America has a highly developed health care system, which is available to all people. Although it can be very complex and frustrating at times it has come a long way from the health care organizations of yesterday. Previously most health care facilities were a place where the sick were housed and cared for until death. Physicians rarely practiced in hospitals and only those who were fortunate could afford proper care at home or in private clinics. Today the level of health care has excelled tremendously.

Presently the goal of our health care is to have a continuum of care for the patient, one which is integrated on all levels. Many hospitals offer a referral service or discharge plan to patients who are being discharged. Plans for the patient are discussed with a discharge planner. The discharge planner is a person who is trained in assessing what the patient's requirements for health care will be after discharge from the hospital. This enables the patient to continue! their care at a level which is most appropriate for them. Items reviewed for discharge planning include but are not limited to therapies, medication needs, living arrangements and identification of specific goals.

A few of the options that are available for persons being discharged from an acute care hospital can include home health care, assisted living facilities, long term care or hospice Home Health Care According to Growing Old in America (1996), 'Home health care is one of the fastest growing segments of the health care industry' (p. 114). Alternatives for home care can meet both the medical and non-medical needs of a patient. These services are provided to patients and their families in their home or place of residence.

Home care is a method of delivering nursing care and other therapies as required by the patient's needs. Numerous alternatives are available for persons seeking health care at home. With transportable technologies such as durable medical equipment, oxygen supply and intravenous fluids there are countless possibilities for treatment within the home setting. As stated in The Continuum of Long Term Care 'Home health programs range from formal organizations providing skilled nursing care to relatively informal networks that arrange housekeeping for friends' (p. 185). This has allowed for home care to quickly become an essential component of the health c! are delivery system in the United States.

In a home health care situation the primary care giver is usually not the physician. The physician is communicated with by phone and with documentation from the caregivers. The primary caregivers are usually the nurses and other team members who are involved directly with the patient's care. Although, the original order to begin home care must be initiated by the physician if skilled care is to be obtained.

According to the 1995 Guide to Health Insurance for People with Medicare 'Medicare pays the full cost of medically necessary home health visits by a Medicare-approved home health agency' (p. 5). This coverage must meet specific criteria, but it can be a relief to family members to know that their loved ones can be taken care of at home without worrying about the expenses. Unfortunately, if the care to be given within the home is termed 'not medically necessary' the expense is not covered. This can include items such as meal and medication delivery, a percentage of necessary durable medical equipment, personal care and homemaker services.

My employment within a home health care agency has allowed for review of services that are not covered by Medicare and / or private insurance. Health care services that are not included can become quite numerous. It is often difficult for family members to understand why specific services are not covered especially when they appear to be necessary for the care of the patient. These costs can add up quite quickly and the impact of the cost can become quite distressing for family members and patients on a limited budget.

In these cases a Social Worker is usually provided to help the patient and family explore other avenues which may enable them to cover their health care costs. Assisted Living Assisted living is an arrangement to residents of a facility that enables them to complete certain daily activities while remaining independent. The services provided enable the resident to achieve maximum function of their activities of daily living. The services are unskilled and non-specialized personnel provide the activities essential to the care of the resident. These services help assist the aged, blind, disabled, and other functionally limited individuals with necessary daily activities which they require help with or are unable to perform on their own. An example of some of the services which may be available are light housekeeping, meal preparation, medication reminders and personal care.

The personal care does not include specific health oriented services which would require the services of a certified or licensed professional. It is stated well in Aging 'Although the level of services provided may vary, assisted living communities all share a common goal: e! na bling people to live as active and independent a life as possible' (p. 212). The goal of an assisted living facility is to have the residents feel independent within their own home. According to the article Assisted Living's Future In Michigan Debated " Assisted living facilities can offer consumers a great opportunity to get personalized care in a comfortable setting' (p. 2).

Currently there is some controversy surrounding the different types of assisted living facilities. In Michigan facilities termed assisted living have no real legal meaning and are not required to be licensed under this name. According to the article Assisted Living's Future In Michigan Debated 'Unlicensed facilities, unsubsidized care, untrained staff, and unmet promises make some places seem more like un-assisted living' (p. 1).

Unfortunately many facilities are misleading as to what level of care the yare providing. Both the government and national organizations are currently addressing this issue. My own experience with an assisted living facility has been quite good. Formerly my grandmother was a resident of an assisted living facility. The facility was specifically built for seniors and was that of an apartment like structure.

