Residential Care Retention Policy

We suddenly and unexpectedly landed in residential care as I needed assisted living (AL) and my wife needed memory care (MC). Provision Living at Columbia (MO) was the only site with apartments available at the time and we had made a deposit as soon as reservations were available for this new facility, just in case.

At what point must we transfer to another site or level of care? There seems to be no single simple answer. Health, age, and money are important. The licensed services provided are another. See ALF and ALF** below for example.

Missouri state law provides one dividing line: Anyone who cannot exit the building unassisted in the time set for a fire drill must move to a nursing home (NH), to skilled nursing {SN) or an ALF**.

Some other examples of where me may fit as time passes, just in case, and the time to make that move without it again becoming another unexpected event:

• Mill Creek (ALF) policy includes retaining residents who can be assisted by one person and moves out residents requiring assistance from two people. It attempts to retain all residents who have paid the full rate for a period of years.
• Tiger Place (ICF) and Boone Landing (IL) retain all residents who are judged to not need SN or a NH, are not a threat to themselves or others, and are paid up.
• Lenoir Woods is a Continuous Care Retirement Community (CCRC). It provides all levels of service. You never have to leave (if paid up for a period of years).
• Provision Living at Columbia (MO) (ALF**) assists in locating other residential care when with in 6 months of running out of money. This appears to be an appropriate lead-time for finding and relocating to available NH options (See below).

For non-residential care persons, have enough money to cover two months private pay, and related costs, in a Medicaid bed nursing home (NH) of your choice (about $15,000/person). You want to be in the bed before qualifying.

http://matchnursinghomes.org/city/columbia-mo-nursing-homes presents Percent of Beds Occupied (64-97%, March, 2016), Overall Rating, and Number of Medicare-Medicaid beds. Call for current pricing and deals. When money runs out you stay in your selected bed and Medicaid takes over the remainder of the bill after applying your Social Security and other (pension) benefits.

http://health.mo.gov/seniors/nursinghomes/pdf/DirectoryCounty.pdf presents Level of Care licenses: ALF, ALF**, SNF, RCF, ICF, and Alzheimer’s unit.  See http://health.mo.gov/safety/showmelongtermcare/lvloflic.php for an easy to read two page list of definitions.

Comparative Memory Care (MC) Costs (Private Pay and Insurance)

                                                                   -13-

Chart 11 is a worst-case scenario. What would the cost be per year if the couple had to rent individual apartments instead of sharing an apartment?

Memory care (MC)/independent living (IL); MC/assisted living (AL); MC/MC; and MC/nursing home (NH) are viewed for each of the residential care sites. In general the cost goes up another $40,000 (IL $40,000; AL $80,000 and separate spaces $120,000)

Tiger Place must now include The Arbors for MC. The two older sites, Tiger Place with The Arbors and Lenoir Woods have higher pricing for fully developed programs.

Mill Creek and Arbors price by level of care. Each level increases in price, as a one would generally expect. Memory care (MC) is the most expensive level as this unit will be in a state of the art, separate building from IL and AL. Opens in the spring of 2016 (15 April).

Provision Living also has a site combining modern (2015) memory care and assisted living. The price for each level is about the same and is less than at a nursing home (purple, NH). Our apartment is about 20 feet from a 12 apartment MC unit that will open later this year.

The only way to get lower pricing is to stay home and use day care (green), about $50,000/year. It only takes 12 hr/day of in-home care (green) to approach the cost of residential care.

So what to do for a couple needing assisted living and memory care in Columbia, MO?

• No money – stay at home or Medicaid nursing home (NH).
• $40,000/yr – in-home care.
• $80,000/yr – residential care including SN or private pay NH.
• Run out of money – Medicaid NH.

Both Lenoir Woods and Mill Creek have Medicaid skilled nursing (SN) beds for residents who qualify (a number of years private pay and private negotiation). This is another judgment call to offset the higher charges for additional services these two sites provide. You do not have to endure continuous stress from planning to move again and to pay for those “aging in place” final days (at the same level of care) in a yet to be determined location.

The quality of home and residential care depends on the buildings, the management, the caregivers and the residents. Staffing (radiant people) and training are critical. 

