Journal of Gerontological Nursing

EDITORIAL 

Home Care-It Doesn't Always Work

Sylvia H Schraff, MSN, RN

Abstract

For a number of years, we have been witnessing a shift in emphasis from institutional-based health care to home health care. Much of this trend is a result of attempts to curtail the rapidly rising cost of health care services. Proponents of the move argue that people respond better to care provided in a familiar surrounding, and that most people prefer their home to an institutional setting. However, I feel we must carefully evaluate this trend, especially as it relates to those most likely to be affected, namely the people with Alzheimer's disease and their families.

As an administrator of a home health agency, I hear numerous stories of families attempting to care for their disoriented, dependent, and often combative member. Home care services supplement the role of the caretaker and provide needed guidance, as well as a respite from their daily demands. Unfortunately, the caretaker is often an aged spouse whose energies and resources are rapidly being compromised. Other family members are frequently not available to help to the extent needed. As the patient deteriorates, the need for more frequent home care services becomes compounded with the problem of limited funding resources for the level of care needed.

For example, home health care services available under Medicare and some private insurance carriers are limited to care that is medically necessary and rehabilitative in nature. The demented patient who has deteriorated to dependency in personal care rarely has needed that are covered by third-party insurers. Medicaid, on the other hand, will provide partial reimbursement for supportive care for income-eligible recipients. Frequently, these services are limited in extent and provide little help to the family facing round-the-clock care. Homemaker services can help the family with personal care, maintenance, and respite. However, we are now witnessing a far greater demand for services than what is available through the various funding sources. Similarly, adult day-care programs struggle with the problems of transportation and limited resources to provide for the needs of the aged adult. Families eventually face the choice of leaving their own employment, hiring full- or part-time help, or finding an affordable nursing home.

But will the families of the future Alzheimer's patient have the nursing home as an alternative to home care? As the move toward prospective payment systems continues, I see an emphasis on short-term, less costly care. Hospitals are expecting nursing homes to provide the rehabilitation needs of their acute-care patients. Medicaid requirements are beginning to mimic the short-term, post-hospital criteria used by Medicare and place further restrictions on the level of care reimbursed. I predict that nursing homes will find the private paying patient and those with fewer care demands more desirable as they attempt to curb costs and live within a prospective payment system.

Already I see nursing homes place limits on the proportion of Medicaid patients they will serve. Beds are often only available to persons with sufficient resources to afford the full cost of care for a set time span. Some homes are refusing admission to patients who are severely demented and require extensive care. Local government-sponsored nursing homes, which have always been overburdened, are turning to management companies to become more cost-effective. No matter how one views the evolving scenario, the plight of the Alzheimer's patient is dismal.

I propose that the nation's health care providers and planners, as well as our legislators, re-evaluate the trend toward deinstitutionalization in relation to the needs of the severely demented individual. By providing disincentives to institutions to care for the long-term patient, we force the demented patient to receive less-than-adequate care. And although the required care is…

For a number of years, we have been witnessing a shift in emphasis from institutional-based health care to home health care. Much of this trend is a result of attempts to curtail the rapidly rising cost of health care services. Proponents of the move argue that people respond better to care provided in a familiar surrounding, and that most people prefer their home to an institutional setting. However, I feel we must carefully evaluate this trend, especially as it relates to those most likely to be affected, namely the people with Alzheimer's disease and their families.

As an administrator of a home health agency, I hear numerous stories of families attempting to care for their disoriented, dependent, and often combative member. Home care services supplement the role of the caretaker and provide needed guidance, as well as a respite from their daily demands. Unfortunately, the caretaker is often an aged spouse whose energies and resources are rapidly being compromised. Other family members are frequently not available to help to the extent needed. As the patient deteriorates, the need for more frequent home care services becomes compounded with the problem of limited funding resources for the level of care needed.

For example, home health care services available under Medicare and some private insurance carriers are limited to care that is medically necessary and rehabilitative in nature. The demented patient who has deteriorated to dependency in personal care rarely has needed that are covered by third-party insurers. Medicaid, on the other hand, will provide partial reimbursement for supportive care for income-eligible recipients. Frequently, these services are limited in extent and provide little help to the family facing round-the-clock care. Homemaker services can help the family with personal care, maintenance, and respite. However, we are now witnessing a far greater demand for services than what is available through the various funding sources. Similarly, adult day-care programs struggle with the problems of transportation and limited resources to provide for the needs of the aged adult. Families eventually face the choice of leaving their own employment, hiring full- or part-time help, or finding an affordable nursing home.

But will the families of the future Alzheimer's patient have the nursing home as an alternative to home care? As the move toward prospective payment systems continues, I see an emphasis on short-term, less costly care. Hospitals are expecting nursing homes to provide the rehabilitation needs of their acute-care patients. Medicaid requirements are beginning to mimic the short-term, post-hospital criteria used by Medicare and place further restrictions on the level of care reimbursed. I predict that nursing homes will find the private paying patient and those with fewer care demands more desirable as they attempt to curb costs and live within a prospective payment system.

Already I see nursing homes place limits on the proportion of Medicaid patients they will serve. Beds are often only available to persons with sufficient resources to afford the full cost of care for a set time span. Some homes are refusing admission to patients who are severely demented and require extensive care. Local government-sponsored nursing homes, which have always been overburdened, are turning to management companies to become more cost-effective. No matter how one views the evolving scenario, the plight of the Alzheimer's patient is dismal.

I propose that the nation's health care providers and planners, as well as our legislators, re-evaluate the trend toward deinstitutionalization in relation to the needs of the severely demented individual. By providing disincentives to institutions to care for the long-term patient, we force the demented patient to receive less-than-adequate care. And although the required care is not medical in nature; it nevertheless requires the skill and expertise of experienced, quality-care personnel with patience and insight to make judgments based on non-verbal clues. I implore those with the power to change public policy and health care systems to evaluate the effect of the current trend and propose solutions that will not jeopardize the welfare of the Alzheimer patient and his family.

10.3928/0098-9134-19850201-04

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