The Difference Between Skilled Nursing and a Skilled Nursing Facility

By Marlo Sollitto

Understanding the terminology used in the long-term skilled care nursing facility industry is an important first step in determining viable care options. When it comes to senior care, some are used interchangeably. Skilled nursing facility, nursing home, and convalescent home are all terms used to describe a residential facility that provides on-site 24-hour medical care.

Confusion often arises surrounding the use of the term “skilled nursing.” It is helpful to consider that skilled nursing is a description of the type of service that is offered. The need for skilled nursing services does not automatically necessitate placement in a facility, because skilled services are available in a variety of senior care settings.

What is Skilled Nursing Care?

Skilled nursing care is a high level of medical care that must be provided by trained individuals, such as registered nurses (RNs) and physical, speech, and occupational therapists. These services can be necessary over the short term for rehabilitation from an illness or injury, or they may be required over the long term for patients who need care on a frequent or around-the-clock basis due to a chronic medical condition. In this case, a skilled nursing facility is required.

Examples of skilled nursing services include wound care, intravenous (IV) therapy, injections, physical therapy, and monitoring of vital signs and medical equipment.

Skilled Nursing Care in the Home

As more seniors choose to age in place, home health agencies have responded by offering skilled services provided by licensed nurses or therapists in clients’ homes. When prescribed by a doctor, these short-term skilled care services can be covered by Medicare, some private health insurance policies, veterans benefits, and long-term care insurance policies.

Utilizing a home health care provider enables an individual to receive highly effective medical treatment, while remaining as independent as possible in the comfort of their own home.

Skilled Nursing Care in Assisted Living Facilities

Seniors who require more assistance than what can be provided in the home may need to consider a move to an assisted living facility (ALF), or in more serious cases, a skilled nursing facility. Assisted living facilities provide a wide range of services to individuals who want to maintain some level of independence but require support with activities of daily living (ADLs).

Assisted living facilities vary widely in the levels of care available, and state licensing often determines the tiers of medical care that can be provided. Residents’ care plans are created, overseen and regularly reviewed by RNs and licensed practical nurses (LPNs).

Skilled Nursing Facility

Some level of security, personal care and nursing staff is available around the clock, but the purpose of assisted living is to provide supervision and support with ADLs, not 24/7 skilled care, as in a skilled nursing facility. If a resident’s care needs exceed what the ALF can provide, they must either hire a home health agency to come in and provide these additional services in their apartment or consider moving to the next level of residential care: a nursing home, or skilled nursing facility.

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The Rising Cost of Skilled Care: Alarming Statistics

Long-term care is expensive. Many people who receive care will need it for more than a year. Americans spend billions of dollars a year on care, and that doesn’t even include unpaid care given family members and friends. Here are some facts and numbers to consider:

Americans spend about $147 billion a year on long-term care services, according to a study done at UCSF. Average cost for care in a nursing home is $91,000 per year ($250 per day), according to a study done by MetLife.

Average cost for care in an assisted living facility is $43,000 per year ($120 per day), according to the same study by MetLife. In California, the average cost is even higher: $120,000 per year ($330 per day) for a nursing home and $47,000 per year ($130 per day) for an assisted living facility.

At-home caregivers are paid $21-$30 per hour for their services
People who turn 65 years old today have a 70% chance of needing long-term care, according to the Department of HHS. Of those who need care, about 30% will need it for more than 3 years. It’s Important to Plan Ahead.  The thought of needing long-term care is not something people like to think about. It’s unpleasant and it’s easy to put off.

However, it’s smart and responsible to plan ahead so that you can pay for it should you need it. Without planning, long-term care costs can quickly wipe out your life savings and assets.

The good news is that there are ways to pay for the costs.

There are even ways to have entitlement programs cover the costs. This option is important if you have savings and assets, like your home, that you want to protect and pass down to your loved ones after you pass away. Learn how you can qualify for these entitlement programs.

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Asset Protection and Skilled Care

For long-term care, Medicaid has become the entitlement program for middle and upper-middle class families to help pay for the cost of care. However, families must “spend down” their assets in order to qualify.

But with careful planning, it’s possible to qualify for these benefits while protecting your assets from forced spend-down. The process is not easy, and most estate planners aren’t experienced or knowledgeable enough to help you accomplish this.

