Book Review – TJEd Companion

When I first decided to home school my children, years ago, I took the time to ponder what I really wanted for their education. Because my oldest was only three when I made my decision, I had time to research, read, and think about this. Ultimately, I decided that my biggest priority was that they develop a love of learning, a desire to embrace knowledge. From there, I had to figure out the best way to instill that desire in them. Four years after I began this journey, I borrowed a copy of “A Thomas Jefferson Education” and realized that its methods embodied virtually everything I wanted for our home school plan. And while that book was more concept-oriented, “A Thomas Jefferson Education Home Companion” gives you the nuts-and-bolts application of the teaching.

I really enjoyed the essays within this book. The three authors split them up amongst themselves, and I quickly got a feel for the different voices. For me, the best way to study the TJEd methods was to see how other families applied them, and what that meant for daily life, and this book is chock full of those applications.

Of course, examples are not the only things in the book. Oliver Van DeMille especially penned a number of concept-based essays. The one that stuck out the most to me was the one that pointed out the shrinking attention span in our nation.

Another essay I enjoyed was about feminism and statesmanship. So many stay-at-home-moms – myself included – tend to look inward once they become mothers, and tune out the outside world. This article really inspired me to continue to nurture and lead, and to not shelter myself completely from the things going on around us. I also really appreciated the points made about self-fulfillment, and how so many women think that this is an either/or scenario. I think Jeppson provides ample proof that it need not be, and again, this was something I needed to hear.

One thing I noted in other reviews of this book: other reviewers think that it may be difficult for a new TJer to NOT conveyor-belt their kids after reading this book. I agree that many of the concepts and applications are suggestions and examples, not must-dos. I was fortunate enough to have worked out most of my plans and desires for home schooling beforehand – and having them closely align with a TJEd – so this was less a problem for me. I’ve studied enough to know that I cannot implement every good idea, because they won’t necessarily work with my family. But someone new to home schooling or a Thomas Jefferson Education may need that reminder – so consider yourself reminded! You can’t do it all, but you can find what works for you and tweak it to your family.

Overall, I really enjoyed this book. I read it, pen and notebook in hand, and took copious notes. It was kind of nice to “study” it after reading “A Thomas Jefferson Education” because I was geared up to take notes and ponder what I was writing down. Again, as long as the reader remembers that a TJEd is *not* a conveyor-belt education, and we should *NOT* seek to duplicate everything we read, they should be able to get a lot out of this book. (Oh, yes, and also remember that a new Hser is NOT going to duplicate the patterns that a ten+ year veteran has perfected.)

Dispelling the Confusion About Different Types of Home Care

Given the enormous volume of information written about home care services, I continue to be amazed at the frequency with which skilled home health care is conflated with non-medical home care, as if they were similar concepts. Some authors even use the terms interchangeably. Nothing could be more off the mark. In this article, I would like to make clear some of the key distinctions between these two kinds of home care.

Skilled home health care is virtually always provided by Medicare-certified agencies and is covered by Medicare and commercial health insurers. The services consist of intermittent visits by skilled professionals, usually a nurse and/or a rehabilitative therapy professional-physical therapy, speech therapy or occupational therapy. Visits take place intermittently over a limited period of time lasting no more than a few weeks, usually initiated after a hospital or nursing home discharge. In conjunction with skilled services, a home care aide may visit once or twice a week for a brief visit to provide in-home assistance with personal care, such as bathing.

Medicare covers skilled home health care under the following conditions (commercial insurers usually adopt the same criteria): 1) The services must be prescribed by a physician; 2) They must be provided by a Medicare-certified home health agency; 3) The patient must be home-bound, a requirement that is loosely defined; 4) The patient must need the care of one or more of the professionals mentioned above, as certified by a doctor.

Now, the eligibility criteria and insurance coverage of home health care have certain implications for consumers that are not always explained. First of all, the patient and family rarely have any role in choosing the agency they prefer. That decision is in the hands of the doctor in conjunction with the hospital or nursing home. Sure, a patient can express a preference for a particular provider if he or she has had a previous experience with home health care, but this is unusual in practice. Fortunately, Medicare has begun to make comparative information available on the internet through the Home Health Compare database. This may help to shift some control back to the consumer over time, because it permits patients and families to obtain quick information within the limited time frame permitted by discharge planning.

The second implication for consumers is that the frequency of home visits and the duration of home health services is also largely out of the control of patients and families. It is the home health agency, governed by the physician’s orders and Medicare’s eligibility requirements, that makes those determinations. And, just to be sure that the home health agencies can’t profit unreasonably from more and more services, Medicare typically pays them by the episode of care, not by the volume of services they perform.

Non-medical home care is a completely different animal. Companies that provide such in home caregiver services employ unskilled personnel, variously called certified nurse aides, home caregivers, home health aides, home companions and other designations. The caregiver services they perform include help with personal care, such as bathing, toileting, dressing and mobility assistance, as well as general companionship, safety supervision and various household tasks. Typically each visit is several hours in length, and many highly impaired care recipients require round-the-clock or live-in care. Conceptually, non-medical home care can be thought of as “assisted living at home.” The care recipient is usually referred to as a client, reflective of the consumer-controlled nature of non-medical home care. Unless the client meets the low-income criteria to qualify for Medicaid, this type of home care is almost always paid out of pocket or by long-term care insurance. Clients select the company that provides the care and can fire the company if dissatisfied.

