Two nursing home visits today, as it turned out. Nursing Home 1, as scheduled, and then Nursing Home 5, which called this morning and was willing to set up a visit for early afternoon.
I liked them both better than Nursing Home 2, but I'm not sure yet how to compare them to each other. Both seemed positive but there approaches are very different. It'll take some work to figure out how they rate.
Nursing Home 1 is an averaged-sized facility - about 100 beds. Farther from me but not far - about 15 minutes away via Interstate. The admissions person who gave me the tour is a social worker, and she seemed to have a better handle on patient care than my guide at Nursing Home 2 the other day.
When you walk in the door, there's a big communal area - a lounge and a dining room and a skylit atrium that all blend into each other. Lots of patients in view, staff having meetings and discussions mixed in with the patient seating. Seemed relaxed and natural. This is apparently how they handle things - they like to promote a lot of interaction. There are no dedicated Alzheimer's units and no locked floors - dementia patients intermingle with everybody else. They have private rooms but discourage using them - Admissions Person said they find people do better in company than in isolation.
There are nice grounds (Interstate in the distance, but well screened). They seem to make an effort to get patients out of doors, which is a nice touch.
Admissions Person and Business Office Person were good about answering my questions and drawing out information - felt like a much more substantive discussion than the one on Wednesday. Business Office discussion included details on the application process for Maryland Medicaid - more on that below. The information kit also included the results of a survey by the Maryland Health Care Commission (naturally Nursing Home 1 comes out well, otherwise they wouldn't be distributing it). The commission, by the way, publishes a set of guidelines and statistics about nursing home quality, which are going to be useful when I get to the short list.
In the parking lot, where I was reading the survey and the price lists and looking like a newbie, I was interrupted by a woman who'd just picked Nursing Home 1 and was moving her mother in tomorrow. She was dropping off some household objects to make the room feel more like home. Had good things to stay about the staff and the quality care, though she'd also made the choice partly for geographic reasons. Still, my first live endorsement, which is a good indicator.
After a break, over to Nursing Home 2, which is just up the street from me, about five minutes away (side note - the entire area is crawling with nursing homes - not sure why).
Nursing Home 2 is an enormous machine - four or five times more beds than the other homes I'm looking at. It's run by a local Jewish charity and it's been around for decades. Has a terrific reputation - it gets written up in all the local magazines - though D says she's had both good and bad experiences there.
Because of its size I was prepared to dislike it, but didn't. It does feel more like a hospital than any of the others - and in fact has its own physicians on staff, and hospital-sized nursing stations on each floor with a full hospital-style staff complement. But surprisingly, it didn't seem impersonal. There was a good level of interaction among staff, and between patients and staff. My tour guide - in this case called a marketing person, which is a little unfortunate - has a patient care background and kept interrupting the tour to talk to patients, and occasionally to head off to the nursing stations to get them attention when they needed it. The downside of this is that there were a lot of patients in distress and vocalizing about it. In that respect the place did seem more like a hospital - which means that I have to spend more time reviewing the staff-to-patient ratios. It could also be that the patients are livelier and more apt to vocalize, and some of the others I've seen have been apathetic or catatonic. It's hard to read the landscape and I don't know enough to be able to interpret it.
Negatives - while there's outdoor space, the patients don't get to use it. I asked, and was told that patients are taken outside about once a week, unless you have private-pay nursing or take them out yourself during visits. Clearly this is a staff ratio issue. One of the problems in a big facility is that bureaucracy takes over, and the patients are managed for the convenience of the staff. Possibly for that reason, Nursing Home 5 favors private rooms (in contrast to Nursing Home 1) - they showed me several and seemed eager to have me start the reservation process. There are dedicated dementia units, including a locked ward. As for the quality of the patient experience, it probably comes down to the quality of the particular supervisors and line personnel you're dealing with - which probably accounts for D's report about the mix of good and bad.
On the whole, the place reminded me of Mt. Sinai Hospital. That's not a complaint - I've had good experiences at Mt. Sinai and they're extremely professional, so the same might be the case here. It brings up the point, though, that none of these places are homes in any conventional sense. They're low-intensity hospitals. Some feel cleaner and more professional, some feel superficial and uncompassionate. None of them so far is warm. We're talking about warehouses for people who've fallen out of society but aren't willing to die quickly enough.
Which means that the assisted living facilities will be worth a look. That's a project for next week. Another project - track down the friend of a friend who's a local emergency physician, and who volunteered to give me his impressions of the health of the patients who live in the local nursing homes and wind up in his ER. That's not the kind of information you get from guidebooks...
An additional observation, for what it's worth - Nursing Homes 1 and 5 are nonprofit, in contrast to Nursing Home 2, which is a for-profit enterprise. That's probably a significant difference. The remaining two nursing homes on the list are for-profit, too, so I'll be able to put the theory to the test.
Speaking of profit, or lack of same - costs are going to be very difficult to figure out. There's apparently no such thing as apples-to-apples. Some facilities quote you a high day rate, but it's inclusive. Others quote a low day rate, but then add on - as much as $70 a month for laundry services, nearly $10 a day for "incontinence products." I'm going to need to put together a spreadsheet and line up all the a la carte items and see how they compare.
On the subject of finances: I need to get together with the Maryland elderlawyer fast. I'm still not clear on how the local Medicaid process works. There seem to be two tracks. Nursing Home 1 told me that I needed to file the Medicaid application immediately, then pay for care during a 20-month waiting period (not counting any additional asset transfer penalties that apply). Nursing Home 2 told me that I'd have to spend down all the transferred assets first, then apply for Medicaid once the assets are down to $2500. I asked what would happen during the (I assume) several months between spenddown and Medicaid approval, but nobody had a clear answer. Clearly it's time to call in the professionals again. The application process, whenever it hits, is going to be as daunting as it was before, up in New York - I've got to pull together the same reams of information - bank and brokerage statements and tax returns going back years, and multiple proofs of citizenship and eligibility. Still, I've been through it before, so while it's daunting, it's not as overwhelming as it was the first time around.
Bottom line: I can't say I'm enthusiastic, but it seems like we're making progress.
I'm still not sure at this stage that a facility is the best thing for him. There's something to be said for keeping him at home, at lower cost, with a good care establishment that I can trust. Seems like a shame to pull it apart, just because I can't travel to New York as easily anymore. Of course, a number of people, including M and Dr. B, have told me that he'll be better off in a nursing home... I'm not going to start those mental gyrations again, at least not yet. But note for the record that every good policy analyst includes "do nothing" as one of the options to be analyzed. You don't want to take action just for the sake of taking action. So when I'm weighing nursing homes against assisted living facilities, and nursing homes against each other, I'll also take a look at the New York apartment option and see where that rates.
That's all for today - it's enough. On Monday new calls and new appointments. With luck, more visits next week. Then, by the week after, a shorter list and a schedule of repeat visits and maybe some cleaner movement toward a decision. At least it's all happening now.
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