This article was first published in the first-quarter 2015 edition of Personal Finance magazine. 

Laura du Preez writes:

“Healthcare issues loom large in later years when illnesses linger and can result in loss of control over daily living. At these times, residents of retirement villages or homes and their children often take comfort in the fact that the village or home has healthcare or frail-care facilities.

But you may be in for some unpleasant surprises if you are not acquainted with exactly what is on offer in a particular village or home, what additional costs you will incur and what you can claim from your medical scheme. The specifics of an illness and the requirements of your care may also determine whether or not you can be assisted in your community or need to go beyond it.

It is important to know that there is a difference between medical care and frail care, and while your medical scheme will pay for your medical care, it will usually not pay for the care you need when you are unable to manage the normal activities of daily living without assistance.

There are some exceptions, mostly among the restricted medical schemes. Open schemes, which must accept anyone who applies to join at any stage of their lives, cannot afford to contribute to the costs of the long-term care you need when you are frail.

What exactly is frail care?

Frail care is the care you need when you are unable to perform activities of daily living, such as eating, personal hygiene and moving about without assistance.

When you are no longer able to look after yourself because of frailty or mental incapability, you are unlikely to return to independent living.

Frail care is the care you need when you are no longer able to look after yourself because of physical frailty or mental incapacity.

Peter Jordan, the principal officer of Fedhealth, a large open medical scheme, says that while medical care falls within the ambit of medical scheme cover, frail care, or any kind of assisted living, is considered a social welfare responsibility.

Alain Peddle, the head of research and development at Discovery Health, says there may be times when you are recuperating from a health event, such as a stroke or an accident, and when you need short-term assistance with daily living before returning to your former independent state. Such short-term help could be covered by your scheme, but cover for the cost of your longer-term accommodation in a frail-care facility is rare.

Bankmed, a restricted scheme, contributes to the costs of frail care on some options. Dr Niri Naidoo, the clinical and operations executive at Bankmed, says that members of the scheme’s top three options, Traditional, Comprehensive and Plus, are entitled to a benefit of 50 percent of the cost of frail care to a maximum of R355 per beneficiary per day. You have to motivate for the benefit, and the claim is assessed by a medical adviser, Naidoo says.

Contributions on the least costly of the three options, the Traditional option, start at R1 917 for a single member earning less than R5 000 a month, to R2 326 for a member earning more than R10 000 a month. These options also pay 100 percent of the cost of home nursing, to a maximum of R270 per beneficiary per day.

Another restricted scheme, Anglo Medical Scheme, has a benefit of R54 355 per beneficiary per year on its top option, which costs R3 170 a month including contributions towards a medical savings account. But the benefit is only for “medically related frail-care services”, which means you will receive it only if you are recovering from an illness, injury or surgery.

Principal officer Fiona Robertson says the aim of the benefit is to keep high-risk members out of hospital, because one expensive hospital event may cost the equivalent of several years of frail care. Once members require constant nursing or assistance, usually when their condition is medically irreversible, they may be classified as at high risk of fractures or repetitive infections, or may be mentally incapable of taking the correct medication, she says.

The scheme will not pay for frail care when the needs are not medical, but the line between social and medical needs is not always clear, Robertson says. Alzheimer’s disease and dementia, for example, are common reasons for granting frail-care benefits.

Jordan says that while your scheme may not cover accommodation and care in a frail-care centre, any chronic medication you require when you are frail, visits to or by a general practitioner (GP) or specialist, as well as the cost of various appliances you might need while in the frail-care facility, may still be paid by the scheme in line with your benefits.

Levels of care

A frail-care facility should be staffed by carers under the supervision of a nursing sister. Carers may be trained to take care of older people, but are normally not medically trained.

Frail-care facilities need to be registered with the Department of Social Development under the Older Persons Act. The Act sets standards for these facilities and requires annual inspections.

The department is also working on introducing training for carers in these facilities.

While “frail care” sounds straightforward, confusion arises when a retirement village offers both frail care and what is known as a sub-acute care facility. To understand what a sub-acute care facility is, it is useful to know what is regarded as an acute care facility.

The Board of Healthcare Funders (BHF), which represents medical schemes and their administrators, issues the practice code numbers that are used by schemes to identify registered healthcare providers. The BHF explains the difference between an acute care facility and a sub-acute care facility as follows:

* Care in an acute care facility: this is typically care in a facility registered and licensed as a hospital by the provincial department of health in terms of the Health Care Act. An acute care hospital has operating theatres and intensive and/or high care units.

