Nursing Home Selection Notes

There are certainly plenty of guides and checklists published on the internet and elsewhere for selecting a nursing home. Medicare has an on-line pamphlet, and also a checklist.  Here are some of my own notes:

1. As I have suggested previously, check out the government websites of nursing homes, and specifically the '5 Star ranking' score of the ones you are considering. As you narrow down your choices you may want to look into the factors behind the rankings.  As an example, I see my son's employer received only a mediocre ranking. That nursing home received 5 stars for "Quality Measures" and 1 star for staffing levels, factors that didn't surprise Martin. Remember also that the rankings are averages of only selected measurements, during certain times.  Critics of the ranking complain that things like patient satisfaction surveys are ignored.  In any case, you won't want a place that puts more effort into 'passing the test' than in improving overall quality.

2. Have a look at the short list of USNews'Honor Roll' nursing homes. Also, watch for other articles and news reports that identify other noteworthy facilities, like Miami Jewish Health Systems and Hebrew Home of Riverdale.  Be aware that the Honor Roll list is based on the government 5-star ranking mentioned above.  These are nursing homes that scored a "5" in all three categories measured, and the list has the same drawbacks as the ranking itself.  Even if you don't select one of these nursing homes, just visiting them probably gives you a good reference for comparison.

3. See what the CNA's who are actually providing hands-on care are saying, in their own forums. While they won't name employer names, you can get an idea of their issues and frustrations. Try to get an idea if the concerns you read about on-line, like inadequate coverage and unrealistic expectations, might be concerns in the places you visit.

4. Before visiting any home, take just a little time to learn some of the tell-tale signs of quality care. Also, remember to trust your nose. You won't always find bad news. In one nursing home I visited, for example, the cleanliness standards and disciplines were so impressive that I had immediate respect for the staff. In another fancier place I was dissappointed.

5. Check out Elder Abuse Attorney websites, and avoid any nursing home owned by companies with frequent problems in their other facilities. You may have to do some research, because ownership is sometimes not clear. One national operator of 200 homes, many of which have been cited by elder attorneys and the AARP, operates under many different local names.

6. While this is not a critical factor in itself, you might check to see if the nursing home is for-profit or non-profit. Although individual institutions vary, staff salaries are typically higher in non-profits.  In the past, most 'honor roll' facilities were non-profit, though that may be changing.

7.  As with any care provider, check references.  Besides families, professional care managers can be a help.  Also, many states have ombudsmen that look into complaints about nursing homes.  For example, Florida has regional ombudsmen who take consumer complaints.  While they usually get involved after there is a problem, it may be worthwhile to check with them during the selection process. 

Once you or your loved ones make your selection, consider having your own private CNA, RN, or care manager visit. Ideally, it should be someone who will not only give personal care and attention on a regular basis, but will be thorough and able to identify possible problems, signs of infection or developing sores for example, as well as observe general conditions and care. Even with regular visits by family members, you will want to verify that all is really well.

Looking for a gift idea for a caregiver? One of the more thoughtful gifts I received in recent years was a nice, lightweight 'anti-gravity' recliner.

These light, durable chairs are perfect for sitting bedside for long periods of time. If you have someone in a care facility, you will find that these chairs encourage lengthy visits. They can be tucked away easily when not in use. Any brand is fine, and prices vary greatly, but the higher quality ones really do last longer and are easier to use.

Just watch the weight.  There are heavier versions of these chair that are well made and good for home use, but they are really too heavy to be transported easily. Also, if the chair is to be used in a hospital or similar institutional setting, made sure it is well labeled.

So often, impressions of caregiver performance are subjective. As with any medical provider, a home caregiver's bedside manner is important. Just as with others providing treatment and care, however, we must not forget that actual, measured results do count.

As a caregiver, you should be aware of whether the client has improved or not under your care, even if the change has been gradual. This is not something you get from impressions, but from your actual daily records.

If you have been keeping a good record you will have the information you need. Key measurements depend on the client. These might be progress in vent weaning, weaning from certain medications, limb flexibility, body mass index, blood pressure, blood sugar, or any other specifically relevant measurement.

While clients and their families may not be attuned to this, the physicians and other professional providers will be. Ask them how the client, and you, are doing. Make sure you understand what they see as the important measurements of progress. Don't hesitate to have them evaluate your results.

As you go along, use the measurements that the physician and other medical providers are reviewing to grade your own performance.

Gertrude

The Classic Cycle: No Information to Information Overload

Stretching your LTC claim dollars

I sometimes work for clients who have Long Term Care insurance policies. Often, these policies have dollar limits to payouts, rather than specific time limits.

One of my clients, a couple, did some research into this, and found that their policy covered care by state-licensed individuals - meaning CNA's like myself.

Many other LTC policies, including those offered through the AARP, also have that same provision that covers the direct use of licensed CNA's.

For reimbursement, the client simply submitted a claim form indicating my license number. The insurance company paid the couple directly, and from that payment they then paid me our negotiated rate. That rate was lower than they would have paid through an agency or other corporate provider.

They would not be able to do this with unlicensed caregivers, but since CNA pay rates are usually the same as those paid to unlicensed providers, and considerably less than rates paid to corporate providers of these services, there was an opportunity for them to greatly stretch coverage.

I would add some points:

1. Clients should use legitimately licensed , self-employed caregivers to prevent 'employer liability' issues.

2. Clients should check that the CNA they use has her own malpractice insurance policy.

3. Follow the normal safe-guards that would apply to any home care agency or individual, including reference checks.

4. Whether considering licensed caregivers, agencies, nursing homes, or assisted living facilities, clients should educate themselves as to signs of quality care .

