Coordinating Home Care for the Frail Aged takes Persistence

It is axiomatic that aged individuals would prefer to remain in the comfort of their familiar surroundings rather than finish their lives in an institutional setting. This is the case whether the person lives in a mansion or a little apartment, in a house with their beloved  front porch or a home with their comforting tiny living room or sunny little back yard. Federal initiatives exist that are intended to promote aging-in-place initiatives. Communities and nonprofits have created transportation assistance, meals on wheels, and related services to assist people to remain in their homes as long as possible. Accomplishing this is not necessarily an easy task, and requires tremendous supports and personnel.

Arranging for care at home becomes even harder as the person’s medical condition becomes more complex and more fragile. The patient needs someone needs to coordinate their doctors’ house calls, their medication refills, the grocery shopping and the comings and goings of home health aides who provide the daily hands-on care. Skilled nursing oversight of the home health aides may be necessary to maintain a level state of health and prevent medical emergencies that lead to the traumatic, disruptive loop of hospitalizations and skilled nursing or therapeutic rehabilitation.

An array of skilled services can be provided in the home through Medicare for a home-bound patient, but full-time home health aide services (sometimes called “custodial care”) are not covered services under Medicare. Health insurance policies generally do not cover such services either. Unless the patient has long-term care insurance, that leaves private payment or Medicaid. The cost to pay for in-home 24/7 care in New Jersey typically ranges from $4,000 a month to as much as $7,000 through licensed, bonded agencies with nursing supervision. According to the 2012 annual report of the Employee Benefit Research Institute (EBRI), people over age 65 only had an average of $56,000 in savings. This isn’t even enough for one year of round-the-clock care in the home.

That leaves Medicaid. In NJ the program has been called Global Options and will now be called the Home and Community-Based Services (HCBSS) portion of the Medicaid Long Term Services and Supports (MLTSS). Under the best of circumstances in the past, a participant could only receive 40 hours of home nurses’ aides services a week. It is unknown just what will occur under the new paradigm of HCBS/MLTSS which will be run through managed care companies. While the program is geared to support individuals outside of a nursing home setting, the individual participants have to need the same level of care as a nursing home resident. This is sometimes called “meeting an institutional level of care.” Thus the person living at home needs 24/7 support with their Activities of Daily Living (ADL’s), but the Medicaid program will not be providing 24/7 support. The person who is coordinating all of this for the frail aged person will need to look vigorously for ways to supplement the limited services available through Medicaid if they want to keep the elder at home.

The NY Times recently reported on a dreadful situation that occurred with a frail 91-year old gentleman in New York City who had a very high level of need for nursing care, but could not receive the services necessary in a home care setting. He was shuttled between hospitals and skilled nursing facilities, and was dropped from home care services by Medicaid managed care companies. His daughter had to be vigorously involved in every step of navigating these various systems.

Vigorous, persistent advocacy is needed to obtain the services needed for a good in-home care plan. As the state rolls out its new program, watch the state DMAHS website to see if there is guidance on just what a patient may be entitled to if they want to remain at home.

For federal statistics concerning aging in America, take a look at

AOA Aging Statisticsv

For legal advice and representation on Medicaid and home care for the elderly and disabled, call 732-382-6070

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