When an individual enters the final stage of life, there are many questions that must be answered.
1. Can the individual continue to live at home?
- What level of care (i.e., skilled, unskilled or a combination of both) will be needed?
- How much care will be needed (part time or full time)?
- Who will provide the care?
- What will care cost?
2. If adequate care cannot be provided in the home, what are the options?
3. What will the options in #2 cost?
Let’s look at each of these questions.
1. Care in the home setting. Can the individual continue to live at home?
The hospice RN Case Manager, Medical Director and the individual’s primary physician, if he/she has one, will assess the individual’s condition and provide advice on the level and amount of care that will be needed.
In the hospice environment, primary companion/sitter care normally is provided by a family member or another caregiver who may be a spouse, significant other, partner or a friend. The vast majority of hospice clients we serve are cared for in this manner.
Please remember that the Medicare Hospice Benefit does not include continuing client care such as companion care, sitters, attendants or homemakers.
In some instances, the client or family may need or choose to supplement care through one of the following options.
- If your loved one is eligible for Medicaid assistance, Medicaid does have a Community Based Alternatives (CBA) program that provides care at no charge. Please see our discussion about Medicaid for more information.
- Private insurance companies may provide some coverage for these services, but you will need to discuss your coverage with your insurance company.
- If private insurance coverage is not available, then private care is still an option, but the client or family will be responsible for the costs incurred to employ private caregivers.
The cost will depend on the amount of private care that the client or family may elect to use, since all other services, drugs, medical supplies and medical equipment are provided by Medicare through the hospice agency.
Private duty, unskilled caregivers, home companions, attendants and sitters are available from home care staffing agencies. Most hospice agencies will have a list of these agencies.
Agencies normally will certify that they have reviewed their employees’ work histories, references and civil/criminal histories. Agency employees typically have been given drug tests and will be bonded or the agency will have professional liability insurance coverage. You will want to confirm this with the agency.
Most agencies will offer rate options, including discounts if the caregiver is hired for longer periods of time. The following are representative agency rates for home health aide caregivers.
Period of Care
Range of Rates in Collin, Denton & Dallas Counties
|hourly (with a 3 hour minimum)
$18 - $20
|hourly overnight (10 hour shift)
$15 - $18
|hourly for live-in (24 hour shift)
$9.50 - $10
* Note that some agencies also charge mileage, typically in the range of $0.50 per mile.
These rates and the rates for other periods of time are subject to negotiation depending on length of service (e.g., weekly or monthly) and level of care required.
Most hospice agencies also know private duty caregivers who may work for less than agency rates. Typically you can expect to pay a private caregiver 15% to 25% less per hour depending on the number of hours you wish the caregiver to work. These rates are negotiable since the private caregiver does not have to follow an agency rate sheet or pay a fee to a staffing agency.
Hospice agencies are aware of the quality of such caregivers’ work because these caregivers have worked for clients who are, or have been, clients of the hospice agency. However, such caregivers will not be affiliated with a staffing agency or the hospice agency. The hospice agency will provide no guarantees or accept responsibility of any kind regarding their work or reliability. The client/family will have the sole responsibility of completing any due diligence they may desire to determine if they wish to hire such caregivers.
In some cases, the client’s condition ultimately may require a level of care or an amount of care that the caregiver and family cannot provide. If the client, family and/or client’s representative determine the client can no longer be cared for at home, then the options described below should be considered.
2. If adequate care cannot be provided in the home, what are the options?
We have listed these options in their order of availability and, in our humble opinion, desirability.
Residential Assisted Living Homes (Group Homes)
Residential assisted living homes are an entirely different approach to long term client care. These homes are a relatively new concept in elder care and hospice care, although they are rapidly gaining popularity as more people learn about them.
These homes are not owned by companies. In almost every case, they are owned by one or two individuals who, while using them to help make their living, maintain a deep commitment and abiding interest in providing a service to those in the community who need it. In many cases, owners also work in healthcare and have an intimate understanding and belief in client care.
These homes typically house 3 to 8 residents depending on the size of the home. They provide the atmosphere and care we believe support the essential concepts of excellent hospice care.
They provide a strong sense of a home-like atmosphere that promotes the residents’ personal comfort, physical and emotional well being, dignity and the feeling of being in a close knit family. They also provide more personalized care based on the caregivers’ more intimate knowledge of the resident.