A day clinic, which has an operating theatre but is not equipped for overnight stays, is also regarded as an acute care facility, the BHF says.

A third type of acute care facility is a mental health hospital that treats patients with acute mental health problems, according to the BHF.

These hospitals should have practice code numbers, which you need to claim for admission, in line with your medical scheme benefits.

* Care in a sub-acute care facility: these hospitals treat you when your condition is less serious, or after your release from an acute care hospital, the BHF says.

A sub-acute care facility is equipped like a hospital, has appropriately qualified and registered nursing personnel and must be licensed by the provincial department of health under the Health Care Act. However, Peddle says a sub-acute care facility lacks operating theatres, high-care or intensive care units, and pathology and radiology services.

In a sub-acute care facility, you will receive high-quality nursing care, but should have no need for the high-tech care you would receive in high care, intensive care or in a theatre unit, the BHF says. Your condition must, therefore, be stable.

Some sub-acute care facilities will treat you only after surgery or if you have a non-psychiatric medical condition, depending on the discipline code allocated to the facility, the BHF says.

Some facilities focus on psychiatric conditions and others offer physical rehabilitation. Some are post-natal units and some offer all sub-acute services.

Sometimes the term step-down facility is used to describe a sub-acute facility. However, the BHF says step-down care is less intensive than sub-acute care and is typically for short stays. It is a substitute for an extended hospital stay, and you may be referred to a facility offering step-down care if you still need significant medical involvement and skilled nursing care of more than three hours, on average, a day, as well as pharmacy and laboratory support.

Sub-acute care facilities also need a practice code number, and if you are admitted to such an establishment, you can claim for your stay there, in line with your benefits, from your medical scheme.

If a sub-acute facility is focused on rehabilitating you to normal or near-normal functioning after a disease or injury, you are likely to have access to practitioners across medical disciplines. The care they provide will be goal-orientated, and once their goals are reached, you are likely to be sent home. For example, you may be sent to a sub-acute care facility after a stroke. A neuro-physiotherapist could assist you to walk, a speech therapist could help with your speech and swallowing, and an occupational therapist could help with your movement, vision and concentration.

Peddle says therapies might be supplemented by consultations with a social worker, dietician, psychiatrist or medical doctor.

This treatment can occur in acute care settings, acute care rehabilitation units and sub-acute care units that are licensed to provide rehabilitation.

Asked if Discovery Health Medical Scheme would require a member to use a particular facility, Peddle says this would depend to a large extent on the range of healthcare services you need, compared with what the facility is able to offer. In all instances, he says, Discovery Health will fund services only from registered healthcare professionals and facilities that have practice code numbers issued by the BHF. This means that if a retirement village has a healthcare facility, it must be registered and have a practice code number before any scheme will consider funding the services it provides within what the scheme regards as clinically appropriate.

Peddle says members of Discovery Health who require extensive medical services – for example, after an accident or stroke – will be referred to the scheme’s care co-ordination programme. The facilitators of this programme have a list of accredited facilities that have agreed to meet the scheme’s requirements.

Jordan says that if you have a stroke and need rehabilitation, it is possible that a retirement village frail-care facility may not be suitable, and you will instead be referred to a rehabilitation centre for the best possible prospect of recovery.

If, for example, you fall and break your hip, you are likely to be discharged from hospital before you are able to walk unaided, Jordan says. Fedhealth would offer you care in an accredited sub-acute facility, where you could get both physiotherapy and nursing care, but this may or may not be the facility at your retirement village, depending on what your village offers.

Many sub-acute facilities are situated at retirement villages and some are open to the public, but there are also some independent ones, such as MCare and Intercare.

You may also be referred to a sub-acute facility if you need convalescent care to recover from an operation or health event. Jordan says the length of your stay in a rehabilitation centre will depend on the treatment plan formulated by a multi-disciplinary team working on your rehabilitation and the clinical appropriateness of the treatment within the care you are entitled to in terms of the prescribed minimum benefits (PMBs). PMBs are benefits that medical schemes are obliged to provide to all members, and they cover all emergencies, common chronic conditions, and conditions that, if not treated, would seriously affect your life.

Similarly, the length of your stay at a sub-acute facility would depend on your circumstances, and in this respect you would be assessed by trained specialist case managers employed by your scheme in line with the level of care provided in the PMBs and your progress. If you are discharged and still need physiotherapy, for example, you may need to access your scheme’s day-to-day benefits, unless your treatment is still covered under the PMBs.

