Episode 4: The Language of Health Care
“Episode #4 – The Language of Health Care” by Sue Lanza and Shawn Carty. Released: 2021. Track 4. Genre: podcast.
Transcription
Sue Lanza:
Hi, everyone. And welcome to another episode of House Guest, the podcast about all things related to the House of the Good Shepherd, a retirement community in Hackettstown, New Jersey. I’m Sue Lanza, the CEO. And I’m joined today by my co-host the Reverend Sean Carty, who is our chaplain. Please enjoy.
Rev. Shawn Carty:
Well, so shifting subjects a little a bit, why don’t we talk a little bit about some of the different kinds of care that we offer here, because we have a variety at the House of the Good Shepherd?
Sue Lanza:
We do.
Rev. Shawn Carty:
We’re not a single kind of place. We have different levels. So tell us about that.
Sue Lanza:
Yeah, we’re technically what’s called a CCRC, which is-
Rev. Shawn Carty:
Another acronym.
Sue Lanza:
I know. I know you love them. And it stands for continuing care retirement community. And what that means is that you have a number of care levels available on one campus. So in theory, residents, who need something, can advance maybe temporarily to a different level and then come back, let’s say, to their independent living. So we have three levels here, actually four when you think about it. We have skilled nursing, which is the highest level of care. It’s also called post-acute care, longterm care. And it’s almost like having a little mini nursing home upstairs. A lot of places are free-standing nursing homes. They don’t have any of the other services. So we have a skilled unit here.
We also have assisted living. So these are folks who need little help with certain things, maybe medications, maybe what they call activities of daily living, ADLS, another little acronym.
Rev. Shawn Carty:
Another acronym.
Sue Lanza:
And that’s just everything, eating, dressing, feeding, whatever it takes for you to get through the day, whatever all your activities are that you think of that you do in the course of a day from making your coffee all the way to getting ready for bed and brushing your teeth. That’s the kind of thing that we would offer assistance with.
Rev. Shawn Carty:
And also managing medications and things like that.
Sue Lanza:
Yes, absolutely. Another type that we have here is what’s called CPC, another acronym, and it’s a comprehensive personal care. And a lot of them are maybe free standing. They’re not part of a bigger campus, so it’s sometimes it’s called CPCH, comprehensive personal care home. And it’s a form of assisted living where they have access to similar things. And in our particular case, that’s where we have a license to bring some Medicaid residents, whereas our assisted living does not. So that’s for us.
And then we have independent living. We have independent living in all different forms. We have smaller apartment studios, one bedroom, two bedrooms. We have them out in apartment building out in the village, which is right outside our main building. And then we have some cottages. So people can live independently, and if they need these other services, they can come and take part in that.
Rev. Shawn Carty:
My understanding, tell me if this is right, is that independent living, we do not provide medical care-
Sue Lanza:
That is correct.
Rev. Shawn Carty:
… unless it’s absolute emergency. Somebody falls. Of course, we’re going to provide some medical assistance in that situation. But generally speaking, folks who live in independent living, if they’re not feeling well, they call their doctor.
Sue Lanza:
Exactly. And this is something that some people have trouble grasping, especially if they’ve come into our building, they’ve been in independent living, and they’ve to use some of our other services. They get to know the staff up there. We do provide some small services at times for people, like for instance, we might do filling a medication box for someone, who lives in independent living, or we check their pendants. Some folks have pendants that they can press for emergencies, things like that. But yes, we do not do that. So if someone has a fall or another situation, we’re going to call 911 and help them get assistance and maybe provide some initial first aid until 911 arrives. But yes, you’re correct.
Rev. Shawn Carty:
Okay. What are some of the other options? And I know you come with a wealth of experience, having worked in this field for quite a while. We offer a lot here, but we don’t offer everything. So tell me about some of the other possible things that you might find elsewhere.
