Residential vs. Community Options
There are a variety of residential programs in New York State designed to care for seniors and individuals with disabilities of all ages who for many different reasons are no longer able to live safely in private residences in the community. All of these programs offer varying degrees of assistance with activities of daily living, meals and sometimes health-related services.
A variety of programs are designed to help older adults remain in their own homes and/or help family members in coping with their relative’s chronic illness or disabilities. These services may be needed on short term or long term basis. While many types of home and community-based services exist for older adults, not all are available in every community.
Other in-home and community services include home care, adult day services (which include social adult day care and adult day health care), hospice care, respite care, home-delivered meals and senior centers.
Medicare, Medicaid and private insurance coverage of the different service options varies greatly. See Covering Costs of Care for more information.
There are a variety of residential programs in New York State designed to care for seniors and individuals with disabilities of all ages who for many different reasons are no longer able to live safely in private residences in the community. All of these programs offer varying degrees of assistance with activities of daily living, meals and sometimes health-related services.
A variety of programs are designed to help older adults remain in their own homes and/or help family members in coping with their relative’s chronic illness or disabilities. These services may be needed on short term or long term basis. While many types of home and community-based services exist for older adults, not all are available in every community.
Other in-home and community services include home care, adult day services (which include social adult day care and adult day health care), hospice care, respite care, home-delivered meals and senior centers.
Medicare, Medicaid and private insurance coverage of the different service options varies greatly. See Covering Costs of Care for more information.
Nursing Homes
A nursing home, also known as a skilled nursing facility, provides 24-hour medical, nursing and other services to frail elderly individuals and persons of all ages with disabilities. These facilities are licensed by the New York State Department of Health (DOH). A nursing home offers a protective, therapeutic environment for those who need rehabilitative care or can no longer live independently because of chronic physical or mental conditions that require 24-hour a day care.
Nursing homes are the most intensive and, therefore, often the most expensive level of long term care aimed at serving people who need high-intensity nursing care and supervision.
What are patient assessments and why are they important?
Before being admitted into a nursing home, the prospective resident must undergo a screening process to determine if a lower level of care would be more suitable for him/her. The screening process begins with a health care professional completing a patient review instrument (PRI). The PRI is used to assess the applicant’s ability to complete “activities of daily living” such as walking, bathing and using the toilet, as well as clinical conditions and the need for specialized services. This health assessment helps to identify physical, medical, social and psychological issues the applicant faces.
If the person is in the hospital and is being transferred directly to a nursing home, hospital social services or discharge planning staff will assist in completing the PRI and the screening process to determine whether nursing home placement is appropriate. If the person is at home or in a community-based program, a certified home health agency should be contacted to complete the PRI. Under these circumstances, a home visit is usually necessary. It is important to give the evaluator honest, accurate and complete information during this visit.
If the individual is a Medicaid beneficiary and is enrolled in a Medicaid managed care plan (see more information on managed care below), the plan will be involved in the administration of the assessment process.
Once accepted for nursing home placement, the person will also undergo a much more extensive assessment process within the nursing home using a form called the minimum data set (MDS). The MDS comprehensively reviews the person’s history and needs. It is a key part of the resident’s overall assessment and is used to develop and maintain an individualized care plan.
Services Available
A nursing home offers a full array of personal, dietary, therapeutic, medical, rehabilitative, social, spiritual, recreational, housekeeping and nursing services. Residents are involved in decisions about their care and receive services based on their individual needs. While many residents need care for extended periods due to chronic illness, a growing number of other patients enter a nursing home for a short stay for restorative therapy services. This may be after surgery or an accident, or to recuperate from a serious illness before returning home.
Living Arrangements: Living arrangements will vary depending upon the facility. Semi-private or private rooms are available with private or shared baths.
Payment
Often, a resident enters a nursing home and initially pays with his or her own money. When that money is mostly exhausted (also known as “spend-down”), the individual can apply to Medicaid for coverage. Spend-down laws allow the non-institutionalized spouse to keep a house, a car and a reasonable amount of assets. Spouses no longer need to “impoverish” themselves by spending down all their money in order to obtain Medicaid funding. Since these laws are complicated and subject to change, LeadingAge New York suggests discussing them with the admitting facility or the local department of social services. The local department of social services can also advise the individual with regard to the requirement, if any, to enroll in a Medicaid managed care plan.
Questions
• When deciding on a nursing home for services, consider asking the following questions:
• Is the nursing home well maintained, pleasing and cheerful?
• Does the staff seem friendly, caring and accommodating to residents and visitors?
• Do the residents appear comfortable, well-groomed and involved in meaningful activities?
• Does the facility conduct resident and staff satisfaction surveys and if so, is this information available for review?
• What are the findings from the most recent state inspection, and can I discuss them with a representative from the facility?
• Are amenities such as private rooms, cable service for individual televisions, and private telephones available? At what cost?
• What activity programs and special events are held at the facility or off-site?
• What religious/spiritual programs are offered?
• How many physicians are on staff? Do you have a choice between the facility’s staff physician and your personal physician?
• Does the facility have staff providing occupational, physical and speech therapy?
• Should hospitalization become necessary, which hospital does the facility use?
• How many residents are under the care of one nurse aide on the day shift? What staff coverage is available on evenings, nights and weekends?
• Who coordinates admissions? How are the rooms assigned? Is there an orientation for new residents?
• Is there a family council to provide input into the kinds of programs and problems the facility may have? How often does the residents’ council meet?
• What may residents bring with them? Is there room for a favorite chair, photographs and wall hangings?
A nursing home, also known as a skilled nursing facility, provides 24-hour medical, nursing and other services to frail elderly individuals and persons of all ages with disabilities. These facilities are licensed by the New York State Department of Health (DOH). A nursing home offers a protective, therapeutic environment for those who need rehabilitative care or can no longer live independently because of chronic physical or mental conditions that require 24-hour a day care.
