Young@Heart

Last night I had the privilege of watching a movie entitled Young@Heart. It is a documentary showing a group of older people (average age 80) who get together with a chorus director (Bob Cilman) and form a chorus which sings such contemporary hits such as “Every Breath You Take”, “Yes I can,can” ‘I got you” and many others. The  movie is absolutely heart warming as it shows these elderly folks rehearsing two to three times a week to prepare for a concert, some leaving their hospital beds  to get to rehearsal.

While crying, laughing and dancing as I watched the DVD, I realized something very important was being shown to us. When old people have a purpose, a passion, they live longer, more satisfying lives. Steve Martin, one of the chorus members (not the comedian) said it well. “If you stop moving you will become a target”. During preparation for the concert two members of the group died, but the chorus continued on, dedicating their efforts to their fallen friends. And even those who passed on, up to their dying day, were trying to make it back to rehearsals and sing.

This is a strong lesson for us and our parents. What are your parents’ passions? Encourage them to stay involved in the activities they love and even find new ones to explore. Hopefully they will happen upon an angel like Bob Cilman, the chorus director of Young@Heart who nurtered the members along the way to enjoy and expand themselves. It’s not such bad advice for each of us, no matter what our age. Follow your passion. Stay involved and grow a little every day.

I encourage you to watch Young@Heart. Better yet, watch it with your parents. You will all be inspired.

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Protect your parents from fraud

I didn’t realize how much elderly people were prayed upon by scam artists until I met with one of my elderly clients recently. He is a retired physician who was a very bright, savvy individual but is now beginning to lose some of his mental sharpness. I met with him and his wife at their home. His wife informed me that he had been receiving 8-10 calls a day from various scammers claiming that he had just won the lottery. They told him that all he needed to do was pass on his bank account information to them and the award would be transferred to his account. More than once his wife encountered him reading his bank account information over the phone to a total stranger.

When I met with my mom at her retirement community (she’s 88) I just happened to take a peek at her mail. 4 out of 5 pieces she received were from organizations requesting money for one reason or another. One was an organization claiming that she was part of the group that had been short changed by social security. They were raising money to approach congress and change the laws to get her money back. It included a very official looking certificate sent by a very  reputable sounding senior’s organization.

I recently read a very good book entitled “The Boomer Burden” by Julie Hall, The Estate Lady (www.theestatelady.com). Her job is to help adult children clean out the homes of their parents when they pass away or move into a retirement community. She cited many shocking incidents of children, friends and family members taking advantage of elderly people. She stated that 50 percent of elderly Americans are victims of financial exploitation. The average age of a victim of financial exploitation is 78!

Julie makes specific recommendations in her book to help adult children protect their parents from fraud.

1. Register your parents telephone numbers with the National do Not Call Registry (www.donotcall.gov/)

2. Discuss with them the list of common frauds ( described in her book) and ask them to contact you if they suspect that anyone is trying to defraud them.

3. Ask your parents to contact you if anyone offers to buy their possessions.

4. Make sure a family member personally visits your parents on a weekly basis.

5. Reduce your parents junk mail for a small fee by going to either of these websites; www.stopthejunkmail.com or www.greendimes.com

Julie points out that an excellent source of information on the many financial scams that your parents may face is the National Center on Elder Abuse. (www.elderabusecenter.org)

Probably the single best piece of advise I can provide is for you to stay in touch with your parents. Be available when they get calls from doubtful people and visits from scam artists who want to do home repairs or claim to be a bank examiner. Communicate with them and know what’s going on in their lives.

What we want in a doctor

Many of us are frustrated by our interactions with our doctors. They often seem rushed and only focused on tests and medication. Rarely do we see a doctor who just sits back and asks “How are you doing?”  Dr. Thomas Graboys was such a doctor. In his book “Life in the Balance” he describes what he seeks in a doctor now that he is sick himself with Parkinson’s disease. I thought it would be very beneficial to share his words with you.