Sue Lanza:
Yeah, memory care is one that is seen a lot, mostly in assisted living sometimes in skilled care. But it’s a specialized program. And it’s more like a social model, less medical, because some of the folks that have memory issues, their bodies are intact and raring to go, but their memory is what’s failing them. So the program really needs to geared around the social model, higher level of activities, lots of environmental cues, and a unit set up so that there’s lots of little spaces that people can wander safely, find little spots, find activities that they can rummage, do things, and really kind of make their day a little bit more interesting. That’s one.
Then there’s also residential care, which is very similar to assisted living, but, again, there’s not a focus again on any medical component there. It’s a different type of licensing. Same thing with boarding homes. We have a boarding home that’s near here in Hackettstown. And boarding homes, family members will say, “Well, why can’t I just go to the boarding home?” “Well, you can, but it’s not going to be like assisted living, where there’s going to be staff that’s going to provide medical care for you.” So you just have to know is that what your loved one really needs?
Then there’s the very high level way above what our skilled unit would be, and there’s two different kinds. One is called an LTAC, and it’s really a long term acute care hospital. It’s usually used for people who come out of acute care. They’ve had a hospital stay, and they need to have some kind of a long-term stay, but it has to be at a very acute level, meaning high levels of nurses and things like that. The other thing is sometimes people leave the hospital, and they don’t need a nursing home or a skilled unit yet. They need what’s called acute rehab. This is rehab that’s offered many hours a day, three, four hours a day. An example of this would be Kessler, so people know that name. And usually somebody goes to something like that if they’ve had a stroke. They need a lot of intensive rehab. And then they step down to a unit like ours in skilled, and then they would get more of the maintenance care. We still offer rehab, but it’s not going to be three or four hours a day.
Rev. Shawn Carty:
Mm-hmm (affirmative). So in acute care, the word acute, I’m just thinking about this. I think of the word acute means it’s more serious.
Sue Lanza:
Yes. It’s immediate.
Rev. Shawn Carty:
Yeah. So when we talk about subacute care, it means it’s a little less serious.
Sue Lanza:
Look at you. Look at you. Did you read the book that we gave you?
Rev. Shawn Carty:
I don’t know if I did.
Sue Lanza:
And they call it post-acute too.
Rev. Shawn Carty:
And then post-acute means-
Sue Lanza:
Same thing.
Rev. Shawn Carty:
…that someone has been in a serious situation, and they need… We also use another term for that however, that I’ve heard is rehab. Is that fair to say?
Sue Lanza:
Yeah. And rehab’s sort of a throwaway term, meaning, “You’re going to go get rehab. You’re short-term, and then you’re going to go home.” That’s usually what it means. But subacute and post-acute are basically saying, “You were in acute care setting in the hospital. You don’t need that high level of care anymore. You’re ready to go down to the next level.” And that’s kind of what we’re here, post-acute.
Rev. Shawn Carty:
Okay. Yeah, that makes more sense now. So let’s make things really complicated and talk about money-
Sue Lanza:
Oh no.
Rev. Shawn Carty:
… because as I have learned, and I know only a minuscule part of this I am sure, one of the things that we pay attention to, as we do our work here at the House of the Good Shepherd, is how is this going to be paid for? And there are lots of answers to that question.
Sue Lanza:
There are. There are a lot of answers, because anything that we look at here has to do with what level of service does someone need, and you know the word, “How independent are they?” And the other piece is then, “What’s their payer source? How are they going to pay for it?” And some of them have different things. So let me just go through them. And the place where it gets the most complicated makes sense. It’s up on our skilled unit, where we have the most complicated care on our campus happening. So there, we have a number of payer sources possible. One is private pay; people can pay out of pocket for care.