Why Most Asset Protection Strategies Fall Short
Many estate planning attorneys and financial planners fail to specifically address the problem of long-term care costs. Because long-term care is a leading cause of financial hardship among seniors, we believe your retirement planning is not complete without an asset protection strategy that specifically deals with long-term care. We all are living longer today, and while that is a great news, it also presents a challenge for seniors who need long-term care in their older age.

How We Can Help You
We believe that every client we work with deserves the human touch. When it comes to protecting your legacy and making sure your health needs are covered, the first and most important step in our asset protection strategy is to understand your family needs, your plans for retirement, and your financial situation. The technicalities, number crunching, and paperwork that follow will naturally take their courses once we understand your needs.

Because this first step is so personal and important, we meet face-to-face with every one of our clients so that we can talk with them in person. We encourage you to contact us and set up a time to meet. It just might be the best thing you’ll do for your legacy, your health, and your family’s security.

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Should I Consider Skilled Care?

You may have concerns about being able to live at home after cancer treatment. Perhaps you have a temporary or permanent physical change or a broader need for assistance with health and personal care. If home health care is not an option, it may be time to consider assisted living or nursing home facilities that provides care in a residential atmosphere.

Many people are opposed to the idea of moving into an assisted living or nursing home facility. You may feel too young or fear the thought of giving up more control. Remember that the move may be temporary. Also, in a good care facility with a supportive environment, you may actually feel more empowered by letting other people assist you with tasks.

Talk to family, trusted friends and your health care team about whether you may have health and safety needs that can no longer be managed at your home. Together you can identify areas where support and problem solving may be needed.When to consider assisted living or nursing homes:

  • Physical health: Limitations caused by chronic diseases or physical disability may cause difficulty performing activities of daily living (ADLs) such as walking, dressing, bathing and preparing meals.
  • Mental health: Diagnosis of psychiatric disorders, such as depression, anxiety, psychosis or dementia may result in confusion, disorientation or isolation.
  • Concerns about medications: Inability to take medication as directed or a possible need for intravenous (IV) drugs or dialysis.
  • Support systems: Lack of a support system, such as key friends and family who can be called in an emergency and are able to assist when you need them.
  • Finances: Difficulty managing your own financial affairs or inability to meet present and future care and home maintenance needs with current income sources.

Assisted Living vs. Nursing Homes:

Some long-term care facilities provide both assisted living and nursing home care. This allows a resident to start out in an assisted living environment and move into the nursing home level of care later if medical needs change. Ask for more information from your health care team or contact care facilities directly.

Here’s an overview of assisted living and nursing home services:

Assisted Living Facilities Nursing Homes
    Assisted living homes are not for people who need constant professional nursing care. They provide a combination of housing, personalized supportive services and health care designed to meet the needs of people who require assistance with the activities of daily living.
    Nursing home residents rely on assistance with most or all activities of daily living, such as meals, bathing, dressing and toileting. Regular medical supervision and rehabilitation therapy are available. These facilities are licensed by the state and may be certified.
    Services include meals, housekeeping services, transportation, health promotion and exercise programs, personal laundry services, social and recreational activities. Provides access to health and medical services such as emergency call systems, bathing, dressing, medication management and needed assistance with eating, walking and toileting.
    Services include medical care, assistance with personal care, meals, housekeeping and social activities. Provides 24-hour skilled nursing care and medical supervision for the more acute (critically ill) patients that are one step below hospital acute care.
    Not usually paid for by health insurance or the Medicare or Medicaid programs. Can be paid for by a long-term care insurance policy, but most individuals pay the cost themselves. Costs will vary depending on the level of care and services provided.
    Sometimes paid for by private pay, private health insurance policies or long-term care insurance policies. Medicare or Medicaid may pay for nursing home care under certain circumstances. Costs will vary depending on the level of care and services provided.

Paying for Assisted Living or Nursing Home Care

Payment may come from your insurance coverage, Medicare or Medicaid, from personal funds or from a combination of both sources. However, if you want to truly protect your assets, we can assist you to secure entitlement benefits that will pay for your skilled care without spending down your assets. Contact us to receive an evaluation to determine if you qualify.  Be prepared with:

  • Your Social Security number.
  • Information about your health condition.
  • The reason an assisted living or nursing home facility is necessary.
  • Information about your current insurance coverage.