Residential assisted living homes are located throughout the North Texas area. In fact, you may have one in your neighborhood and not even realize it.
These homes are no different than yours except for the fact that their interiors have been modified to accommodate residents with disabilities. Doorways have been widened, railings have been added to bathrooms and other modifications have been made to ensure resident safety and ease of access. Residents rarely leave the home and you seldom notice any activity around the home that is any different than that around your own home.
When you walk into a residential assisted living home, it will look exactly like your own home. It will have either residential style carpeting or hardwood floors. Each resident has his/her own room, almost always with its own bathroom. Some homes have a few semi-private rooms or rooms that share a bathroom, but private rooms with private bathrooms are the normal configuration.
All residents have access to all of the common areas of the home just as they would in their own homes and are able to live just as they would in their own homes. Residents are encouraged to add their own furniture, photographs and keepsakes to make this home THEIR home.
Caregivers stay in the home around the clock to attend to the residents. Caregiver-resident ratios are typically no more than 4 or 5 to one to ensure that each resident receives proper attention and care. All aspects of care are provided, including helping with the activities of daily living, ensuring that medication schedules are maintained, preparation of meals and maintaining a clean and safe environment.
Since there are far fewer residents in these homes than in nursing homes, the caregiver staffs are much smaller. Staff members typically live in the home for one or two weeks at a time rather than the three shift operations used in most skilled nursing facilities. As a result, the caregivers get to know clients intimately, including their likes, dislikes and preferences. This promotes a more family oriented and caring atmosphere for the resident.
The Texas Organization of Residential Care Homes (TORCH) at www.txtorch.com is a good source of information on residential assisted living homes. You may also want to visit the Texas Department of Disability and Aging website for their list of long term care facilities. Their lists include both skilled nursing facilities and residential assisted living homes. This website provides a brief description of each facility and also displays the results of annual inspections made by the State.
Most homes will be licensed by the State. However, there are many wonderful unlicensed homes as well. Homes having three or less residents do not have to be licensed and licensing, or the lack of a license, does not represent a statement about the quality of the home or its services. We have clients in a number of unlicensed homes. The care and atmosphere they provide meets, and in some cases, exceeds the quality of licensed homes.
As with all aspects of finding care for your loved one, you must conduct your own due diligence to ensure the venue you select provides the best possible care and surroundings. You may want to consider using the questions we list in the “Nursing Homes” section as you search for care for your loved one.
Unfortunately, there are extremely few such facilities in North Texas. Typically, they have long waiting lists, essentially removing them as a helpful option.
Also, please remember Medicare does NOT pay for room and board in hospice facilities. This will ALWAYS be a private pay issue unless you have private insurance that covers this cost.
While we don’t wish to generalize about nursing homes, we believe our following comments are fair characterizations of these facilities.
Nursing homes care for large numbers of residents. Because they must operate as safely and efficiently as possible, they typically have the look and feel of a “facility” rather than a home environment. Most have a basic configuration of a ten to twenty semi-private or private rooms on a long hallway in one or more wings of a facility.
Residents pass the time either in their rooms or in a lounge-type common area typically located on the same floor. They receive their meals in a common dining area that may be on a different floor. While clients usually have the ability to add items from home and arrange their rooms to provide more homelike surroundings, the rooms will still closely resemble a standard hospital room. The floors will be covered either with industrial carpeting or have non-slip linoleum/vinyl type flooring coverings to help the nursing home staff maintain cleanliness and resident safety.
Nursing homes do not typically provide the feelings of security, comfort, familiarity and general “hominess” that clients associate with their own homes. Because the caregiver staffs work on a two or three shift basis, many different people may be involved with client care, making continuity of care and personalized care more difficult.
Also, nursing homes by necessity work on relatively rigid schedules to ensure everyone receives the daily care required. This means the residents have to live on the facility’s schedule and not their own. This works against the hospice philosophy of retaining control of your own life and your own schedule.
If you’re looking for a nursing home, here are some ideas to consider.
Do Preliminary Research
Go to http://www.oag.state.tx.us/elder/select.shtml, which is the Texas Attorney General’s website, to understand the State’s perspective about nursing homes.
Look. What choices are available in your area?
- What’s important to you and your loved one………nursing care, meals, a religious connection, hospice care or perhaps a Special Care Unit for Alzheimer’s/dementia care.