People can pay using a combination of what they call their Medicare Part A benefit, so they would’ve had a hospital stay where, traditionally, you would have at least three days of a hospital stay for the same type of thing. Let’s say you went in for a hip surgery. You were in there to have your hip surgery. You were in there for more than three days, let’s say. Then you come to us for your post-acute care. Your Medicare Part A skilled benefit would be what would pay for the first 21 days, if you needed them. But of course, there are guidelines that we don’t use up the all the days. And you may need 21 days. You may need eight days. Who knows? It’s a dependent factor. But on the 21st day and beyond to 100 days, you’re in a co-pay situation. Medicare will pay for some of that. But then the individual has to pay for the rest. Sometimes they have an insurance that will cover that, like a secondary insurer they call that, whereas Medicare is the primary insurance. And otherwise they have to pay for it. And each year Medicare comes out with an amount that is the copay amount for that every year. So if you came to our building, it would be the same amount as if you went to Alabama. It’s going to be the same amount for that copay.
Medicaid’s the other one. So Medicaid is a state program. It’s a federal program, but it’s state initiated. So there’s differences in the state. And it is for individuals, who meet certain qualifications financially. They have to have a certain spend down that they’ve reached, and they’re kind of out of resources, so this is going to be supplementing their care. And the Medicaid office determines what they call their budget and their budget is they have maybe some income coming in, maybe social security check or a pension check. They turn that over, if they’re qualified, to the facility and then the facility gets of some reimbursement in addition to that. And that makes up the payment for their stay with us.
Then we have managed care and insurances. Everybody’s heard of Aetna, Cigna, Blue Cross Blue Shield, United Healthcare. Those are all examples of managed care contracts. And each facility would have a different group that they’re contracted with, and then they would have a rate that, depending on what goes on here, that the insurance company would actually pay for us for a daily rate, that’s contracted just for us for that stay here. But they also get weekly updates when someone’s on insurance, and they can get cut, like, “Okay, the insurance company has decided you’re done, and you’re going to have to be discharged.” So when we have someone on insurance, it’s the same thing with Part A if somebody’s staying with us for a short stay, we have to make sure that they have a safe discharge plan, because that insurance company could cut them right off, and they need to have a place to go that’s safe for them.
The other thing is hospice care that you can contract with different hospice providers, and they’ll provide different levels of care for someone, daily visits by a nursing assistant or weekly visits by a nurse. Different companies offer different situations, but room and board is not paid for. So you’d have to either pay for it privately, Medicaid, or some other manner, like sometimes long term care insurance. So it’s complicated.
Rev. Shawn Carty:
It’s very complicated.
Sue Lanza:
It’s a lot of like, “Blah, blah, blah.” I saw your eyes rolling back in your head. Let’s be honest. I know they couldn’t see this on the tape.
Rev. Shawn Carty:
The one I probably know the most about is actually the one you just mentioned, which is how hospice care-
Sue Lanza:
Oh, you’re right. You do know about that.
Rev. Shawn Carty:
… because I have family members, who work in that area. And I would simply, at this point, want to put in a little bit of a plug to say, and this is partly from my perspective as a priest, “Plan ahead. Think through these things.” All the clergy I know would be delighted, I put a little caution around that, but delighted to talk about thinking through living wills and thinking through all kinds of things related to hospice care. Because as I have seen over the years, hospice care sometimes opens up opportunities that people don’t know about, that there’s a level of care that they can receive, because of that. When you’ve made some decisions around how you see your care going in the future, sometimes hospice care can support those decisions in ways that people haven’t thought about. So something important to think about.
Sue Lanza:
No, you’re right about that. No, that’s a whole topic in itself of the whole hospice continuum, because we often have people, who are here, and this happens in every facility, not just unique to here, where they hear hospice, and they just think, “Oh my gosh, Mom’s going to be dead. Well, how can this be?” And people go on and off hospice. They get better, and they’re fine. It doesn’t mean you’re going to die tomorrow. Often people don’t avail themselves of those services until it’s so far down the line that they’re not even able to take advantage of some of the good things that hospice offers, so…
Rev. Shawn Carty:
Right. Well, as I’ve often said to people, it won’t kill you to talk about death.
Sue Lanza:
Good point. Can we put that on a T-shirt?
Rev. Shawn Carty:
We can probably do a whole podcast on that.