Nursing homes are the most intensive and, therefore, often the most expensive level of long term care aimed at serving people who need high-intensity nursing care and supervision.
What are patient assessments and why are they important?
Before being admitted into a nursing home, the prospective resident must undergo a screening process to determine if a lower level of care would be more suitable for him/her. The screening process begins with a health care professional completing a patient review instrument (PRI). The PRI is used to assess the applicant’s ability to complete “activities of daily living” such as walking, bathing and using the toilet, as well as clinical conditions and the need for specialized services. This health assessment helps to identify physical, medical, social and psychological issues the applicant faces.
If the person is in the hospital and is being transferred directly to a nursing home, hospital social services or discharge planning staff will assist in completing the PRI and the screening process to determine whether nursing home placement is appropriate. If the person is at home or in a community-based program, a certified home health agency should be contacted to complete the PRI. Under these circumstances, a home visit is usually necessary. It is important to give the evaluator honest, accurate and complete information during this visit.
If the individual is a Medicaid beneficiary and is enrolled in a Medicaid managed care plan (see more information on managed care below), the plan will be involved in the administration of the assessment process.
Once accepted for nursing home placement, the person will also undergo a much more extensive assessment process within the nursing home using a form called the minimum data set (MDS). The MDS comprehensively reviews the person’s history and needs. It is a key part of the resident’s overall assessment and is used to develop and maintain an individualized care plan.
Services Available
A nursing home offers a full array of personal, dietary, therapeutic, medical, rehabilitative, social, spiritual, recreational, housekeeping and nursing services. Residents are involved in decisions about their care and receive services based on their individual needs. While many residents need care for extended periods due to chronic illness, a growing number of other patients enter a nursing home for a short stay for restorative therapy services. This may be after surgery or an accident, or to recuperate from a serious illness before returning home.
Living Arrangements: Living arrangements will vary depending upon the facility. Semi-private or private rooms are available with private or shared baths.
Payment
Often, a resident enters a nursing home and initially pays with his or her own money. When that money is mostly exhausted (also known as “spend-down”), the individual can apply to Medicaid for coverage. Spend-down laws allow the non-institutionalized spouse to keep a house, a car and a reasonable amount of assets. Spouses no longer need to “impoverish” themselves by spending down all their money in order to obtain Medicaid funding. Since these laws are complicated and subject to change, LeadingAge New York suggests discussing them with the admitting facility or the local department of social services. The local department of social services can also advise the individual with regard to the requirement, if any, to enroll in a Medicaid managed care plan.
Questions
• When deciding on a nursing home for services, consider asking the following questions:
• Is the nursing home well maintained, pleasing and cheerful?
• Does the staff seem friendly, caring and accommodating to residents and visitors?
• Do the residents appear comfortable, well-groomed and involved in meaningful activities?
• Does the facility conduct resident and staff satisfaction surveys and if so, is this information available for review?
• What are the findings from the most recent state inspection, and can I discuss them with a representative from the facility?
• Are amenities such as private rooms, cable service for individual televisions, and private telephones available? At what cost?
• What activity programs and special events are held at the facility or off-site?
• What religious/spiritual programs are offered?
• How many physicians are on staff? Do you have a choice between the facility’s staff physician and your personal physician?
• Does the facility have staff providing occupational, physical and speech therapy?
• Should hospitalization become necessary, which hospital does the facility use?
• How many residents are under the care of one nurse aide on the day shift? What staff coverage is available on evenings, nights and weekends?
• Who coordinates admissions? How are the rooms assigned? Is there an orientation for new residents?
• Is there a family council to provide input into the kinds of programs and problems the facility may have? How often does the residents’ council meet?
• What may residents bring with them? Is there room for a favorite chair, photographs and wall hangings?
Assisted Living and Adult Care Facilities
Assisted Living and Adult Care Facilities (ACFs) serve individuals who cannot or do not want to remain at home, and do not need continuous nursing care as would be provided in a nursing home. These facilities provide assistance, while emphasizing the resident’s autonomy and independence. It is not surprising that these options have become so popular since they offer “home-like” settings and can be less expensive than some alternatives. In addition to providing long term residential services, many assisted living facilities also allow short-term stays to give family caregivers a break, called “respite” care.
There are several categories of licensure within the umbrella terms of ACF and assisted living, and they all provide a similar package of services. Some have additional licensure or certification to provide specialized services or accept Medicaid. All are licensed and overseen by the New York State Department of Health (DOH).
Two types of ACFs that typically serve seniors are adult homes and enriched housing programs. Both provide assistance with activities of daily living, assistance with medication administration, monitoring, supervision, case management, activities, and housekeeping. The most significant difference is that enriched housing is more of an apartment model, with a kitchen. An adult home does not have a kitchen. Technically, the adult home has higher staffing requirements and must provide three meals a day, but the enriched housing model has evolved so that most operate much like adult homes, with the layout of the living space being the most significant difference. Either model may have shared or private rooms.
Services Available in All Adult Care Facilities
• Nutritious meals;
• Hospitality services including housekeeping, laundry and sometimes transportation;
• Case management;
• Monitoring and supervision;
• Activities and recreational opportunities;
• Personal care services, including help with grooming, dressing and bathing; and
• Medication assistance and supervision.
Some ACFs may have additional licensure, which is where the term “assisted living” comes in. There are two categories of licensure for assisted living in New York State – the Assisted Living Residence (ALR) and the Assisted Living Program (ALP). This additional licensure enables ACFs to build upon their existing services and provide specialized services, discussed below.
Assisted Living Residences
ALRs provide the same package of services that an ACF does, but are also held to some additional requirements. All ALRs have a specific individualized service plan for each resident and specific consumer disclosure statements about what services they offer and what these services cost. ALRs also have a specific medical evaluation form which must be completed by a physician prior to admission.