Illness interrupts (book excerpt: Life in the Balance)

Thomas Graboys, MD

A few days before a regular six-month appointment with my neurologist, John Growdon, in late 2006, I was asked what, if anything, I would like him to do for me that he wasn’t doing already. My answer was quick and sarcastic: “I’d like him to call me every month to ask how I’m feeling,” I snapped, as if a busy doctor with hundreds of patients in his care would have time for that.

But the more I thought about it, the more I realized that my glib remark cut close to the truth. I want to be on his radar screen. I want him to be thinking about my case, not just when I am in his office, but when he reads about new treatments and new insights into Parkinson’s and Lewy body dementia. I want him to be turning my case over in his head once in a while, and I want to know that while there is nothing that exists today to reverse my dementia, he is thinking from time to time about how to make my life better.

When I saw Growdon a few days later, I asked if we could increase the frequency of our regular consultations from every six months to every three months, to which he readily agreed. Why? For the simple reason that the Parkinson’s path is taking me through very unfamiliar and forbidding territory. I want a guide — someone I trust who knows the medical terrain, someone who has been down the path with others — to be there in spirit and in mind.

I want someone mindful of the pitfalls, the traps, and the forks in the road. It may well be that little will change in my clinical condition over three-month intervals, but I don’t want to see Growdon every three months merely to size up incremental changes in my symptoms or to tweak my medications; I also want the comfort of his presence and to know that every once in a while we can, in [former New York Times literary critic Anatole] Broyard’s words [written while dying of prostate cancer], brood over my situation together.

In my own practice, I developed a keen sense of just how deeply appreciated and how profoundly comforting small acts of kindness and mindfulness can be for the patient and his or her family. Dropping in on a hospitalized patient at the end of a busy day, not to check the chart or to do a quick exam, but just to say “Hello, I just came by to see how you are. Is there anything you need?” Calling a patient at home a few weeks after their annual visit to see how their new diet and exercise program is progressing.

Writing a letter of condolence to the family of a patient who has died (a sorely neglected necessity, in my view). These small acts say to the patient and the family, “I know you ache, I know you suffer, I know you are in pain,” and allow doctor and patient to meet on the common ground of their mutual humanity.

I am not a surgeon, but when a patient of mine was scheduled for surgery, cardiac or otherwise, I always tried to pay a social visit in the hospital the night before, or tried calling them at home if they weren’t yet hospitalized. I can’t prove it, of course, but I believe such a visit or call decreases operative mortality. Such social calls were invariably welcomed and comforting. There is no way to measure the curative and healing power of such a bond between doctor and patient, but I am utterly convinced of its salutary effect.

It is also hard to overstate the importance of the doctor’s literal laying-on of hands. Years ago I had a patient, Mrs. H, who had been hospitalized with terminal gastric cancer. It was her cancer, not her heart disease, that was threatening her life; but every day, as I rounded with my medical students and stopped to examine Mrs. H, I routinely listened to her heart. One day, under pressure of time, I forgot; and as I turned to leave, she said, “Dr. Graboys, aren’t you going to listen to my heart?” I was embarrassed and flustered in front of my charges and immediately struck by the fact that although she knew her heart was not her major problem, she needed and wanted the reassurance of my touch.

As I reflected on the experience later, I also realized that Mrs. H. had interpreted my actions as a commentary on her condition. My failing to listen to her heart that day signaled a loss of hope in her situation. If I could no longer be bothered to examine her heart, it meant the cancer was so serious that it had rendered her heart problem irrelevant. Conversely, by examining her heart, I had been signaling hope that she was not succumbing to her cancer.

Similarly, a doctor’s words — as my mentor, Bernard Lown, [MD, renowned cardiologist and Nobel Peace Prize winner] has written — can maim or they can heal. The physician who offers nothing more than impeccable clinical judgment can, nevertheless, draw the cloak of illness tight around a patient with carelessly chosen words.

Too many times, patients have come to me and said that another cardiologist described their heart as a “widowmaker” or a “time bomb.” The stress and anxiety thus induced by the doctor can turn him into a prophet. Words that allay stress, words that allow room for hope — not false hope, but hope — can allow the patient to shift the burden of worry onto the physician.

