A GUIDE TO MAKING PLACEMENT DECISIONS

The following is a guide to help consumers make placement decisions. Placement in a nursing home (facility) is not as simple as finding a hotel room. There are a complex set of questions to answer, each with its own unique set of follow-up options. The first thing to do, if feasible, is to discuss the need for placement with the potential resident. It is not possible (and indeed, not ethical) to force admission to a nursing home against the will of a legally competent person, especially if they have decisional capacity.

Once the issue of consent has been dealt with, placement choices are dependent upon several determinations. These are:

Where is the person currently residing?

What will be the initial payment source?

What type of care is the person seeking?

How Do I Find Placement When Still a Patient in a Hospital?

When a person is in a hospital, the ultimate responsibility for finding a placement lies with the hospital social worker or discharge planner. (The social worker may tell the family that placement is a family responsibility.) Families need to be involved in making choices and decisions as they are able. They can call facilities and seek placement, visit prospective facilities, and give the hospital information they need in order to facilitate placement. They really do not have any say over the final nursing facility (NF) chosen if they have given the responsibility of finding the placement to the hospital. The hospital has a strong financial incentive to make the placement.

Placement from a hospital is generally easier than from the community for several reasons. They are: the nursing facility is able to access Medicare reimbursement for up to 100 days, depending upon the diagnosis and progress of the resident. Longterm care insurance often kicks in only after a hospitalization. The required admission paperwork (physical, diagnosis, assessments etc.) usually accompanies someone from the hospital; nursing facilities sometimes have arrangements with hospitals to facilitate placement; some hospitals pay the first month's charges to ease the way for residents during the application for Medicaid (KMAP) process. For someone coming from the community, these helps are often not in place, and nursing facilities often have a hard time getting family cooperation in procuring these documents.

Hospital social workers are generally well-informed as to alternative community resources which a person may want to use instead of the nursing facility. They can help families make arrangements for these services.

It is good advice to work with the discharge planner, to be as active as possible in the search for a facility, and to physically go to the chosen facility prior to placement, if able to do so. Given that beds are scarce in KY, there is little genuine choice for consumers. Those being placed from hospitals, using Medicare reimbursement, are currently the most attractive prospects to nursing facilities.

How to I Find Placement from Another Nursing Home?

If a person is in another licensed nursing facility, the burden of placement depends upon who initiates the transfer. If the resident wants to move, the burden of finding the new placement rests with him but--the social services department of his current facility--is obliged to give assistance. If a person is in a Personal Care Home or a Family Care Home, the administrator may give assistance, but is not required to. Local state social workers from the Department of Social Services are obliged to give assistance to residents in this area, but practically speaking, it doesn't happen often.

If the facility is initiating the transfer--for any reason--the burden for finding a new placement lies with the facility. All transfer and discharge rights may be exercised by the resident in this instance. Once the transferring facility has identified and officially secured a new placement, the resident may accept or refuse.

Can I Find Placement from My Own Home?

If the placement is to be made from the community, the problem is much more difficult. For a person who will be private pay, the problem is less difficult. However, in this instance, the family/potential resident needs to make an important calculation. If they want to enter a nursing facility and do not really need the service, the question is--will they medically qualify for nursing facility placement when their money runs out and they need to apply for Medicaid? Remember--to qualify for Medicaid, a person must be both poor enough and sick enough. If the person might run out of money before they become sick enough, continued stay might be threatened. Families may want to consider other community services until nursing facility placement becomes a physical necessity.

It is illegal for the facility to directly inquire how much money an applicant has, but practically speaking, they will want to know and find out in order to determine how long it will be until the resident becomes Medicaid eligible. If there is a potential that an applicant will need Medicaid coverage at some future point, the family needs to check to see if the facility has certified beds and if the bed the applicant is going to occupy is certified. Some facilities are totally certified for Medicaid, some are not. People with few resources should avoid facilities with few or no certified beds.

If Money Is Not a Problem, How Do I Find Placement?

If money is not an issue, then neither will placement be an issue. This applicant has a full range of choices. It will then be wise for the family to visit the potential facilities several times unannounced; to chat with other residents and families about conditions; and to, of course, ask the staff all of the questions which are suggested in handouts from AARP and other sources.

Two very good issues to consider are: what type of environment does the potential resident enjoy; and, which of the proposed facilities is most accessible to family members who will form a support system for the resident?

I Know I Will Need Medicaid Right Away. How Do I Get Placement?

