A team of researchers at Ohio State University Medical Center has found a chemical marker in the blood that shows a significant increase under chronic stress and is linked to an impaired immune system response in aging adults. The team, led by Dr. Janice Kiecolt-Glaser, reports in the June 30, 2003 issue of Proceedings of the National Academy of Sciences on a 6-year study of elderly people caring for spouses with Alzheimer’s Disease. With the caregivers, the team found a four-fold increase in an immune system protein — interleukin 6 (IL-6) — as compared to a control group of non-caregivers. Only the stress of caregiving correlated to the marked increase of IL-6 in the caregiver group. All other factors, including age, were not significant to the outcome. Even the younger caregivers saw an increase in IL-6.

The study also found that the caregivers had a 63% higher death rate than the control group. About 70% of the caregivers died before the end of the study and had to be replaced by new subjects. Another surprising result was that high levels of IL-6 continued even three years after the caregiving stopped. Dr. Glaser proposes that prolonged stress may have triggered a permanent abnormality of the immune system.

The problem is if this response is initiated repeatedly over a long period; it can have a dangerous effect on the body. This repetitive initiation of the stress response is common among caregivers — especially those caring for loved ones with dementia. Providing supervision or physical assistance many hours a week and over a period of years turns out to be extremely stressful. This type of stress is often unrelenting, occurring day after day and week after week. And the long-term effects of this stress are more pronounced in middle-aged and older people who are precisely the group most likely offering long-term care to loved ones.

If you are a caregiver, please give us a call.  Through a properly-designed Life Care Plan for your loved one, the Farr Law Firm can help you minimize or eliminate much of your stress.

- Walking
- Bathing 
- Dressing
- Using the bathroom
- Helping with incontinence
- Managing Pain
- Preventing unsafe behavior
- Preventing wandering
- Providing comfort and assurance
- Providing physical or occupational therapy
- Attending to medical needs
- Counseling
- Feeding
- Answering the phone
- Meeting doctors’ appointments
- Providing meals
- Maintaining the household
- Shopping and running errands
- Providing transportation 
- Administering medications
- Managing money
- Paying bills
- Doing the laundry
- Attending to personal hygiene
- Helping with personal grooming
- 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 click on the links below which will take you to the corresponding chapter in my book — The Virginia Nursing Home Survival Guide. You may also access all of these chapters from my Website under the “Resources” tab:  

chapter 1 – THE CAREGIVER’S ROLE
chapter 2 – WHAT IS A NURSING HOME?
chapter 3 – SELECTING A FACILITY
NURSING HOME EVALUATION TOOL
chapter 4 – MOVING YOUR LOVED ONE
chapter 5 – HOW TO PAY FOR NURSING HOME CARE
chapter 6 – MEDICAID PLANNING
chapter 7 – MEDICAID FAQs
chapter 8 – HOW TO GET THE BEST POSSIBLE CARE
chapter 9 – THE RIGHTS OF NURSING HOME RESIDENTS
chapter 10 – RECOGNIZING ABUSE & NEGLECT
chapter 11 – PROTECTION FROM ABUSE AND NEGLECT
chapter 12 – IF YOU SUSPECT ABUSE OR NEGLECT
chapter 13 – ESTATE PLANNING & POWERS OF ATTORNEY
chapter 14 – LEGAL ASSISTANCE
APPENDIX A: VIRGINIA NURSING HOMES BY REGION
APPENDIX B: VIRGINIA AND NATIONAL RESOURCES
APPENDIX C: AREA AGENCIES ON AGING
APPENDIX D: ELDER ABUSE RESOURCES
APPENDIX E: GERIATRICIANS
APPENDIX F: GERIATRIC CARE MANAGERS