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Voices: Alliance Insurance Group’s David Thurber on Third-Party Care in Assisted Living

This article is sponsored by Alliance Insurance Group. In this Voices interview, Senior Housing News sits down with David Thurber, Counsel and Business Advisor at Alliance Insurance Group, to learn about the benefits and drawbacks of bringing third-party care into an assisted living facility, and how to navigate those conversations with prospective residents. He explains how to avoid the common pitfalls of bringing third-party care into a community, as well as the steps operators can take to ensure the safety and security of the community at large during that process.

Senior Housing News: Bringing third-party care into assisted living is difficult for several reasons. Let’s start with the operator who might be resistant, even though it can be a tool to retain census. What should operators weigh when considering how to handle outside care?

David Thurber: Using third-party care providers when necessary is an asset to both the marketing and care teams in any senior living organization. In that process, organizations need to be deliberate and intentional.

Effectively, the facility needs to balance the interests of all stakeholders with the residents’ desire for third-party help. The Community also has to balance the safety and security of others in the community with the exposure to and liability for the actions or inactions of third-party caregivers who are brought into the community. I also want to include sitters here — oftentimes just family members, friends or neighbors are asked to be a sitter. I’ve had a number of clients ask, “How do we bring in a sitter to take care of our resident?”

Non-professional support like a sitter can bring a heightened level of exposure, because these are likely ordinary people off the street, and we don’t know their background or their proclivities and propensities. Injury, drugs, assault and theft are a few of the risks that come to mind. Those are the kinds of considerations operators need to have when deciding on a process to bring in third-party caregivers.

Families who have moved their loved one from independent living to assisted living aren’t always thrilled to hear that their loved one now needs additional outside care inside AL. What are the best ways for operators to navigate those conversations?

Thurber: Third-party caregivers may come into play either because the family itself wants the additional support or care or because the community has recommended the need for such care; maybe as a last resort before having to pursue a skilled nursing option. There is an expense in there, and there is a discussion that needs to occur. I think initially, it is important to set expectations, which is elementary when a family brings their loved one into an assisted living or skilled nursing facility. Setting those expectations early is critical, and that can be achieved through either the resident agreement, the marketing discussions or the one-on-one discussions with the family, resident or legally authorized representative of that individual. We’re okay with operators bringing in third-party caregivers. The regulations, generally speaking, in all states allow for that, but there’s a process to it. We need to talk the stakeholders through that process and communicate the various issues we are concerned about as we move forward.

Residents have the right to enhance their care by contracting with third-party caregivers. How do operators balance those rights against the community’s rights to maintain a safe living environment for all stakeholders?

Thurber: Again, it is about discussing expectations and discussing the liability issues at length — not only for the individual resident but for the community as a whole. There needs to be a discussion around due diligence in the selection process of any third-party provider, and whether an agency provider might be an option as opposed to an individual. It’s important to evaluate the quality and competency of the individual.

Is the physician involved in the discussion and the decision-making? Is there a therapist or a therapy clinic the resident is working with? I think those are some of the things community leaders should talk about with the residents.

I think the community can also set up some guidelines, maybe a guide or a handbook itself that would provide families and residents with a method for bringing in a third-party caregiver, or home health type of aide.

For operators that are considering getting involved in the resident’s process to hire outside caregivers, what liabilities are lurking, and how does the community mitigate exposure to liability for any malfeasance injury, or death to other residents or staff?

Thurber: This is an issue that’s been embedded in the conversation so far. The more hands-on a community gets in the selection process, the more exposure they face. When the community gets into the actual decision-making, the community is effectively, like it or not, giving its good housekeeping seal of approval to the person or agency that the family selects. The family then relies upon the community’s recommendation. Therein lies the hook for potential community liability.

I think it’s a balancing act for the community to decide just how involved they want to be in the process. Does the community see their involvement as a value added benefit? If they are going to get involved, they have to ask themselves: “Do we have the right staff to conduct the due diligence to ensure what we’re recommending is safe for the resident?”

If there isn’t enough staff, then I think the community is taking on a very large risk. To mitigate that risk, the community can provide a series of questions to the family, perhaps a guidebook like I mentioned earlier, to identify important issues in the selection decision. For example, who are they? What’s their experience? Do they have any referrals? Do they have insurance? Have they had prior problems that we know about or can find out about?