Some ALRs are also approved by DOH to provide specialized services for people with Alzheimer’s disease or other cognitive impairments, and these are called Special Needs Assisted Living Residences (SNALRs). These facilities have specialized programming, services, staffing and environment designed for people with these special needs. It should be noted that people with dementia or Alzheimer’s disease can live in “basic” Assisted Living or even an ACF. SNALRs are for those who need a specialized environment to ensure their needs are met.
With additional certification, ALRs can provide or arrange for nursing care and other additional services in the facility as a resident’s needs increase, also known as “aging in place”. These added services can include things like getting help with walking up and down stairs, assistance with transferring, help with other activities of daily living and nursing services. ALRs approved by DOH to provide these services are called Enhanced Assisted Living Residences (EALRs). Most people who need 24-hour nursing or medical care will need a higher level of care, however. It is important to note that EALRs may designate some or all of their beds as enhanced. In addition, these facilities can determine what types of “enhanced” services they will provide, or what resident needs they will be able to meet. This is spelled out in the admission agreement, and the facility should be able to describe their services to an interested consumer.
Both Special Needs and Enhanced ALRs must meet specific safety and staffing requirements to become licensed, and must also provide the basic services outlined below under “Services Available in All Assisted Living Residences.” ALRs can be certified to provide special needs and/or enhanced services, or simply provide “basic” ALR services.
Assisted Living Program
The Assisted Living Program (ALP) is the only assisted living option in the state that can accept Medicaid as payment. That being said, ALPs also accept individuals who can pay out of their own funds.
The ALP allows a person living in an ACF to remain in that setting even if the person becomes more frail and needs extra medical or personal care services. Combining the services of an ACF and a home care agency, the ALP is similar to the Enhanced Assisted Living Residence, as it too is an “aging in place” model.
Payment for ACFs and Assisted Living
Medicare does not cover assisted living or adult care facility services. Currently, there are limited options for low-income individuals. In New York, only the Assisted Living Program (ALP) is covered by Medicaid. Some facilities accept Supplemental Security Income (SSI), but these facilities are dwindling in number since the SSI payment is well below what it actually costs a facility to care for residents. Some veterans or spouses of veterans may be eligible for certain benefits which can assist in paying for ACF or assisted living services. In addition, some long term care insurance policies will cover assisted living. These options should certainly be explored, though circumstances and policies will differ. Most often, residents and their families pay for assisted living out of their own funds. Facilities have different ways of charging for services, and any ACF or assisted living facility should be able to explain the system and what exactly it covers.
At present, Medicaid managed care does not cover assisted living services, but this will change as time goes on. Managed care may cover services provided to participants residing in assisted living or ACFs, such as home care. When this arrangement occurs, the facility will coordinate services with the managed care plan.
Questions
• When deciding on assisted living or ACF for services, consider asking the following questions:
• Is assisted living or an adult care facility appropriate, based on an assessment of the person’s physical, financial, mental and lifestyle needs? If needed, professional help is available to assist with this process. Ask your health care provider for information.
• What are the criteria for admission to the facility you are considering? How is the need for services determined?
• What services are included in the basic plan and what services are available for an additional fee?
• What is the dining environment like?
• What religious/spiritual programs are offered?
• Does the administrator seem to know the residents and interact with them?
• Are the staff friendly and professional?
• There are several different types of assisted living. If you have specialized needs, ask how the facility will make sure your needs are addressed.
• Can this facility meet your anticipated future needs? If you have a degenerative disease, for example, will you be able to stay or move on to another setting?
• What happens if you deplete your resources? Will you have to move to another facility?
• If you have long term care insurance, Medicaid, SSI and/or Veteran’s benefits, does the facility accept them for payment?
• What sort of relationships does the facility have with nursing homes, hospitals and home care agencies, should the resident need more or different care?
• Under what circumstances could a resident have to leave the facility?
Assisted Living and Adult Care Facilities (ACFs) serve individuals who cannot or do not want to remain at home, and do not need continuous nursing care as would be provided in a nursing home. These facilities provide assistance, while emphasizing the resident’s autonomy and independence. It is not surprising that these options have become so popular since they offer “home-like” settings and can be less expensive than some alternatives. In addition to providing long term residential services, many assisted living facilities also allow short-term stays to give family caregivers a break, called “respite” care.
There are several categories of licensure within the umbrella terms of ACF and assisted living, and they all provide a similar package of services. Some have additional licensure or certification to provide specialized services or accept Medicaid. All are licensed and overseen by the New York State Department of Health (DOH).
Two types of ACFs that typically serve seniors are adult homes and enriched housing programs. Both provide assistance with activities of daily living, assistance with medication administration, monitoring, supervision, case management, activities, and housekeeping. The most significant difference is that enriched housing is more of an apartment model, with a kitchen. An adult home does not have a kitchen. Technically, the adult home has higher staffing requirements and must provide three meals a day, but the enriched housing model has evolved so that most operate much like adult homes, with the layout of the living space being the most significant difference. Either model may have shared or private rooms.
Services Available in All Adult Care Facilities
• Nutritious meals;
• Hospitality services including housekeeping, laundry and sometimes transportation;
• Case management;
• Monitoring and supervision;
• Activities and recreational opportunities;
• Personal care services, including help with grooming, dressing and bathing; and
• Medication assistance and supervision.
Some ACFs may have additional licensure, which is where the term “assisted living” comes in. There are two categories of licensure for assisted living in New York State – the Assisted Living Residence (ALR) and the Assisted Living Program (ALP). This additional licensure enables ACFs to build upon their existing services and provide specialized services, discussed below.
Assisted Living Residences
ALRs provide the same package of services that an ACF does, but are also held to some additional requirements. All ALRs have a specific individualized service plan for each resident and specific consumer disclosure statements about what services they offer and what these services cost. ALRs also have a specific medical evaluation form which must be completed by a physician prior to admission.