Jordan says Fedhealth has a special benefit for physiotherapy, which is paid from the in-hospital benefit for 30 days after discharge, leaving your day-to-day benefits intact. The scheme also has an appliance benefit should you require a walking aid or crutches, he says.

Lizzie Brill, manager of the Oasis Care Centre, situated within the Oasis Retirement Resort in Century City, Cape Town, says large schemes, such as Discovery Health and the Government Employees Medical Scheme, have care co-ordinators who oversee treatment and care for patients who have, for example, suffered a stroke. Typically, these schemes pay a global fee to a rehabilitation facility that covers most of the treatment and care required from a multi-disciplinary team.

Some schemes, however, have separate annual benefit limits of, for example, R35 000 for physiotherapy. The limit will not apply if the condition is a PMB, such as a stroke, and the service is required as part of its treatment.

Dementia

In two other situations there may be confusion about whether your condition and care is covered by your medical scheme. The first is when you have a form of dementia, such as Alzheimer’s disease.

Despite the fact that Alzheimer’s is a progressive and terminal illness, you are unlikely to receive much help from your scheme.

The disease generally affects people when they are over the age of 65, and in the advanced stages requires full-time care, which is usually not covered by your medical scheme. Alzheimer’s is not a PMB, and most schemes cover the chronic medication you require from your day-to-day benefits, which are usually inadequate.

Jill Robson, the regional director of Alzheimer’s South Africa, says Alzheimer’s medication is expensive – in the region of R800 a month – and other medications may be required for other symptoms, such as anxiety or depression. Alzheimer’s patients may also need brain scans, which cost thousands of rands, she says. Some schemes pay for scans only if they are done in hospital and others impose co-payments.

The treatment of other illnesses in patients with Alzheimer’s is also often more expensive as a result of the disease, Brill says.

She says her experience has been that certain restricted schemes offer some benefits for Alzheimer’s, but most open schemes do not, because such long-term care is not regarded as medical care, but as care you require as a result of ageing.

According to Robson, some 750 000 people in South Africa have Alzheimer’s. A group, Alzheimer’s in Action, has launched an online petition to collect signatures from friends and relatives of Alzheimer’s patients who object to the lack of medical scheme cover for the illness.

When you need full-time care, despite the fact that you live in a retirement village with a frail-care centre, you may find that the frail-care centre will not admit residents with dementia.

Some facilities have a separate wing for dementia and Alzheimer’s patients, however. The Oasis Care Centre, for example, has a sub-acute care facility with a licence to provide sub-acute and physical rehabilitative care, a frail-care section for people who are physically frail but still mentally competent, and an entirely separate dementia and Alzheimer’s wing.

Brill says the Department of Health encourages the registration by frail-care centres of separate dementia wings, because dementia have such different needs and they may have behavioural problems. This results in mentally strong but physically frail patients not wanting to be housed together with those who have dementia.

Although not everyone shares the view that dementia patients should be housed separately, Robson believes that it is best. Dementia patients can wander into mentally competent residents’ rooms and upset those residents with their behaviour, she says. They need to be in facilities where they are protected from wandering off and are not at risk of being allowed to leave the facility by someone who is not aware of their condition.

Brill says dementia patients need to be cared for by staff that are not only passionate about providing special care for these residents, but also have been trained to provide appropriate care for them.

The Oasis Care Centre facility for dementia and Alzheimer’s patients is like the frail-care centre, but has its own qualified nursing sister on duty and staff nurses and carers who have been trained by Dementia SA, she says. Continuous in-house training is also required to ensure the best care, Brill says.

To make matters worse for retirement village dwellers who develop Alzheimer’s disease or any other form of dementia, if their village’s frail-care centre is unable to accommodate them, they may be asked to leave the village if they are regarded as being a nuisance to other villagers. In this case, family members will have to find alternative accommodation and care.

When it’s near the end

The other situation that gives rise to confusion about what is covered is imminent death. Medical schemes are obliged to pay for what is known as palliative or terminal care intended to improve quality of life when there is no prospect of prolonging life. Typically, care focuses on pain relief.

The PMBs state that when death is imminent, your scheme must pay for comfort care, pain relief and hydration. These can be done in a sub-acute care unit or hospice environment that may be provided by a retirement village frail-care facility.

Peddle says Discovery Health determines the appropriateness of the facility for your condition and the treatment required. If the nurse or GP who provides the palliative care has a practice number and can bill your medical scheme, the scheme should pay for these services, according to your benefits.

Jordan says Fedhealth will approve treatment in an accredited hospice or nursing facility for palliative care. He says while palliative care is a PMB, the scheme also has a specific benefit for the terminally ill of R25 000.