Sue Lanza:
We probably could.
Rev. Shawn Carty:
So…
Sue Lanza:
Yeah.
Rev. Shawn Carty:
So what is involved in someone coming to the House of the Good Shepherd or another place that might offer them some housing or care that they might need? I know it’s based on the payer things, based on the different levels of care. It’s complicated, so I would imagine that the admissions process is something that has to be done pretty carefully.
Sue Lanza:
It is. And admissions is really for skilled nursing. You’re getting a referral from another facility, and that’s another term. A referral is just… And we have different ways of getting them. We get them electronically. We get them by phone. We get them by fax still. And a referral simply means person X is in a facility, like let’s say the hospital will near us, and they’re in need of some type of post-acute care. So we have to evaluate that and see, “Do we have an appropriate bed? Can we care for them?” And then based on all that information, we’ll make a decision. The director of nursing will look at their clinical needs, will assess their financial needs. Is there a payer source? And if we can meet all of those, and we have an appropriate bed, we will bring them in.
The application process is more of something for somebody, who’s at home and is thinking of moving into, let’s say, assisted living or comprehensive personal care, or they’re going to come into independent living. They’re going to make an application. We’re going to get some basic medical information, just so that we know kind of where things are. And then they’re going to be evaluated again from their financial side to make sure that they can stay here with us for a period of time.
And then, we have this thing on skilled kind of called the payer mix. And this is sort of those secretive things, but we look at how do we have a mix of people that able us to stay financially solvent. And every facility has this, because you can’t really survive, if you just have one level of service. If you have all Medicare people, you’re going to have a high level of staff. You’re going to need so many nurses and so many aides. But if you had all Medicaid residents, you might not be able to pay for all your staff. So having a healthy mix of those, of long-termers and short-termers, who come and go, it makes for a good unit.
Rev. Shawn Carty:
Mm-hmm (affirmative). Well, I can say too, from my perspective, as chaplain here at the House, that one of the wonderful things about this place is that it does have a diverse group. We have folks of varying levels of independence and varying levels of need medically speaking. And somehow, we all get to be part of this one big place called the House of the Good Shepherd. And you and I know from previous podcasts that we used to talk about this place as the family. They would address letters to the residents here as, “Dear family members,” not family members of the residents, but the family here at the House. And there’s a, I think, kind of a nice mix of that.
Sue Lanza:
There is, definitely, definitely. I think people get to know each other too, by the fact that some of our independent folks or assisted living, they move through different levels, so the whole building knows everybody that’s somehow or other. So it’s interesting.
Rev. Shawn Carty:
Well, a funny little example of that just recently, that, as you know, right now for chapel services, we can’t have a complete mix of people. It’s folks from a particular area of the house, so independent living or assisted living or folks from skilled nursing. But we do have a camera in the chapel. And so folks from around the house are participating in the services by watching on their TVs. And I hear very often from people saying, “Oh, I haven’t seen so-and-so for so long, because they’re in a different part of the house. It was so nice to see them on the camera at chapel,” just to caught a glimpse of somebody. And we really are; we’re connected to each other. And I see that over and over with our residents, how much they care about each other. And someday, we’ll get to do things altogether again. I know we will, but right now it’s a-
Sue Lanza:
We’re still waiting for that, but we get closer all the time.
Rev. Shawn Carty:
We are. We are.
Sue Lanza:
Yeah.
Rev. Shawn Carty:
Now there are some other terms that we use here that I thought I could ask you about.
Sue Lanza:
Oh, my goodness.
Rev. Shawn Carty:
So I’ve got a little list here. One of them is the word census. And I think I know what this means, but you probably have the definitive answer.
Sue Lanza:
Well, when we think of the word census, we think of the census takers that come, and they’re taking it. We find out how many people are in the United States.
Rev. Shawn Carty:
Right, every 10 years, it’s… Yeah.