Some ALRs are also approved by DOH to provide specialized services for people with Alzheimer’s disease or other cognitive impairments, and these are called Special Needs Assisted Living Residences (SNALRs). These facilities have specialized programming, services, staffing and environment designed for people with these special needs. It should be noted that people with dementia or Alzheimer’s disease can live in “basic” Assisted Living or even an ACF. SNALRs are for those who need a specialized environment to ensure their needs are met.
With additional certification, ALRs can provide or arrange for nursing care and other additional services in the facility as a resident’s needs increase, also known as “aging in place”. These added services can include things like getting help with walking up and down stairs, assistance with transferring, help with other activities of daily living and nursing services. ALRs approved by DOH to provide these services are called Enhanced Assisted Living Residences (EALRs). Most people who need 24-hour nursing or medical care will need a higher level of care, however. It is important to note that EALRs may designate some or all of their beds as enhanced. In addition, these facilities can determine what types of “enhanced” services they will provide, or what resident needs they will be able to meet. This is spelled out in the admission agreement, and the facility should be able to describe their services to an interested consumer.
Both Special Needs and Enhanced ALRs must meet specific safety and staffing requirements to become licensed, and must also provide the basic services outlined below under “Services Available in All Assisted Living Residences.” ALRs can be certified to provide special needs and/or enhanced services, or simply provide “basic” ALR services.
Assisted Living Program
The Assisted Living Program (ALP) is the only assisted living option in the state that can accept Medicaid as payment. That being said, ALPs also accept individuals who can pay out of their own funds.
The ALP allows a person living in an ACF to remain in that setting even if the person becomes more frail and needs extra medical or personal care services. Combining the services of an ACF and a home care agency, the ALP is similar to the Enhanced Assisted Living Residence, as it too is an “aging in place” model.
Payment for ACFs and Assisted Living
Medicare does not cover assisted living or adult care facility services. Currently, there are limited options for low-income individuals. In New York, only the Assisted Living Program (ALP) is covered by Medicaid. Some facilities accept Supplemental Security Income (SSI), but these facilities are dwindling in number since the SSI payment is well below what it actually costs a facility to care for residents. Some veterans or spouses of veterans may be eligible for certain benefits which can assist in paying for ACF or assisted living services. In addition, some long term care insurance policies will cover assisted living. These options should certainly be explored, though circumstances and policies will differ. Most often, residents and their families pay for assisted living out of their own funds. Facilities have different ways of charging for services, and any ACF or assisted living facility should be able to explain the system and what exactly it covers.
At present, Medicaid managed care does not cover assisted living services, but this will change as time goes on. Managed care may cover services provided to participants residing in assisted living or ACFs, such as home care. When this arrangement occurs, the facility will coordinate services with the managed care plan.
Questions
• When deciding on assisted living or ACF for services, consider asking the following questions:
• Is assisted living or an adult care facility appropriate, based on an assessment of the person’s physical, financial, mental and lifestyle needs? If needed, professional help is available to assist with this process. Ask your health care provider for information.
• What are the criteria for admission to the facility you are considering? How is the need for services determined?
• What services are included in the basic plan and what services are available for an additional fee?
• What is the dining environment like?
• What religious/spiritual programs are offered?
• Does the administrator seem to know the residents and interact with them?
• Are the staff friendly and professional?
• There are several different types of assisted living. If you have specialized needs, ask how the facility will make sure your needs are addressed.
• Can this facility meet your anticipated future needs? If you have a degenerative disease, for example, will you be able to stay or move on to another setting?
• What happens if you deplete your resources? Will you have to move to another facility?
• If you have long term care insurance, Medicaid, SSI and/or Veteran’s benefits, does the facility accept them for payment?
• What sort of relationships does the facility have with nursing homes, hospitals and home care agencies, should the resident need more or different care?
• Under what circumstances could a resident have to leave the facility?
Senior Housing
Senior housing facilities are made up of several apartments or cottages for independent living for adults aged 55+ (note: minimum ages can be higher than 55, and some facilities must admit younger disabled individuals). These facilities provide a secure, residential environment, but do not directly provide the type of extensive health care associated with nursing homes or assisted living. Those services may be available through separate arrangements with home care agencies or other providers. Senior housing offers privacy and independent living in buildings that are safe and well maintained. Many are architecturally designed to address some of the physical limitations that growing older may bring. For example, bathrooms may be equipped with handrails and grab bars or electrical outlets placed within easier reach. Many are equipped with 24-hour emergency call systems.
Services Available
Senior housing may be provided in a stand-alone facility or as part of a retirement community that offers other services. Many senior housing facilities also offer or can arrange for a variety of supportive services such as meals, transportation, housekeeping, social activities, counseling, recreational programs, daily visits or telephone reassurances.
Payment
Monthly rents vary depending on the size of the housing unit, the location, the services offered and the income group the building is designed to serve. Subsidized housing is a type of senior housing that requires applicants to meet certain income qualifications to be considered for an apartment. Subsidized senior housing is overseen by the U.S. Department of Housing and Urban Development (HUD) and the New York State Homes and Community Renewal (HCR). “Market-rate” housing is not subsidized and is open to individuals whose incomes enable them to pay the monthly rents that are typical for that geographic region and type of facility.
Questions
When deciding on senior housing for services, consider asking the following questions:
• Is the facility located close to family, doctors, pharmacy, grocery, shopping, houses of worship and public transportation?
• Are there entrance fees?
• What is the monthly rent?
• Are there other charges for services or meals?
• Does the facility arrange for coordination of health services?
• Does the facility offer transportation services or coordinate transportation for residents?
• What type of floor plan does the facility offer? Is it or can it be adapted as residents “age in place?”
