Transitional Care Center - Ever heard of it?

[Virginia]

I have a neighbor who has some kind of kidney problem. She also has macular degeneration. I told her a long time ago to ask her Doctor if there was any help she might get.

He sent people from Transitional Care/Center. (Not to be confused with Transitional Living) Anyway, they were formerly a part of Hospice. They have a lady that comes 4 times a week and helps her with whatever she might need - not to include house cleaning. She has to pay for that. The lady helps her with a bath if she needs help, helps shampoo her hair, even blow dries and puts it in rollers. She carries out the trash, changes the bed linens and I am not sure exactly what all she does, but mostly personal things.

Anyway, I looked them up and the main criteria for getting them is that you must have an irreversible disease, and be on therapy. It is called aging in place and allows many people to stay in their own homes rather than have to go to assisted living.

It is paid for by Medicare.

I do not know if all states have this, however it seems like a really good thing for those who need it. There is a drawback. You can only go out occasionally. In my case it would mean that I could not go out to eat with family every week and do some of the other things I still do.

They only stay with her for about an hour and a half each time depending on what she needs. She is far from blind and reads books on a lighted Kindle, so she really is not so bad off. However, I think the kidney disease she has is a serious one.

She asked if they have MS patients, and the lady she has said they do and a couple of them they sometime see in the morning and again in the evening, so apparently they are not in good shape.

Didn't know all of this was out there and wanted to put the word out here just in case anyone has a need. They will go to your home, apartment or even if you are in assisted living and still need some extra help.

Sally, don't know if this would be available in Ohio or if you have a need for it.

[agate]

I didn't know about this, or if I did, it was under some other name. I found one example in the US but there seem to be other companies offering it as well:

Only registered and activated users can see links., Click Here To Register...

[Virginia]

Agate, not the same thing I don't think. The people here do not bridge a gap between hospital and home. They just come, once you are approved, as often as you need them and stay a length of time that is dependent on your needs, in your home. They can recommend a rehab if they think it will benefit a person, but a hospital or rehab stay is not a must. They fix food for the person, and do other personal things that I mentioned. Seems like a good deal since you pay nothing for it.

[Catdancer]

When I looked up transitional care Medicare there was only one program listed, and it is for only a 30 day period beginning the day a person is released from the hospital (or other long term care facility) back to their own home. It does provide the kind of services you outlined, but only for that 30 day period. I will do some more looking.

There is a visiting nurse program in all 50 states that also is paid by Medicare. That's what I use. They offer different levels of care based on need, including meal preparation and/ or coordination with programs like meals on wheels, bathing, shampooing, dressing, most of the things you have listed, along with skilled nursing care if needed, and physical and occupational therapy. This is also paid for by Medicare.

When I was at my sickest, I had visiting nurses three days a week to do wound care, home health are twice a week for bathing (they would be the ones to do whatever personal things I needed, like pedicures, changing bed linen, light meal preparation..), and physical therapy 3 tines a week. Now the nurse only comes monthly to change the catheter. Home health aides and therapists come 2-3times a week, but if I get strong enough to independently transfer, they'll stop coming. But how often they come is personalized, based on an individual's needs. You access this through your doctor.

Yes, there are restrictions about how much you are allowed to do outside the home. It depends on the agency and how they interpret that. Clearly if you are independently driving, walking relatively unimpaired, able to bathe yourself, go shopping and to church by yourself, they wouldn't serve you. But if you require major assistance to do those things -- help from family or friends, adaptive equipment, etc., they're pretty flexible. Usual family outings are encouraged. As are visits to places of worship, and of course whatever medical visits you need. In fact, just yesterday my aide was encouraging me to go out more, afraid I was becoming TOO tied to the house! Of course it's only been two weeks that I've been able to be up and about, but she was happy to learn that I'd gone out to lunch one day, and went and got my haircut another.

Anyway , another service you might want to know about. Visiting nurses.

[Virginia]

This lady has definitely not had a stay in the hospital - yet. I say yet because they have recommended that she go for 5 days to their hospice house so they can evaluate her to see what her actual needs are. She is afraid that when she goes they may find that she doesn't need them, or at least not 4 times a week.

She has two sons, both live out of town but come into town and spend a night or two with her. They generally talk to the people from this place and help make decisions. She is very assertive, but has been known to be hard to get along with at times, so I think they feel they had better take somewhat of an active role. She gets out more than I do, but that is because she makes a lot of Doctor appointments. I am not saying they are not warranted, but some have been a little questionable. She has called 911 on several occasions. Regarding that, she may have had a 2 day stay in hospital some time back before she got these people or knew about them. They were formerly a part of hospice.

[Earth Mother 2 Angels]

((((((Virginia)))))) ~

Do you happen to have a link to a website about this program? I'd like to know more about it for elderly friends (and for me and Jim for the future perhaps). Thanks!

