Tag Archives: Home Care

Will Doctor Shortage affect Residential Care and Assisted Living?

Interesting article that discusses a possible doctor shortage.  They note that even if everyone gets insurance coverage that raises questions about how the new insurance programs might affect doctors, seniors and the care settings that rely on doctors including Residential Care Homes and Assisted Living Facilities.

The article points out that offering insurance that does not pay the doctor adequately might give access to more people and not encourage more doctors to participate in medicine, to  go into medicine or to accept Medicaid even if it is offered.

Medicaid Growth Could Aggravate Doctor Shortage.




This is not a new issue.  While Medicaid pays 100% in most cases it pays 100% of 7-10 dollars or 7-10 dollars for a visit.  That is for a doctor’s office visit.  If you negotiate special rates like a hospital or the doctors in California the fee schedule might be more but in all cases the fees are less than it costs to provide the services unless there are other subsidies.  Hospitals get paid other ways and offer Medicaid covered patients care in their clinics.  I think of that as a lost leader but most doctors can’t do that so I see some truth in this article.  We need to ask how will expanding coverage increase the demand for doctor’s care and how will those services be divided or re apportioned.   Will Residential Care Homes and Assisted Living Facilities or other long term care settings be negatively affected?   Might doctors choose to care for younger healthy Medicaid patients with fewer needs if the same fee schedule is used for a doctor’s visit?  If so would fewer doctors opt to see the complex, sick, older patients?

I recall recently hearing that Medicaid pays for visiting nurse services just like Medicare does.  However, the compensation is so much less than Medicare pays that I could not find any visiting nurse companies that accepted what the covered Medicaid fee was for a visiting nurse visit.  While it was “covered” it was not available.  Has anyone experienced that or something similar?

Let’s start the discussion.

While Residential Care Homes and Assisted Living care settings are generally private pay and therefore won’t be directly affected from that aspect they will be affected in how difficult it is to get your doctor, see your doctor and not only seeing his assistant, and for the facilities to get the paper work they need.  Indeed, already the required electronic prescriptions cause issues for the Assisted Living and Residential Care homes who need the hard copy prescription for their files and often do not get it.

Time will tell how this plays out.  Let’s all help each other to learn and interact with these changes.

 Share your experience and comments here.

Check out these fantastic Residential Care alternatives to the Assisted Living and Home Care.  Compare Family -Style care of a Residential Care Home to Home Care and Assisted Living Facilities which are more institutional care models.

Residential care, Assisted Living, and Home Care all offer custodial care but what varies is the care team you choose when you choose any care setting.  Who is doing the day to day training, supervision, and support of a hands-on management and who is doing the custodial care?   Look for the care team to get the best Assisted Living, Residential Care, Home Care, Retirement Community, Hospice Care, Dementia Care, Alzheimer’s Care and Memory Care in any care setting.  Look beyond the setting label and find out who you are getting before you buy.
Tender Loving Care Senior Residence -Or
Tender Loving Care Senior Residential Care, Costa Brava 
Educational video links
TLCSRLV youtube Channel.  Subscribe for free.
Assisted Living and Residential Care Home Video Tour.
Assisted Living and Residential Care Home Testimonial
Dr Shawn McGivney

What is Home Care, Home Health Care, In-home care, skilled care and unskilled custodial care?

What is Home Care, Home Health Care, In-home care, skilled care and unskilled custodial care?

“Home care” is a simple phrase that has varied meanings for different people.  Generally, there are two types of Home Care Services-

1)- Home Health Care

services – which are services provided by a licensed professional, like a nurse (RN), Physical ( PT) or Occupational therapist (OT) , Speech therapist (ST) or a doctor (MD). They make physical assessments and provide specific treatments and teaching as directed by your doctor.