If the person is going to be on Medicaid immediately, and is physically in need of nursing facility care, there may be serious barriers to finding placement. Families need to visit potential facilities, explain their need, and be open about finances. They need to offer to cooperate fully in procuring the necessary admission physicals and Medicaid application. A local physician must document the need for nursing facility care. They need to politely "badger" the facility in order to keep "their" family member in the forefront. Waiting lists can be a tool facility staff uses to pacify families of Medicaid eligible residents and families must not rely on them as a means of finding admission to a facility. With occupancy rates as high as they are in KY, the facilities do not have to call potential applicants, especially those coming in from the community setting.

Nursing homes also pick and choose among incoming residents on other factors. If the potential applicant is combative, wanders, or is generally difficult, the facility may not choose to admit, even if they have the space. Diagnosis of mental illness is also a barrier to placement.

Nursing homes usually require incoming residents to pay for the first month's stay. This is legal. However, the family/resident should request a receipt for the payment and to have the facility be returned to the resident before a facility can bill KMAP for the resident's stay.

It is technically illegal in KY to discriminate against applicants for admission based on their source of payment. In practice, however, such discrimination goes on all the time. Such practices have been reported to the state but with no apparent response. It is also illegal to discriminate against persons with disabilities such as certain types of infections (MRSA, HIV), the new TB, morbid obesity, etc. So far, this has not been challenged so case law has not yet been established in KY. The reality is that in KY, nursing facilities essentially can pick and choose among applicants until they find those who best serve their needs.

What About Placment in Locations Other Than Nursing Home?

Placement into the Personal Care Home (PCH)and Family Care Home (FCH) setting varies by region of the state. In central KY, FCHs tend to have vacancies. [A separate Info Sheet is available to help families with this process.] PCH placement is difficult for someone who will be relying on State Supplementation (the PCH equivalent of Medicaid). Private pay residents usually have no barriers except space available. It may be wise for PCH applicants in frail health to look at PCH facilities which are affiliated with nursing facilities. This can make movement from one level to another easier psychologically. Often, residents in this "multi-level" type of setting can remain in Personal Care longer because their needs can be met by the more skilled staff of the nursing facility portion of the facility.

Can I Be Forced into a Nursing Home Against My Will?

Families may sometimes be tempted to make a placement against the wishes of the potential resident. Families sometimes feel that they must either coerce placement or conceal the true nature of the placement. It is important to know that openness in relationships continues to be crucial, even after a person reaches the stage, physically and mentally, when they need nursing facility care. A resident may, in time, come to forgive a move to a facility which they perceive to be an action against them, but it is much harder to forgive lies told to them. Lying to someone initially builds a foundation of dishonesty which may make the entire nursing home experience more difficult. Families should explain the realistic choices available to the resident and to the family in light of current family/health/work situations.

It may be wise to talk with an Ombudsman, social worker, or attorney about ultimate responsibility for decisions in the case of: legally competent adults with decisional capacity; legally competent adults who lack decisional capacity; adults who have given permission for others to make decisions on their behalf. It is best if the potential resident can be involved in all family discussions about placement and for them to be actively involved in the decision making. Secret discussions and discussions over the head of the older person can be very disturbing and make adjustment to placement much more difficult. This is particularly true for persons with dementia--they often hear portions of conversations and interpret the content in a catastrophic manner.

For some people, nursing home placement is their choice and a very positive experience. People who have been socially isolated and or in fragile health often value the congregate setting and feel reassured to have nursing assistance available.

What Resources Are Available in the Community to Help Me?

Consumers are interested in the quality of placement as well as the actual process. Contacting our local Long-term Care Ombudsmen can be helpful at this point. An Ombudsman can:

• share current information about the state surveys of facilities

• direct consumers to family groups and other previous consumers who can share

opinions and experiences;

• give an overview of care at a specific facility based on the experience of their office; and

• educate consumers on how to assess the quality of life and care in NFs.

The local Senior Citizens' Center is also a good source of information.

One general useful issue to think about is how close is a potential facility to the family members who will be providing support. A facility close to family may, in the long run, be more desirable than one far away, regardless of differences in the quality of care or the attractiveness of the facility. If families are close to facilities, they visit more often and can support the resident in their quest for quality care and quality of life.

After considering the above, families may want to contact the Longterm Care Ombudsman in their area. This person may be contacted by calling the State Ombudsman at 1-800-372-2991. That office will refer you to a local Ombudsman. Ombudsman can give families additional information about: the careplanning process; what good care practices look like; the regulatory system and how families and residents can make their concerns known; resident rights; resident and family groups; and, of course, the role of the Ombudsman in the longterm care system.

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