Getting old happens in phases


LIHU’E — Quality of life and allowing for self-reliance is what older adults

and their families say is most important to them when it comes to considering

long term health care options, said John McDermott, state long term care


“In the simplest terms people want care options that are

accessible and affordable,” he said.

As life expectancy is extended, older

adults experience phases of aging. During the first phase, many older people

are healthy and independent .

But as the years go by, seniors generally

begin to notice a diminished capacity that leads into a semi-independent phase.

This may be that they are no longer able to drive, shop and prepare meals for

themselves but are still able to take care of personal hygiene and have no

acute medical needs.

Often a family member or spouse is able to provide

the additional support. If necessary community-based programs are available

providing services to support the existing informal support network.

In the

third phase of aging, dependency begins and the elderly person becomes more

homebound and less able to participate fully in the community, services shift

to the home setting, community based care and long-term residential


Home and Community Based Care

Home Care health services are the

growing trend in elder health care services. Home care services promote,

maintain or restore health and minimize the effects of injury or illness says

Dardanelle Ka’auwai, coordinator for St. Francis Medical Services on


Many older persons don’t require around the clock care in a

hospital or nursing home. For that reason, home care is often an effective,

less costly alternative to hospitalization.

Today services that are

traditionally delivered in a clinic setting are being provided to homebound


Dr. Rand D. Mundo, Kaua’i podiatrist, makes regular visits to

homebound elderly and the care is covered by insurance. Other Kaua’i physicians

who care for the elderly as part of their general practice are returning to a

“country doctor” style of practice.

Dr. Thomas Williamson, with the Ohana

Physicians Group, has several patients who he visits at home. Both doctors say

they do it because the need is there.

The economics that make home care

attractive to insurance providers are that the elder’s food, shelter and

personal expenses are already covered.

Although providing medical services

at home may be costly, it is more practical than institutional care, said Terry

Hill, social worker for Wilcox Hospital.

Hill says even more important to

many older adults is the desire to be at home with their families. While family

members may want to be involved in the care of their loved ones, they may need


On Kaua’i, St. Francis Medical Center has been providing home

skilled health care services for 22 years. The center provides post hospital

care, rehabilitative services or other treatments for a specified period of


Home care is a growing choice for elders and their families said

Ka’auwai who believes the service is under utilized. “Education is the key to

receiving and maximizing the services that are available,” said Ka’auwai.

Home care covers a wide range of services which allow a person to remain

at home despite their infirmity. Skilled nursing services such as inserting

feeding tubes, catheters or breathing devises can now be done at home. In some

cases, physical and occupational therapists provide care for patients at


Transportation to doctor appointments, providing assistance with

dressing or toileting, and sending someone into the home for a few hours just

to give family members caring for an elderly person a break are some of the

kinds of services available.

Frail older adults who are unable to remain

at home alone during the day can receive proper care and attention at Adult Day

Care Centers which expands the ability of many to keep a loved one in a family


One of the newest options in community-based care is the Adult

Residential Care Home. An ARCH is a family home or facility licensed by the

Department of Health. The facilities offer 24-hour living accommodations.

For an older adult who is no longer able to remain at home, there are a number

of alternatives which may be appropriate, depending upon the degree of frailty,

the availability of the alternative, and the extent to which the costs can be


One of the alternatives is the adult residential care homes which

provide live-in, around the clock care for elders who need help with their

daily activities. Most ARCHs are single family residential units.

Room and

board, supervision and assistance with activities of daily living such as

personal care, supervision of medication, transportation to medical and dental

offices, and planned activities are usually provided in an ARCH.

They may

be as small as housing 1-5 residents. ARCH generally cost $3,000 per


Mary Marquis, of TIMAO Health Services, a company that handles ARCH

placements, said the idea is to keep the elder within the community.


try to place people as close to their original home as possible, that way

friends and family are able to stay in touch.”

Skilled nursing facilities

like Wilcox Hospital Day Care also offer all day nursing care, health and

social services and provide a place where families can place their elders while

they work.

Cost of long-term care

Sometimes, a nursing home is the

best option for an older adult who can no longer be cared for at home.

Intermediate care facilities (ICF) provide skilled nursing care eight hours a

day and other personal and supportive care on a 24 hour basis.

Intermediate care becomes an option when the community-based home care

service becomes impractical or no longer feasible. This type of facility will

cost close to $10,000 a month.

In facing Long Term Care issues what a

family or individual can afford and what is covered by medical insurance

becomes an issue for many.

Medicare is a federal health insurance program

that pays medical bills for almost all people age 65 or older who have worked

under the Social Security system.

Over the years reduction in Medicare

reimbursement has becomes a major issue for older citizens. Because of the

insurance limits many older adults opt to purchase a supplemental policy like

HMSA 65+ provides a gap coverage insurance. The cost is about $65 a


Medicaid is a medical assistance program which pays for medical care

for people receiving welfare benefits and for people with low incomes

regardless of age.

Michael Ratcliffe, county Senior Law Program attorney,

said it’s important for older adults and their families to be informed about

the financial and legal issues related to paying for long-term health care.

The issue of assets and responsibility for payment of long-term health

care can be upsetting for seniors who find that they will have to use all of

their assets to pay for their care.

Many seniors on Kaua’i have really no

other assets than their home, which they had planned to pass on to their

children after their death, said Ratcliffe. But new laws allow for the

government to place liens against the property as a reimbursement for the cost

of long term care.

Ratcliffe said that federal regulations require the

state to recover Medicaid payments from medically institutionalized recipients.

The recovery cost amounts are based on the long-term care expenses, but at

$10,000 a month within a year most all of the home’s assets will be used to

cover the medical care.

A Kalaheo family is still paying on their mother’s

medical bill from extended hospital and rehabilitation care four years ago. The

89-year-old woman had only Medicare insurance and the coverage did not last as

long as the need for service.

Families or older adults who need legal

advise on Long Term Care liabilities should contact the Senior Law Program at

246-0573. The service is free.

The Executive Office on Aging has a very

useful web site that address may issues around long term care at


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