It's the Fourth of July - Salute our Veterans with Quality Care!

When families come to see me regarding the long-term care needs of a loved one, we always identify two goals. The first, and most important goal is good quality care. The second is to obtain that care in a manner that does not completely impoverish the older person and his or her spouse. In developing a plan to pay for good care, we have to identify all sources of funds to help pay for that care. The most overlooked source of help with long-term care costs is a Veteran's Administration (VA) benefit that pays monthly income to veterans and their spouses, and to the surviving spouses of deceased veterans. This benefit is commonly known as "Aid and Attendance Benefits."

In 2008, an unmarried veteran can receive a cash payment of as much as $1,554 per month. A widow or widower of a deceased veteran can receive up to $998 per month. Married veterans can receive up to $1,842 per month. While this is not enough to pay for 24-hour care, it can be of great help for the senior who is still living at home or in community-based care, and needs to bring in some extra help to remain independent.

Like Medicaid, the VA Aid and Attendance benefit is a means-tested program. Generally speaking, assets have to be reduced to approximately $80,000, plus the home and one car, in order to qualify. The applicant must have limited income, however, high medical and care costs can be used to offset the applicant's income.

In addition, the Aid and Attendance benefit is limited to wartime veterans and their spouses. The veteran does not have to have a service connected injury or have served in combat; military service during wartime for even one day is sufficient. The veteran or his or her spouse must need assistance with activities of daily living. Even if the veteran has assets exceeding $80,000, it is possible to plan to obtain Veteran's Aid and Attendance benefits.

Unlike Medicaid, there is no five-year "penalty period" if the applicant has transferred assets out of his or her name. The eligibility rules regarding planning are not as restrictive as the Medicaid eligibility rules. By doing planning to obtain Veteran's Benefits, it is sometimes possible to pay for care while staying out of the Medicaid system. Still, Veteran's Benefit planning should always be done by an experienced elder law attorney who understands the Medicaid rules, just in case the veteran may someday need to qualify for Medicaid assistance.

Do you know a military veteran who served our country during wartime, and who could use some extra money to pay for care costs? If so, please give him or her a copy of this article. Planning for Veteran's Benefits is an excellent way to provide extra income to help the veteran and his or her spouse receive the care they need, while staying independent as long as possible.

Geoff Bernhardt is an elder law attorney in Portland, Oregon. For more information on
his firm and on Elder Law planning, please see his website at www.elderlawpdx.com.

Dad's Odd Behaviors Don't Mean He Has Alzheimer's-He's Just Getting Older, Right?

By Jacqueline Marcell, Author, "Elder Rage"

For eleven years I pleaded with my elderly father to allow a caregiver to help him with my ailing mother, but after 55 years of loving each other--he adamantly insisted on taking care of her himself. Every caregiver I hired to help him sighed in exasperation, "Jacqueline, I just can't work with your father--his temper is impossible to handle. I don't think you'll be able to get him to accept help until he's on his knees himself."

My father had always been 90% great, but boy-oh-boy that temper was a doozy. He'd never turned it on me before, but then again--I'd never gone against his wishes either. When my mother nearly died from an infection caused by his inability to continue to care for her, I immediately flew from Southern California to San Francisco to save her life--having no idea that in the process it would nearly cost me my own.

EARLY SIGNS OF DEMENTIA?
I spent three months nursing my 82-pound mother back to relative health, while my father said he loved me one minute but then get furious over some trivial little thing and call me horrible names and throw me out of the house the next. I was stunned to see him get so upset, even running the washing machine could cause a tizzy, and there was no way to reason with him. It was so heart wrenching to have my once-adoring father turn against me.

I immediately had the doctor evaluate my father, only to be flabbergasted that he could act completely normal when he needed to! I could not believe it when the doctor looked at me as if I was crazy. She didn't even take me seriously when I reported that my father had left the gas stove on without it lighting, or that he had nearly electrocuted my mother. Luckily, I walked into the bathroom just three seconds before he plugged in a huge power strip, which was in a tub of water--along with my mother's soaking feet!