Just doing some homework to confirm that the person coming in is competent, safe and responsible. Ultimately, as part of that handbook or guidebook, the third-party caregiver needs to sign in. Like anybody coming into the building has to sign in, we know when they’re there and can talk about that.

What other protocols and policies should the community establish for outside care providers?

Thurber: As we have been discussing, the community needs a clear written policy that describes the methodology by which third-party caregivers can be brought into the community. They should incorporate the state regulations where appropriate.

I think a policy and/or handbook that everybody can read and see, is key. It establishes expectations and a safer environment for all to operate. The policy should also require third parties to identify themselves by name tags and or attire to separate themselves from the community employees, so that other people in the building know they’re not an employee of the facility and indeed are a third party, independent contractor. Again, one more thing to mitigate liability for any unwanted actions by the third party.

The final issue is determining what to do with the information the third-party caregiver acquires in the course of providing care or support. Where does that information go? Does it go back to the doctor? Does it go into the care file that gets delivered to a director of nursing or a caregiver in the facility? That has to be thought through carefully as well, and should be part of the community policy and/or handbook.

Should the community receive information from the third-party care provider? If so, what are the issues related to doing so?

Thurber: The defense bar seems to be a little divided on this question. Some defense lawyers don’t believe that any third-party care information should be put into the file unless it goes through the physician. In this scenario, the physician provides whatever information he or she deems appropriate to go into the file and determines how that information might alter the care plan.

Others focus on the greater mission, which is simply to care for people. In doing so, it is better to have all resident information available to determine the best course of care. They believe caregivers should always know what that information looks like and it shouldn’t matter how they get it.

I think there’s some risk in that. Anytime a facility gets information out of the blue, they should always triage that with a physician or Director of Nursing before they enter it into the file or alter the care plan. I think having the physician somewhere in that process is critical, and it will certainly help absolve the community from liability if changes are made that lead to complications.

How do you assimilate and assess the information and the care file with current physician orders and care plans, and do you think the resident’s physician should be the gatekeeper for all resident healthcare information? If not, who should be?

Thurber: Fundamentally, the physician should be the gatekeeper. Secondarily, the director of nursing and/or the medical director at the facility should review any information from a third-party provider. That would be the order of operations for how a third-party provider’s information should be assimilated into the care plan or care file of the facility.

Again, triaging information is always a good idea. Certainly it’s a good idea when it comes from a third-party provider. Some third-party care providers, therapists, or home health care providers actually participate in weekly roundtable meetings with community staff and contribute their observations.

If that information happens to come from, say, a sitter who was hired by the family to observe and help them 24/7, not all of the information will be important. The assessment of that information needs to be thoughtful and carefully performed. The triaging idea mentioned earlier would be a perfect place to go over this information.

With the pandemic still raging, how has the need for outside care in senior housing changed, and how has the receptiveness to that need changed among all the stakeholders?

Thurber: The pandemic has created many issues for our clients, but staffing is top of mind right now. Anything and everything that can be done to augment resident care ought to be evaluated and considered in the context of this staffing crisis. Third-party caregivers, home health aides, perhaps sitters, can all be a part of that solution. All of the issues we’ve been discussing simply become more important.

However, third-party caregivers are expensive, and it is the family’s decision to bring them in. At the end of the day, the family has to foot the bill. Operators may be better off leaving it an independent decision by the family and the resident themselves. Providing a policy or handbook as we have discussed will help them make that decision.

I think third-party providers are also far and few between as a result of this pandemic. Everybody is looking for help, and it’s harder to find capable, competent, thoughtful, mature, responsible individuals to work in our industry at any level. That includes in the third-party care environment as well. Hence, the need for thoughtful due diligence by the decision maker(s).

Editor’s note: This interview has been edited for length and clarity.

Representing over 50 carrier experts and more than $84 million in premiums, Alliance was built on the belief that its clients’ commercial insurance dollars should come back to work for them. To learn more about how Alliance Insurance Group can help your organization, visit allianceinsgrp.com.

The Voices Series is a sponsored content program featuring leading executives discussing trends, topics and more shaping their industry in a question-and-answer format. For more information on Voices, please contact sales@agingmedia.com.

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