What is Long-Term Care?

When a person requires someone else to help with physical or emotional needs over an extended period of time, this is long-term care. This help may be required for many of the activities or needs that healthy, active people take for granted and may include such things as:

Walking
Bathing
– Dressing
– Using the bathroom
– Eating
– Helping with incontinence
– Managing Pain
– Preventing unsafe behavior
– Preventing wandering
– Providing comfort and assurance
– Providing physical or occupational therapy
– Attending to medical needs
– Answering the phone
– Meeting doctors’ appointments
– Maintaining the household
– Shopping and running errands
– Providing transportation
– Administering medications
– Managing money
– Paying bills
– Doing the laundry
– Attending to personal hygiene
– Writing letters or notes
– Making repairs to the home
– Maintaining a yard
– Removing snow

The need for long-term care help might be due to a terminal condition, disability, illness, injury, or infirmity due to advanced age. Estimates by experts are that at least 60% of all individuals will need extended help in one or more of the areas above during their lifetime. 

When the need for care lasts only for a few weeks or months, it is typicallyed called “short-term care” or “rehab care.”  Typical reasons for short-term care include:

Rehabilitation from a hospital stay
Recovery from illness
– Recovery from injury
– Recovery from surgery

True long-term care, meaning care needed indefinitely, or at least for many months or years, is typically needed due to the following conditions:

– Chronic medical conditions
Chronic severe pain
– Permanent disabilities
– Dementia
– Ongoing need for help with activities of daily living
– Need for supervision

Long-term care services may be provided in any of the following settings:

– In the home of the recipient
In the home of a family member or friend of the recipient
– At an adult day services location
– In an assisted living facility or adult foster home
– In a hospice facility
– In a nursing home

Custodial Care vs. Skilled Care
Custodial care and skilled care are terms used by the medical community and health care plans such as health insurance plans, Medicare, Medicaid, and the Veterans Administration. They are used primarily to differentiate care provided by medical specialists as opposed to care provided by aides, volunteers, family or friends. The use of these terms and their application is important in determining whether a health care plan will pay for services. Generally, skilled services are paid for by a health care plan and custodial services, not in conjunction with skilled care, are not covered. However, custodial services are almost always a part of a skilled service plan of care and, by being included, custodial services are paid by the health care plan as well. 

According to the American College of Medical Quality:

Skilled care is the provision of services and supplies that can be given only by or under the supervision of skilled or licensed medical personnel. Skilled care is medically necessary when provided to improve the quality of health care of patients or to maintain or slow the decompensation of a patient’s condition, including palliative treatment. Skilled care is prescribed for settings that have the capability to deliver such services safely and effectively. 

Custodial care is the provision of services and supplies that can be given safely and reasonably by individuals who are neither skilled nor licensed medical personnel. The medical necessity and desired results of skilled care must be clearly documented by a written treatment plan approved by a physician. A patient may have skilled and custodial needs at the same time. In these circumstances, only those services and supplies provided in connection with the skilled care are to be considered as such. The treatment plan must include: 
The applied therapies;
The frequency of the treatment which is consistent with the therapeutic goals;
The potential for a patient’s restoration within a predictable period of time, if applicable;
The time frame in which the prescribing physician will review the case for the purpose of evaluating a patient’s status and before reassessing the medical necessity of ongoing treatment; or
– The maintenance, palliative relief, or the slowing of decompensation in a patient’s status, if applicable.
Determinations of the medical necessity of skilled care must be based on the applicable standard of care.”

A skilled care provider can also provide services normally thought to be provided by custodial caregivers. Such things as help with activities of daily living and so-called instrumental activities of daily living are often furnished by skilled providers in the course of their treatment. Or a skilled care plan may call for services that can be delivered by a custodial caregiver but it would still be under the skilled plan of care for that individual. On the other hand people who deliver custodial services may from time to time perform those activities supposedly reserved for skilled providers. Such things as taking blood pressure, administering medicines, giving shots or changing wounds might be provided under certain circumstances by a custodial provider.

The terms skilled and custodial do not refer to specific types of long-term care services but rather who delivers those services. Also the delivery of skilled services must be done under a written plan of care which often includes custodial care services.

Does Medicare Cover Custodial Care?
Yes, but only for short-term care, not for long-term care. Medicare pays for custodial care in a nursing home, but only if the patient is in the nursing home in a skilled care setting for which it provides payment. Medicare will not pay for custodial care in the absence of a skilled care plan.  If you are enrolled in a traditional Medicare plan, and you’ve been in the hospital at least three days, and you are admitted directly from the hospital into a skilled nursing facility for rehabilitation or skilled nursing care, then Medicare may pay the full cost of the nursing home stay for the first 20 days, and may continue to pay part of the cost of the nursing home stay for the next 80 days — with a per day deductible that you must pay privately (although there are Medicare supplement insurance policies that sometimes cover that deductible).

Medicare-covered Nursing Home Stay
A patient receiving skilled care in a nursing home from Medicare not only receives care from skilled providers such as nurses, therapists or doctors but also receives care from custodial providers such as aides or CNA’s. This care usually consists of help with bathing, dressing, walking, toileting, incontinence, feeding and medicating. Medicare does not exclude the custodial services but pays the entire bill because custodial care is a necessary part of the skilled care plan in a nursing home.

Medicare-covered Home Care
Custodial care is always a part of a skilled care plan for home care. The patient receives skilled care from a nurse or therapist and custodial care from an aide for help with bathing, dressing, ambulating , toileting, incontinence, medicating and possibly feeding. Medicare pays for both types of services.

Medicare-covered Hospice Care
The hospice team consists of a doctor, a nurse, a social worker, a therapist when needed, a counselor and an aide to provide custodial care. Help with activities of daily living is provided at home or in a Medicare approved hospice facility. Custodial care is always a part of a hospice plan of care and Medicare routinely pays for these services. 

Please note that there is no such thing as a custodial nursing home.  All nursing homes are by definition skilled care facilities because they have nurses who are skilled care providers.  Also be aware that not all states license intermediate care facilities which might provide less than 24 hour registered nursing care. “Skilled care patients” in nursing homes are referred to as such because they are receiving payment from Medicare or sometimes payment from private health insurance plans.  Practically all nursing home residents have medical needs but Medicare and other insurance plans will only pay for patients that have certain acute medical needs where recovery is anticipated.  Patients with chronic medical problems are typically not covered by Medicare but will be covered by Medicaid provided that all of the financial and medical eligibilty crieria for Medicaid are met.

For more information about long-term care, nursing homes, qualifying for Medicaid, and other related topics, please order my book — The Nursing Home Survival Guide paperback or Kindle Edition.

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About Evan H Farr, CELA, CAP

Evan H. Farr is a 4-time Best-Selling author in the field of Elder Law and Estate Planning. In addition to being one of approximately 500 Certified Elder Law Attorneys in the Country, Evan is one of approximately 100 members of the Council of Advanced Practitioners of the National Academy of Elder Law Attorneys and is a Charter Member of the Academy of Special Needs Planners.

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