- You should look for a nursing home that is conveniently located near your home. You will want to visit your loved ones frequently to give them the assurance you still love them and they are not forgotten. Not only that, but letting the nurses and administrators see you often will minimize the possibility of unsatisfactory care for your loved one.
Talk with friends, relatives, social workers, religious groups and hospice agencies to find out what places they suggest. Ask doctors which nursing homes they feel provide good care.
Develop a preliminary list of potentially acceptable facilities.
Visit the Texas Department of Aging and Disability website to begin the process of removing undesirable facilities from your list.
As the first paragraph on this website indicates, “The Department of Aging and Disability Services (DADS) offers the information in this website to help you evaluate the quality of long term care services. You can use Long Term Care Quality Reporting System (QRS) to obtain specific information about a particular long term care provider or to compare providers in a particular area. QRS provides information that can help you identify providers that may meet your family member's needs, but it is not meant to serve as the only basis for choosing a particular provider. “
Contact each facility on your list. Schedule meetings with the Administrator/ Director and the Nursing Director, plus a tour of the facility including the specific area where your loved one would be living. During this call, ask several qualifying questions in another effort to reduce the number of facilities on your list.
- Is the facility licensed by the State and certified by Medicare (or Medicaid), if that is one of your criteria?
- How many residents live there?
- What is the maximum capacity of the facility?
- What is the monthly cost? Is this cost all-inclusive or are there other fees, deposits or costs of any kind?
- What are the visitation rules? Can family members visit whenever they wish?
- Is there a waiting list? If so, what is the estimated time for the next opening?
- Does the facility allow its residents to use the hospice agency of their choice or does it require residents to choose from a list of agencies it has selected?
By Federal regulation (Code of Federal Regulations; Title 42, Section 418.24) residents having Medicare and/or Medicaid coverage have the right to pick the specific hospice agency of their choice.
However, if a facility does not choose to enter into a working agreement with the hospice of your choice, you will not be able to use that hospice. The facility will inform you that you may either use a hospice on their “approved” list or move to a facility that will allow you to use your chosen hospice.
Depending upon how strongly you feel about using your chosen hospice, you may want to remove the facility from your list. You may also want to ask them what criteria they use to allow certain hospices access while denying access to other Medicare/Medicaid certified and State licensed hospices.
(We say this because Medicare is currently conducting an ongoing investigation of nursing homes, hospice agencies, their owners and medical directors for possible inappropriate relationships and client referral activities.)
- How long have the Administrator/Director and other department heads (nursing, food, and social services) worked at the facility. If the key staff has changed often or is inexperienced, quality of care potentially could become an issue.
Don’t be afraid or embarrassed to ask questions during your meetings with the staff and while on the facility tour, since you will be paying them for the care they provide to your loved one. At this point you want to understand and develop a comfort level about the facility and its staff. The issues you want to understand include:
- Staff qualifications. You shouldn’t simply look for a licensed nursing home. The nurses who will be caring for your loved one must also be licensed by the State. It’s also good to verify that several on staff are trained for emergency care and critical care as well as for natural disasters or other tragic events.
Consider asking these questions.
- What is your staff turnover rate among your RNs? Home Health Aides?
Although your loved one may not need a great deal of care of attention at the moment, this will probably change in the future as he/she gets older. Staff turnover is important since changes in caregivers can be frustrating and unsettling for older residents. Also, short term staff may also have less commitment and attachment to individual residents.
- What is your ratio of staff to residents on each shift? RNs? LVNs/LPNs? Home Health Aides?
As a general rule a staff ratio of 1:8 or less should be the maximum you should consider for every shift.
- What is the experience level of the specific staff members who will be caring for my loved one on each shift?
- Can I interview the specific staff members who will be caring for my loved one?
- Can I speak with current residents and/or family members of current residents as references for the facility?
- Do the staff members who will be providing direct care have experience caring for residents with the same illness/condition/disease?
- Respectful staff. Even though the staff may be very professional and highly experienced, the way they interact with residents should be scrutinized closely. Don’t ever leave your loved one with people who don’t respect him/her. Before you choose a nursing home, as part of your inspection visit, note how residents are being treated and whether residents appear to be happy and content.
If possible, talk to relatives of other residents to better understand the environment provided for residents. This is particularly important. If residents and/or their families don’t have positive things to say about the facility, chances are your loved one will not be happy there.