• What is the facility’s policy when the resident needs more health care services?
Senior housing facilities are made up of several apartments or cottages for independent living for adults aged 55+ (note: minimum ages can be higher than 55, and some facilities must admit younger disabled individuals). These facilities provide a secure, residential environment, but do not directly provide the type of extensive health care associated with nursing homes or assisted living. Those services may be available through separate arrangements with home care agencies or other providers. Senior housing offers privacy and independent living in buildings that are safe and well maintained. Many are architecturally designed to address some of the physical limitations that growing older may bring. For example, bathrooms may be equipped with handrails and grab bars or electrical outlets placed within easier reach. Many are equipped with 24-hour emergency call systems.
Services Available
Senior housing may be provided in a stand-alone facility or as part of a retirement community that offers other services. Many senior housing facilities also offer or can arrange for a variety of supportive services such as meals, transportation, housekeeping, social activities, counseling, recreational programs, daily visits or telephone reassurances.
Payment
Monthly rents vary depending on the size of the housing unit, the location, the services offered and the income group the building is designed to serve. Subsidized housing is a type of senior housing that requires applicants to meet certain income qualifications to be considered for an apartment. Subsidized senior housing is overseen by the U.S. Department of Housing and Urban Development (HUD) and the New York State Homes and Community Renewal (HCR). “Market-rate” housing is not subsidized and is open to individuals whose incomes enable them to pay the monthly rents that are typical for that geographic region and type of facility.
Questions
When deciding on senior housing for services, consider asking the following questions:
• Is the facility located close to family, doctors, pharmacy, grocery, shopping, houses of worship and public transportation?
• Are there entrance fees?
• What is the monthly rent?
• Are there other charges for services or meals?
• Does the facility arrange for coordination of health services?
• Does the facility offer transportation services or coordinate transportation for residents?
• What type of floor plan does the facility offer? Is it or can it be adapted as residents “age in place?”
• What is the facility’s policy when the resident needs more health care services?
Continuing Care Retirement Communities
Continuing care retirement communities (CCRCs) are unique because they offer a full range of living arrangements for their residents – independent housing, assisted living/adult care facility and nursing home – within one community. This allows a person to enter the independent housing facility and, as their care needs increase, the services provided by the CCRC are increased without the person having to move out of the community. This also allows couples to remain in close proximity to one another.
Payment
Residents pay an entrance fee and monthly charges out of their own funds and/or from long term care insurance benefits. In exchange, they have guaranteed access to the entire range of services provided in the community. By guaranteeing access to services for a person’s remaining lifetime in exchange for payment, a type of CCRC called a “life care community” also provides an insurance product that makes them subject to the laws and regulations of the New York State Department of Financial Services, in addition to the Department of Health.
CCRCs are an attractive alternative to many seniors, since they provide security in knowing that the resident’s future health care and other needs will be met by the same organization, and that the monthly fee remains predictable even if the level of services needed changes. This allows a resident to budget for the cost over time.
In 2004, the New York State Legislature approved the development of a limited number of fee-for-service CCRCs that offer the same services as other CCRCs, although residents pay a daily rate for each level of care that can increase or decrease based on changes in the resident’s service needs.
Questions
When deciding on a particular CCRC for services, consider asking the following questions:
• What are your current living expenses vs. the costs of the retirement community?
• Is there a policy that allows a refund of the entrance fee in the event that you leave the community?
• How long has the CCRC been in business? How about the organization that operates it?
• What services are included in the monthly fee? What services are offered for an additional change?
• What kind of health care is available on-site (physicians, dentists, clinic, etc.)?
• What activity programs, educational opportunities and transportation services are available?
• What opportunities are there for involvement through resident councils?
More Resources Available Here: https://www.leadingageny.org/providers/ccrc/consumer-resources/all-about-continuing-care-retirement-communities/
Continuing care retirement communities (CCRCs) are unique because they offer a full range of living arrangements for their residents – independent housing, assisted living/adult care facility and nursing home – within one community. This allows a person to enter the independent housing facility and, as their care needs increase, the services provided by the CCRC are increased without the person having to move out of the community. This also allows couples to remain in close proximity to one another.
Payment
Residents pay an entrance fee and monthly charges out of their own funds and/or from long term care insurance benefits. In exchange, they have guaranteed access to the entire range of services provided in the community. By guaranteeing access to services for a person’s remaining lifetime in exchange for payment, a type of CCRC called a “life care community” also provides an insurance product that makes them subject to the laws and regulations of the New York State Department of Financial Services, in addition to the Department of Health.
CCRCs are an attractive alternative to many seniors, since they provide security in knowing that the resident’s future health care and other needs will be met by the same organization, and that the monthly fee remains predictable even if the level of services needed changes. This allows a resident to budget for the cost over time.
In 2004, the New York State Legislature approved the development of a limited number of fee-for-service CCRCs that offer the same services as other CCRCs, although residents pay a daily rate for each level of care that can increase or decrease based on changes in the resident’s service needs.
Questions
When deciding on a particular CCRC for services, consider asking the following questions:
• What are your current living expenses vs. the costs of the retirement community?
• Is there a policy that allows a refund of the entrance fee in the event that you leave the community?
• How long has the CCRC been in business? How about the organization that operates it?
• What services are included in the monthly fee? What services are offered for an additional change?
• What kind of health care is available on-site (physicians, dentists, clinic, etc.)?
• What activity programs, educational opportunities and transportation services are available?
• What opportunities are there for involvement through resident councils?
More Resources Available Here: https://www.leadingageny.org/providers/ccrc/consumer-resources/all-about-continuing-care-retirement-communities/
Managed Long Term Care Plans
The state’s Medicaid redesign efforts are making managed long term care (MLTC) the primary care model for Medicaid recipients who need community-based long term care services for 120 days or more. Medicaid recipients aged 21+ who need such care will be required to enroll into MLTC. For these Medicaid recipients, MLTC plans will take the lead in coordinating needed home and community based services, with actual services provided by a network of contracted providers. There are several types of MLTC plans: one type focuses on Medicaid services, while two other types cover and coordinate both Medicaid and Medicare services.