This is generally covered by Medicare but is on a short term basis and has to focus on one skilled need and not for the day to day care man y need and want.  Medicare generally pays for this for an episode that last about 6 weeks or 10 visits and then needs to be reevaluated.  While Skilled Home Health Care is paid for by Medicare on a short term basis, the custodial care, or Day to day care,  is usually not paid by insurances and is private pay.

2)-  Home Care

services- which are provided by personal care assistants, Certified Nurse Aides (cna), Home Health Aides ( HHA) or caregivers.  They provide custodial care or assistance with Activities of Daily Living (ADL’s) like dressing, bathing, cooking, cleaning etc..   While cna’s, hha’s, and caregivers have many labels to describe custodial care givers the training is similar and is very simple and basic.  The main training is to make sure caregivers of all labels are screened for criminal records and are free of contagious disease.  The training or licensing is met by a quick care doctor’s employee physical  and TB screen.  That is the general training required by the state or the agency hiring them.  As in most jobs the more advanced and targeted training comes after they are hired from the institution you choose.  That owner, administrator, doctor or supervisor of those caregivers is the one who will be training, adjusting the training, and modifying the training to meet the individual patients needs.

In fact, care giving is a highly skilled job and requires advanced social skills, patience, a personality of a caregiver like a mother, medical skills and familiarity with medications and the process to obtain, administer and monitor their effects, and use DME (Durable Medical Equipment) in the process of carrying out the doctors and skilled nurse’s orders.  Even more important is that this training is ongoing by the doctor, administrator, managers of the agency who is supervising the home care workers to ensure the training is individualized and adjusts as the residents care needs change.  We caution all to look more closely at whom you are getting as a caregiver and who you are getting to fill that role as the caregiver’s supervisor, trainer, and manager when choosing any care setting.


Costs of custodial home care.

Custodial home care is generally private pay and is not covered by Medicare or Medicaid.  Medicaid does have some waiver programs but these are not the standard and require that you are poor and have Medicaid. For most people these services of home care and personal care are private pay.  The Medical, Short term, Skilled Nursing, Home Health care noted above is short term  and only supplements the family care or privately paid custodial home care services.

While many will say why isn’t custodial home care covered by insurance, the answer is a practical one.  If it were covered all would want live in, 24/7, day to day help for custodial care, housework, shopping, or a personal maid and caretaker.  Of course, that is a job for families and is not generally available.

Ways to get the Best, Most Cost Effective, Home care.

In fact, the custodial care team you choose, administrator, supervisor, and manager and direct care staff, will provide, execute, and be a big part of the medical treatment and execution of that treatment your doctors orders.  Taking the time to find the best care team will be the most important part of your plan to save money, reduce redundant and disjointed care, and get the best value for your private pay senior care dollars.  If you think of any service team you can understand that while the coach or doctor makes suggestions it is up to the direct care team to execute that plan.  Also it is up to the players in the trenches to tell the coach that they are getting beat on the rush by the other side so that the coach can adjust and double team that opponents player who is beating his player.  As we know admitting you need help or are getting beat is difficult and we believe that is a skill that the care team system develops by developing trust among and between the administrator, manager and caregivers or in this example coach and his players.

What we can do is to take the time to meet the care team that we do hire in any care setting to assist us when our loved ones start to need a little assistance. 

Meet the entire care team including the owner and administrator who will train, direct, manage the care no matter what setting the care is provided in including Assisted Living, Residential Care Home, Home Care, Hospice Care, Retirement Communities, Dementia Care, Alzheimer’s Care, and Memory Care.  If you have not met the owner, administrator and caregivers you do not know who you are getting.


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Check out these alternatives to Home Care and Home Health Care. 

These care settings offer custodial care but with day to day training, supervision, and support of a hands-on management with decades of medical and custodial care experience. Look for the care team to get the best Assisted Living, Residential Care, Home Care, Retirement Community, Hospice Care, Dementia Care, Alzheimer’s Care and Memory Care in any care setting.  Look beyond the setting label and find out who you are getting before you buy.

