My dad is in Assisted Living, 94, and suffers both from congestive heart failure and early stages of dementia. He has fallen many times, and he only feels comfortable in his wheelchair and his recliner. He went from being able to walk without assistance last November, to shuffling, to a walker, wheelchair, and now just sitting. I went to see him yesterday, and his decline was disturbing. Now he sits completely doubled over in his recliner. He's in no pain. We tried unsuccessfully to get him to sit up.

He's been under doctor's care, the CNA's at his AL place take care of him. Now he's also under Hospice care due to his decline in health. In talking with Hospice today, they are suggesting he go to a Long Term Care facility. What exactly is that? All I really know is that it's like a hospital, but more nurses and CNA's to watch him. Then Hospice called back to suggest I have a CNA sit with him instead. So now I don't know what to do. They gave me 4 places to check out, which, of course, I will. Your thoughts?

Long Term Care facility, Skilled Nursing/Rehabilitation facility and Nursing Home are basically the same thing. They are all facilities where the level of care given is similar to that of a hospital. Nursing Homes and Long Term care facilities are interchangeable and mean the same thing. Nursing Care is supervised by RNs and/or LPNs and medication is given to the residents by RNs, LPNs, LVNs, or Medications Aides. CNAs assist the residents with their ADLs (bathing, dressing, transfers, walking, eating, etc.).  Many nursing home residents have physical or mental health issues that require attention from nursing professionals24 hours a day and nearly half of nursing home residents had dementia, and more than half spent most of their time in bed or in a wheelchair.  Nursing homes often feature shared bedrooms, and their atmosphere might seem more like a hospital than a home.  The ratio of RNs, LPNs, and CNAs to number of residents is higher than that of an Assisted Living facility.

Hospice visits residents in nursing homes/long term care facilities as well as assisted living and people’s homes. Hospice does NOT offer 24 hour/7 day a week care and if your loved one is going to require someone to physically care for them 24/7, then a nursing home might be more appropriate.

You said that your Dad is in an Assisted Living facility and that “the CNA's at his AL place take care of him.” IF the CNAs are adequately supervised by a RN or LPN 24hours/7days and are able to perform all of your Dad ADLs (bathing, dressing, transfers, walking, eating, etc.) for him, then maybe he can stay at the Assisted Living facility.  However, as Ahmijoy has mentioned, if Hospice is suggesting that you hire an EXTRA or ADDITIONAL CNAs to sit with your Dad so that he has 24 hour/7 day nursing care, then it might be better to transfer him to a long term care facility. 

Also, what experience does this Assisted Living facility and staff have in taking care of people who are dying and are on Hospice?  If the AL staff have little or no experience caring for dying residents, then it would be better if your Dad was transferred to a long term care/nursing home where the staff has cared for residents who are dying and on Hospice.

EDIT: You might want to read Igloo's response about their experience with hospice on the question:
Helpful Answer (6)
Reply to DeeAnna
Ahmijoy Aug 13, 2018
Your answer is so much better than mine! 👍🏻
If he has to go into long term care/nursing home, do not just arbitrarily pick one. Even if his AL recommends it, do your research. I've seen some that are horrible despite being recommended by her doctor, and Mom was just there for rehab. Look for nurse to patient ratio. Medicare rates them. We found this out rather late, but were prepared for Mom's third rehab stint using this rating system. This is a good place to start:

Even the rating system is not always accurate. Patients who have an advocate always do much better so never be afraid to speak up wherever he lands. If you can afford it, I agree with the CNA sitting with him.

Is there an actual hospice facility in your area? We were blessed to have one open last year. This is a much much better solution for end of life care, but not all cities have them.
Helpful Answer (6)
Reply to Cindy916

The same thing happened to my dad. He became wheelchair bound from a fall, fracture and surgery. Assisted Living wouldn’t take him back so Long Term Care was the next step. Same thing as a nursing home just a nicer word. It costs $10,000 a month. If dad had stayed in AL plus had to pay 24/7 sitter fees it would have been more than that. So do what is in his best interest and where he will be safest. Do the math as well. Best to you.
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Reply to Harpcat

Many Assisted Living facilities are limited to what equipment they can or can not use. If they can not use equipment to transfer a person from a bed to a chair by using a Sit to Stand or a Hoyer Lift. If they can not use equipment it makes it more difficult for staff to transfer someone.
A Skilled Nursing facility or a Long Term Care facility can use equipment and they should have more staff to help with the residents.
I am wondering what the actual reason for them to suggest a LTC facility. There is no way a CNA has to sit with anyone (waste of a CNA when anyone can "sit" with someone) If they are concerned about the way he is sitting slumped over there are wedges and pillows that can be used to position someone. Also a Broda Chair is awesome for helping with positioning as more parts of the chair are adjustable. The seat reclines so slumping forward is not a problem, the back reclines as well and that helps prevent the slumping forward. My Husband was on Hospice and they ordered one for him and it was great. Not great for taking him for a walk as it was a bit more difficult to maneuver but we managed.
I would question more why they suggest this. Unless they think your Dad will need more direct care. But the Nurse from Hospice will come once a week no matter where he is. I can not believe he would be put on more medication, more medication might mean extra cost from the AL where he is. Unless they anticipate the use of Morphine and Atropine as needed and it would be more difficult to get AL staff to monitor that.
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Reply to Grandma1954

