Family foster care reverses live-in equation
Operational challenges are the same, though
Mohammed won’t go to the mountain, you say? Then why not have the mountain come to Mohammed? Finding qualified caregivers willing to live for days or weeks in clients’ homes is the greatest challenge involving live-in services. (See February 1999 Private Duty Homecare, p. 18.) If your live-in program has never gotten off the ground for this reason, then consider flip-flopping the equation by having clients live with caregivers.
One New Jersey company that has done so now has more caregivers than clients. The Hackensack, NJ-based Visiting Homemaker and Home Health Aide Service of Bergen County (VHSBC) also has many happy clients, grateful to have help with their daily care needs in a family, rather than institutional setting, according to Patricia Mahmarian, LSW, director of the Alternate Family Care Program.
VHSBC started the program in 1992 as part of a New Jersey Medicaid Waiver pilot. Now, in addition to approved waiver clients, the company also offers family foster care to those who self-pay for the service. "It’s an alternative to nursing home care, and it’s significantly less than assisted living or nursing homes," says Mahmarian.
Savings are important
VHSBC charges private pay clients around $1,800 a month. It receives $1,200 per month for those covered under the Medicaid Waiver program.
Clients need assistance with activities of daily living, but don’t want to enter a nursing home. Typically, they either have no family in the area, or their loved ones cannot meet their day-in, day-out care needs. Program goals include:
• keeping clients in a home setting;
• providing them with assistance on a daily basis;
• helping them be as independent as possible.
The program appeals to many seniors because it is less expensive than both nursing home and live-in care, and "it’s like moving into a family instead of being isolated," Mahmarian says. Others see it as an intermediate step, allowing them to sell their house and get their financial affairs in order before being forced to do so in a crisis situation.
Caregivers come from all walks of life and have many different family situations. "Some are RNs, some are home health aides, some are retirees. Some want to stay home while their children are home, some have full families, some empty nests," Mahmarian reports.
All caregivers must pass a rigorous review that includes:
• a completed application that explains the person’s interest in the program.
• personal interviews;
• personal and employment reference checks;
• verification of automobile, homeowner, or rental insurance coverage;
• criminal background checks on all household members over 18;
• a physical exam, Mantoux test (for all household members), complete medical history, and immunization record;
• home inspection and remediation of any hazards.
Mahmarian interviews all applicants, carefully evaluating their motivation. "If they’re interested in it for the income only, it won’t work. There’s not that much to be made." Depending on the client’s care needs, caregivers may work part-time outside their home, full-time outside employment is not allowed.
Those without previous caregiving experience must complete a 2-week, 60-hour training course that covers a variety of personal care issues, from transfer and bathing techniques to mental health concerns in the elderly.
VHSBC does not require that caregivers’ have one-story homes, but many of them do, Mahmarian says. The residences must meet the same type of safety and access issues required with other in-home care programs, such as having smoke detectors and removing fall hazards.
In addition to offering a private room to each client, caregivers must help clients with their activities of daily living, prepare meals, take them to medical appointments, clean their rooms and clothes, and ensure that their social needs are met. VHSBC expects caregivers to "integrate clients into their family so that they’re not just living in the home," Mahmarian notes. It also requires them to write weekly narratives documenting their client’s status.
Caregivers are independent contractors and sign contracts with VHSBC agreeing to meet the needs of a specific client outlined in the document. They must provide two weeks’ notice before terminating a contract.
Match skills and needs
Potential clients meet caregivers before join- ing the Alternate Family Care program. VHSBC matches caregiver skills and interests with clients’ care needs. It also attempts to link clients’ personal preferences and caregivers’ lifestyles. For example, a client may not wish to live in a home with pets, or a Jewish person may prefer to live with a Jewish family.
Despite careful matching, each family foster care relationship needs careful nurturing and supervision, according to Mahmarian. "So many things can go wrong. It needs constant attention," she says.
Sometimes caregivers become overwhelmed and have difficulty dealing with clients’ care needs. Sometimes conflicting sleep and wake cycles or meal schedules between clients and caregivers create problems. Or, clients may want company at times when the caregiver doesn’t. "All the things that can go wrong in a home," she adds.
The first few weeks are the toughest for clients. "It’s very stressful initially," says Mahmarian. To smooth the transition, VHSBC care managers visit the home twice the first week, weekly for the next month and then at least monthly with periodic unscheduled visits thereafter. At each visit, in addition to assessing the client’s overall health status and vital signs, the care manager speaks with the client in private so that he or she can comfortably air any problems or concerns.
The rewards are great
VHSBC helps coordinate referrals to support groups and community health services for both caregivers and clients, and it may also send social workers or therapists for clients. The company adjusts fees or uses grant funding when clients have limited resources. It also encourages client participation in adult day care programs.
Despite such attention, some relationships simply don’t work out. VHSBC places clients with other caregivers if they wish to continue in the program. Failed placements "are very upsetting to clients" and the major drawback of the service, according to Mahmarian.
Grant funding that has helped support the Alternate Family Care program will soon end, so VHSBC is now evaluating and may restructure aspects of the service, Mahmarian says. For example, in the past, it accepted clients without fully verifying their financial resources.
Mahmarian is also actively marketing the service to hospitals and nursing homes, at community gatherings and in local ethnic newspapers. "It will definitely grow if other health care professionals know about it," she says.
The state of New Jersey is also doing its part to increase the number of family foster care clients covered under its Medicaid waiver program, according to Suzanne Watson, director of the Alternate Family Care Program for the New Jersey State Department of Health and Senior Services. Watson is based in Trenton. Statewide, there are now about 80 clients and some 115 caregivers.
"We have high hopes. It’s been successful in many other states, and we want it to be as viable an alternative in New Jersey," she says.
About 26 states have some type of family foster care waiver program. Washington and Oregon, each with thousands of clients, are the two largest, she adds.
New Jersey hopes to relocate 1,000 nursing home residents into the community. As a first step in making the program more financially reasonable for providers, the state is now surveying them to determine their cost of operations. It also hopes to introduce legislation exempting caregivers from current state laws that require those with more than one client to obtain a boarding home license, Watson reports.
Despite operational challenges, both VHSBC and the state of New Jersey are committed to family foster care. "The program is so worthwhile. Some people do so much better. They’re interested, they’re involved, they become part of something else. And the rewards for caregivers are great. The satisfaction is so great in knowing you helped clients," says Watson.
Sources
• Patricia Mahmarian, LSW, Program Director, Alternate Family Care Program, Visiting Home-maker and Home Health Aide Service of Bergen County, 298 Union St., Hackensack, NJ 07601. Telephone: (201) 488-0041.
• Suzanne Watson, Director of the Alternate Family Care Program, New Jersey State Department of Health and Senior Services, P.O. Box 722, Trenton, NJ 08625-0722. Telephone: (609) 588-2903.
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