Tender Loving Care Senior Residence


Tender Loving Care Senior Residence, Costa Brava  –

Educational video links

TLCSRLV youtube Chanel.  Subscibe for free .

Frustrated with Home Care Service? Get Home Care answers here! 


Dr Shawn McGivney


High Tech or High Touch to Age in Place?

Aging-in-Place-tlcsr.comHigh Tech or High Touch to Age in Place?

Will Video chat and online telecommunications really make it possible?

When I read the NYT article Choices Give New Meaning to “home Sweet Home”


My first reaction was they are missing the main points of what is needed in Senior Care and Aging in Place

.  Seniors need interpersonal, human, contact and the emotional and social connection that brings.   

 Seniors generally miss the lack of social contact, lack of being needed, even if it is needed just as a companion and co TV watcher.  Somehow I don’t see an  I-pad screen sitting next to you and watching your TV in your home with you will replace the feeling and idle chit chat having a real person in the chair next to you offers.

video-monitoringWhile video conferencing will undoubtedly be a tool it more reasonably

will be a tool a new breed of old fashioned, primary care doctors who accept the role of being a full time Doctor and the responsibility of making all the medical decisions.  

They will visit the house, know your family and social system and then can use these tools to support that direct, personal, attention all people need.

Know-Your-Doctor!If you build on the care team idea and continuity of care with ONE DOCTOR who does home visits, sees you in your own home regularly, and then add in some outside Home Care, a Back up video monitoring option that can succeed.

While the programs and ideas we have known and used for decades, simple home modifications, and meals on wheels do give hope to those who are at home they will not begin to replace what they really need which is a doctor supervised home care team where the doctor visits, knows the senior and the seniors entire family.

In the picture of the NYT article it looks like the two granddaughters and their mother all are very involved in the care of their grandmother.  If you have the human staff, then of course staying home is possible now!  The point I do not want you to miss is no technology will replace what senior’s need which is care and care from the same, consistent, care team.  If that is your own family and family are at home and not working then of course that works.  Even then you will do best with a Doctor and back up care system of known doctors and caregivers who you have an interest in and who in turn have an interest in you.

High Touch before High TechSeeing a new doctor, new caregiver, is always the same no matter what their training. 

That is a new interpersonal contact and as a new interpersonal contact their can only be the care and caring two people share on the first hand shake and no more. 

No one just feels safe when meeting any stranger and the stranger also takes time to earn trust from you.  That is how relationships and caring that comes from a relationship develop.  I do not see technology replacing that any time soon.

High-Touch-before-High-TechTechnology is good, if the Senior is able to interface with it and does not have ANY cognitive decline but that is exactly why all seniors need home care, they can’t do it for themselves due to physical and or cognitive decline in function.  If they can use the technology then they don’t need it. 

Moreover, if they can do it now when they age more this technology only plan will fail.

If the senior has used video chat in the past of course then they might be better able to use it now.  Most have not and are two or three decades removed from that technology.

Finally, communication skills will vary, language, and social customs and maybe most importantly understanding the fine print of your insurance.  What is covered and what is not will always require a care giver and generally younger person to sort out for most seniors

What is needed is Coordination of Care from the top down.  You need a doctor you really can call your own.


Instead of looking for video conferencing one might look for care settings like

Tender Loving Care Senior Residence

Tender Loving Care Senior Residence, Costa Brava

Where they offer continuity of care, complete with a relationship you can count on as you age.  They too use email and internet but we use it to help the family remain connected to the parent.  We know families all want to have the physical plant, staffing, skills and time to be able to care for their parents but often time s they do not have all of those resources.   We have staff sit with residents to email the families to help the FAMILIES feel connected and less guilty that they can’t do more.