MLTC enables individuals whose continuing health care needs would qualify them for admission to a nursing home, or who are determined to need 120+ days of long term care services in the community, to remain in their home while receiving a broad array of customized services and supports. While most MLTC enrollees are eligible for both Medicaid and Medicare, people can pay out of their own funds and some long term care insurance coverage may be available.
The three types of MLTC in New York State are the Programs of All Inclusive Care for the Elderly (PACE), Medicaid Advantage Plus (MAP) plans and “Medicaid Only” or “Partially Capitated” MLTC Plans. Enrollees are assigned a care coordinator and use a team that may include physicians, therapists, nurses, social workers and home health aides to plan, provide and coordinate all needed services. Transportation to necessary medical services is part of the service package. Most organizations encourage the person and their family to be a part of the care planning process.
For each Medicaid and/or Medicare enrollee, the MLTC plans receive a fixed monthly premium which is used to provide a package of services tailored to an individual’s needs, including services that traditional Medicaid and Medicare do not provide. Compared to traditional Medicaid and Medicare, services are more coordinated and more customized, while out-of-pocket expenses are usually lower.
PACE seamlessly combines Medicaid and Medicare services. MAP plans integrate Medicaid and Medicare in a bit more complicated manner. “Medicaid Only” MLTC plans provide only Medicaid long term care services and help coordinating Medicare services for the enrollee. Therefore, it is important to review and understand the scope of services that each type of plan offers. All PACE plans have a day center and fully licensed clinic that participants use as needed while some other plans tend to rely more on home care. PACE participants must be at least 55 years old, while other plans enroll individuals as young as 18. The state has also launched Fully Integrated Duals Advantage (FIDA) plans in the downstate region that operate similar to MAP plans.
The state’s Medicaid redesign efforts are making managed long term care (MLTC) the primary care model for Medicaid recipients who need community-based long term care services for 120 days or more. Medicaid recipients aged 21+ who need such care will be required to enroll into MLTC. For these Medicaid recipients, MLTC plans will take the lead in coordinating needed home and community based services, with actual services provided by a network of contracted providers. There are several types of MLTC plans: one type focuses on Medicaid services, while two other types cover and coordinate both Medicaid and Medicare services.
MLTC enables individuals whose continuing health care needs would qualify them for admission to a nursing home, or who are determined to need 120+ days of long term care services in the community, to remain in their home while receiving a broad array of customized services and supports. While most MLTC enrollees are eligible for both Medicaid and Medicare, people can pay out of their own funds and some long term care insurance coverage may be available.
The three types of MLTC in New York State are the Programs of All Inclusive Care for the Elderly (PACE), Medicaid Advantage Plus (MAP) plans and “Medicaid Only” or “Partially Capitated” MLTC Plans. Enrollees are assigned a care coordinator and use a team that may include physicians, therapists, nurses, social workers and home health aides to plan, provide and coordinate all needed services. Transportation to necessary medical services is part of the service package. Most organizations encourage the person and their family to be a part of the care planning process.
For each Medicaid and/or Medicare enrollee, the MLTC plans receive a fixed monthly premium which is used to provide a package of services tailored to an individual’s needs, including services that traditional Medicaid and Medicare do not provide. Compared to traditional Medicaid and Medicare, services are more coordinated and more customized, while out-of-pocket expenses are usually lower.
PACE seamlessly combines Medicaid and Medicare services. MAP plans integrate Medicaid and Medicare in a bit more complicated manner. “Medicaid Only” MLTC plans provide only Medicaid long term care services and help coordinating Medicare services for the enrollee. Therefore, it is important to review and understand the scope of services that each type of plan offers. All PACE plans have a day center and fully licensed clinic that participants use as needed while some other plans tend to rely more on home care. PACE participants must be at least 55 years old, while other plans enroll individuals as young as 18. The state has also launched Fully Integrated Duals Advantage (FIDA) plans in the downstate region that operate similar to MAP plans.
Home & Community Services & Supports
Home Care
Regulated by the New York State Department of Health (DOH), home care consists of nursing, therapy or personal care services provided in an individual’s home. Different categories of home care include licensed home care services agencies (LHCSAs), certified home health agencies (CHHAs) and Long Term Home Health Care Programs (LTHHCPs). The most common services provided are help with activities of daily living (such as laundry, shopping, housekeeping, personal hygiene and meal preparation), skilled nursing services, and physical, occupational and speech therapy. Home care helps individuals who have long term needs related to a chronic illness or disability, or short term nursing or therapy needs after a hospitalization. Home care is often an important part of assisted living services, and is provided in senior housing as well as individual homes. The service is also discussed in those sections of this guide.
LTHHCPs provide home care and other supportive services to help people who would otherwise qualify for nursing home care to remain in their homes. The Nursing Home Transition and Diversion (NHTD) waiver or the Traumatic Brain Injury (TBI) waiver also provide services to help people who have high level needs to remain in the community, however the programs deliver these services in different ways.
Adult Day Services
In New York State, adult day services come in two forms – a medical model called “adult day health care” (ADHC) and a social model called “social adult day care” (SADC). Adult day services programs offer a safe, secure, stimulating environment for people whose family circumstances allow them to remain in their homes in the evenings (and possibly on weekends), but who need some sort of supervision during the daytime. Adult day services are very appropriate for a person whose needs are ordinarily met by their own family members or friends, especially when those people may work outside the home during the day but are generally at home in the evenings and on weekends.