Finding Facilities:

Other good sources:

  • Elder care advocates, such as through an area agency on aging.
  • Hospital discharge planners.
  • Hospital or care facility social workers.
  • Doctors or other members of your medical team.
  • Local and national cancer organizations.
  • The Joint Commission (for reports on facilities).

You can also check with your local Department of Consumer Affairs or Better Business Bureau to see if any complaints have been filed against a facility.

Factors to consider:

  • Licensure and certification: Is the facility licensed, certified and does it have a good record of providing quality care?
  • Cost: How will the costs be covered for this living arrangement?
  • Assistance: Does the facility provide the medical and personal assistance you need to manage your daily needs?
  • Facility philosophy: What goals does the facility have for residents? For example, does the facility encourage residents to be active and independent?
  • Medical care: Does the facility have reasonable access to medical care, treatment centers and a hospital if necessary?
  • Life in the facility: Are social or learning opportunities offered along with medical and practical care?
  • Residents: Would you be comfortable living in the same environment with the residents of the facility?

Visiting a Facility:

The best way to find out whether the facility appeals to you is to visit the facility on multiple occasions and at different times of the day. Be sure to talk with both residents and staff. First, call the facilities that are of initial interest to find out if they accept your type of payment plan and if they have space available. Next, arrange for at least one visit to the facility and if possible, make two or three visits.

Tips for your visit:

  • Try to visit at least one time unannounced, during a meal time and on a weekend. This will allow you to see the food they serve and how many staff members are available on the weekend.
  • Speak with residents and staff members to find out what life is really like in the facility.
  • Make a list of what factors are most important to you, such as:
    • Level of independence given to you.
    • Comfort of the environment.
    • Cost and insurance coverage.
    • Convenience to family and friends.
  • Bring a friend or family member with you so you can get their impressions.

Preparing for the Change:

Many placements made directly from the hospital to a skilled nursing facility are temporary–an average of four to six weeks. However, even in temporary situations, such a major change in your life can bring up feelings of loss or fears about the future. You may experience grief about having less independence and feel anxiety about leaving familiar surroundings. Such feelings and concerns are understandable and many people have them.

Consider sharing your feelings with trusted family, friends and other people who are in your situation, such as a support group. If your feelings about this decision become overwhelming, talk to a professional such as a hospital social worker, psychologist or counselor.

Contact us today to discuss your Skilled Nursing Facility needs. We can help and you can protect your assets and choose from virtually any facility in California.


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Know Your Home Care Options

Knowing your care home options begins with understanding the difference between custodial vs. skilled nursing care. The difference is critical because many patients end up unnecessarily in skilled nursing settings.

What is custodial care?
Some examples of custodial care would include help with dressing, bathing, help out of bed, help to the bathroom, incontinence, and assistance for patients with wheelchairs and/or dementia. Alzheimer’s patients who have a tendancy to wander usually have only custodial care needs.

What is skilled nursing care?
Some examples of skilled nursing care would be assistance with an i.v. g-tube, tracheotomy, open wound, ventilator; care usually provided by trained skilled nursing staff including registered nurses (RNs), certified nursing assistants (CNAs), or licensed vocational nurses (LVNs).

Is a skilled nursing home the right setting?
If you visit your local nursing home you may realize that most patients do not have g-tubes, i.v.’s, tracheotomies, ventilators, etc. Most patients have only custodial care needs. Reasons why these patients end up in nursing homes vary, but the primary reasons may include:

1. Most consumers (including doctors) are not familiar with alternative care settings for patients with 24-hour custodial care needs,

2. The assumption that nursing homes (since they have nurses) always provide the highest level of care despite the fact that many community based care settings (see below) have higher staff to resident ratios,

3. Many are low-income and medi-cal does not pay for any other care setting.

What alternative settings exist for patients with custodial care needs?
Alternative settings include larger assisted living (sometimes referred to as retirement homes) or small residential board and care homes (also referred to as residential care facilities for the elderly or RCFEs). In the case of RCFEs, small family homes with 4-6 residents, staffing levels (1 staff to 2-3 residents) far exceed that found in skilled nursing settings (usually 1 direct care staff to 17 patients). While it is true that nursing homes may provide a higher level of medical care for patients with skilled nursing needs, patients without skilled nursing needs tend to do better receiving care in home-like settings that have high staffing levels

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Does Having a Living Trust Automatically Protect My Assets from Health Care Costs?