- Cheerful environment. We don’t want to place our loved ones in a sad, dreary place. What we want is for them to enjoy the remaining years of their life in the comfort of a safe and happy environment full of good people. A cheerful environment will at least guarantee that the nursing home won’t be boring. Find out what activities they have for the clients. Do they have organized games and other entertainment to make living there more enjoyable?
- Fully furnished rooms. The rooms need not look like 5-star hotel rooms. However, they should be comfortable, have proper ventilation and a “homey” feel.
Also, can residents furnish their own rooms and bring their own belongings with them? For many people this can make an enormous difference to their emotional well being. Most people like to have their own belongings, including photos, keepsakes and favorite items of furniture around them so they feel more at home.
- Layout: Small details like the layout of rooms where socializing is done can make a big difference. When tables and chairs are arranged in small groups rather than one large circle there generally will be more interaction among the residents. There should also be staff available to help people who aren't mobile to move from group to group so that they can socialize as they wish.
- Complete safety features. You should see adequate handicap access throughout the facility. Smoke alarms should be installed in every room, including the bathroom and common living areas. Many elders can no longer move very quickly so, if a fire should occur, they could have a hard time moving to safety.
Appropriately placed handrails are important since elders often have problems with balance. Conveniently placed call buttons are also a sign of a higher quality facility.
- An acceptable record. You should ask to review the results of public health inspections to determine whether there have been recent violations. You can also visit the Texas Department of Aging and Disability website, if you haven’t already done do to see the results of State inspections.
If violations have been noted, the problems should have already been resolved. If you see a record of reoccurring violations, you may want to remove the facility from your list.
- Stimulation: There is very good evidence that stimulation is vital to stop people deteriorating once they enter nursing homes. A lot of homes have very good success with activities programs for their residents. You should seek evidence that these activities are not only offered as described but that they actually take place. Most homes claim to offer such things but in practice some homes never actually conduct the activities that are scheduled.
- Menus and Food: Another quality of life issue. You should visit during meal times to observe the quality of food and food choices residents receive. Rather than relying on descriptions, you should observe and sample the quality of the food. Ensure that assistance is offered with eating to those people that need it.
- Resident Choices: Check whether residents with higher care needs go to bed at the same time. Are there set meal times? In other words are things run for the benefit of the residents or to make life easier for staff members? Despite their care needs, residents should, as far as humanly possible, be treated as capable adults and their wishes respected for how they wish to live their lives.
- Visit again. It is very important that you visit each facility you are considering one or more times without advance notice. Try another day of the week or time of day so you will meet other staff members and see other activities.
Once you have helped a loved one move into a nursing home, particularly a Medicaid funded nursing home, you need to continue your inspection and evaluation of the facility on each of your visits. Generally speaking, the monthly rates at Medicaid facilities are lower than other skilled nursing facilities, which means less money is available for payrolls and the other expenses associated with operating such a facility. This can sometimes result in situations where resident care is potentially compromised.
You should also ask family members, and perhaps even close friends, to help with this ongoing inspection and evaluation process when they visit.
Be sure to report any observations or concerns immediately to the attention of Director of Nursing and/or appropriate nursing staff, if you feel that your loved one’s health is at risk. Contact the Director/ Administrator, if you don’t receive a satisfactory response to your concerns in a reasonable amount of time.
Note that the facility is not required to respond directly to anyone who doesn’t officially represent the resident. Most communication will have to come from the resident, the resident’s medical representative (who has been identified in a document signed by the resident or the resident’s power of attorney) or the person legally authorized to be the resident’s power of attorney.
When visiting, consider these items.
- Ask to see the plan of care to determine the amount, level and frequency of care your loved one is scheduled to receive. Review it carefully, ask for your own copy and ask to have it revised if it is not addressing all needs.
- Monitor during your visits that the staff is following the care plan. Ask the nursing aides actually providing care if they have seen the care plan and if it is reviewed with them regularly or when any changes are made.
- Visit at mealtimes to see if your loved one is eating well and receiving any necessary assistance from staff members.
- Watch for weight loss especially by inspecting upper arms and calves. Ask to have your loved one’s weight monitored weekly and review the results. Note and ask about any significant changes.
- Check to see if your love one is receiving enough liquids by looking for signs of dehydration. Even with the best of care, older people can become dehydrated very quickly and easily. Look at the lips and inside the mouth for signs of dryness. Check to see if liquids (water, juices, etc.) are accessible and readily available.
