Eldercare Whisperer

Unknowingly, I have become the go-to person for all things about old people in my circle, near and far. I have counseled with elders and their families in my parish, in my neighborhood including social media neighbors, my friends and contacts, my distant family clans, and my friend’s and family’s friends and acquaintances. And, most recently as the caregiver to my mother, I have navigated community service providers to provide both her and me with the support we needed. I have become the Eldercare Whisperer. To me, this speaks volumes about how complicated and tedious it is for lay people to navigate our current system, to develop a plan, purpose, and direction, and to facilitate a plan and course of action.

In my urban setting, there is a multitude of service providers. This is a fortunate circumstance as it breeds competition and ease of access. However, it can also be overwhelming and confusing, at the same time. This leads people to look for personal recommendations most often from their physicians, from other health providers in the community, or people who have gone through it themselves or with their parents.

Upon performing a google search of assisted living facilities in Fairfax County where I reside, 60 facilities are listed with the Department of Social Services (DSS). That represents an overwhelming amount of choices and assisted living facilities do not have star-ratings or other consumer-ratings as do nursing homes. When my mother became eligible for Virginia Medicaid home and community-based services, I was provided a list of providers by Fairfax County to choose from to fulfill the 43 hours of personal care services for which she had been approved. There were 204 agencies listed which provide Medicaid services to home-based clients in Fairfax County. The most interesting fact is that 44 of the 204 agencies started with “A” so that they would be the first seen in an alphabetical listing. Knowing this marketing strategy, I skipped the A’s and went with BG Healthcare because they also train personal care attendants which I knew was a benefit to both the employer and client. The final example to demonstrate the ease of access in my community is the yellow pages listing of 39 non-emergency medical transportation companies, not including taxis, Uber, or public transportation. These include both wheelchair and stretcher transportation of non-emergent nature.

In my community of Fairfax County in an urban setting outside a major city, lack of access is not due to a lack of service providers. Lack of access is based on the ability to pay or not, language barriers or poor communication, or because of fragmented services or uncoordinated care. This is where I see the most significant challenge in my community of elders which will persist unless changes happen within the system or a new model of senior services is developed to navigate through this life stage. The remainder of the essay will address specific service’s access based on payer type, and affordability as this is most often the greatest challenge for our aging population.

Medicare Part A Services

For hospitalized elders covered by Medicare Part A, the hospital case manager typically obtains a skilled nursing bed, when needed and qualified, and notifies the patient and family about discharge plans. Little choice is often given and certainly not enough time to make an educated decision is provided given the pressures of hospitals to discharge. If an elder is in the hospital and not meeting or wanting skilled nursing inpatient care (Medicare A SNF stay) than a referral to a home health agency (Medicare Part A covered service) is made by the caseworker. The caseworker will suggest a service provider, have you sign a waiver that you know you have a choice in providers although not offering a list of providers, and make the referral to the indicated agency. Unless you have had a prior relationship with a home health agency, most often the elder and their caregiver will go to the referred agency. This process is considered efficient in our health care system and in fact, does expedite a discharge from the hospital. However, most caregivers feel pressured and uninformed about choices and options. Medicare Part A benefits will also cover hospice care in acute care settings, long-term care settings, or in the home.

Medicare Part B Services

Whereas Medicare Part A is considered hospital insurance, Medicare Part B is regarded as medical insurance. In a nutshell, Part B covers medically necessary physician visits, outpatient care, home health services, durable medical equipment such as wheelchairs and hospital beds, mental health services, and many preventative medical services. One of Part B covered services is ambulance transportation to a hospital or skilled nursing facility. There are limited other conditions for coverage. For example, end-stage renal disease patient transported to a dialysis facility. Part B will also cover home health services such as intermittent skilled nursing care, physical, occupational, or speech therapy, and medical social services. Part B will include medical nutrition therapy services for diabetes, kidney failure, or a kidney transplant. Part B will include mental health care on an outpatient basis. This is most often prescribed for depression, anxiety, or grief. The newest additions to covered services under Part B are telehealth and transitional care management services. The most underutilized covered assistance under Part B is second surgical opinions. For surgeries that are not an emergency, Medicare covers second and, in some cases, third surgical opinions. In my opinion, if more seniors got second or third opinions many of the services would not be needed because unnecessary surgeries would not be performed.

Medicaid Services

Through the Medicaid Home and Community Based Services (HCBS) in Fairfax County, eligible seniors or disabled individuals have both access and financial support for personal assistance including ADL care in the home, light housekeeping, personal laundry, and grocery shopping; adult day health care; limited respite care; and transportation to/from doctor’s appointments and some other limited services. In addition to these services, food stamps are provided for those unable to afford adequate nutrition or meals can be delivered to the home once a day for homebound clients. Medicaid provides nursing home care to seniors who meet eligibility criteria. In Fairfax County, a Medicaid waiver is granted for a small percentage of adult foster or group home care recipients. Self-Pay Services There are a variety of services which are accessible to those seniors who can pay a fee-for-service. All the services previously included in this essay included. Also, assisted living is exclusively private pay in Fairfax County. Home repair and maintenance is also self-pay unless you have the good fortune of a church or other volunteer organization which helps with maintenance or making home modifications for disabilities. Support groups for stroke, cardiac, grief, and mental health issues are most often found within non-profit organizations and are free of charge to those seeking the services. Someone seeking these services must do a fair amount of research to find the group, location, and time. No transportation assistance is provided. Conclusion

To encapsulate the services mentioned herein within my personal experience with my mother. I used Medicare Part A for skilled nursing rehab care, ambulance transfer, and home health nursing and rehab services. I used Medicare Part B for physician visits, mental health/grief counseling, durable medical equipment, outpatient physical and occupational therapy, and outpatient diagnostic and other procedures. I used self-pay for respite care, personal care, transportation, home maintenance, and adult day health care. I used Medicaid for personal care attendants, respite care, adult day health care, and nursing home care. My mother was fortunate to have me as her eldercare consultant. She would not have been able to afford a private consulting team.

In Fairfax County, all Medicaid HCBS and nursing home clients have been moved to the new Commonwealth Coordinated Care Plus managed care program and have been assigned a case manager. The private sector is still limping along without a great deal of system coordination. In Fairfax County, there is four private geriatric care manager consulting firms. These are very expensive and are not well known. Geriatric care managers will be a field of potential growth in the future especially in a community such as Fairfax County. It is my interest to start a non-profit company which can help navigate this life stage servicing all payer types.