When it comes to providing human services Technology is only as good at the Individuals and the relationship they have to expand that relationship.  If you text a stranger you will be less inspired than if a known friend texts you and shares the same idle chit chat.  If you don’t know your doctor or are meeting a new doctor 3-4 times a year it is likely those will be “first dates” with the trust and caring that goes with a first date as opposed to trust that is earned through a relationship.

Value the direct care team and you will get the best care and best value for your Senior Care Dollars.

Disclaimer. I am a doctor who offers old fashioned primary care in a residential care home and know all of the patients and families by their first names.

Dr Shawn McGivney

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Hospital and Nursing Home InActivity VS Exercise in Assisted Living

Hospital and Nursing Home Inactivity Vs Assisted Living

Is Nursing Home rehabbing the best exercise after the hospital or is Assisted Living with structured care and doing daily exercise a comparable choice? 

This NYT article raises a good question about activity in the hospital and by extension Nursing Home Rehab where you are on your feet 43 minutes a day.  They go on to point out that if you are allowed to walk more, provided an setting or support system that encourages twice or more a day activity that is better than less activity.  We add in questioning the definition of the phrase “rehab” since we believe that confuses many who would walk more, do more, if they were allowed to be in a setting that encouraged ambulation.  For example being on your feet more, walking to meals, doing day to day tasks that most people would do in a more supervised Assisted Living or structured care setting might give one more activity than in many hospitals or other nursing home type settings.

Trapped in the Hospital

Paula Span

http://www.tlcsr.com/blog/|nursing home word pic

Nursing Home Rehab vs Assisted Living that has adequate staff and continuity of care to do assisted activity with seniors


A nursing home, which is the most common form of senior rehab, might only have them on their feet for 43 minutes a day.  While the senior gets “rehab” from a licensed physical therapist  they don’t get a lot of walking and ambulation for the remaining 23 hrs a day.  If walking and ambulation are rehab then one might get more “rehab” or exercise in an Assisted Living or Residential Care home that focus on continuity of care and activity.

Just because the hospitalist doctor, who generally does not know you, and might have less  interest in your condition months later since he does not expect to see you,  suggests “rehab”, meaning nursing home rehab  don’t assume you will get a lot of exercise.   In fact, the system delegates your rehab to just the time you are in rehab which is not very long.  The staff do their jobs but the floor staff like the senior  to rest, and not get up, since they don’t have time to supervise that.

If you knew your doctor, your doctor participated in the care both in the hospital and after the hospital he might feel differently about your expected functional decline in nursing home rehab.  Now the NYT is confirming this view.

We caution that all Assisted Living Homes may not have adequate staff or systems set up to allow or encourage mobility but note that if your setting favors continuity of care and senior independence it might be a good alternative to Nursing Home Rehab.  All of these are speculative and each needs to discuss this with their doctor and health care team.

Free or paid by Medicare nursing home rehab  is not always the best care, most care, or most exercise.

We bring this point up since many hear that nursing home rehab is free or covered by Medicare for 100 days.  They want to use up this free resource.  At first glance saving a few bucks is a good ideas but when you consider that many my decline further and  not regain their previous community mobility with extended nursing home or hospital  stays and the inactivity that accompanies them.

All nursing homes are not the same. Some staff will get you up and walk with you but practically it is hit or miss. Also management will direct staff to stay on task and walking with residents takes time, time that staff could be doing something else. Also walking with residents is risky for the institution in that the patient might fall so they want to be extra safe.  Of course the senior wants to take that risk since to live a full life requires walking.  If they fall it wont be the first or last time and that is ok.  Aging and life are risky.

Example of a Assisted Living Care Option that probably does offer more exercise and supervision than many hospital and rehab settings.

At http://tlcsr.com we have a negotiated risk agreement with falls and encourage people to walk knowing that our encouraging then will encourage them to do more and when they do more they might not ask for help and fall.  That is an acceptable risk the patient and family agree to which is the negotiated risk agreement.  That should become a model for care.

Read this and share your comments.