The facility provided social and recreational activities on a continual basis. There was also transportation service available for residents who wished to use it. My grandmother thoroughly enjoyed living in an assisted living facility where she had the opportunity to make numerous friends, participate in activities and remain independent. Long Term Care Long-term care patients are categorized by having a chronic condition and / or disease. The long-term care facility can be either hospital-based or freestanding. It consists of an organized medical staff, which provides continuous nursing services under professional nurse direction.

The patient's status is reviewed on a regular basis to determine if they meet criteria to remain at the facility. The long-term care facility is regulated by state li censure regulations, federal regulations and Joint Commission on Accreditation of Health Care Organizations (JCAHO). State li censure is mandatory, Federal regulation is only necessary if the facility participates with Medicare and Medicaid, and JCAHO standards are voluntary. Long term-care is very expensive and it often becomes a financial catastrophe for the elderly person and their family. Private insurance is unlikely to cover the full cost of care and Medicare only pays for a limited amount. The person usually must eliminate a substantial amount of their assets to become eligible for Medicaid which covers long term care.

According to Growing Old In America 'In order for elderly persons to qualify for nursing home care under Medicaid, they usually must reduce their personal financial status to the poverty level (p. 119-120). Regretfully, the cost is not the only disturbing factor of a long-term care facility. Family decision to place my grandfather who was suffering from Alzheimer's disease into a nursing home was a very difficult and emotional experience for everyone involved.

Regular visits by all family members continually raised concerns about the quality of care that he was receiving. Staffing was also a concern for our family. It seemed there was not enough staff to meet the needs of the patients within the facility. Although licensing agencies regulated these aspects, this was not comforting to our concerns. Fortunately, we were able to move my grandfather to a different facility. The nursing home was newer and better staffed and all family members felt more comfortable about the care he was receiving.

The experience of placing a loved one into a long term care facility is one I would prefer to not experience again. It is comforting to know that there are good facilities avail ab! le and caregivers that really care about the patient's needs. These aspects are very important for families to understand before making a final decision when they must place a loved one into a facility. Hospice Unfortunately the last resort for some patients may be hospice care. Hospice is an organized program that offers dying persons and their families an alternative to traditional care for terminal illness. As stated in Aging 'Hospice care is exclusively for dying people.

It therefore brings expertise to helping patients and their families face issues specific to death and dying' (p. 180). Hospice enables the patient to receive palliative medical care, while meeting the psychosocial and spiritual needs of the patient, their family and friends. Hospice programs also offer bereavement services for 13 months (or beyond if required) following the patient's death for any family members or friends who wish to receive the service. The article The Continuum of Longterm Care emphasizes 'The philosophy of hospice is that terminally ill individuals should be allowed to maintain life during their final days in as natural and comfortable a setting as possible' (p. 198).

The quality of life of the terminally ill patients relies heavily on the psychosocial skills of their health care team. The health care team consists of a physician, nurse, social worker, chaplain, home health aide and volunteers. The team develops an individual care plan which will provide an appropriate support system for the patient and their family up to and beyond the patient's death. Weekly meetings allow the team to focus on the changing needs of the patient and make adjustments to their plan.

Hospice care can be received in a variety of organizational settings. The most preferred setting is of course within the patient's own home, but nursing homes, hospitals and long term care facilities are a few who can also provide hospice care. Hospice care is a covered benefit under Medicare and most private insurance companies. The regulating agencies that set the standards for hospices are Medicare, the National Hospice Organization, Joint Commission on Accreditation of HealthCare Organizations (JCAHO) and state hospice agencies. Have found that the medical record content in a hospice program contains an extensive amount of identifying information in regards to the patient and their primary caregiver (s). All aspects of patient care are well documented and assure well-coordinated, continuous care.

The medical record acts as a communication tool between the different team members and is used on a continuous basis throughout the patient's care. Conclusion Although there are many options other than those listed for healthcare after discharge from a hospital, The most important aspect for a person is to be well informed and knowledgeable about the variety of options available. It can be very confusing, especially to an elderly person when talk of finances, regulations and covered and non-covered items are discussed. It is our responsibility as future health care administrators to provide adequate information to the person who is opting for alternatives to health care..