Social Adult Day Care is oriented toward the social aspects of life and may include games, memory orientation exercises, music, dancing and reading in a safe and supervised environment. These programs also provide a meal, some help with daily living activities (such as mobility and grooming), and offer supervised field trips and special events. These programs may be located in the community, or in adult care facilities (see the section above on “Assisted Living and Adult Care Facilities”). SADC programs are overseen by the New York State Office for the Aging (SOFA). Funding sources include contracts with managed long term care plans, some grant funding from the local offices for the aging and private pay.
Adult Day Health Care has a strong medical component. These programs are staffed by a number of professionals including a registered nurse able to conduct assessments, manage medications and perform medical tasks. These programs must be sponsored by a nursing home or a hospital, and provide social activities in addition to medical services. They are required to provide physical, occupational and speech therapy to people who need these services. In addition, they provide a full range of personal care services (from some help to total assistance with mobility, eating, dressing, bathing, grooming and toileting), social services, case management and at least one meal per visit. ADHC programs must provide or arrange transportation to and from the program. These programs are regulated by the New York State Department of Health. Funding sources include fee-for-service Medicaid, contracts with the Veterans Administration, Medicaid managed care plans as well as private pay.
Hospice
A hospice is an agency licensed by the New York State Department of Health to provide medical, spiritual and emotional care to individuals with life-limiting illnesses with a prognosis of six months or less to live if the disease process proceeds on its expected course. Many hospices have added “palliative care” to extend services to more people who could benefit from receiving health care treatment to prevent or reduce pain and suffering earlier in their illness or disease process. Hospice care can be given in the home, a special hospice facility, hospital or a nursing home. Hospice also provides supportive services to the individual’s family.
Respite
Respite service provides infrequent and temporary overnight care for ill or disabled older adults for a few days or weeks. It gives caregivers (family members or friends) a short break from the stresses or responsibilities of providing constant care, enabling the caregiver to maintain a normal routine. Respite care is normally offered for three consecutive hours or longer in a day, and up to six weeks in any calendar year. Respite can be delivered in a variety of settings, including assisted living facilities, nursing homes, and a home in the community. Respite care is offered under the LTHHCP, NHTD waiver and TBI waiver programs (see the “Home Care” section above). Respite services are generally in short supply and should be reserved as early as possible. Generally speaking, respite services are overseen by DOH.
Home-Delivered Meals
Home-delivered meals, often called “meals-on-wheels,” are provided to older adults who are unable to prepare their own well-balanced meals either on a temporary or long term basis. Often these individuals are recovering from a recent illness, surgery or other condition, which impairs their independence, creating a situation in which they become nutritionally at-risk at a time when proper nutrition is especially important. In New York State, Area Agencies on Aging provide home-delivered meals with funding from federal and state governments, local funds and participant contributions. Individual participants may use Food Stamps, cash or checks as their contribution. Home-delivered meals are also a covered service under the LTHHCP and the NHTD waiver program (see the “Home Care” section above).
Senior Centers
Senior centers offer a broad spectrum of services and activities such as social and education services, health, nutrition, and a community resource for information and recreational activities. These centers are offered by various community groups, churches and local governments. Some senior centers are regulated by the New York State Office for the Aging and Office of Children and Family Services. These centers must provide information and referral to other needed services, group activities, counseling and outreach. Participants must be at least 60 years of age and be income-qualified.
Payment for Home and Community Based Services
The cost of in-home and community-based services varies depending on the type of program and amount of services needed. Medicare, Medicaid, long term care insurance and private insurance are payment sources for some home and community-based services. Medicare tends to cover these services on a short-term basis following a hospital stay, whereas Medicaid may cover services over a longer period of time. Insurance policies have specific criteria for what services are covered, for how long, and under what circumstances. Check with your insurer for more information.
Most of the other services above are available to people out of their own funds. Some localities have special programs for individuals with low incomes. Some services, such as home-delivered meals or respite, may be covered by Medicaid as a part of a package of comprehensive services provided through the LTHHCP or the NHTD waiver program. Local programs and agencies may provide additional supportive services and help with cost. For further information, check with your local social services department or office for the aging.
In addition, in areas of the State where mandatory enrollment in managed long term care has taken effect, the Medicaid recipient may be required to enroll in managed care once they reach the threshold of receiving certain community based long term care services for more than 120 days. The managed long term care plan then becomes the primary provider of the individual’s services, often coordinating with other providers to supply care and services.
Questions
When deciding on in-home and community-based services, consider asking the following questions:
• What are the credentials of staff providing the services? Sometimes people hire people informally to help take care of some of their daily needs. Bear in mind that hiring through a licensed or certified agency provides some consumer protections such as training, criminal history record checks and insurance.
• Is the community service provider accredited by a national organization or formally connected to an existing health care provider such as a nursing home, hospital or retirement community?
• What sort of back up or additional support can family members or friends provide or arrange to make sure the person can remain in the community safely?
• What specific services are provided and at what cost? What services are covered by insurance, and for how long? Are there more appropriate and less costly alternatives available?
• What happens when services are discontinued? Does the provider help the individual to access other services if warranted?
Home Care
Regulated by the New York State Department of Health (DOH), home care consists of nursing, therapy or personal care services provided in an individual’s home. Different categories of home care include licensed home care services agencies (LHCSAs), certified home health agencies (CHHAs) and Long Term Home Health Care Programs (LTHHCPs). The most common services provided are help with activities of daily living (such as laundry, shopping, housekeeping, personal hygiene and meal preparation), skilled nursing services, and physical, occupational and speech therapy. Home care helps individuals who have long term needs related to a chronic illness or disability, or short term nursing or therapy needs after a hospitalization. Home care is often an important part of assisted living services, and is provided in senior housing as well as individual homes. The service is also discussed in those sections of this guide.