Much later, I was furious to find out that my father had instructed his doctor (and everyone he came into contact with) not to listen to anything I said because I was "just a (bleep bleep) liar"--and all I wanted was his money! (Boy, I wish he had some.)

Then things got serious. My father had never laid a hand on me my whole life, but one day he nearly choked me to death for adding HBO to his television--even though he had eagerly consented to it just a few days before. Terrified and shaking, I dialed 911 for the first time in my life. The police came and took him to a psychiatric hospital for evaluation, but I just could not believe it when they released him saying they couldn't find anything wrong with him. What is even more astonishing is that similar horrifying incidents occurred three more times.

CAREGIVER CATCH 22
I was trapped. I couldn't fly home and leave my mother alone with my father--because she'd surely die from his inability to care for her. I couldn't get healthcare professionals to believe me--because my father was always so darling and sane in front of them. I couldn't get medication to calm him, and even when I finally did--he refused to take it, threw it in my face, or flushed it down the toilet. I couldn't get him to accept a caregiver in their home, and even when I did--no one would put up with him for very long. I couldn't place my mother in a nursing home--he'd just take her out. I couldn't put him in a home--he didn't qualify. They both refused any mention of Assisted Living--and legally I couldn't force them. I became a prisoner in my parents' home for nearly a year trying to solve crisis after crisis, crying rivers daily, and infuriated with an unsympathetic medical system that wasn't helping me appropriately.

GERIATRIC DEMENTIA SPECIALIST MAKES RIGHT DIAGNOSIS
You don't need a doctorate degree to know something is wrong, but you do need the right doctor who can diagnose and treat properly. Finally, I stumbled upon a compassionate neurologist specialized in dementia, who performed a battery of blood, neurological and memory tests, along with CT and P.E.T. scans. He reviewed all of my parents' many medications and also ruled out all the many reversible dementias. And then, you should have seen my face drop when he diagnosed Stage One Alzheimer's in both of my parents--something that all of their other doctors had missed entirely.

TRAPPED IN OLD HABITS
What I'd been coping with was the beginning of Alzheimer's, which starts intermittently and appears to come and go. I didn't understand that my father was addicted and trapped in his own bad behavior of a lifetime and that his habit of yelling and pounding the table to get his way was now coming out over things that were illogical and irrational... at times. I also didn't understand that demented does not mean dumb (a concept that is not widely appreciated) and that he was still socially adjusted never to show his "Hyde" side to anyone outside the family. Even with the onset of dementia, it was amazing he could be so manipulative and crafty. On the other hand, my mother was as sweet and lovely as she'd always been.

BALANCING BRAIN CHEMISTRY
I learned that Alzheimer's is just one type of dementia (making up 65% of all dementias) and there's no stopping the progression nor is there yet a cure. However, if identified early there are medications that in most people can mask/slow the progression of the disease, keeping a person in the early independent stage longer--delaying full-time supervision and nursing home care. (Ask a Dementia Specialist about the FDA approved medications: Aricept, Exelon, Razadyne and Namenda.)

After the neurologist treated the dementia and then the depression (often-present in dementia patients) in both of my parents, he prescribed a small dose of anti-aggression medication for my father, which helped smooth out his volatile temper without making him sleep all day. (Boy I wish we'd had that fifty years ago!) It wasn't easy to get the dosages right and not perfect, but at least we didn't have to have police intervention anymore! And once my parents' brain chemistries were better balanced, I was able to optimize nutrition, fluid intake, and all their medications with much less resistance.

CREATIVE BEHAVIORAL TECHNIQUES
As soon as the medications started working, I was finally able to implement some creative behavioral techniques to cope with all the bizarre behaviors. Instead of logic and reason--I learned to use distraction, redirection and reminiscence. Instead of arguing the facts--I simply agreed, validated their frustrated feelings, and lived in their reality of the moment. I finally learned to just "go with the flow". And, if none of that worked, a bribe of vanilla ice cream worked the best to get my obstinate father into the shower, even as he swore a blue streak at me that he'd just taken one yesterday (over a week ago)!