Peddle says Discovery Health’s Compassionate Care Benefit offers benefits for the terminally ill beyond the PMBs. This benefit provides:

* Access to psychosocial support for the member and his or her family, aimed at easing the resumption of normal life and preventing the consequences of traumatic situations.

* Access to any medication the member requires to be comfortable, and this is not limited to pain medication. This medication is also not restricted to a formulary (or list of approved medications), which normally applies to PMBs.

* A choice of caregiver – a nurse, GP or hospice. In the case of PMBs, these services are usually provided by nurses.

* Pathology services where this is required as part of the member’s medical management.

Peddle says that medical management delivered by a registered healthcare professional – that is a nurse, GP or social worker – will be covered by the scheme as far as it relates to palliative care. The scheme will not, however, cover any bills from a frail-care facility that is not registered with BHF and does not have a practice number.

Discovery Health has introduced a new service this year offering home-based palliative care, as well as home care for other needs, such as wound care and intravenous infusions. These services from nurses and caregivers contracted by Discovery Health are covered by the scheme in line with your benefits.

You can also get respite care – temporary relief for the caregiver to an elderly person – but this will not be covered by the scheme.

HEALTHCARE FACILITIES ON OFFER

There are about as many different healthcare facility arrangements as there are retirement homes and villages, Paul Rosenbrock, a director of the South African Association of Retired Persons, says.

Some villages have no healthcare facilities, some offer home-based care, some have only a frail-care centre and possibly an on-duty nurse, and others offer a full range of services, from assisted living to sub-acute care and rehabilitation to frail care, as well as separate facilities for people with dementia.

Assisted living is also known as midcare or supported living. In most cases, a person will live in his or her own unit, but enjoy support from cleaning services, a carer assisting with personal hygiene and the administration of medicine, a nurse on 24-hour call and meals. Often, these units are available to rent or are sold on a life rights basis – you buy the right to live in the unit for the rest of your life or until you are too frail to live alone. If you buy a life right, when the last-surviving partner dies, the right ceases. Some value may be returned to your estate, but not the full resale value of the unit – for example, your estate may be reimbursed your original purchase price, or the purchase price plus a percentage of the profit on the sale.

Marelize van Rooyen, an estate agent and market research consultant to retirement village developers in Cape Town, says some developers of villages with frail-care or sub-acute care facilities provide the equipment and the building for a healthcare facility and then bring in a company with the necessary expertise to run it. In other cases, the facility is owned by the body corporate of the retirement village.

Val Heighway, a former nursing services manager at the Cape Peninsula Organisation for the Aged (CPOA), says most CPOA-associated homes and villages offer frail care. Many now also offer home-based care, which delays the need for frail care, because frail care, with staff on duty for 24 hours a day, is expensive. Once you need 24-hour care, however, frail care is cheaper than home-based care, she says.

CPOA employs professional nurses on all shifts and provides occupational therapy groups daily. Palliative care is provided, and assistance is obtained from a hospice.

Some newer villages have purposely chosen not to provide healthcare centres, preferring instead to promote home-based care and the concept of “ageing in place” – or ageing in your home and community.

Rayne Stroebel, the managing director of Gerontological Research, Training, Education and Care (Geratec), which offers catering, caring, housekeeping, management consulting and training to retirement villages and facilities involved in the long-term care of older people, says that around the world there is a move to ageing in place.

He says the health and mental state of residents in frail-care facilities decline much more quickly than those of people who remain in their communities. In addition, healthcare facilities tend to become bottomless financial pits, and when they are a drain on a village, a facility will start cutting corners, leading to potential problems.

Keeping people in their communities means that they buy from a care provider only the services they need. Rosenbrock says the advantage of this is that if a healthy spouse is not strong enough to provide for all his or her ill partner’s needs, the couple can enlist home-based services, to help with bathing, for example, and the healthy spouse can continue to do whatever he or she is still capable of doing, such as cooking.

Van Rooyen says a common problem with healthcare facilities is that retirement villages start with relatively young residents, between the ages of 60 and 65, but 10 to 15 years later, the residents are older and have greater medical needs, so the costs of running the healthcare facility rise.

Henry Spencer, the former chief executive of the Association for the Aged and the manager of a retirement village, says that villages in which the majority of residents have been in the village for some time tend not to attract younger residents, even when vacancies arise.

