by Ann M. Colford

Spokane has long been touted as a preferred place for retirement. But what happens when caring for an aging loved one begins to overwhelm an individual and his or her family? Is the Inland Northwest a good location for quality long-term care?

No one likes to think about dealing with seriously disabling conditions, but experts advise all of us to plan ahead and anticipate the possibility of needing long-term care. Just what kind of long-term care choices are available to an individual depends a great deal on that person's resources, both financial and familial. People with a supportive family and adequate capital have a full range of options available to them, so the issue becomes one of maintaining control over one's life, according to Jeff Bair, executive director of the Waterford on South Hill Retirement Community.

"Many of our residents are forward-thinking folks, where independence is the key to how they live their lives," he says. "We advise people to make decisions up front rather than in a time of crisis."

The Waterford is a continuing care retirement community, meaning that various services and types of living environments are available within its campus-like grounds. "Every community has its own personality," Bair explains. "Our community is made up of residents, homes, shops and workers of all types. It's like a microcosm of a small town."

The Waterford has separate cottage homes around the campus, along with apartment-style independent-living homes in the main building. Bair says most of the people living in these homes lead very independent lifestyles within the broader community. A small number of assisted-living homes are available within the main building, Bair says. "These are just like the independent living homes, but the residents can get some help with their needs, like taking medications, bathing and meals."

In addition, the Waterford offers a memory care center for those with memory-related issues, along with a complete skilled nursing area for residents requiring more extensive daily medical needs, whether on a short-term or long-term basis. It's this full range of services and levels of care that makes the continuing-care communities so valuable.

"We have people move in here early in their retirement phase, but they like to know that the health care is here," explains Bair. "Many know that as they age they may need some health care support, so they are planning ahead."

Planning ahead is the key, says Bair, not just to maintaining control of one's own life, but to avoid later headaches and heartaches for one's family. "It can be a daunting responsibility to look through the options, look at the personal resources, and take on the responsibility of making choices for someone else," he says. Still, he sees Spokane's long-term care market as strong and diverse. "For a city of this size, the consumer has a lot of choices. There are many options out there for folks. There's such a variety in providers that there will be all different levels for people who can pay privately."

Full-spectrum retirement communities are not the only options, of course. Home health agencies and private individuals can deliver services ranging from chore services to round-the-clock nursing care within an individual's home, if staying at home is desired and feasible. Many times, however, all of the caregiving duties fall upon a spouse or adult child. Adult day care facilities can provide a few hours of respite a day for caregivers, but often families must face the wrenching decision to move a loved one into a residential setting.

Joel Loiacono, executive director of the Inland Northwest chapter of the Alzheimer's Association, says residential care is frequently necessary for the health of the caregiver, especially when dealing with Alzheimer's or other forms of progressive dementia.

"The home is the best environment, but at some point in the disease process, many people have to go into residential care," he says. "You need a lot of support systems for Alzheimer's, and often a caregiver is all alone. We often lose home caregivers first, due to the stress of care." Loiacono hopes family caregivers will take their own needs into account and look at residential care without guilt. "The old stereotype of long-term care facilities as warehouses for the dying has pretty much disappeared," he says. "A lot of places are like homes now, but with staff on hand 24 hours a day."

The type of residential facility that's appropriate in a given situation will vary according to the level of care required by the individual. Residential facilities in Washington are licensed by the Department of Social and Health Services (DSHS) in several categories. Assisted Living facilities are generally private apartments with additional services: meals, personal care, medication assistance, limited supervision, organized activities and limited nursing services. Facilities are staffed around the clock, and help is always available. In an Adult Residential Care facility, a resident has a room rather than a separate apartment, and the services are similar to assisted living. Some assisted living and adult residential care facilities have special dementia units geared toward those with Alzheimer's and other conditions affecting memory. These units provide the additional supervision and attention that dementia patients demand.

