A Patient Advocate's View

What are your options when you run out of money?

“My mom is running out of money in the assisted living, hospital or rehab, so she will have to go on Medicaid and live in a nursing home.”  I have heard  these words so many times, I can’t count them.

On most of these occasions, my role is to help the family make the decision to accept hospice for their loved one because they have waited so long, hoping the patient was going to get well and go home.  But recently, I found a large gap between what the system has to offer in between independent living and the nursing home.  A lot has to do with licensing and advertising.

In this case, the client was suffering from moderate dementia, she used a walker but had no other medical complications. Her heart was healthy and she didn’t have diabetes or COPD. She was living in a private residence for seniors, but not a licensed assisted living according to state law and therefore not covered by Medicaid. However, everyone assumed that because the residence offered room and board and everyone there used either a walker or a wheelchair, that this was an Assisted Living Facility.  In fact, they were advertised on many web sites under the heading Assisted Living Facility. I don’t think this was the fault of the residence. There is simply no distinction on these websites between those that qualify for Medicaid and those that are private. It is up to the family to shop around.

The cost of the stay at most private residences is about $5000 a month, including assistance from a licensed home care agency that provided help with bathing, dressing and medication. Sometimes the bill can be as much as $7000 including Cable TV and other utility bills and personal services such as hair cuts and toe nail clipping. If the patient does not have diabetes, toe nail clipping is not covered under Medicare.

I was called in to help with the Medicaid application, pending the move from the independent residence to the nursing home. The financial paperwork had been with the nursing home for months.  Since the nursing home accepted that I would be able to help the patient qualify for Medicaid, we were asked to speak to the admissions nurse to get a move in date. That’s when we found out that the patient did not medically qualify for admission to the nursing home, as she was able to perform most physical activities of daily living with a minimum of supervision. Even though she was not mentally able to live on her own, dementia is not considered a reason to confine a patient to a nursing home level of care.  We realized that it would even be cruel to condemn the woman to a life of laying in bed or sitting in a wheelchair, just because her memory wasn’t what it used to be.

Now, here is where the gap in the system showed itself. No one could point me to where the client could find the level of care she needed that would be covered by Medicaid. The nursing home staff suggested someone might be able to take her into their home.  Since the woman did not have any family, I was pointed to unlicensed homeowners who will take a persons social security check in exchange for room and board. I couldn’t accept that in all good conscience, so I pulled out my trusty SUN-B Directory. There I found Fred Altman, who I remembered is like a real estate agent for senior residences. He said there was only one place in about a 50 mile radius that would be appropriate.

As it turns out, the facility is licensed as an Adult Home and so can accept Medicaid, when the resident is in need of a higher level of assistance with activities of daily living, but not ready for a nursing home. The kicker here is that since the facility is set up to treat people requiring this higher level of care, many services that this client needs are included in the basic rent.  Medication Management, assistance with bathing and dressing, making sure the resident gets to meals and activities are all covered. For this client, it meant that she would not even need to qualify for Medicaid as she had sufficient income to pay for her monthly expenses.

This was a very good ending to a story that could have gone another way. The person could have been made homeless without the intervention of the people at the original Senior Residence, who called the alarm early enough for something to be done. The woman could have been pushed into an inappropriate setting if the Nursing Home hadn’t been ethical about her qualifications.  Or the Adult Home could have been full, as I am sure they will be soon, as more and more people live longer, but just need a little help.

by Caryn Isaacs, Patient Advocate

Resources: Senior Umbrella Network of Brooklyn ;

Fred Altman,;

August 17, 2012 - Posted by | Uncategorized

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