Then finally, I was able to get my father to accept a caregiver in their home (he'd only alienated 40 that year-most only there for about ten minutes), and with the tremendous help of Adult Day Health Care five days a week for them, and a weekly support group for me, everything started to fall into place. It was so wonderful to hear my father say once again, "We love you so much, sweetheart."

ALZHEIMER'S / DEMENTIA OFTEN OVERLOOKED
What is so shocking is that no one ever discussed the possibility of Alzheimer's with me that first year. I was told their "senior moments" and intermittently odd behaviors were just old age, senility, stress, and a "normal part of aging". Since one out of every eight persons by the age of 65, and nearly half by the age of 85, get Alzheimer's Disease--I should have been alerted to the possibility. Had I simply been shown the "Ten Warning Signs of Alzheimer's", I would have realized a year sooner what was happening and known how to get my parents the help they so desperately needed.

If any of this rings true for you or someone you love, I urge you to seek early evaluation from a Dementia Specialist-immediately!

TEN WARNING SIGNS OF ALZHEIMER'S
(Reprinted with permission of the Alzheimer's Association)

1. Memory loss
2. Difficulty performing familiar tasks
3. Problems with language
4. Disorientation of time and place
5. Poor or decreased judgment
6. Problems with abstract thinking
7. Misplacing things
8. Changes in mood or behavior
9. Changes in personality
10. Loss of initiative

Expanded Descriptions: http://www.elderrage.com/alzheimers.asp

Jacqueline Marcell is a former television executive whose caregiving experience resulted in her first (bestselling) book "Elder Rage", a Book-of-the-Month Club selection being considered for a film. Over fifty endorsements include: Hugh Downs, Regis Philbin, John Hopkins Memory Clinic, and the National Adult Day Services Association who bestowed on her their Media Award. She also hosts the "Coping With Caregiving" radio program www.wsRadio.com/CopingWithCaregiving. Jacqueline is also an International speaker who has delivered over 150 keynotes, including to the Florida House of Representatives. She also writes a Q&A column for AgingCare.com, and Blogs for HealthCentral.com and ThirdAge.com. Jacqueline is also a breast cancer survivor who advocates that everyone (especially caregivers), closely monitor their own health.

Power of Attorney for Finances: An Essential Tool for Elder Care Planning

Most people understand the need to have a will, so that when they pass away, assets will go to their chosen beneficiaries. Most people do not realize that they also need to appoint a power of attorney to make financial decisions and manage assets for them, if they become incapacitated.

If you think about it, most any financial decision we make requires a signature. Selling a house, writing a check, entering into agreements, etc., all require that we be able to sign documents. A signature itself is not even enough; the law imposes a requirement that the person signing the document have sufficient mental capacity to understand what they are signing.

As we age, there is a greater possibility that a time will come when we are not able to sign important legal documents. Or, even if we can sign our name, we may not understand what we are signing. At that point, assets are frozen unless someone has been given the legal authority to make financial decisions for you. The best way to do this is through a power of attorney for finances.

A power of attorney for finances is a document you can sign to appoint another person to make important financial decisions for you in the event you become incapacitated. The person you appoint is called your "agent". It is a good idea to name one or more alternate agents, in the event your first choice is unable or unwilling to serve in that role.

As an Elder Law attorney, one of the most common phone calls we receive is "I need to get power of attorney for my Mom." My answer is always, "that's great, we'd love to help your Mom. Let's schedule a time for her to come in and discuss it." "Well, that's a problem," replies the caller "because Mom has Alzheimer's Disease, and she won't understand what you are talking about."

In this situation, it may be too late to get a power of attorney. A power of attorney must be signed by a person who is legally competent. This means the signer must have the ability to understand the nature and importance of the document. If someone already has Alzheimer's Disease, or dementia, or has suffered a stroke, it may be too late to sign a power of attorney. Therefore, it is important to sign a power of attorney while a person has mental capacity to understand the document.

When deciding who should be your agent, remember that the most important qualities are honesty and good financial management skills. The main disadvantage to having a power of attorney is, a dishonest agent could use the power of attorney to misappropriate your assets. Therefore, only appoint the most trustworthy people to serve in this role. There are also professional trust companies that may agree to serve as your agent.