The “final” choice, at any one time, seems to be a balance between money available and when you can qualify for Medicaid. Hospice is free (does not include room and board).

Our current question is, Do we find a less expensive site in Boone County and not run our of money or stay here and transition to a Medicaid nursing home (NH)? Ten weeks here at Provision Living at Columbia (MO) has certainly taught us a lot about what to look for and what we would miss if another site lacked that feature or quality.

Comparative Assisted Living (AL) Costs (Private Pay and Insurance)

                                                                  -12-

On average, assisted living costs are about double independent living costs ($80,000/yr instead of $40,000/yr) for a couple in 2015 (Charts 8 and 10).

Tiger Place had a high entry level independent living cost but has the lowest assisted living cost as the same price covers both levels of care (blue MIN). This advantage is lost if you become in need of all of the services provided (red MAX).

Provision Living at Columbia (MO) also had a high entry level independent living cost but has an assisted living cost comparable to Mill Creek and Lenoir Woods. In other words bundled pricing and level of care pricing can yield different and the same total costs depending upon which level of care is needed. It takes a spreadsheet to sort this out.

When day care is added to Mill Creek assisted living, the cost equals that at Provision Living with a full service plan. This requires a judgment call as to which set of services fit the resident the best. The same judgment is required to consider in-home care at 6 hr/day.

The nursing home (NH) Medicaid Missouri state reimbursement (capitation) rate of $6,000/mo ($72,000/yr) is shown at two levels in Chart 10 to show the effect of one person having long term care (LTC) insurance (blue MIN). Some insurance pays for AL. Medicare does not (in 2015) pay for AL for long term care.

A residential care administrator must review every long-term care (LTC) policy. Both the benefits and the site license must be considered. The insurance will only pay if they match; also check the care plan for by item or all-inclusive billing.

Comparative Independent Living (IL) Costs (Private Pay)

                                                                 11

Chart 8 includes comparable costs, for a couple, I selected for similar space. This has been a team effort by our primary care physician, in-home care manager, Medicare HMO, five specialists, and administrators at seven residential care sites who act more as counselors for a good fit than as sales persons.

Tiger Place developed “aging in place” where services are delivered to each apartment. This has a life extending effect.

Provision Living just opened. It has a combined entry level of independent living and assisted living (and for us, memory care) in one building. It therefore has a higher entry level cost (and lower care plan costs than Tiger Place).

Mill Creek (Americare operates it and Tiger Place) has a lower entry level cost than Tiger Place as only room and board are provided for independent living (IL). My wife can obtain day care for an additional fee that includes a daily trip between independent living (IL) and memory care (MC) buildings.

Lenoir Woods is the oldest, most developed, and low in cost at the independent living, entry level, of care. It provides “aging on campus” with separate buildings for each level of care.

Remaining at home (no rent or mortgage) would cost about half of the cost of moving to these independent living residential care sites. But adding just three hours a day in-home care would equal this cost of residential care (about $40,000/yr without the car in residential care).

The remaining three sites have no support for memory care as the name is now used: a safe and secure environment. At these sites you come and go as you wish.

By all accounts, The Terrace (with a new addition) is a fun retirement facility that gives you the choice to cook or not cook ($31,000 - $36,000/yr). The Village of Bedford Walk expects you to cook but will serve one noon meal a day just in case ($30,000’yr). Boone Landing provides space for medical and non-medical services on site. The combined resort (no cooking) and convenient in-house health support results in a price of $44,000 - $51,000/yr (2015).

The range of MIN-MAX costs, in Chart 8, is strongly related to space (Chart 9.) But how space is used is as important as the square feet. This is very important in all seven sites. Each has a set of best-fit properties that must be visited (sometimes more than once) to see if you get that “I like it” response.

Again, these are all comparable costs. There are many lower cost apartments, if available. Single bedroom apartments are lower in cost than two bedroom apartments.

Recent practice is that pricing will go up 4% a year. If the cost of a mortgage or rent is added to the in-home MIN, then IL can be less than living in your house.

