If you are at the independent living level, you are probably deciding between remaining in your own home, or moving to an independent living retirement community.

If you require any kind of supervision, assistance with the activities of daily living (ADLs) such as bathing, dressing, walking, eating and performing toilet functions, or if you need skilled nursing care, you may be considering moving to a residential care facility for the elderly (RCFE) or a skilled nursing facility. Or you may decide to remain in your home, and hire a home care or home health care agency.

Here are explanations of the major kinds of care and services seniors may require. Most of them can be provided either in the home, or in a specialized facility.

Adult Day Care

Adult day care is offered primarily to give a break to family members or friends caring for a homebound elderly senior. Local adult day care programs focus on frail elderly people suffering from dementia or Alzheimer''s, or recovering from a stroke or other debilitating illness.

The senior is brought to the day care site several days a week, usually for about five hours per day. Activities are arranged, a nutritious meal is served, and there is time for general socializing with the other seniors.

Bill Griffon, vice-president of Central Coast Community Health Care, says that as more elderly healthcare services and programs become capitated in the coming years, people will be looking for ways to keep frail and confused elderly relatives out of high-cost institutions such as skilled nursing facilities. Adult day care programs will grow, to take care of the increasing number of seniors choosing to remain in their homes.

Payment is usually nominal, as many of these programs are operated by non-profit groups and co-sponsored by municipalities.

Subacute/Transitional Care

This level of intensive medical or nursing care is usually required after surgery or a serious illness, including a stroke or heart attack.

The goal of transitional or subacute care is to rehabilitate patients and restore them as quickly as possible to their previous level of functioning, or to the best level of functioning they can manage.

Transitional care is usually delivered in a distinct part of an acute care facility, such as a hospital or medical center. It involves more complex medical conditions than subacute care.

Subacute care is usually delivered in a skilled nursing facility when the patient is discharged following surgery or hospitalization.

Services provided are two-fold:

1) Skilled, intensive professional nursing care in the following areas: post-operative recovery, complex wound care, intravenous therapy, HIV care, ventilator and respiratory care, catheter care and management dialysis, brain injury care and treatment, pain management, hospice services, respite care, diet and specialized feeding, diabetic management, medication delivery and monitoring, and general skilled monitoring and observation.

2) Skilled rehabilitation services including physical, occupational and speech therapy; treatment and training to recover strength, range of motion, cognitive and speech ability, and ability to move from place to place and in and out of bed; assessment of the patient for self care, communication, speech and swallowing, and mobility.

Payment is on a daily or per diem basis, which varies at each facility. Medicare offers reimbursement for medical care directed by a physician, for a limited period of time. MediCal covers certain patients in certain situations. Private pay or private insurance is required for other situations.

Rehabilitative/Restorative Care

Following surgery, a serious illness or condition such as stroke or heart attack, a senior may require specific skilled care in order to recover certain physical and mental abilities. The goal is to return the individual to his or her prior level of daily functioning, or, when that is not possible, to the highest level of functioning that is possible.

Care may include physical therapy, occupational therapy and speech therapy provided by licensed professionals. It may also include care and services provided by non-licensed staff trained and directed to assist with restorative activities, such as re-learning to walk, eat, speak, and care for one''s personal hygiene.

Rehabilitative care is generally conducted with greater intensity or aggressiveness than restorative care, but both deal with the same problems. Care can be brief, or may last for a long time when serious damage was suffered. It is provided in the hospital, in a sub-acute or transitional facility, in a skilled nursing facility, or sometimes in the home.

Payment is covered by Medicare, MediCal or insurance when care is ordered and directed by a physician.

Case Management

If you need help figuring out a plan of care for yourself or a loved one, you may wish to consult a case management specialist. They provide in-depth home assessments, develop care plans, arrange support services and provide on-going monitoring for seniors with multiple needs. Case management can be provided no matter where the senior lives but there is no reimbursement for any fees charged.

Home Care

Professional home care providers offer seniors a wide variety of non-medical personal services to enable them to live comfortably in their own homes for as long as possible. The goal is to preserve the senior''s normal routine within familiar surroundings.

Home care providers perform the same kind of services that family members might provide, but are unwilling or unable to provide to the extent required by the individual.

Home care agencies are not licensed. Many employ state-certified nursing assistants (CNAs) or certified home health aides, but this is not required by law.

Typically, a home care provider offers personal assistance for individuals who, due to an illness, injury or aging, need help with daily activities such as bathing, dressing, cooking and light housekeeping. Tasks may include watering plants, walking the dog, cooking meals and providing social company.

Home care providers are not allowed to give skilled nursing or medical care. They may not, for example, give injections or put medicine in the senior''s mouth, although they may remind seniors to take medication at the appropriate time.

Mary Cwikla, office manager of Central Coast Senior Services, notes that often a home care provider is able to do more than a family member, particularly when it comes to bathing or changing bedpans or diapers for incontinent seniors who feel embarrassed to have their children do this.

