I could turn the placement over to the VA social worker. He'ld then get put in the first place to have a bed. If I do the placement myself, I can shop around. Not that there's a whole lot to distinguish one place from another. The better nursing homes require "private pay." He has no assets and only a small income. He is already approved for institutional Medicaid. So I have to pick from among the homes that accept Medicaid. (The better places brag that they accept Medicaid. There's a twist to that. Some of their residents outlive their wealth, even when they have considerable assets and income. So, after a few or more years of paying the big bucks drain them of their financial resources, then and only then, the nursing home will allow them to stay on as patients "on institutional Medicaid." I had one wealthy relative who went into a swanky nursing home. What I heard was that, to be accepted as a resident, she had to let the facility have some sort of a "lien" on all her wealth, so that she could not "gift" it to her family, while she was alive and in this facility. It had to be used to pay for her care. It's a "quid pro quo" deal, with an element of "gamble" in it for the n. home. In exchange for you paying the big bucks for as long as your wealth lasts, the home will accept the smaller Medicaid payments, when your assets are exhausted. Some of these homes even had a less swanky section of the facility that you would be moved to when you could no longer pay privately. I worked for 5 years in a place like that. Some of these high-end facilities are operated by religious organizations. (Examples I know of, firsthand, have affiliations that are Catholic and Lutheran. They hold themselves to higher standards AND have the revenue stream that makes that possible.)

Facilities run for profit, that are not marketing to the very affluent, simply are not oriented toward high quality care, just like McDonald's is not oriented toward the best nutritional standards. They can't be. I happen to have worked in 3 facilities that did derive most of their revenue from Medicaid and did have above average standards. All 3 were non-profit. One was operated by a Franciscan order of sisters. Another was publicly owned and operated by a large city. Another was owned by one of this country's most affluent Indian tribes. That's what it takes to get proper incentivization. There has to be a board of directors who are answerable to something other than maximizing the bottom line. For-profit chains do care about not getting sued. That doesn't fix everything. They accept losing some lawsuits as just a cost of doing business. Increasing regulation has not had the desired effect either. Facilities do worry constantly about running afoul of "regs." All procedures are structured to avoid triggering a "reg violation." That actually drains effort away from designing care to best meet patient needs. Nurses aren't encouraged to rely on their own discretion to make decisions about how to allocate the attention of staff when need outstrips the man-hours available to meet need, as will happen whenever we don't have a private caregiver assigned to each patient. (Filling water pitchers will take precedence over getting residents to the bathroom because "state surveyors" can more easily check the temperature of the water pitchers than whether or not incontinent patients are left unchanged all day.)

There are federal standards and state standards. Poor states don't seem to have the same standards as richer states. For instance, in poor states, nurses' aids are allowed to pass medications. That results in nurses not having much interaction with patients. After decades of working in long-term care, I am able to see how conditions are actually deteriorating in some respects.

Anyway, my job isn't to write a treatise on what's wrong with this multi-billion dollar industry. I have to decide what to do about one particular elder whom I care about.

I thought that the Medicaid Waiver program, which provides in-home help with caregiving, as an alternative to institutional placement costing the government upwards from $8000/month, would make this doable for me. It's a crappy program that is nothing like what I envisioned 3 years ago when I helped my bf qualify for it.

I keep putting off giving up on doing the care myself. I tell myself to just try harder to keep this arrangement afloat. The result is I'm just getting worse and worse depressed. I'm starting to not care about him. It was never a great relationship . . . but it was what I had. It had lasted a long time. I always seemed to give an awful lot for what I got in return. Now I feel depleted . . . like my soul is bankrupt. I believe depression comes from having an approach to life that doesn't work very well. That's my story for sure. I'm a mess now.