Comparative Aging in Place at Home Costs (Private Pay)

                                                                -10 -

Work on my residential care spreadsheet (Maintaining a Safe Cognitive Impaired Environment) stopped when my health failed to the point that I could no longer take care of my wife at home. It is now over two months later since we moved to Provision Living at Columbia (MO). Just a three mile free move. One day of packing; two hours loading; two hours unloading; and another couple of hours and all the packing stuff was out of the apartment. The time to move had come and there was no waiting list for the new apartment

The original emphasis in the spreadsheet (2014) was on independent living (IL). During 2015 that turned to assisted living and to memory care. Now we are concerned about what follows assisted living/memory care and finances. Our original instructions were, “I want a phone number”, to a person who actually knows you and Gma and a plan of what to do next. We owe this to our kids.

The spreadsheet works well with money, square feet of space, and the time and number of meals. However it can easily give false impressions. Nothing is simple as everything can have many related parts and timing (and billing). Our move is a good example: one person stayed with the process from start to finish to see that all did go well, including taking care of us for the day.

So, I am breaking the spreadsheet summary dated, 22 December 2015, into four parts. The first three have us living together, as we have, and the last one has us living in separate spaces; something we cannot do financially.

• Aging in place at home.
• Independent living (IL).
• Assisted living (AL).
• Memory care (MC). 

 AGING IN PLACE AT HOME

This first step has been a good learning experience; for less than we were paying for Medicare insurance (dropped from over $11,000/yr to zero; BlueCross/BlueShield to Essence Boone County MO HMO). A 3-hour service period, from Home Instead Senior Care, seems to be the optimum for memory care. We selected three days a week after I was in the hospital emergency room, twice, and later admitted twice. Boone County Hospital provided food and a bed for my wife each time.

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We learned a lot about memory care. Well-matched (bonding) caregivers made residential care facility visits possible. We learned that the “new family” we would be a part of is different at each facility. We ended up grouping the facilities “health oriented”, “both” and “fun retirement”. This grouping ranked the cost of joining; from higher to lower priced independent living (IL) entry costs (Chart 8).

In-home care for just a 3 hr/day matched the cost of IL when charged by the level of care. At this level you are just paying for room and board. Day care can be added at Mill Creek. Tiger Place and Provision Living include assisted living (AL).

The Norovirus

9 Mar 2016                                          -9-

Chart 6. Daily Values

The month after establishing my Sleep Number at 40 (with appropriate bed positioning and pillows) was fairly uneventful with the exception of two dates: 15 and 26 of February (Chart 6) when I caught the norovirus. (As did everyone else living here at Provision Living at Columbia (MO).)

Chart 7. Running Three Value Averages

The remaining interplay of Sleep Score (blue) and Sleep IQ (red) can be assigned to stress and other things (Chart 7). In general, the BASIS sleep score (blue) over Sleep IQ (red) still indicates feeling better (less pain). This happened immediately after each bout of the virus.

Chart 8. Heart Rate (orange) and Perspiration (green)

The two bouts of the virus were very different. The first one was violent with an average 24 hour heart beat of 79/min; the second was 58/min. The first recorded two spikes in perspiration at 3:00 am and 8:00 with extended vomiting and some diarrhea (Chart 8). (Sweating increased in the evening, on Chart 8, as my wife generally covers we up with all the covers on the bed when she turns in.)

The second bout of the virus was just feeling cold and chilling, but again I spent the day in bed. On both days in bed my back pain did not increase as expected. 

On the 8 March 2016 (day 36) I overslept from 5:00 am to past 8:00 am. My back pain did not increase but actually decreased. I went on a mile walk, standing up normally for the first time in months. I can now get in and out of the car without having to use my hands to direct my feet. The back of my hands no longer burn.

How pain in so many places can appear and completely disappear in this fashion supports the mind-body connection (stress and pain). It is scary to not be able to stand up straight. It is amazing to feel normal again; or as I have said many times, “I do not have to push twice as hard against the ground to stand up or to walk.”

Mind-Body Medicine (Interesting reading and viewing.)

The center for mind-body medicine  http://cmbm.org/self-care/

http://umm.edu/health/medical/altmed/treatment/mindbody-medicine

https://www.theconnection.tv

Breaking the Bond

 3 Mar 2016                             -8-

“Just leave her here and we will call you in one to two weeks”, San Antonio, Texas. This was our introduction to memory care about two years ago.