Here is a summary of the key factors that characterize skilled home health care:

  • Requires a doctor’s prescription
  • Nursing, therapists, social workers
  • Patient must be house bound
  • Performed by a Medicare-certified agency
  • Limited visit frequency and duration of services
  • Consumer usually not in control
  • No sustained presence in the home
  • Covered by Medicare or health insurance
  • Providers paid by the episode of care
  • Accountability to doctor and insurer (Medicare), not just to patient

And here are the ways non-medical home care is different:

  • No doctor’s prescription required
  • Home companions, nurse aides, home caregivers
  • Irrelevant whether client is house bound
  • Agency does not need to be Medicare-certified
  • Length of visits and duration of care determined by client and family
  • Consumer in control
  • Sustained presence is central to the service: “assisted living at home”
  • Not covered by Medicare or health insurance
  • Providers paid by the hour or by the day
  • Accountability to the client and family

Family Home Care for Solitary Seniors

This report is a composite of observations of a Senior citizen in her normal life setting. It represents near optimal family coordination to assure:

1. Adequate personal security
2. Relative Senior independence
3. Medication compliance
4. While maintaining normal life function for the children.

Let’s call her Helen and she’s an 89 year old African American woman. A petite108 pounds and five feet tall, Helen is the Mother of three professional children who maintain her status as the family’s alpha female. She lives alone since being widowed some 20 years ago. Her dedicated home companion is an obedient 150 pound black Great Dane named Titan. Her home is a 3500 square foot, brick, and tri-level home on a wooded acre in suburban North Carolina. It still appears modern despite its 50 year age, and has lots of stairs.

As a retired college Math PhD, Helen maintains a current computer with internet access but uses it infrequently due to ease of use and security concerns. Luckily Tracy, her Granddaughter, is available for in-home IT consultation. The wall mounted kitchen TV constantly broadcasts CNN from early morning to her bedtime. It provides continuous background noise in the large home, despite the audio volume being too low for her to understand. When she wants to hear details, she stands and watches closely.

Helen’s memories of recent events and details are usually clouded, forgotten and repetitive. Cognitive function such as reasoning, calculating and remote memory is still above average. Managing her bills, real estate, checking account, taxes and investments is time intensive and laborious. It’s accomplished by her and Sharon, her daughter in weekly segments. Playing Bridge was her passion and favorite social pastime, until four years ago when she stopped playing.

Dr. Spruill, her Internist, reports that her overall health is appropriate for her age, as she is a Cancer survivor and has several chronic, yet well controlled illnesses. Medication management and compliance are monitored daily by her kids. Her activities of daily living are conducted without assistance. Though the noon meal is delivered, eating is usually inadequate and requires being reminded. The exception is the nightly cup of Breyer’s Butter Pecan ice cream before bed.

Adventures outside of the homestead occur about twice a week for her. She accepts invitations to college events, if not sports related. Though no longer maintaining driving privileges, at least once weekly she’s taken to a local restaurant and attends one of several local churches. Recently, as a speaker at a testimonial event for a friend, the audience was entranced as she recited twenty lines of poetry from memory. The poem was learned at 22 years old but practiced prior to performance.

As the sole survivor of her parents and siblings, most of Helen’s extended family live within75 miles. Children, Grandchildren and Great Grandchildren all frequently participate in her life with visits and group events. Twice daily phone calls monitor her wellbeing. The older kids visit at least once weekly, maintaining the homeland, keeping health appointments and doing the laundry. This is prime time for monitoring personal habits, medication compliance, and performing a physical assessment. These visits last from a few hours to several days at a time. The highlight of the week is the mandatory Sunday phone conference call with Helen and the three older kids. It doesn’t matter where the kids are in the country, attendance is expected. Music and reminiscing are usual themes with a weekly personal update followed by a current events challenge. Episodically business issues are discussed but seldom settled. Everybody enjoys these get-togethers, usually.

For security purposes, the kids maintain a substantial home monitoring system along with an emergency pendant, fire extinguishers and night lights. Fall detection and video surveillance systems are controversial, as Helen resists intrusive or invasive technologies. Personal independence is the principle upon which most decisions are measured.

Here’s some advice before planning any family based home care model. Top priority should be given to monitoring well-being and safety… primarily precautions with multiple back up plans and redundant resources. The overall goal should be to provide therapy that combats the onslaught of loneliness, memory loss, chronically diminishing technical skills and mobility compromise. The individual needs and behaviors of each Senior should be determined. This assessment should include a close evaluation of mental and physical capabilities and limitations. A third party analysis of the plan might enhance its value and efficiency while promoting family confidence.

Dr. David W. Trader, Geriatric Psychiatrist, describes socialization as an essential element for Seniors to attain a satisfactory quality of life. Our research reveals that in prehistoric times, human predecessors found group behavior to be requisite for survival, as it is in many insect and animal species. Socialization has multiple beneficial effects on isolation, memory loss, diminishing skills, and mobility. The caregivers’ mission is to identify and address these critical factors.

Despite Helen’s limited needs and exceptional mental status, the principles applied to this home care model produce an above average quality of care which is achieved by:

1. Establishing quality standards and goals
2. Modifying methods of care based on customized Senior needs and their environment
3. Importantly, sharing the duties and costs throughout the family which decreases early caregiver “burn-out”.

Our next article will discuss the strengths and weaknesses of this family based home care plan.