Sue Lanza:
Yeah. When we’re talking about the census, we’re talking about what are the number of people in each service area that we’re taking care of on a particular day. And it’s very important to us to keep track of that, because we do billing according to that. We have to know Mrs. Jones had 21 days of this service, and it’s billed at this rate, or they were out for a period of time. We have to keep, and we do keep, like every other facility, very detailed records of this for billing purposes.
Rev. Shawn Carty:
Hmm, okay. And how is that different from occupancy?
Sue Lanza:
Occupancy is however many beds you have or… We call them beds in skilled, but apartments in the other areas. Of that number that you have, what is the percentage that are occupied at that time? So we have certain occupancy goals that we want to keep. Having a campus that has 90-plus percent occupancy makes for a thriving community. It’s not happy, when there aren’t as many people. And I know in the first year of COVID, it was kind of an up and down thing. But then in the last year, or six months to a year, our occupancy in a lot of our areas grew tremendously from a lot of marketing events and kind of getting back out there. So it makes for a great community to have a higher occupancy threshold.
Rev. Shawn Carty:
Yeah. It feels fuller. And you’re bumping into people in the hallways and things like that.
Sue Lanza:
Yeah.
Rev. Shawn Carty:
Now, I know we’re responsible to follow directions from a number of different organizations, including one that I know this is acronym, CMS.
Sue Lanza:
You do?
Rev. Shawn Carty:
I do.
Sue Lanza:
Go ahead. Tell me what it is.
Rev. Shawn Carty:
Centers for Medicaid Services.
Sue Lanza:
Medicare and Medicaid.
Rev. Shawn Carty:
Medicare and… Okay, I was close.
Sue Lanza:
No, you were good. That’s good.
Rev. Shawn Carty:
And then of course, the Department of Health and Department of Community Affairs, and those are state organizations, right?
Sue Lanza:
That is correct.
Rev. Shawn Carty:
So tell us what those groups do and why they’re important for us to know about.
Sue Lanza:
So the center for Medicaid and Medicare or the federal government, they’re the ones who tell us kind of, “These are general guidelines.” So there are federal guidelines and rules that we have to follow. And some of them, they’ve been dictating a lot of the directives regarding COVID and the vaccine and all these other things. So you see them. They’ve been in the news more, I think, than they’ve ever been their whole life. But we get funding from Medicare and Medicaid. We bill them for services that some of our people have, so we have to follow their rules. And they call them rules of participation, meaning rules of participation in their program. So if you’re not following these rules, you can’t take this money, so there’s certain things we have to do.
On the state level, every state has their own department of health, and ours might be more stringent in some areas or less stringent in some areas than CMS. Whichever the most stringent rule is, is the one that applies. So if let’s say how we take care of medical records in New Jersey is more stringent than what the federal government says, that’s the one that plays out for us. Department of Health is the one, who would oversee the licensing and regulatory structure for skilled, assisted living, and the CPC, the comprehensive personal care, situations. The Department of Community Affairs in New Jersey is the one that oversees the independent living, which doesn’t have a true license, but we have certain guidelines that we have to follow. But they’re much more vague compared to the stringent guidelines we have to follow, let’s say, for the skilled unit.
Rev. Shawn Carty:
I see. Okay. Now there’s one word that I have learned strikes fear in the hearts.
Sue Lanza:
Oh Oh no, no, no. What is it? Oh, no, don’t scare me with this.
Rev. Shawn Carty:
It’s the word survey.
Sue Lanza:
Oh…
Rev. Shawn Carty:
I will tell those who are listening to us that I learned very quick, when a survey is happening, one of the most important jobs I have is to pray.
Sue Lanza:
Well, I was going to say, I thought you were going to say hide, because you also go and hide somewhere. I don’t see Sean for weeks [crosstalk] time.
Rev. Shawn Carty:
I call that, “Working on my next sermon.” But in any case, it strikes fear into the hearts for folks, although don’t know that it necessarily needs to. But it’s essentially, would inspection a word you could use?
Sue Lanza:
Yeah, it’s an inspection.