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 Click for The Best, Most Cost Effective, Assisted Living and Senior Care Alternatives.

Tender Loving Care Senior Residence

TLCSR, Costa Brava

Dr Shawn McGivney

10 Things Assisted Living Homes wont tell you!

10 Things Assisted Living Homes wont tell you!!  Smart money tells you what to watch out for when dealing with an Assisted Living Sales Person.

We generally take a more postive view and talk about focusing on continuity of care and complete care but felt this was right on and wanted to share it.

We especially note how seniors and their families are mislead by their views that they need only a little help and avoidance of the fact that they will need much more care in the very near future if they need any assistance today.

If they dont need assistance and there is no reason they are looking for an “assisted” care setting then one might ask why are you looking?  What we see is the Assisted Living sales force promising what other caregivers will do for them.  However, the details of there are 3 caregivers covering 50 residents in a large area is a detail that is missed.

Smart money notes that Assisted Living is a short term fix.  That is because they cost alot for the limited care they provide and when the increased care needs come many are forced to move.  Also in general Assisted Living has 1 administrator in charge of 150 sick people.  Common Sense tells us that the level of direct protective supervision might be in question.

Assisted living and home care generally are the lowest values for senior care dollars. They prey on a seniors desire to remain indepenent and young and falsely advertise that they can keep them living at home or in a hotel type care settings. Those are just not reasonable assumptions. Seniors need to be cautious of all care settings and spend time looking for continuity of care.

Read the 10 Things Assisted Living Homes wont tell you by smartmoney and let us know which ones you like or add your own.


How do you balance cost and value? While reducing staff helps the businesses bottom

line is that helping you get the most care, best care, and continuity of care you want?

Is that a good value for you?
Help us spread the word.  Click for Free Ways to help.

It is up to you to make this viral!


Two examples of great value for your senior care dollars.  Both offer continuity of care!

Tender Loving Care Senior Residence – Great alternative to Assisted Living In Las Vegas and Home Care In Las Vegas for heavy care needs, memory care, dementia care and Alzheimer’s Care.

Tender Loving Care Senior Residence, Costa Brava – Great Assisted Living in Las Vegas and Home Care in Las Vegas for more active seniors transitioning to needing assistance.  Both offer high levels of continuity of care.

Dr Shawn McGivney

Physical care VS. Emotional Caring In Assisted Living and Senior Care settings in Las Vegas

While all care settings try to differentiate themselves Assisted Living, Home Care, Dementia Care, Alzheimer’s Care, Memory Care, Hospice Care, Residential Care, Elder Care all offer the same thing – CARE!

What varies is the degree of caring you get and feel as both a resident and as a staff member or provider.  Both resident and staff feel better if they know each other and have some kind of a progessional or social relatioship.  That is why continuity of care and having a relationship is so improtant.

Going further physical care could be described as just doing the task like giving a shower.  Caring might be the added small talk about a common event that makes both people share the moment or have a relationship of sorts with the physical care.

In fact there is a significant difference between doing the physical task of giving a shower and then giving a shower combined with a friendly discussion of recent events, recent visitors, or activities both care giver and resident have experienced in the day to day life. That later is emotional health and goes a long way to change physical care inot caring and maximize emotional health for both caregiver and resident.

We believe this is a small part of starting to explain the power of relationships, the humanism needed for and involved with in care and caring.

This distinction applies to “care” in all care settings Assisted Living, Assisted Living Facilities, Home Care, Hospice Care, Medical Care, Dementia Care, Alzheimer’s Care, Memory Care, Elder Care, Respite Care, Hospital Care, Residential Care, and all of the care settings.