- If your loved one is at risk for pressure sores (also known as bedsores and decubitus ulcers) due to limited mobility, check to see if staff following preventive measures such as proper cushioning (egg crate or air mattress on beds and chairs) or padding of high risk areas (heel and elbow protectors) and frequent positional changes, especially when in bed or chair for long periods of time.
- Check for developing bedsores or any signs of skin breakdown. Inspect heels, elbows, sacral/coccyx area (above buttocks also known as tailbone), upper back, ear cartilage and any bony areas such as shoulder blades and base of neck. If you see any redness, press gently to see if the skin blanches or whitens. If the skin remains reddened, it may be start of a pressure sore that requires specific care. In this case, notify the staff so they may inspect more carefully for signs of potential skin breakdowns.
- Check for toileting problems such as onset of incontinence. Note whether staff is available to assist to bathroom when needed and on a regular basis. If adult diapers are used, determine whether usage is based on need or staff convenience. Check if diapers changed regularly by looking for reddened, irritated skin and rashes in diaper area.
- If getting physical therapy or any other special therapies, check to see if schedule is being followed. Attend a therapy session to observe what therapy is actually provided, how it is provided (gently or aggressively) and whether progress is noted over time.
- Check to see if staff members follow posted daily activities schedule and if your loved one is encouraged to participate and given necessary assistance in order to participate.
3. Costs of Nursing Homes and Residential Assisted Living Homes
Residential assisted living homes and nursing homes are private pay facilities, meaning the resident must pay a monthly fee to live there. The Medicare Hospice Benefit does NOT include a provision for paying the monthly room and board costs to live in these types of facilities.
Under certain conditions, Medicare does pay for stays in nursing homes, if the facilities are also certified rehabilitation facilities and the client enters the facility directly from the hospital for rehabilitation care. However, this is not, and should not be confused with, hospice care coverage under the Medicare Hospice Benefit.
Monthly costs in Medicaid nursing homes are paid either partially or completely by Medicaid, depending on the Medicaid recipient’s financial situation. Please see our discussion of Medicaid for more information.
Veterans should be aware that the Veterans Administration does have certain benefits that may apply to provide payment for some or all of such monthly expenses. Veterans should contact the Veterans Administration for more information.
Let’s look at the typical cost structure of residential assisted living homes and nursing homes in the North Texas area.
Residential Assisted Living Homes
- Semi-private rooms
Semi-private rooms are not typically offered in these facilities. However, you should ask the homes you are considering about the availability and cost of semi-private rooms. In the homes who do offer semi-private rooms, the published rates can run from $1,800 to $2,500, depending of level of care required, the size of the home and the size of the bedroom occupied. Rates include room, board and around the clock care.
- Private rooms
Published rates typically run from $3,500 to $4,500 per month, depending of level of care required, the size of the home and the size of the bedroom occupied. This rate includes room, board and around the clock care.
- Note that rates are somewhat negotiable and you should discuss care requirements, costs and payment terms prior to signing an agreement. In particular, you should ask if there are any costs or fees other than the monthly rate and if a refund is provided for a partial month of residency.
- Nursing home monthly rates, including fees and optional services, will be in these approximate ranges depending on the level of care required, the facility’s size and its environment (in other words, how “upscale” it is).
- Semi-private rooms - $4,500 to $5,000
- Private rooms - $5,500 to $6,000 (up to $8,000 for luxury facilities)
Medicaid nursing home rates
- Semi-private rooms - $3,000 to $3,500
- Private rooms - Medicaid facilities normally place Medicaid funded residents in semi-private rooms.
Note the rate difference between Medicaid funded and private nursing homes. We will leave it to you to make a judgment about the potential quality and extent of care residents receive in nursing homes that receive roughly $1,500/month less than other nursing homes. Please see our page on “Hospice Benefit Providers” for more information on Medicaid and Medicaid funded nursing homes.
So, where is the best place for a hospice client to be……..at home, in a residential assisted living home or in a nursing home?
Only the client or the client’s representative and family can make this decision......this choice.
However, if your choice narrows down to a nursing home or a residential assisted living home, the best way to evaluate the difference between them is simply to visit several of each type. The differences between them will be immediately obvious and will allow you to make an informed decision that is in the best interests of your loved one.
Autumn Journey Hospice
5347 Spring Valley Road
Dallas, TX 75254