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October 9, 2015 | 26th Tishrei 5776

10 Guiding Principles of Long-Term Health Care

Important things to consider when planning long-term health care

Start long-term planning as early as possible.

It is important to be proactive, as opposed to reactive. Plans are best made when you are not subject to the emotional stresses that result from the need for immediate decision making. If you start early enough, affordable Long-Term Health Care Insurance ("LTHC Insurance") is available.

Effective Long Term Health Care(LTHC)planning requires short, mid and long-term considerations. To best accomplish this, the planning process should begin as early as possible. If you start before any major problems arise, affordable Long Term Health Care Insurance is available. If you are able to get LTHC Insurance, you should carefully review the policy before purchasing it.

There is a virtual smorgasbord of policies available, and you should look for the one that best fulfills your needs and that is offered by a reputable company. However, very often we do not start the process of considering long-term health care planning until we are in the middle of a crisis. At such times, insurance will not be obtainable. In addition, because of the stresses and strains of the situation, we are often forced to have to make decisions under a great deal of pressure.

The planning process has many facets to it: financial, emotional, intra-family conflicts, location, dependency, and religion, to name a few. Because of all these, and other factors, you must be proactive. You should start the planning process when minds are clear and before serious problems arise that will eliminate important planning options.

Educate yourself about Home Health Care, Assisted Living Facilities, Skilled Nursing Facilities, and Continuing Care Retirement Communities.

In order to make the decision that is best for your family situation, you must know all the alternatives that are available in your community. New and innovative programs are being developed constantly, and they should be explored. Many communities have professional planners with whom you can consult.

Many options for long-term health care are available. For many, staying at home is the ideal situation. It allows the individual to maintain his or her habits and routines and to stay in touch with neighbors who provide companionship and support. For those who desire (and are able) to stay at home, many states have home health care programs. Most good LTHC Insurance policies have home care provisions. In addition to private companies that provide nursing and custodial assistance, many religious communities have also responded to this need.

If home health care is desired, you should choose the service carefully . While most providers are reliable, there are some who are not careful in the selection of caregivers. Remember that your loved one will spend most of his or her time with the caregiver, and can grow dependant on that person. If the caregiver is not reliable or worse, if that person is not properly skilled or trustworthy, much damage may result. It is also important that there be consistency in the relationship between the loved one and the caregiver. You do not want to have to switch caregivers too many times. You must also remember that the caregiver is not a substitute for family. It is important for you to maintain constant contact with both the caregiver and your family member.

If the conditions are such that remaining at home is not practical, then other alternatives exist. Assisted living facilities are now springing up everywhere. These facilities provide the opportunity for your family member to live somewhat independently, usually in an efficiency-type apartment. They meet the needs of older individuals who need some assistance in the activities of daily living but who do require the skilled health care that is provided in a nursing home. Generally, such facilities feature a community dining room as well as kitchenettes in each living unit.

They often have a medical staff and nurses on the premises. The staff makes sure that the family member's special needs are being met, including assistance with the taking of necessary medication and help in getting around if necessary. Monthly fees are charged which include room and board; however, the cost of an assisted living facility is much less expensive than that of a nursing home. States can adopt "waiver" programs to provide government financial assistance for residents, however many states have not yet made a serious attempt to provide financial assistance for assisted living.

For those individuals who do require skilled nursing care, nursing homes (also known as skilled nursing facilities) meet those people's needs. That is not to say that a person who needs only custodial care will not be admitted to a nursing home. However, if government assistance is sought, custodial care will not be covered. In the nursing home setting, the individual receives daily attention and assistance in the Activities of Daily Living (ADL). The activities of daily living include: eating, dressing, bathing, transferring (getting in and out of bed or chair), toileting, and continence.

Nursing homes provide medical services and custodial care in one central location. While very few individuals want to move into a nursing home, it sometimes becomes the only alternative available, especially when there is a need for medical supervision, and no family member is able to provide that level of care. Unlike residing in an assisted living facility, living in a nursing home by definition results in a loss of independence and privacy. Unlike residents in an assisted living facility who have their own units, residents in nursing homes generally share a room.

Like assisted living facilities, nursing homes charge a monthly fee. Government assistance is available (in the form of Medicaid) for those who meet eligibility requirements. Nursing home costs vary throughout the country, but it is not unheard of to see costs as high as $6000 to $7000 per month. Remember that the quality of nursing homes vary greatly. Just because a nursing home charges more does not mean that its quality of care is better than a less expensive one. Before placing a loved one in a nursing home, you should check it out carefully.