Living Trusts are a popular estate planning vehicle to avoid Court involvement and statutory probate costs in the administration of a decedent’s estate, large attorney’s fees and lengthy delays in the distribution of assets. However, it is a common misunderstanding that a Living Trust is a shield from creditors, including lawsuits and Medi-Cal estate claims. In most cases, Living Trusts do not protect assets from claims and in fact if not properly done may add roadblocks to proper long term care planning.

One of the most common misunderstandings stems from the belief that because one has assets in a Living Trust, that person does not own the assets and therefore Medi-Cal, for example, can’t count them or subject them to recovery claims. In most situations, in fact, the person does control the assets. Consequently Medi-Cal and creditors can claim against them.

There are several ways a Living Trust can be utilized to help protect assets from nursing home costs. There must be very specific clauses, containing very specific wording, in order to take advantage of these protections. If the language is not contained in the Trust document, the Trustee may be powerless to take the steps necessary to protect the family’s assets. Very simply put, most trusts simply DO NOT allow the family to manage the trust to protect a lifetime’s work.

Some of the provisions that should be included in the trust are:

* The authority to apply for Government health care benefits.
* The authority to maximize eligibility for all health care programs.
* The authority to take all steps to create eligibility.
* The authority to make unconditional and unlimited gifts in excess of the per year limit for non-taxable gifts.
* The authority to transfer community property from one spouse to another.
* The authority to irrevocably transfer assets to heirs while living to avoid estate claims.
* The authority for either Trustor to amend the Trust.
* The authority to amend the Trust using a Power of Attorney.
* The authority to create revocable or irrevocable trusts

Watch out for “Boiler Plate” provisions!

Many so-called “Estate Planning” attorneys and low cost trust mills, simply push a button on the computer and turn out a generic, one size fits all, Trust. These in many cases include provisions (or more importantly, lack provisions) that have no application to the client’s estate. One very common example is the creation of an A/B Trust, which freezes the deceased spouse’s one-half of the community property and makes a portion of the Trust, IRREVOCABLE! The surviving spouse essentially loses all control over those assets. Remember, most trusts are created to deal with DEATH. People needing care may be incompetent or incapacitated but they are NOT DEAD. Most competent attorneys no longer do boiler plate A/B Trusts.

Durable Powers of Attorney for Property and Personal Affairs must have specific language and provisions to be effective for incapacity and Medi-Cal planning.

Your Durable Power of Attorney must have very specific language in order to do Long Term Care planning for a person who is incompetent or incapacitated. These provisions generally include: broad gifting powers; powers to undue community property to separate property; powers to take over the handling of one’s Living Trust if they are unable to do so, including the power to amend; the power to apply for and take any steps necessary to obtain Public Benefits. They should also be immediate, not springing. Also extremely important is the ability to create a life-care contract. Remember that a Power of Attorney for Health Care does not allow someone to make financial decisions.

What Now??

If your Trust and Powers of Attorney were created by a “Trust Mill” or other inexperienced professionals, or do not contain these provisions and safeguards, it is not too late. You CAN make changes, but it must be done while alive and competent. Don’t wait for circumstance to force decisions upon you.


The dramatic, wide-ranging privacy rules of HIPAA took effect April 14, 2003. These regulations, considered to be the most significant development in health care legislation since 1965 apply to virtually every health care provider and organization in America. It is absolutely imperative that Advance Health Care Directives and Durable Powers of Attorney for Finance as well as your Living Trust now contain very specific HIPAA compliant provisions. Most current documents DO NOT contain these provisions. Without the appropriate release authority language your Attorney-in-Fact may not be able to act on your behalf.

The foregoing report is designed solely for the purpose of providing very general and limited information on the subject matters. Readers should have their estate planning documents reviewed to determine their legal sufficiency and whether they need to be amended or replaced. Nothing here is intended to be legal advice.