Another care option that's available in Washington is the Adult Family Home, or AFH. These homes are licensed to care for up to six residents. They provide room, board, laundry, necessary supervision, assistance with activities of daily living, personal care and social services. Most adult family homes have 24-hour staffing. Some homes are licensed to provide nursing services, as well, which allows a resident to remain in the same familiar place as his or her care needs change. Adult family homes provide a comfortable home-like environment, but homes tend to specialize in one or a few conditions -- dementia, mental illness, elderly, developmental disabilities -- so it's necessary to do some research to find the right fit.

The highest level of care available is a Skilled Nursing Facility, or nursing home. Nursing homes provide full 24-hour supervised nursing care, along with personal care, therapy, supervised nutrition, organized activities, social services, room, board and laundry. Nursing home residents generally are more fragile and need more specialized or complex nursing care; some stay for just a short time, while recuperating from a hospital stay and then more on to a lesser level of care when they are able.

The monthly fees at residential facilities will vary, depending on the type of facility and the level of care, but rates of $2,500 to $4,000 per month are not unusual. Those without the financial resources to cover this kind of outlay must rely on the state's Medicaid system, a joint federal-state program administered in Washington by DSHS.

Christine Faber is the Deputy Regional Administrator of Home and Community Services, a division of the Aging and Adult Services Administration (AASA) within DSHS and the office that handles adult residential placement in this area.

"Our goal, first and foremost, is to offer the best long-term care to meet people's choices," Faber says. Her office handles community-based services, as well, she says, "for those who choose to and are able to stay in their own homes."

For the past decade, the state's emphasis has been on in-home care; a growing percentage of AASA dollars now goes toward community-based services that help maintain clients in their own homes. Research has shown that the cost of providing services in a client's home is far lower than the cost of patient care in a nursing home, and most clients and families would prefer to continue in-home care for as long as possible. According to Faber, clients receiving in-home care account for 52 percent of the average monthly caseload at AASA for the current biennium, but the cost of their care only adds up to 25 percent of the agency's budget. By comparison, while only 28 percent of AASA clients reside in nursing facilities, their care claims 48 percent of the budget.

In Spokane, many of the community-based services are administered by Elder Services, a division of Spokane Mental Health. A spokesperson for Elder Services says, "Our first goal is to look at every way to keep the person at home. If a home caregiver is involved, we would explore options like respite care and increased hours. If the family or the client then decides on a higher level of care, we would assess the need and direct them toward assisted living, an adult family home, or a nursing home."

To qualify for Medicaid long-term care services, an individual must meet both financial and functional eligibility requirements, Faber says. "The financial guidelines vary depending on the person's status and the program," she says. "In addition, the person must have medical or functional needs that need to be addressed."

The first step, then, for a Medicaid-funded residential placement is to submit a financial application with Home and Community Services. Next, a level-of-care assessment is required to determine the person's functional needs. This assessment is done by either a social worker or a nurse and will determine what type of program or facility the individual is eligible to enter. Once eligibility has been established, then it's time to find a vacancy in an appropriate facility.

"Typically, if there's family involved, then the choice of facility is the choice of the family or client, but we can give you ideas of where to look." One source of information is the agency's Web site, which allows anyone to search for licensed facilities by type, location, and specialty. Because of the steps involved, Faber recommends starting the eligibility process as soon as you suspect that services may be needed in the future. An attorney who specializes in elder law may be able to assist in pre-eligibility planning.

Despite the difficulties -- both logistical and emotional -- inherent in finding long-term care, the consensus is that the Spokane area offers a wide array of quality choices. Now, the experts say, the goal is to keep the options there and improve on them. Faber says, "Washington state has one of the best ratings in the country for long-term care. Our state made a commitment to caring for our elders a number of years ago. We're aware of complaints from providers that the Medicaid funding isn't enough to cover costs, so we're collecting information to take to the legislature to look at appropriate pay levels."

Joel Loiacono of the Alzheimer's Association says, "We expect facilities to provide trained staff and a homelike environment, yet the Medicaid funding for adult family homes and boarding homes [Adult Residential Care facilities] isn't adequate." Low Medicaid reimbursement rates for facilities could translate into more limited choices in the future, he adds. "Without the funding, you narrow your options."

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