Love & Light,

Rose

[Virginia]

Rose, I tried to look it up on the internet and found Only registered and activated users can see links., Click Here To Register.... I don't know if this will work in your area. This lady would not qualify for Medicaid. She has told me that Medicare is paying for it. I have long term care and I am afraid they would want to pay out of that. I want to save that in case I have to go into an assisted living facility.

Some Transitional Living is for recovering drug addicts. If you find this it is not the right one. I would like to ask her but I am afraid she would not know a link to look them up. Her Doctor got them for her, and her sons came and took care of all the paper work.

P.S. Try Only registered and activated users can see links., Click Here To Register....

[agate]

Virginia, this may be the one Cat Dancer mentioned and seems to be for only 30 days as she said:

Only registered and activated users can see links., Click Here To Register...

Does your neighbor maybe have "end stage renal disease"? I hate this term but noticed how often it crops up in Medicare literature as one of the rare exceptions to their usual rules. She may be eligible for this program under some special arrangement for persons with end stage renal disease.

[Lazarus]

My mother had someone who came to her apartment once a week. She helped her exactly as you said....personal chores, laundry even. It must have been Medicare because that is all she had. The woman came for years I think. I will have to inquire from family but I think it is more common than we all thought to be eligible for home help.

[Virginia]

Agate, she has never told me she had "end stage renal failure", though she may have. She has only said her Father had the same kidney disease that she has. She does go into their hospice house next week for 5 days to be re-evaluated I think. Then, if she is recertified it will be for three months. She has to be recertified every three months. If they feel she does not need them after next week then the problem goes back to her and her family I guess. They say the hospice house is really nice. I still think this is good information to have. I don't know if any of you were able to pull the link up that I gave.

[Virginia]

I just tried the link and found I could not pull it up from here either, but if I put it in my search engine at home it comes up readily, and gives a lot of information. The only thing is that if one does not know what they are looking for it keeps pulling up Transitional Living which is not what this is.

[Earth Mother 2 Angels]

((((((Virginia)))))) ~

Your first link took me to a site, which listed agencies providing caregivers in my area.

Your second link took me to a list of Transitional Living programs. primarily for drug/alcohol rehab.

I think the main consideration is what Medicare covers. That may depend upon what is covered by our Supplemental Part B plans.

Four years ago, our elderly neighbor was placed on Hospice care at home, with the expectation that he would die within 6 months. He died earlier this year. He was taken off of Hospice and placed on home care. A nurse visited once a week to take his vitals, and 3 times a week an aide visited to bathe him. His wife took care of him the rest of the time. She is 88, and her husband died at the age of 94. From what I gather, all of this was covered by Medicare.

My son, Jon, is a Palliative Care patient, meaning he has a condition, which will not improve and likely cause his death ~ a step up from Hospice. Because he has an indwelling catheter and a trache, he is on a nursing service for the rest of his life. He is permitted 2 visits per month as needed. But if more visits are required, he will receive them. His nurse has to re-certify him every 2 months to remain on the service. This is exclusively nursing care, because my husband and I provide Jon with his 24 hr care.

Jon is a recipient of a federal program, funded by federal, state, and local (county) tax dollars, In Home Supportive Services. He qualifies as an indigent, because he has no resources as an adult. He hires me to be his caregiver through this program. He could hire anyone, but he chose me. But to qualify for IHSS, which isn't available in every state, the recipient needs to be poor and disabled or elderly, and require care to remain safely in their own home. At one time, IHSS considered a burial plot an asset.

Some elderly IHSS recipients turn over their assets to their children/family, so that they can qualify for the services. Then, their family member takes over their care and is paid by the IHSS program for that care. This isn't fraud. This is survival for many families, who simply do not have the funds to provide private care, or whose loved one doesn't have appropriate insurance to pay for the care.

In the 1990s, home care seemed to be the wave of the future. I don't think we're quite there yet, and I feel that we should have progressed much farther than we have.

But there is progress ~ Granny Pods:

Only registered and activated users can see links., Click Here To Register...

All you need is space and plenty of money ...

Love & Light,

Rose

[Virginia]

Thanks Rose, I know that this lady would not qualify for any kind of indigent program. She does have some money, but her income, which she could not turn over to her sons would alone mean that she would not be eligible. She retired from State government as an auditor, and she gets Social Security and she has told me she gets a lot of Alimony, which I believe is true. So her income is quite good.

It sounds more like the program that your neighbor was placed on when he did not die within the 6 months time frame. It does mean that there may be help out there if people know where to get it. I just went to their website and read about payment and it said no patient was ever turned down due to lack of money. It said it is paid for by Medicare, Medicaid, Most Insurance and private funds.

I would not want to do this because I have Long Term Care. Therefore, I feel sure they would want them to pay and I would want to keep that in case I have to go into a nursing home. To use it up for very short visits would be a shame - unless of course I knew I had a short time to live, and this would keep me in my home.