A power of attorney should always be prepared by an experienced elder law attorney. It is possible to obtain a generic power of attorney from a legal stationery store. However, this form will not give the agent the ability to make many types of important decisions for a disabled person. An experienced elder law attorney can provide a power of attorney that will give your agent flexibility to make important financial decisions if you are not able to make them yourself, such as disability planning, creating trusts, long-term care cost planning and tax planning.


Geoff Bernhardt is an elder law attorney in Portland, Oregon. For more information on his firm and on Medicaid planning, please see his website at www.elderlawpdx.com.

How an Elder Law Attorney can Help with Long-Term Care Planning

Elder Law attorneys help older people and their families with all of the legal consequences of aging. These consequences tend to fall into three categories: surrogate decision making for finances and health care; estate planning; and long-term care cost planning. We use powers of attorney for finances and advance directives for health care, wills and trusts, and a variety of strategies to help people get and pay for good care. When an older person lacks the ability to pay for care over their life expectancy using private savings or long-term care insurance, an elder law attorney will advise him or her on qualifying for long-term care assistance through the Medicaid program.

It is appropriate to refer an older person and his or her family to an elder law attorney for possible Medicaid planning in most cases where there is a need for long-term care. The elder law attorney will meet with the elder and his or her supportive family members. We will look at the income and resources available to the elder, and try to assess the level of care needed. We will also consider the needs of other family members, such as a healthy spouse or a disabled child, who may be dependent on the same income and resources for support. We can then advise the elder and his or her family whether the private resources are sufficient to pay for the care of the elder and to support the healthy spouse and any disabled children. If there is any chance the private resources will be insufficient for these purposes, the elder law attorney will suggest Medicaid planning.

Medicaid planning involves the restructuring of an elder's finances in order to qualify for Medicaid long-term care assistance without losing everything. Medicaid is a means-tested program, and the elder's assets often have to be spent down to very low levels before he or she will qualify. In the case of an unmarried person, his or her assets have to be spent down to $2,000. If the ill person is married, the healthy spouse can keep a portion of the assets, however, this portion is usually insufficient to pay for the spouse's care for his or her life expectancy. Through the process of Medicaid planning, an elder law attorney can get a much better result for the ill person, a healthy spouse, and any disabled children.

The bottom line for this type of planning is good care and personal dignity for the elder. In our system of health care, money is often necessary to insure a good quality of life for the elder. Protected funds can be used to support a healthy spouse in the community, pay for a geriatric care manager for the ill spouse, and provide for special needs items for a disabled child. An elder law attorney is an important part of the long-term care team and can make a tremendous, positive difference in the dignity and quality of life for elders facing serious health issues.

Geoff Bernhardt is an elder law attorney in Portland, Oregon. For more information on his firm and on Medicaid planning, please see his website at www.elderlawpdx.com.

Assisted Living- The Good, Bad and the Ugly

There are almost 35,000 Assisted Living Facilities licensed and operating in the US today. These communities range widely in size, price and amenities and are all fiercely competing for your businesses. The real trick is finding the one the suites your needs, life-style, and pocketbook.

What is Assisted Living?

The typical Assisted Living model is based on apartment style living with care services built in. This model encourages independence and autonomy while providing supervision and daily assistance with care needs. Meals are typically served in a main dining area with the intent of a social gathering while enjoying meals selected by the residents. Activities will be offered, including outings, scenic bus rides, and trips to the grocery store, bank, and doctors visits on designated days of the week.

What type of care is provided in Assisted Living?

Assisted Living provides custodial care, not medical care.

• Bathing, Dressing, Toileting, Grooming, Mobility, Medication Management
  
• Cooking, Housekeeping, Transportation, Laundry

What can I expect to pay for Assisted Living?

Most Assisted Living facilities structure their costs on an "ala carte" system. You will be quoted a "base cost" or "room and board cost" ranging from $1500-$3000 per month, depending on geography, size of apartment, and amenities offered. Expect to see additional costs added on right away. Based on an assessment of your care needs, the price will increase accordingly. This price can vary from month-to-month, especially if care needs drastically improve or decline over time.