LTHHCPs provide home care and other supportive services to help people who would otherwise qualify for nursing home care to remain in their homes. The Nursing Home Transition and Diversion (NHTD) waiver or the Traumatic Brain Injury (TBI) waiver also provide services to help people who have high level needs to remain in the community, however the programs deliver these services in different ways.
Adult Day Services
In New York State, adult day services come in two forms – a medical model called “adult day health care” (ADHC) and a social model called “social adult day care” (SADC). Adult day services programs offer a safe, secure, stimulating environment for people whose family circumstances allow them to remain in their homes in the evenings (and possibly on weekends), but who need some sort of supervision during the daytime. Adult day services are very appropriate for a person whose needs are ordinarily met by their own family members or friends, especially when those people may work outside the home during the day but are generally at home in the evenings and on weekends.
Social Adult Day Care is oriented toward the social aspects of life and may include games, memory orientation exercises, music, dancing and reading in a safe and supervised environment. These programs also provide a meal, some help with daily living activities (such as mobility and grooming), and offer supervised field trips and special events. These programs may be located in the community, or in adult care facilities (see the section above on “Assisted Living and Adult Care Facilities”). SADC programs are overseen by the New York State Office for the Aging (SOFA). Funding sources include contracts with managed long term care plans, some grant funding from the local offices for the aging and private pay.
Adult Day Health Care has a strong medical component. These programs are staffed by a number of professionals including a registered nurse able to conduct assessments, manage medications and perform medical tasks. These programs must be sponsored by a nursing home or a hospital, and provide social activities in addition to medical services. They are required to provide physical, occupational and speech therapy to people who need these services. In addition, they provide a full range of personal care services (from some help to total assistance with mobility, eating, dressing, bathing, grooming and toileting), social services, case management and at least one meal per visit. ADHC programs must provide or arrange transportation to and from the program. These programs are regulated by the New York State Department of Health. Funding sources include fee-for-service Medicaid, contracts with the Veterans Administration, Medicaid managed care plans as well as private pay.
Hospice
A hospice is an agency licensed by the New York State Department of Health to provide medical, spiritual and emotional care to individuals with life-limiting illnesses with a prognosis of six months or less to live if the disease process proceeds on its expected course. Many hospices have added “palliative care” to extend services to more people who could benefit from receiving health care treatment to prevent or reduce pain and suffering earlier in their illness or disease process. Hospice care can be given in the home, a special hospice facility, hospital or a nursing home. Hospice also provides supportive services to the individual’s family.
Respite
Respite service provides infrequent and temporary overnight care for ill or disabled older adults for a few days or weeks. It gives caregivers (family members or friends) a short break from the stresses or responsibilities of providing constant care, enabling the caregiver to maintain a normal routine. Respite care is normally offered for three consecutive hours or longer in a day, and up to six weeks in any calendar year. Respite can be delivered in a variety of settings, including assisted living facilities, nursing homes, and a home in the community. Respite care is offered under the LTHHCP, NHTD waiver and TBI waiver programs (see the “Home Care” section above). Respite services are generally in short supply and should be reserved as early as possible. Generally speaking, respite services are overseen by DOH.
Home-Delivered Meals
Home-delivered meals, often called “meals-on-wheels,” are provided to older adults who are unable to prepare their own well-balanced meals either on a temporary or long term basis. Often these individuals are recovering from a recent illness, surgery or other condition, which impairs their independence, creating a situation in which they become nutritionally at-risk at a time when proper nutrition is especially important. In New York State, Area Agencies on Aging provide home-delivered meals with funding from federal and state governments, local funds and participant contributions. Individual participants may use Food Stamps, cash or checks as their contribution. Home-delivered meals are also a covered service under the LTHHCP and the NHTD waiver program (see the “Home Care” section above).
Senior Centers
Senior centers offer a broad spectrum of services and activities such as social and education services, health, nutrition, and a community resource for information and recreational activities. These centers are offered by various community groups, churches and local governments. Some senior centers are regulated by the New York State Office for the Aging and Office of Children and Family Services. These centers must provide information and referral to other needed services, group activities, counseling and outreach. Participants must be at least 60 years of age and be income-qualified.
Payment for Home and Community Based Services
The cost of in-home and community-based services varies depending on the type of program and amount of services needed. Medicare, Medicaid, long term care insurance and private insurance are payment sources for some home and community-based services. Medicare tends to cover these services on a short-term basis following a hospital stay, whereas Medicaid may cover services over a longer period of time. Insurance policies have specific criteria for what services are covered, for how long, and under what circumstances. Check with your insurer for more information.
Most of the other services above are available to people out of their own funds. Some localities have special programs for individuals with low incomes. Some services, such as home-delivered meals or respite, may be covered by Medicaid as a part of a package of comprehensive services provided through the LTHHCP or the NHTD waiver program. Local programs and agencies may provide additional supportive services and help with cost. For further information, check with your local social services department or office for the aging.
In addition, in areas of the State where mandatory enrollment in managed long term care has taken effect, the Medicaid recipient may be required to enroll in managed care once they reach the threshold of receiving certain community based long term care services for more than 120 days. The managed long term care plan then becomes the primary provider of the individual’s services, often coordinating with other providers to supply care and services.
Questions
When deciding on in-home and community-based services, consider asking the following questions:
• What are the credentials of staff providing the services? Sometimes people hire people informally to help take care of some of their daily needs. Bear in mind that hiring through a licensed or certified agency provides some consumer protections such as training, criminal history record checks and insurance.
• Is the community service provider accredited by a national organization or formally connected to an existing health care provider such as a nursing home, hospital or retirement community?
• What sort of back up or additional support can family members or friends provide or arrange to make sure the person can remain in the community safely?
• What specific services are provided and at what cost? What services are covered by insurance, and for how long? Are there more appropriate and less costly alternatives available?
• What happens when services are discontinued? Does the provider help the individual to access other services if warranted?