Today at Provision Living at Columbia (MO) we share a one-bedroom and one-office apartment adjacent to a 12-apartment memory care unit that has yet to open. Our life is comparable to living in our house with the exception of great meals and the daily exercise periods. When the  “worries” strike any time of the day, a 10-20 minute drive will generally provide relief for a couple of hours.

Experience here and at our house indicates that about nine-days is needed for a memory care patient to adjust to something new, in general. There are other concerns that can override this. These concerns can last for weeks with varying form and intensity.

“Richard?” This call was repeated every 15-20 minutes when I was not in sight at our house and again in the past two weeks here also. My wife’s greatest fear was obtained by a Home Instead caregiver when helping my wife fill out the forms for Provisional Living at Columbia (MO): fear of losing me (which has many meanings).

Our room care person reported to me yesterday: “She needs you. She is constantly checking on where you are.”

It is sometime between 7:00 and 9:00 pm that she comes into our office room and sits down on the daybed that she says what is the most endearing and heart wrenching. In a low voice, almost a whisper, she will say, “I love you.” (One meaning is: “Do not leave me here alone.”)  

It is now a very real $84,000/yr question (estimated at about  $500,000 in five years): Is there a better fit that may include skilled nursing care and have Medicaid beds in reserve? Or do we go back to our house for the summer and wait for Provision Living at Columbia (MO) to mature?

Should we break the bond? That is, memory care for my wife and a room or apartment within walking distance for me. (We do not drive alone now.)

Is breaking the bond, to the extent we live separately, just acceleration of what is taking place now; with my wife being fully integrated into memory care during the day? We are learning from a couple we often dine with, who rent an apartment on each side of the “door”.

Is my stress building again? Coming here is related to a marked reduction in stress for me, in reduction in severe back pain. It is time to print out the BASIS and Sleep Number bed data for the past three weeks, which include both of us having the norovirus.

Risk and Fear

 2 Mar 2016                            -7-

The positive side of life is having the confidence to fulfill your ambitions. “Live well and die young.” (Die young is young in spirit, not in years.) The negative side of life is managing risks.

The same risk can be perceived differently in different situations. Familiarity, habit, and addiction change our fear of a risk, or of being aware of it at all.

Falling is a high-risk event in residential care. One resident continues to use her 4-wheeled walker, just in case. She can walk without it; but the fear of what might happen (and what has happened to others) overrides her confidence.

In normal life, we can measure the degree of fear by the cost of managing the risk: insurance (car, house, life, health, long term care, and funeral). Law requires minimal car insurance. Hospice is free.

Long term care comes in two forms, home and residential, and in a variety of flavors. Home care is the lowest in cost (in money), and for most people with a spouse, or other relative, the only option. Most risks are managed by 911.

The tension between risk and fear increases when spouses have different health care needs and do not qualify for (or cannot find) Medicaid beds in a nursing home. We still have a number of unsettled risks and related fears (costs).

RISK/ACTIVITY	HOME CARE	RESIDENTIAL	FEAR/COST
Wandering	Monitor/Care Giver	Monitor/Residential Assistant (RA)
Falling
Memory Care &	$22/hr	One Apartment	$5,000 + $1,500
Assisted Living		Two Apartments	$5,000 + $5.200
Provision Living  Level of Care Two		Dressing, Grooming Escort to Activities	$600/mo
Skilled Nursing	$25/hr	Hospital, 24 hr/day Nursing Home	Insurance & Medicaid
Medication	$0	$650/yr Co-Pay	Accurate Delivery
Meals	Individual	Group Activity
Bouncing Ball	One-On-One	Group Activity	Greatly Enjoys
Care Giver	Three hour period  $66/period	RA Available Around the Clock
Air Quality	Clean Air	ScentAir	Allergies
Back Pain Score	2-9	1-3	Stress?

The properties of the above cell contents are not directly comparable as money, risk or fear. Skilled marketing can also manipulate their relative values.

Did we make the right choices last year? Yes. A three-month respite has made my back manageable; my wife’s health status has been determined; and after 16 years, part of the furniture is out of the house for easy repainting of interior walls.

Now I need to drop independent living and to add nursing homes to my spreadsheet while considering the above risks and fears.