Prepared by Gary R. Lieberman of the Law Offices of McCarty & Lieberman, Elder Law Attorneys since 1962.

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Understanding Nursing Home/Skilled Nursing Facility Costs

Nursing home costs are a big part of nursing home care and can vary widely depending on the state you live in. Average costs are around $70,000 per year so you need to know how you’re going to pay for nursing home care. It’s important to understand the limitations of insurance in covering costs:

  • Medicare only covers limited stays in nursing homes. Skilled nursing or rehabilitation service sare covered for a period of about 100 days after a hospitalization. Medicare does not cover custodial care (such as assistance with feeding, bathing and dressing) if that is the only care needed.
  • If your income and assets are limited, you may qualify for Medicaid, which does cover most of the costs of nursing home care. However, not all nursing homes accept Medicaid. If you suspect that you may need extended nursing home care in the future, you may want to contact an elder law attorney to learn more about which assets are protected and to what extent. For example, if you have a spouse living at home, your home is normally not considered in eligibility for Medicaid for nursing home purposes, and some of your savings may be partially protected as well.
  • If you have long term care insurance, check the provisions of your plan to see what portion of nursing home coverage is protected.

The Unknown Alternative

Skilled care costs do not have to cost you your life savings.

You can preserve your estate and take advantage of a little known Government program that will cover virtually 100% of the costs of skilled care in California – and nearly all facilities qualify!

This Government Entitlement Program will:

  • virtually pays 100% of all skilled care costs
  • gives YOU the CHOICE of care facility – nearly all in California qualify

For the past 10 years BPG Consulting Group has had a 100% success rate helping seniors and their families navigate the application and submission process, and getting approved for this entitlement program which will stay with them through their final day.

Facility Resource Group provides complete application preparation and submission to the County for their review and approval, with continued consultation and ongoing assistance for the lifetime of the beneficiary. All benefit strategies are created in strict compliance with all State and Federal Entitlement Program rules and regulations.

CLICK HERE to request your free consultation

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Choosing a Nursing Home Facility

Finding a nursing home

Finding the right nursing home is not easy, and you may be under pressure to move fast due to a recent hospitalization or deterioration in condition. The more information you have, the greater your chances of finding the right fit for you or a loved one. Here are some tips on narrowing down your options:

  • Start with referrals. Does your family physician or specialist have any recommendations? Or do you know any friends or family who have used different homes? Knowing someone with first-hand experience with a home can help you narrow your choices. However, remember your needs may differ: one size does not fit all.
  • Educate yourself. Online resources for nursing homes include ranking sites that utilize existing state data to rate nursing homes. Every state has what is called a long term care ombudsman, which can be a valuable resource about the current condition of a nursing home. Advocacy groups can also provide hints on searching for the right facility. See the resources section below for more information.
  • Consider your medical needs. Different nursing homes may have more expertise in different areas. Are they experienced in handling your condition of interest, such as for Alzheimer’s or a stroke? Or are you looking for more short term rehabilitation?
  • Factor in distance. In general, the more convenient the home, the easier it is for family and friends to visit.

Planning a visit

Once you’ve narrowed down your list of homes, it’s time to plan a visit. Visiting is key to understanding if a home is right for you. As with other senior housing options, it’s the people that make the place, both the residents and staff. In a nursing home, you’ll also need to make sure that the medical care is delivered appropriately and promptly.

What to look for in staff:

  • How is the staff turnover? What is the staffing level on weekdays, weekends and evenings?
  • Do they have time to speak with you or does it feel rushed?
  • How would they manage your health condition? How are medications and procedures arranged? And how do they handle emergencies or accidents such as falls?
  • Do they appear genuinely interested in you, and do you see them interacting warmly with current residents?

What to look for in current residents and their families:

  • Do the residents appear happy, engaged? Or excessively groggy and overmedicated? Do they seem clean and well groomed? Do they seem like people you’d enjoy getting to know? How do they respond to you? Try to observe social gatherings such as meals or other activities. If needed, are residents getting timely help to eat, and with getting to and from the gathering areas?
  • If you see a family visiting, you can ask them their impressions of the home and how their loved one has been treated. Ask if there is a family council and if you could attend.