What is “skilled” care vs custodial care.

http://tlcsr.com/blog | assistance

Caregiver is a skilled position even if some do not describe it as “less skilled”

Insurance companies constantly try to define custodial care as something less, of lower value, lower price than “skilled” care. In fact, people pay more attention to the caregiver than the insurance defined skilled views of the nurse or doctor. the reason for that is trust and continuity of care. When, not just if, something happens in the day to day life of a frail senior who needs assistance the only skills that will matter are the skills of the person the resident can get and that in general is of the caregiver. The caregivers interpersonal skills, compassion, caring are used every minute of every day to provide feeling good, comfort, redirection and to help empower the senior to remain positive, active, productive and feeling good. That in fact is a skill. Call it patience, compassion, good family values, faith in God, but whatever you call it that is indeed what the senior needs and wants.


http://tlcsr.com/blog-trust-honesty-comittment Words and ideals we all value highly

Caring is therapy for someone who needs assistance.

What is the “Value” of not getting “care” from the controlling Caregiver? How can a senior who needs assistance really monitor and protect against this? Care Setting and the leadership being hands on, day and and day out, from top levels of ownership down to the caregiver is essential and the only way to provide care with caring?

The alternative might meet a physical care need but at what emotional cost.  These images of the controling caregiver are firghting to most seniors.

http://tlcsr.com/blog | abuse-man- in-wheelchair Scolding and Control are not caring

http://blog.tlcsr.com | Controlling-Staff Controling Staff.

Cost to the Senior of a Controlling Caregiver

Patience, interpersonal skills, and familiarity with dealing with a person who is older and has many complex medical issues that are unlikely to resolve is a skill. Unlike dealing with a child where cure is likely and possible in this case cure and getting younger is much less likely. Seniors know that but no one including the senior will say that. It is ego dystonic, to say you want to die or accept getting old even though we all do it every day. God or a higher being can play a role and does increasingly play a role as we get older and more disabled. As humans we need things to believe in and God and the best interpersonal skills you can find are the first line treatments for all that ales you.

Emotional health and Feeling is the final expression of all disease. 

Patch Adams, in Movie Patch.  If you treat the disease you win or loose but if you treat the person you win no matter what the outcome!

No matter what the label Alzheimer’s, Chronic Pain, CHF Congestive Heart Failure, Arthritis the end result will be I don’t feel good. Doctor are trained to look only at the physical part but the many levels of social and emotional therapies are often over looked or discounted. Be it due to physical pain, depression, fear of the future all diseases are expressed the same way. You feel bad. Doctors cant describe it, define it, or study it but we all feel it and can understand it. Indeed, your doctor is uniquely positioned to help you balance cost, effect, side effects, incidental social and implementation and even financial consequences of all the physical and emotional or social choices that are available to you. If you were a doctor you would know the physical stuff and if he were you he would know the social stuff but when both of you have a relationship and know each other continuity of care, caring and the best outcome are possible. That outcome is feeling the best you can given your unique, individual, set of physical, social, and financial illnesses. While many try to be “case managers” including elder law attorney, social workers, nurses in fact there are only two real choices you since you are the most aware of your social and emotional health or how you feel and / or “your doctor”. I use the term “your Doctor” going back to a time when continuity of care was the standard. Hopefully this blog and your examples can help others value people in our lives.

Some People incorrectly under value those who keep the Family, Social System, and Frail safe.  Mothers, Teacher, Doctors Caregivers.

-A mother who works all day to care for the kids and husband and arranges the social system. Not easy, but not values by dollars.
-a Teacher who listens, stays after class to help someone who is behind so they are not embarrassed to catch up or get a head.
-a care giver who calls and visit when you go to the hospital. or is available to look after your kids and your grandmother because she can it helps the bigger system out.
-a doctor or lawyer who goes beyond the standard description to help you understand the system and potential related costs.

All of those examples are things that are “not needed”, not valued in dollars, but are often provided to take physical, “less skilled” care to the highest level of care and include caring.

Comment to help others see the value of people in their lives.
Help us spread the word. Click for Free Ways to help.
Click for The Best, Most Cost Effective,
Assisted Living and Senior Care Alternatives

Dr Shawn McGivney