Assisted living (AL) is for people who can get up and toilet and manage themselves. If they lose that, their level of care goes up to nursing home (NH). NHs are not AL facilities. AL will not keep a total care person.
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Reply to cetude

Have a frank talk with someone you trust to give you honest answers at the AL - I know that the care available in an AL is not always enough to ensure that someone can die with adequate care, support and comfort, particularly overnight and on weekends and holidays when they are so often short staffed.
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Reply to cwillie

We just moved my father into memory care, which is not as expensive as a nursing home, but I think they would categorize it as "skilled nursing" or "long term care". The official name is "specialty care". They are available to him at all times for personal assistance, they escort him to meals. They eat the same food as that prepared for the assisted living residents and they can use all the facilities/services in the rest of the building if supervised. There is nursing staff on site and additional medical staff available on call. Medical staff comes to him; they have the portable xray and lab testing on site as referenced by Ahmijoy. They don't have a hoist and are unable to accomodate unusual feeding methods. If he reaches that point, he would have to be moved again into a nursing home.
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Reply to Invisible

My understanding of long term care is a Skilled Nursing Facility. These facilities have registered nurses and licensed practical nurses on staff along with aides (CNA and STNA) and therapists. At my mom’s, they were able to tend to most of her medical needs in-house. They had a portable x-ray machine for when residents fell and also could test for infections, call the doctor and get a prescription without having to take the resident to the ER. It is like a hospital, a “resident hospital” if that makes sense.

Does Dad really need someone to sit with him all day if he is pretty much immobile? If you have to pay for a sitter, which is what this is, it will cost you about $15 an hour and I don’t think it’s covered.
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Reply to Ahmijoy

Dear Sir,

I hate to say it but I feel Obama Care is your fathers failure. I have gone down this road on Three Separate occasions with my parents. Upon discharge from the hospital your father, or his advocate, was given a Notice from the facility of intent. At this point you should argue, fight like hell, you will almost loose the first round. But being proactive, you will win after three denials.

You have to present to Medicare that your father was never in this position. That you and your doctor agree, assuming you find a doctor to write in your fathers chart taht he needs advanced medical necisity of in-patient physical therapy. Im home PT/OT is very limited. Keep fighting for the best outcome for your loved one. Otherwise, then argue that they need agressive outpatient pt at least 3 times per week. Also ask your doctor to add to the PT order's for your father to receive "Balance Therapy" which gives any out patient facility additional hours or therapy for your father.

Helpful Answer (1)
Reply to CaringSon2

Often I see postings on other topics where people suggest the LO needs to go to a nursing home. Many of these cases do not NEED a nursing home yet. Back in the day, most places were called that, but not all really fit the bill and were not as nice as (many) current AL facilities.

As noted by others, a nursing home or LTC is much more medically oriented. This means they have more actual nurses to provide the medical care needed, which will increase the cost associated with them. AL, which would include MC, provides some hands on care, but it is limited. They have a nursing staff, but it is also limited. If someone requires a lot of hands on, such as transfers, medical interventions, etc, nursing home may be more appropriate. Some AL will provide more hands on, but will charge more for those services. If someone is still mobile, able to do some/most ADLs or need some assistance with them and just need a safe place, AL/MC is the better option, if one can afford it. I have read that some nursing homes also have MC units, but suspect that like the NH itself it is more oriented to those with cognitive AND medical issues. The only way to know for sure is to check out any/all that are available in your area and find out the cost and what they provide.

As for expense - I have posted comparisons elsewhere. Just as example, if you hire a company to provide 24/7 care in the home, it can be as or often more expensive than a facility. When we hired one company for initial one hour to be increased as needed, it was $20/hr. That cost varies depending on the region you are in (as does AL, MC and nursing homes), but using that for comparison and understanding that off-shift, weekends and holidays will cost even more per hour, consider this:

$20/hr x 24 hr x 365 days = $175,200/year!! That equates to $14,600 per month.

Again, it could be more, it could be less, but it will be in this range, which is about the same, give or take. BUT, you have to add to that the cost of rent or RE taxes, food, utilities, etc, and you can see that it will cost MUCH more if you bring help in. If affordable (usually not) and one prefers to keep LO in their home, this might work. If you limit how much outside help, it will be less expensive, but more taxing on whoever is the primary care-giver. Some people question if they are getting $11,000 worth of care in a facility, but one has to consider that cost pays for A LOT MORE than just what personal care the LO gets!

That said, yes, many people cannot afford these costs, but either way those costs are there unless the family can provide ALL or most of the care. Many cannot, so the only options are Medicaid to cover a facility or continuing to provide care alone or with limited help. Medicare, Medicaid and VA do provide limited in-home services, but there are restrictions and they are limited.

This current situation is an unprecedented one - back in the day more elders died from medical conditions at a much younger age. With better medical care many are living longer lives, albeit with medical issues and the increase in cognitive decline is exploding! Hopefully this will wind down some, but currently we are faced with this and have to do the best we can to ensure the LOs are cared for properly.
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Reply to disgustedtoo

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