Rev. Shawn Carty:
Tell us about survey and all the various forms of that.
Sue Lanza:
Yeah. I mean, it’s a slice in time. I’ve been an administrator 35 years, so I’ve gone through a few of these. Every year, there’s an annual survey, at least. Maybe not so much in assisted living, but in skilled, you get an annual survey, except for the year of COVID where 2020 was just completely missed for obvious reasons. But they do an annual survey, so they’re going to come in. They’re going to take a sample of your resident population, usually 20%. They’re going to look at them from head to toe, all their records up and down, ask staff questions, watch everything that we do. And they’re going to say, as of this day and time, where you stand.
So it’s really important, because there’s a whole star rating on Nursing Home Compare. That’s a resource for families that you can look up. If you go to medicare.gov, you can go to Nursing Home Compare, and you can see where any particular facility stands on their health inspections, their overall rating, their life safety, how are they doing on what they call quality measures or certain measures that tell us that we’re meeting certain guidelines in areas like bladder and bowel infections, things like that. They want to keep an eye on that. But then there are things, like we had the latest COVID type thing, which is called a special-focused infection control survey. We’ve had a number of those. We probably had four of them in skilled over the period of time, and we had one in assisted living.
And they basically come in and they want to see… They’re not looking at everything about the resident. They’re looking at how is the staff providing the care that they need to for wherever the facility is in the time of their outbreak or not outbreak or whatever’s happening. But they traditionally have come out after someone has reported an outbreak, so that’s why all this daily reporting. Somebody actually does read it somewhere. And they say, “Uh oh, we better go see this facility.” And we are not unique in that. Every facility has had these visits. So, they’re quite a bit for the staff, because they have to show that they’re donning and doffing their PPE properly, there’s all that terminology again, and just handling things right up to, not just the resident care, but down in the kitchen. Are sanitary conditions being met in the kitchen? Is the staff down there doing what they need to do? They’re looking at the whole building and how are we handling infection control.
And based on how the survey goes, if you have anything that they find that’s a deficient practice, and it could be something minor to something major, you have to write what they call a plan of correction. You’ve probably heard me talk about this ad nausea as well.
Rev. Shawn Carty:
I have heard the term, yes.
Sue Lanza:
You have heard of it.
Rev. Shawn Carty:
And I have a sense of what it means, but you’re the expert here, so…
Sue Lanza:
Yeah. But basically they ask you to look at different elements. If there was a deficient practice, how does it affect, and how’d you correct it for maybe the one resident that it impacted? What would you do to make sure it doesn’t happen to all the residents? And then, what would you do to prevent it from happening going forward? And how would you monitor that? Those are the ways that they look at. So your answer and your plan of correction has to meet all those things. Boy, this was very trying for me to have to tell you all these definitions. Why are you doing this to me?
Rev. Shawn Carty:
Well, it’s good to be clear about all these things, I think. And I think we’ve come to the end of our list of terms that we wanted to make sure we included in the podcast today. I’m afraid to ask, though, if you’re going to quiz me.
Sue Lanza:
Well, I was going to do it off the air, because I thought it really wasn’t fair to you. And I need you to have a very sharpened pencil.
Rev. Shawn Carty:
Oh, very good.
Sue Lanza:
I know. Isn’t that great? So, well, I think it’s great that our listeners tuned into this. I don’t know how many people were interested, but I hope they were, because some of this stuff you hear all the time, and you don’t know what the heck it means. So I think we’re signing off for now to our next podcast. So thanks everybody. I’m Sue.
Rev. Shawn Carty:
And I’m Sean.
Sue Lanza:
Thanks so much. Bye-
Rev. Shawn Carty:
Bye.
Sue Lanza:
… from House Guest.
Thanks for listening to this episode of House Guest, the podcast, which is dedicated to all great things about the House of the Good Shepherd, a retirement community in Hackettstown, New Jersey. To learn more about us, please visit our website, hotgs.org. Thanks for listening. See you next time.