What to look for in the facility:

  • Cleanliness. Does the facility appear clean? Do you smell urine or strong deodorizers that may be covering up the smell of urine?
  • Food. What kinds of meals are normally served? Does it look nutritious and appetizing? How are special diets handled? What kind of help is available with meals, and do they have to be eaten at the same time or in a common area?
  • Arrangement. Traditionally nursing homes have been run like a medical facility, including a centralized nursing station and set medication and mealtimes. Some nursing homes are now moving to a different model, with smaller communities and communal areas. If this type is available in your area, it may provide a more homely feel.
  • Activities. What quality of life activities are available for residents? Are outside activities also arranged as well, health permitting?
  • Experience with your condition. If a loved one has Alzheimer’s, for example, is there a special care unit or specialized staff and activities? How does staff handle behavioral problems like agitation, or wandering?
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Skilled Nursing Facilities and Convalescent Homes


As the population ages, more and more of us are faced with the prospect of moving either ourselves or an older family member into a nursing home. It may be a decision that arrives suddenly after a recent hospitalization or you may have gradually noticed more and more needs becoming difficult to manage in other types of housing. The decision can be a stressful one for both the older adult and their family. Additionally, there are many misconceptions about nursing homes. It’s important to learn all you can about how nursing homes work, when a nursing home is the best option, and how to find the nursing home that is best for you or a loved one.

What is a Nursing Home (Skilled Nursing Facility)?

A nursing home is normally the highest level of care for older adults outside of a hospital. Nursing homes provide what is called custodial care, including getting in and out of bed, and providing assistance with feeding, bathing and dressing. However, nursing homes differ from other senior housing facilities in that they also provide a high level of medical care. A licensed physician supervises each patient’s care and a nurse or other medical professional is almost always on the premises. Skilled nursing care is available on site, usually 24 hours a day. Other medical professionals such as occupational or physical therapists are also available. This allows the delivery of medical procedures and therapies on site that would not be possible in other housing.

The label “nursing home” has negative connotations for many people. Yet nursing homes provide an important component of senior housing options. It’s important to separate nursing home myth from fact.

Living arrangements in a nursing home

The ambience and layout varies from nursing home to nursing home. For example, some rooms may be private and others shared. Rooms may have their own bathroom, or they may need to be shared with others. Some meals may be provided in the room, while others may be in a centralized dining area.

While nursing homes have traditionally been set up in a medically-oriented design, with ease of patient care being the primary goal, some homes are now moving to a newer design model. This features smaller communities of 10 to 30 people within a home, private kitchens, communal areas and continuity of staff.

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When Should I or a Loved One Consider a Nursing Home?

Whether you and your family are facing a quick decision about a nursing home due to a recent event, or have been coping with a worsening progressive disease such as Alzheimer’s or Parkinson’s, considering a nursing home is not an easy decision. Emotions such as guilt, sadness, frustration and anger are normal. Working through the possibilities of housing, finances,and medical needscan help you and your family make an informed decision.

Here are some questions to ask when considering a nursing home:

  • Has the senior been assessed recently? If a nursing home is being considered as the next step from a hospitalization, this probably has already been done. However, if a senior is considering a move from home or another facility, a more formal assessment by a medical team can help clarify the senior’s needs and see if other housing options may be a possibility.
  • Can the senior’s needs be met safely in other housing situations? The risk of falls may be too great, or the senior’s medical needs may no longer be able to be met at home or in another facility. If the senior needs 24-hour supervision, or is in danger of wandering off or forgetting about a hot stove, for example, a skilled nursing facility may be the best option. If the senior’s needs are solely custodial, though, an assisted living facility may be a better fit.
  • Can the primary caregiver meet the senior’s needs? Caregivers are often juggling the needs of work, other family, and their own health. It’s not possible for one person to be awake and responsive 24 hours a day. Sometimes other family members can help fill in the gap. Day programs, home care services, and respite care, where a senior temporarily stays in a nursing home, may also provide the support a caregiver needs. However, there may come a point where medical needs become too great and home care services are unable to bridge the gap or become too expensive.
  • Would the need for a nursing home be temporary or permanent? Sometimes, a temporary situation may be covered through home care, or family members might be able to rotate care on a short-term basis. However, if the level of care is expected to be permanent, this may be too expensive or coverage might not be enough.
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