Stroebel says retirement villages with healthcare centres are booming, but younger generations will not necessarily choose these villages, now that there is a trend towards ageing in place. They are likely to prefer villages that form partnerships with service providers. For example, Geratec is in partnership with, among others, Langverwacht, a retirement apartment block in Stellenbosch. Geratec provides care, catering and cleaning services and has guaranteed the residents of Langverwacht that they will not have to move from their apartments to get the healthcare and other services they need.

Van Rooyen says villages that partner with providers such as Geratec typically have a healthcare centre with consulting rooms, a nurses’ station and emergency stabilisation room, but care, including nursing care, is delivered in your home. She says some newer villages have a frail-care centre nearby for those who need it and/or an independent dementia village.

Evergreen Lifestyles, a division of the Amdec property development group, has four retirement villages in Cape Town and one in Johannesburg where home-based care is promoted. The company believes home-based care is the best option, Arthur Case, the former general manager, says. frail-care facilities are sad places, as people seldom move out of them and only a small percentage of people really need to use them, he says.

Evergreen Lifestyles has trained nurses providing nursing care, and all homes and apartments have emergency buttons with which to summon assistance 24 hours a day. The healthcare functions are outsourced to the CPOA in the Western Cape and 24/7 Care in Johannesburg. Healthcare staff will also check on you to see that you are being cared for properly through home-based care.

Case says home-based care is likely, at its cheapest, to work out to about R16 000 a month, because two live-in workers are required to provide care each week. If the carers do not live in, four a week are needed.

Frail-care facilities cost between about R13 000 and R25 000 a month, depending on the facility and the quality of care, he says, although Robson says she knows of places that charge about R5 000 a month.

Lizzie Brill, the manager of Oasis Care Centre in Century City, Cape Town, says Oasis encourages home-based care for those who would like to use these services, but residents must use carers or nurses from agencies that Oasis has approved.

There will always be a market for frail care, because some people are not comfortable with carers or nurses in their homes up to 24 hours a day, she says.

In addition, Brill says when older people are cared for at home they often become isolated and their interaction with others is limited to their care givers, especially in families where younger members have moved overseas.

Brill denies that the Oasis Care Centre is a sad place, saying all the facility’s residents are encouraged and assisted to live full lives as far as possible. A full-time occupational therapist runs daily programmes, which include events and activities, as well as outings. In addition, Brill says the centre’s facilities are like a five-star hotel, which few residents and patients, even the wealthiest, could themselves provide.

She says while home care has its place, it is the daunting demands of running a fully-fledged care centre that have led some developers and bodies corporate to shy away from running such facilities.

Van Rooyen warns about retirement developments that make promises about developing healthcare facilities but never deliver on these promises.

She says often the villages have not been developed as retirement villages as defined in the Housing Development Schemes for Retired Persons Act, and the “promises” are not included in the deed of sale, which leaves you unable to take action against the developer.

Van Rooyen says some villages are marketed as “retirement lifestyle estates”, but they are not registered under the Act.

She advises you to look for a developer with a proven track record to make sure the village is registered under the Housing Development Schemes for Retired Persons Act, and that the frail-care facility is registered under the Older Persons Act. Then read the agreement of sale and the village’s constitution, she says.

Stroebel says people often move into a retirement village during a crisis and do not do enough research. He suggests talking to as many people as you can at a village about the facilities and how they are run.

Rosenbrock suggests you read the constitution and rules of each village you are considering.

A resident of Noordhoek Manor on the Cape Peninsula told Personal Finance magazine that the brochures about the village stated that it offered sub-acute and frail-care facilities. But after she moved in, the village decided to scale down its healthcare services and offer only frail care.

Villagers who need sub-acute facilities are expected to use facilities at a nearby village, the Noordhoek Manor resident says.

Mike Vietri, the chief executive officer of Faircape, the developers of Noordhoek Manor, says the village’s management rules bind it to offering primary healthcare through nursing staff. He says the village fully complies with these obligations and more. In 2011, Faircape obtained a sub-acute care licence to try to improve the Noordhoek Manor healthcare centre’s occupancy levels. Vietri says there was limited demand for this service and it was therefore withdrawn. The licence is maintained, however, so that, if there is a demand for this service, it could easily be re-offered.

Thuli Mahlangu, the chief director of care and services to older persons at the Department of Social Development, says the Older Persons Act, which came into effect in 2010, has introduced some protection for people living in retirement villages and homes, including the registration of frail-care facilities, but there are still many gaps. The department hopes to introduce amendments to the Act to Parliament to deal with some of these loopholes, she says.

Mahlangu says the department is aware of the issue of retirement villages not building healthcare facilities as promised, or, after opening them, declaring them too expensive and shutting them down.”

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