Home care may be hired on an hourly basis, for seniors who want assistance just a few hours each day or week. It may also be provided on a 24-hour or weekly basis, usually at reduced rates, for seniors who need extended long-term care.

Medicare does not reimburse for home care, so unless a senior has a specific clause in his insurance policy covering extended care, all fees must be paid from private resources. With typical costs exceeding $200 a day for round-the-clock home care, this becomes an expensive option. Nevertheless, home care is an increasingly popular option as more seniors choose to continue living in their own homes. MediCal does pay for home care for qualifying seniors.

Home care providers typically take care of seniors living in their own homes, or in an independent living facility or congregate community. Seniors living in a licensed residential care facility or skilled nursing home may not hire home care providers to perform the same tasks that staff in their facility is supposed to perform according to the requirements of that facility''s state license. In such cases, home care providers may work out a plan of care together with staff in the licensed facility, so that no duplication of tasks results.

Home Health Care

Home health care providers typically offer the same services as home care providers, but they are also empowered to provide medical services such as nursing, therapy and nutritional advice

Home health care agencies are licensed by the state Department of Health and provide services in coordination with the senior''s attending physician.

Medicare and, when appropriate, MediCal will reimburse fees when a senior''s physician determines that skilled nursing care is needed for a senior living in his or her own home, and when the home health agency providing that care is certified by Medicare. Services may be provided by non-certified agencies on a private pay basis.

A certified home health care agency such as Community Home Health Care in Monterey is able to provide skilled nursing care by a registered nurse; physical rehabilitation services by a licensed physical therapist or occupational therapist; assistance with recovery of speech and swallowing capabilities by a speech therapist; and instruction for other family members or caregivers who wish to enhance the senior''s program of care.

Home health care agencies also provide certified or non-certified home health aides to assist with the activities of daily living, including personal hygiene, dressing and grooming, meal preparation and light housekeeping. So long as this "personal care" element of the home health care agency''s work is carried out as part of the client''s entire package of services, Medicare will cover a certain portion of the cost.

A well-rounded agency is also able to provide social workers, case management experts and other professionals to help with counselling and long-term health care as well as financial planning.

Although most clients utilizing the services of a home health care agency live in their own homes or an independent living retirement community or congregate facility, home health care providers may also go into licensed residential care facilities for the elderly when their tasks do not overlap with the tasks of licensed staffmembers. They may not be hired to go into skilled nursing facilities, where their work would involve a duplication of services that is forbidden by state licensing regulations.

Respite

This is an invaluable service offered to help family members or other private caregivers who need a brief "time-out" period to rest from taking care of an elderly senior who lives at home. On a short-term basis, the senior is transferred to the respite provider''s facility, or a home care agency may come into the home to relieve regular caregivers

Any facility may offer respite services, from private people working out of their own, non-licensed homes, to RCFEs and skilled nursing facilities that have empty beds.

Depending on the provider, respite care may include personal care assistance and other non-medical homemaker services (feeding and meal preparation, light housework, grocery shopping). In a licensed facility, respite care may include medical services as prescribed by the senior''s physician, such as nursing, therapy, nutritional support and services provided by a certified health aide.

Payment is usually on a daily basis, typically for a period ranging from a weekend to one or two weeks.There is generally no reimbursement except MediCal when the respite care is provided by a licensed facility with free MediCal beds.

Hospice

Hospice care is appropriate for individuals diagnosed with a terminal illness. The goal of hospice care is to enable the patient to live out his or her days as comfortably as possible, with the greatest amount of dignity.

Because hospice is only called in during the final stages of an individual''s life, it is available in any setting, from a private home to a skilled nursing facility. Hospice of the Central Coast also offers in-patient care at Hospice House in Monterey. Medical care focuses on relieving pain, managing symptoms and preserving quality of life rather than prolonging life. This is not a "cure-oriented" service.

Hospice care is holistically based. It is delivered by an interdisciplinary team typically composed of physician, nurse, social worker, chaplain, pharmacist, volunteers and family members, and it focuses on the medical, social, financial and emotional needs of the patient as well as the entire family. Bereavement services are offered to family and friends.

Care is available round-the-clock, seven days a week. Hospice care includes drugs or biologicals related to the patient''s primary hospice diagnosis; medical supplies; durable medical equipment; in-patient respite care, to relieve primary caregivers; and any other non-medical care needed to help the patient and family through the dying process. Patients routinely receive periodic in-home services of a nurse, home health aide, psychosocial professional, and other members of the hospice interdisciplinary team.

Fees are capitated on a per diem rate, based on Medicare or commercial benefits. Under Medicare, the patient is responsible only for drugs or biologicals, up to a maximum of $5 per prescription, and in-patient respite care for no more than five days, which costs the patient about $5 per day. Medicare, MediCal and most private insurance plans provide reimbursement for hospice care. n