a nursing facility that is certified by the government to accept Medicaid-financed individuals. Approximately 90 percent of New Jersey's licensed nursing facilities are certified to accept Medicaid residents. Many assisted living facilities and alternate family care programs are also participating in the Medicaid program. However, that doesn't mean a specific facility will have an opening for a Medicaid funded individual at the time you're trying to place someone.
SSI is a federal income assistance program for the aged, blind and disabled. SSI is a primary source of payment for New Jersey's Residential Health Care Facility (RHCF) residents, as Medicaid does not make provisions for the RHCF setting. SSI is supplemented by the State of New Jersey to assist in paying for RHCF services. In New Jersey, approximately 40 percent of the RHCF residents are recipients of SSI, 50 percent are using private funds and the remaining 10 percent rely on a variety of other sources.
This category of financing includes individual insurance plans other than Medicare or Medicaid such as Veteran's Benefits; Municipal Assistance benefits; and long term care insurance policies. These sources account for about 5 percent of long term care payment.
Increasing numbers of individuals have private long term care insurance that covers some or all of the expenses of care in a long term care setting. This is an especially valuable way to protect the assets and resources of individuals who do not qualify for Medicaid or other assistance. If you explore this option, be sure to carefully compare the benefits and costs of several policies. Information about insurance is available from the Department of Health, Division of Senior Affairs.
Membership in some fraternal, religious, social, and union organizations includes as a benefit the payment for some long term care services. In addition, some organizations own and operate long term care settings for their elderly members, whose expenses may be subsidized to some extent. Check with the appropriate organization for details.
Approximately 24 percent of all New Jersey long term care residents pay for their care out of private funds.
Financial planning for long term care services is as important as planning for your retirement. For most people it is difficult to imagine needing long term care services. A 1995 poll by the Gallup Organization shows that 76 percent of Americans believe they will never have the need for any type of long term care service. According to the Health Insurance Association of America, however, approximately 50 percent of all people over 65 will spend some time in a nursing facility during their lifetime.
Families that have the foresight to plan for long term care needs and not rely solely on public assistance programs will find that costs do not have to come as such a surprise or burden.
The internet continues to bring information to our fingertips, including that regarding personal health and well-being. While this technology can be very helpful when seeking resources, it can also create confusion if the information is complex.
There are many websites available that offer a variety of comparison tools for consumers seeking information about long term care options and facilities, including the Nursing Home Compare site on the CMS web site as well as the New Jersey Department of Health web site. While providing factual information, these tools have their limitations. Specifically, information contained on these sites is often geared toward individuals who are able to interpret long term regulations. For those who do not understand the complexities of these regulations, the information provided can create more questions. Therefore, it is recommended that individuals looking into long term care options make personal visits to the facilities in which they are interested. During these visits, conversations with administration, staff and residents can provide invaluable information to complement that obtained through other means.