By checking into their actual LTC policies, clients may find simple ways to stretch their benefit dollars.

Regards,

Gertrude , from my Elder Care Notebook

Saw Horses and Quality of Care

The Wisconsin technical colleges have a series of 80 training videos online (Lessons 1 - 80) that can be useful for caregivers. The series is geared towards training aides in hospitals and the like, but the techniques and precautions apply to home care as well.

These are classroom-type lessons, so the style might be a bit tedious for casual viewers. Even so, the lessons are organized well, and you can pick your subjects.

Several of them can be especially informative for those who have loved ones in care facilities. So often, I am discouraged by the actual practices in nursing homes or even hospitals that seem wonderful to the casual observer. They remind me of a friendly, personable mechanic who shouldn't be touching your car.

I'm not alone in this. This month's Consumer Report magazine includes a survey of patients in hospitals, and of nurses in those same hospitals. The survey highlighted the differences between what patients were concerned about - with the care level, facility, and all - compared to what their nurses thought they should have been concerned about. The nurses considered the lack of coordination among the providers (communication) and deficiencies in hand-washing discipline to be the two most significant things that the patients should have been worried about. Very few of the patients picked up on these, especially the hand-washing.

All this leads to a seemingly simple video topic - Lesson 22 Bed Making. If you watch the video, at least the first half, you can't help but notice the emphasis on sanitary practices necessary for even this ordinary task. Next time you are in a hospital or long term care facility, observe the bed making. Watch the details. This is one, just one, small indication of the quality of care and attention to safe practices in the facility.

I'm impressed when I see tasks like this being done to proper standards. You should be, too. If you see that the staff attends to every detail, as these lessons will explain, compliment them and their supervisor. If you see short-cuts, however, be concerned. Friendly faces (at least in your presence) don't make up for lack of good practices.

Again, the Bed Making procedures are just an example. All the procedures laid out are important, of course. A carpenter friend once said that his boss had job applicants make a quick set of saw horses in the interview. The boss could tell all he needed to know from that. Bed making is something like that. Watch the video, and you'll see what I mean.

Gertrude

http://eldercarenotebook.blogspot.com/

 Engaging a Private Caregiver

By engaging a private caregiver, you can often get a highly qualified professional at affordable rates. With the latest developments in licensing, insurance, and on-line resources, you might consider hiring a licensed CNA.

When considering a CNA, ask for the caregiver's license number, and check it out with your state's Department of Health, either on-line or by phone.

Licensing. Exams for CNA's have become standardized across many states. State licensing also includes law enforcement checks, with FBI checks as appropriate. Many states maintain easily accessible databases of licensees. License holders also have continuing education (CE) requirements.

Insurance . Professional liability insurance is now available for individual caregivers. Check that the person you engage has a professional liability policy. If your favorite caregiver doesn't have a policy, you might suggest that she obtain one.

Self-employed contractor. Much has been made about the risks of being an 'employer.' To stay clear of problems, use a licensed professional who offers services to the public as an independent contractor. Quoting the IRS: "the general rule is that an individual is an independent contractor if (the person for whom the services are performed) has the right to control or direct only the result of the work, and not what will be done and how it will be done or method of accomplishing the result ." Use a licensed professional who has the necessary training and experience to do the job.

Internet resources . Most states have on-line databases of licensed professionals, which provide the licensee's status. For those that want a more current background check than provided by the state licensing board, there are numerous on-line services. These typically charge nominal search fees.

Spot-checking. One of my clients' families had a motion-sensor video security system installed in the foyer. If desired, comings and goings could be monitored, spot-checked, or even communicated by email. The added advantage of that system was that, combined with cell-phones, it could be an entertaining form of communication. Of course this is only appropriate if used with discretion.

Affiliations . If you are planning to use a CNA extensively, check that she has back-up resources available. Many independent CNA's have good networks, including caregivers with prior hospital or other institutional experience. Some private caregivers have close affiliations with RN's. This can be especially helpful in complex cases.

Long Term Care insurance eligibility. Licensed caregivers are eligible providers under many LTC policies (including the AARP long term care policies offered through Genworth). Check with your agent or refer to your policy. You may be able to get more 'bang for your buck' hiring directly.

Financial & Quality advantage . By engaging a caregiver directly you can sometimes get professionals of caliber that you might not have access to through an agency, and at significantly lower cost.

The result. For short-term needs, or in transitional situations, using an agency may make more sense. For longer-term situations, the key relationship is between the actual caregiver and the care recipient. With the developments in licensing, the availability of professional insurance, and advanced technologies, private caregivers can be a rewarding alternative.

GertudeCNA

I came across this posting on a national home health care agency's web site, in the company's "franchise opportunities"section.

Yolanda: " ....I am currently unemployed. I am an automotive management professional..... I have an entreprenurial spirit, very passionate and motivated to work hard. But now, I want to build a future for myself and my family that I can grow, nurture and build a retirment from. I have always wanted a business of my own and I agree that the elderly population is growing and a nursing home is not always the answer. I have grown up in a home where my grandmother lived with us to the end and also my great aunt. We believe in great home care where the elderly can be around family. I am very interested in this line of business because I lived my teenage years with a bedridden grandmother. It can be done!

Franchiser : "Yolanda, you sound like many of our [Home Care Agency] franchisees. In fact, we have a new franchisee here in our training class right now that was laid off from her job at Ford recently..."

And this, from a different national agency (their use of bold letters, not mine):

Our Franchisees
With our hiring practices, support, and training, it is not required for our franchisees to have a medical background, just the drive to succeed. Our company’s mantra is “Failure is Not an Option.” Join our franchise team to start reaping the benefits of an unlimited revenue stream.

Remember those real estate infomercials?