What are the advantages to Assisted Living?

• Less expensive than nursing home care
• Private apartments to optimize privacy, autonomy, and independence
  
• Three meals a day served in a social dining atmosphere
• Security and call bell systems
  
• Designed with accessibility in mind (roll-in showers, etc)
• Exercise programs
• Care Services available- to be used as little or as much as you require
  
• Activity programs designed to keep residents active, social, and healthy
• Most have a beauty parlor on site

What are the limitations of Assisted Living?

• Despite staff presence and encouragement, some residents can become isolated
• Most do not allow residents to cook, for safety reasons
• Assisted Living can not accommodate residents who are wandering or exit seeking
• Minimal staffing requirements in most states. On average, expect to see 1 caregiver for every 30 residents during peak hours, and much less at night
• While facilities tout their abilities to care for residents through the end of life, many will ask families to hire private caregivers or transfer to a higher level of care if the residents needs are beyond the scope of their staffing levels

What do I look for in an Assisted Living community?

• Ask to see the latest survey
• Invite yourself to lunch (most will happily invite you first). Do you have menu options? Can family or friends join you for a meal? What is the cost for guest meals?
• Do the other residents interact well with each other? Are the staff friendly and kind? Do they know the residents by name?
  
• What is the caregiver-to-resident staffing ratio for each shift?
• Is a nurse available? What hours is the nurse in the building?
• Does the facility have a comfortable atmosphere? Is it clean? Are there any noticeable odors? What safety features are available?
• Is transportation available? Is there an additional cost?
• How often is the care plan reviewed? Is the resident or responsible party involved in the review? (they should be)
• What is the turn-over rate for staff? *Note* Most facilities have a high turn-over rate. It's a huge problem. What is the facility doing to keep current staff and attract new quality caregivers?
• If you have a pet, ask about any fees you will be expected to pay for your pet. Typically, an additional move-in fee and cleaning deposit will be incurred.
• What cost of living increases can be expected? (we have noticed 3-6% yearly for most communities)
• If the community can no longer meet your needs, how much notice will you receive and what assistance will be available to relocate to another level of care?
• Trust your instincts!!!

Who pays for Assisted Living?

• Private Pay (you)
• Long Term Care Insurance- Check your policy for coverage, waiting periods, etc...
• Medicaid- If you already qualify for Medicaid, or will qualify in the near future, make sure the facility you are considering has a Medicaid contract- many do not. You can check with the facility or your local Agency on Aging office for a list of contracted facilities in your area. If a facility does have a contract, chances are they are trying to balance Medicaid v.s. private pay in the building. Some will have a waiting list for Medicaid, so plan ahead. Do not wait until a crisis to start your search!!!
• MEDICARE DOES NOT PAY FOR ASSISTED LIVING

If you are just starting your search for an Assisted Living Community, you may consider working with a geriatric care manager or placement and referral agency to guide you. These professionals will know the communities in your area and save you valuable time and energy.

Amie Clark, Founder of The Senior List
www.TheSeniorList.com

What is a Retirement Community?

Retirement Communities/ Independent Living Facilities are most appropriate for seniors who can manage their health care needs on their own or with assistance from family in an apartment type setting. Independent Living does not offer health care services or assistance, but may offer a monthly meal plan, housekeeping, social activities, and transportation. Some communities will partner with an In-Home Care agency to provide some services to residents. Services may include Medication Management, Bathing and Grooming Assistance, or Incontinence care. If additional care services are being provided, at some point the cost of the apartment and care will equate that of an Assisted Living Community. Some Independent Facilities are located on a campus where other levels of care are offered should one need them in the future.

Independent Living costs range from $1000-$2500 per month, depending on apartment size, amenities, and meal plan. Some Independent Facilities will provide one to two meals per day and may offer a meal plan if a resident prefers to cook occasionally.

Only private pay is accepted at Independent Facilities. Medicaid does not cover housing costs for Independent living. Long Term Care Insurance typically does not cover Independent Living, but may cover the cost of outside in-home care services.