Continuing Care Retirement Communities (CCRC) are facilities that combine all of the above methods. They are very popular with middle and upper income individuals. Generally, if your loved ones are married, they move into the community together, as if it were a retirement community. There, they can engage in recreational and social activities with members of their age own group. But what differentiates the CCRC from a retirement community is that the CCRC offers different living levels. If the need arises for your loved one to require assisted living, he or she moves into the assisted living part of the facility. If skilled nursing care is needed, the person moves into the nursing home section of the community (or, if there is no nursing home facility in the community, contracts for nursing home care are in place with local facilities).

Generally, an admission fee is paid at the time of entry into a CCRC, and then a monthly fee is paid thereafter. The resident signs a contract with the CCRC that obligates the facility to provide housing, activities, and health care support. The admission fee is varies from facility to facility, depending on the size of the living unit and the number of activities provided. Many contracts provide for partial refunds of the admission fee in the event of the "premature" death of a resident.

Also available in some areas are continuing care arrangements that allow the family member to remain at home until such time as skilled nursing care is needed. Under such plans, the provider will send home health aides to the family member's house as needed. When a determination is made that skilled nursing care is required, the family member will be moved into a nursing home. An initial entry fee and monthly fees will cover all of the costs for such care.

The entire family should participate in the planning.

One person should not make the decision, all members of the family, including the person needing care, should participate in the long-term care planning process. Certainly, if the loved one is competent to give input, that input should be given great, if not total, weight. If all family members participate in the process, they then all have ownership of it. This certainly helps to avoid recriminations later on.

It also helps family members with deal with the inevitable guilt that sometimes arises. By having everyone participate, an understanding of the emotional and financial impact of the decisions can be shared by all. After the family agrees on the plan, certainly one person can be appointed to make the necessary arrangements. If that is the case, the designated person should keep all the other family members up to date on a regular basis. It is often a good idea to hold regular family meetings to discuss the process, and to review how decisions may be affecting the loved one.

Assemble the financial documents of the loved one and organize them as early as possible.

The cost of long-term health care is expensive. Generally, admission offices request financial statements prior to a person's admission. It is important to assemble the financial information as early in the process as you can. Memories fade easily, and the location of financial records and even the existence of assets can be forgotten.

Financial planning can be done to lawfully protect some of the assets of the loved one, but planners need accurate financial records. If an application for medical assistance such as Medicaid is going to be made, complete and accurate financial data will be needed. Often records dating back at least three years are requested. It is important that full disclosure is made both to the facility (if requested) and to the Medicaid officer taking the application.

Assemble and review necessary legal documents.

Regarding the issue of long-term health care planning, there are certain legal documents that must be prepared and executed by the family member while he or she is still legally competent to do so. Often routine documents such as the last will and powers of attorney should be specially prepared to take care of long-term health care planning.

Powers of Attorney should be drafted to deal with the issues of gifting (if the family member wishes to make gifts) and decision-making. The powers should be checked to see if they meet with the state-of-residence requirements. They should also be checked to see if they are durable. This is especially important, because in many states, if the power is not durable, it will become invalid in the case of incompetence or incapacity.

If Medicaid is going to be needed, an attorney should also carefully check the wills. Proper drafting of the wills can minimize and/or avoid the loss of benefits of a Medicaid recipient if his or her spouse predeceases the patient.

Advance medical directives (AMD) should also be discussed with the family members. Typically, there are two parts to an AMD. The first part is a proxy directive. This part appoints a person or persons to make medical decisions for the patient if he is incapable of making his or her own decisions. The second part is the instructions directive. This portion expresses the desires of the patient concerning end-of-life decision-making. It is a guide for the holder of the health care proxy.

It generally contains the wishes of the patient concerning the use of artificial means to keep him or her alive if death is imminent. Often hospitals and nursing homes request an AMD prior to admission. If the patient does not have one, these institutions generally provide prepared forms. In such cases, these documents are often executed under the stress of the situation, and sometimes do not reflect the actual wishes of the patient. If your family member wants to execute an AMD, it is recommended that this be done well in advance of his or her admission to a facility and that it not be a boilerplate form, but one that reflects the desires of the person.

If family members accompany their loved one to an attorney's office to have any or all of these documents reviewed or drafted, they must remember that the client is the loved one. The attorney should meet with the client alone to determine his or her wishes without any pressure from the family members. While family members can be present for a portion of the meeting, the attorney should excuse them when the actual details are being discussed, and they should not be upset or insulted when such a request is made.

Choose a facility that allows for ease of visiting.

When selecting the appropriate facility for your family member pay careful attention to its location. While financial factors are important, the emotional need of the family member to spend time with family and friends cannot be overlooked. If placement in a facility is necessary try to find a facility that is convenient to everyone, but especially the spouse of the family member. While this advice seems so obvious, I have seen situations where the loved one is placed in a facility that is inconvenient for visits by the spouse who is living at home.

