Making The Right Move. Gillian Eades Telford

some help to accomplish some instrumental activities of daily living (iadl). iadls are defined as actions that help elders do the essentials to remain independent, including shopping for food, house cleaning, banking, gardening, driving, or being able to walk longer distances or take public transit. Her son helped with her income taxes and some banking and drove her to the grocery store on occasion. She also had a cleaning person who helped clean her apartment.

       An encounter with the regional health services

      For her 80th birthday, Mrs. Martino took a cruise to Alaska. Unfortunately, she fell, badly breaking her ankle. There was no doctor aboard, so the freighter diverted and deposited her in an acute care hospital at the nearest port, where they operated on her ankle. Within three weeks, she was able to return home. She was fortunate to have purchased medical insurance; otherwise, the bill could have been thousands of dollars.

      She was in a wheelchair when she was discharged from hospital with her leg in a cast. Although the physiotherapist had taught her how to walk on flat surfaces and up and down stairs with crutches, she was still weak.

      On her return home, Mrs. Martino contacted her family physician, who instructed her to call the local health unit so she could receive some in-home help. The intake nurse arranged for an assessment by the continuing care division of her regional health board. Most regional health boards have a continuing care division of some kind. It may also be called the long-term, extended, or chronic care division. This division usually provides a comprehensive range of community-based, supportive health care services to assist people whose ability to function independently is affected by long-term (i.e., more than three months) health-related problems.

      Mrs. Martino explained that she was living alone and that she had a number of chronic illnesses, besides the fact she was in a wheelchair with a broken ankle. Because she could not currently do many of the activities of daily living without assistance, she needed immediate help or she was at risk of being hospitalized again. She was assessed and was assigned a case manager, who worked closely with her family physician. The case manager is usually a registered nurse who can coordinate health care services, teach family members how to care for their elders, plan further client care based on a health assessment, and communicate with physicians regarding medical progress. Mrs. Martino’s case manager decided that she needed the following homecare support:

      • A resident care aide/nurse aid/homemaker who would help her bathe, dress, make her bed, prepare her meals and buy the food, and clean the apartment.

      • A physiotherapist to give her exercises to help her regain her muscle tone and provide therapy to regain mobility. The physiotherapist also showed her son how to assist with these exercises. (Note: Many states and provinces charge a fee for physiotherapy services. Check with your state/province medical plan to see if these services are covered.)

      • A nutritionist to provide instructions on how to prepare meals that accommodated her diet restrictions (i.e., foods low in sugar for her diabetes and low in salt for her heart condition).

      • An occupational therapist to suggest ways she could make bathing, cooking, and cleaning easier as she became more mobile. (Occupational therapists also assess your physical and mental limitations and home facilities. They will recommend changes, assistive devices, or adaptations in the environment to increase your independence.)

      In a few short weeks after arriving back in her apartment, Mrs. Martino was able to maneuver the wheelchair; then graduated to a walker, crutches, and finally a cane. Six weeks later, she was able to do everything for herself, and she resumed her activities and social lifestyle.

      Supportive Health Care Services

      Through the supportive health care services offered in her community, Mrs. Martino was able to recuperate with relatively little difficulty. Supportive health care services is a generic term that includes many programs, not all of which may be available in your area. Some services may be government sponsored and others may be private. Your family doctor, hospital, hmo, Eldercare Locator, local health board, or senior services organization will be able to help you determine what services are available and how to contact them. Also see the section “How to Get in Touch with Health Care Services” at the end of this chapter. Following are some of the services they may provide:

      Case management services

      Professionally trained staff are usually available to help clients connect with the appropriate services needed. Case managers assess, consult, teach, and link clients to the most appropriate care providers. Case management is a good idea on paper, but in fact, case managers often have up to 350 clients. Often, only clients who are in crisis are managed because there is just no time to do a good job for everyone. Case managers in hmos may have less of a caseload.

      In-home support homemaker services

      This long-term program may also be called home support, home care, continuing care, or community care. To qualify, you must be assessed by a nurse, social worker, physiotherapist, or occupational therapist. Most in-home support programs use homemakers with special training or resident care aides or certified nurse aides to assist elders with personal care such as bathing, dressing, and grooming.

      Home care is usually free if you do not have much income; otherwise, payment is on a sliding scale depending on income. The assessors from the long-term care program in the continuing care division of the health unit look at your last income tax return to determine how much you will be asked to pay. If you have adequate income, you will have to pay well for the services you receive. Many private agencies that are not contracted to the regional health board charge less to clients for homemaker services than government-supported agencies. In the United States, home care may be covered under Medicare Part B or another private insurance plan, but certain conditions apply.

      In-home care provides care appropriate to your needs as decided by the case manager. You are assigned a worker for a specified number of hours a day or week. Because of health care cutbacks, this service is often rationed in many communities, and is typically designed to enhance and complement the support you receive from family and friends. You can often purchase more hours of service from the agency that supplies your worker.

      The regional health boards usually contract with an agency to have them provide home care. The agency may be either for profit or nonprofit, and there is no guarantee that you will get the same person each time. Although these agencies bid for government contracts at the regional health board level, no specific standards of care exist. So the quality of staff may vary from poor to superior.

      Residential care services

      Residential care services range from private luxury retirement homes to skilled nursing facilities or chronic/extended care nursing homes. In the United States, all nursing homes are private and the government does not subsidize care, so you will pay as you go. Medicare can cover some certified skilled nursing facilities, and Medicaid will pay for these same facilities if a client qualifies. Some nonprofit and religious homes, as well as Medicare and Medicaid homes, are available. You should check with your local health authority or senior services for more information.

      In most Canadian provinces, residential care services operate under the auspices of the continuing care division of your local health authority. They are usually government supported and accessible to all elders who pay only the accommodation cost of $23 to $36 per day. The health care component is free because health care in Canada is free. Depending on the province in which you live, the number of hours of care is usually restricted to approximately 1.5 hours of nursing care in a 24-hour period per client. The care is supervised by a registered nurse, but most personal care activities are performed by resident care aides.

      See Chapters 4 and 5 for more detailed information on the kinds of homes available.

      Shared supportive living services

      Also known as family care homes, these are single-family residences that care for up to two