What are the advantages of a Retirement Community?

• Nutritious Meals, Activities, and Housekeeping offered
• Maintain Independence in a social setting
• No upkeep or utilities to manage (except personal phone and cable)

What should I look for when searching for a Retirement Community?

1. I personally prefer retirement communities to be adjacent to another level of care, most commonly, an assisted living or residential care facility. If a move occurs in the future, it is much easier to move across the courtyard instead of the other side of town.
2. What amenities are offered? Are the activities varied? Is an exercise program offered?
3. If your loved one is driving, is there reserved and covered parking available for residents?
4. Are pets allowed? Is smoking allowed on campus?
5. How involved is the management staff in the lives of the residents? Will they notify you if they see changes in your loved one?
6. How often are meals served? Is there a flexible meal plan option? Is the cost of meals included in the overall price?
7. How is the food? Invite yourself for lunch (most will offer)- observe staff interacting with the residents. Is there a social atmosphere in the dining room or are residents keeping to themselves. Do residents seem happy? Do the staff know the residents by name? The dining room is a great indication of the "mood" of the building.
8. How does the physical building look? Is it well kept? Are repairs needed? Ask about the maintenance response time. How available are they for minor repairs for the resident's apartments (light bulbs, hanging pictures, etc...)?
   

When is it time to transition to higher level of care?
First, I would suggest that if a resident requires care to begin with, a retirement community will only be a temporary solution. If a resident has lived in a retirement community and is requiring more supervision, can't safely manage daily activities, and requires frequent checks from staff, a higher level of care is needed.

Amie Clark, Founder of The Senior List
www.TheSeniorList.com

What is In Home Care?

In Home Care is designed to support those who do not desire or need to leave their homes, but do require assistance with one or more of their daily activities. Care in the home can take on a variety of shapes and sizes and can incorporate family, friends, and professional assistance. I think most people, given a choice, would prefer to receive assistance from someone they know, family or friends. There are certainly situations, however, that family or friends providing care is not appropriate, or does not appeal to everyone, including the family and friends. If professional support needs to be hired, here are a few considerations and questions to ask the agencies you are interviewing.

1. Most In-Home Care agencies have hourly minimums, usually 2-4 hrs. If a shift does not meet these minimums, the client may still have to pay for the full shift.
2. Make sure the agency you are considering is licensed, and caregivers are bonded and insured.
   
3. What kind of training and orientation do the staff participate in?
4. Is there a nurse to oversee the caregivers and provide training?
5. What is the process if a caregiver is sick or does not show up for a shift?
6. What are the fees? Do you pay less for longer shifts? Does the agency bill monthly or weekly? Do they provide transportation to doctor appointments, grocery store, etc...?
7. Does the agency have access to other resources in the community should you need them?
8. Check inspection results at medicare.gov.
   
9. Ask to see references and testimonials. You can review online ratings from other consumers.
   

What is the advantage of hiring my own private caregiver?

• generally less expensive than working with an agency
• caregiver is your employee, they work for you.
• may be able to exchange care services for room and board, this works well for students

What is the advantage of hiring an agency?

• agency pays taxes, insurance, etc... No liability on your part, less risk
  
• shift will always be covered
• agencies are regulated and must pass inspections to operate
  

What type of Assistance can a caregiver provide?

• Bathing/ Grooming
  
• Light Cleaning
• Shopping
• Laundry
• Meal Preparation
• Toileting
• Dressing
• Mobility
• Night care
  

How Much Does In-Home Care Cost?
I have seen quite a range for costs, anywhere from $12-$22 per hour, depending on geography and duties of the caregiver. If the caregiver is a CNA, the cost will typically increase due to training that the individual has received.

Who Pays for In-Home Care?

• Private Pay (you)
• Long Term Care Insurance- check your policy for restrictions and make sure agency is able to accept payment from Insurance provider
• Some Health Insurances- check your policy
• Medicaid- offers limited in-home care programs for those who qualify

Amie Clark, Founder of The Senior List
www.TheSeniorList.com