For many people, visiting a loved one in a nursing home is not easy. It can be depressing. The demand of visitation often conflicts with the family life of the children of a loved one who is in a facility. If distance becomes a factor, it can easily result in a reduced number of visits. For obvious reasons, one cannot overlook the importance of visitation to the institutionalized family member. For less obvious reasons, visitation by the children, grandchildren, and spouse is important to them as well. One cannot underestimate the guilt that is often felt by these individuals if they do not regularly visit their loved ones.  

Carefully scrutinize the facility.

No matter what facility is chosen, due diligence is required. Check out its physical plant, staff, medical department, rooms and dining facility. Often a good measure of the cleanliness and organization of a facility is the way the dining room is administered. Get and check references from other residents' families. Check with the local Department on Aging (or its equivalent) to see if any complaints against the facility have been lodged. If Medicaid is going to be required, make sure that the facility is certified.

Make sure that you have the opportunity to carefully review the documents that are required to be signed for admission into the facility. If possible, have those documents reviewed by legal counsel with experience in the area of long-term care. In the case of CCRCs it is especially important to check out its financial stability, in addition to the other factors mentioned above, because CCRCs usually require a significant up-front investment in the form of an admission or entry fee.

If the CCRC is not financially stable, that initial investment may be lost if the CCRC goes out of business. The Continuing Care Accreditation Commission certifies many CCRCs, although it must be remembered that such accreditation is expensive, and many fine CCRCs are not registered with them.

Familiarize yourself with the federal, state and foundation funding requirements.

As you can see from the above discussions, long-term health care is expensive. Depending on where you live, assisted living facilities can cost from $1500 to $4000 per month or even higher. Skilled nursing facilities can cost from $3000 to $7000 per month. At some point in time, public or foundation assistance may become necessary. You should know in advance what programs are available, and their requirements.

Contrary to popular belief, Medicare pays for very little of nursing home care. Generally, Medicare will pay for the first twenty days, and then co-pay for the next eighty days (in 2000, the copay rate for the patient was $97 per day). But Medicare will only pay if skilled nursing home care is medically mandated, if it is for rehabilitative purposes, if rehabilitation is actually taking place, and if the admission to the nursing facility is from a hospital admission.

According to statistics, Medicaid pays for about half of all nursing home costs. Unlike Medicare, which is not a resource-based program, Medicaid determines eligibility on the basis of financial need. Both the resources and income of the applicant are reviewed to determined eligibility. The complexity of Medicaid (which is a federal/state cooperative program) is beyond the scope of this discussion. It is enough to say that the program is available for low income and minimal asset individuals who are blind, aged, or disabled.

Advance financial planning can reduce the impact on individuals who will be seeking Medicaid. It is also important to know that while the federal government sets certain minimum financial standards, the states are free to establish less restrictive standards. Thus the Medicaid programs vary from state to state.

In addition to governmental programs, many private foundations, religious institutions, and charities provide assistance for long-term health care. Availability of these resources varies from community to community, and steps should be taken to determine whether such assistance exists in your community.

Do a Budget.

Vital to sound financial planning is a well-thought-out budget. This is especially true when only one spouse is going into an assisted living facility or nursing home. Often inexperienced planners fail to take into consideration the ongoing costs of the "at home" spouse.

If careful planning is not accomplished, especially when a person is in an assisted living facility, where there is little in the way of government assistance, funds can be depleted during the lifetime of the individual. If that happens and the individual is not medically eligible for nursing home assistance, the financial burden of caring for the loved one will fall on the family members. This can cause a great deal of stress and sometimes, resentment.

Since nobody has a crystal ball that will predict the future, a good financial plan will consider various scenarios. It is important that alternative funding sources are established in advance should funds be depleted during the lifetime of the family member, prior to Medicaid eligibility.

One must also be very careful about transferring of assets in order to speed up eligibility for Medicaid. While Medicaid does not now forbid such transfers, there are penalty (ineligibility) periods that can result from such transfers. If not done carefully, such transfers can result in Medicaid ineligibility periods that can extend beyond the available financial resources of the family member. And know this: nursing homes can legally require the removal of a resident for nonpayment of the nursing home bill.

Most important, allow for the afflicted family member to retain his or her dignity at all times.

The overriding factor in the planning process should be the dignity of the loved one. Family members should go into the planning process with the understanding that the loved one's quality of life should guide all of the decisions being made. Financial factors such as the protection of assets, while important, should be secondary to the needs of the afflicted family member.

Each of the planning items listed above must be accomplished with full attention to the maintenance of the loved one's dignity. It is a terrible thing to for a person to lose control from a person. It is even more so when control is taken away. When at all possible, explain what you are doing to your loved one and have he or she involved in the process.

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