So I know what I look for in a doctor.

Government Programs-Part Two

Medicaid

How can Medicaid pay for your parents’ extensive health care costs? Medicaid is a program jointly funded by the federal and state governments. Each state manages its own program. Medicaid is designed to provide assistance to the indigent. A third of the payments from Medicaid provide payments for the elderly who are in nursing homes. Other funds are provided for those who are disabled or without financial resources. Medicaid does not currently provide any benefits for assisted living or home care. It is strictly for those individuals who are in a nursing home.

In the past, a number of families transferred assets from their parents to other family members to qualify them for Medicaid assistance. Parents transferred their homes, investments, and savings accounts to their children and then applied to Medicaid. Unfortunately, the number of the elderly applying for Medicaid has increased so much in recent years that it has become a very substantial part of most states’ budgets.

Restrictions on Qualification

As a result, the federal government has put severe restrictions on qualification for Medicaid. Monthly income limits differ depending on whether the applicant is single or married. For a married couple, the spouse remaining in the community (community spouse) can retain all of his or her income. The community spouse’s income would not be counted in determining the applicant’s eligibility for Medicaid. However, all of the applicant’s income must be counted for his or her long-term care except for certain deductions. These deductions may include a personal need allowance not to exceed $60 per month (less in some states), an allowance for a dependant child living at home and, depending on the community spouse’s income, a portion of the spouse’s income for living expenses known as the Minimum Monthly Maintenance Needs Allowance (MMMNA). In 2008, this amount ranges from $1,711 to a high of $2,610 per month.

If the community spouse’s income is less than the MMMNA, a portion of the applicant’s income may be used to meet that minimum. The balance will go to the nursing home providing care. If the applicant is single, he or she cannot exceed Medicaid income limits and qualify. The limit for 2008 is approximately $1,911 per month but varies from state to state.

Countable Assets

To qualify for medicaid coverage, the recipient’s countable assets cannot exceed $2000. The  community spouse of the Medicaid recipient may keep half of the couple’s joint assets up to $104,400 (in 2008). In any case the community spouse may keep the first $20,880 (in 2008), even if it exceeds half of the couple’s assets. These figures vary from state to state.

Countable assets consist of all investments such as stocks, bonds, mutual funds, checking and savings accounts and CDs. Countable assets also include any personal or real property as well as any art and collectibles.
Non-countable assets consist of personal possessions such as clothing, jewelry and furniture and the applicant’s primary residence. Further, non-countable assets include one vehicle not to exceed $4500 for unmarried applicants (there is no value limit for a vehicle for married applicants). Non-countable assets also include prepaid funeral plans, certain amounts of life insurance and retirement funds which cannot be cashed in because they are in payment status (however the latter will be considered under the income limits).

Based on these restrictions, it is very difficult for most people to qualify for Medicaid unless they have already used up their assets to pay for care. But the income restrictions usually exclude most people from being accepted into the program.

Be Careful With Gifts

The federal government has made it extremely difficult for a family to attempt to transfer assets away from their parents to qualify for Medicaid. The sick parent must apply for Medicaid at the time they wish to enter the nursing home. The government first calculates the family’s assets and income. If these meet the qualifications, Medicaid then checks to see if the parents have made any gifts to their children or others within the last five years. If the parents have made any gifts that delay their qualification for Medicaid, the government uses a very simple formula.  They are very thorough in checking all your parents’ financial records bank accounts and investment reports. Let’s assume your parents transferred $100,000 from their bank accounts to you four years ago and your father has just entered a nursing home. The nursing home then applies for Medicaid to cover his costs.

The Feds then look over his records and determine that four years prior to entering the home, he gave you $100,000. They then divide this gift by the average monthly cost of a stay in the nursing home in your father’s state to determine the number of months your dad is disqualified from getting Medicaid. In Massachusetts, in 2008, that number was $7380. $100,000 divided by 7380 is 13.5. That means Medicaid will not pay for his care for 13.5 months even though he qualifies based on current income and assets.

Gifts of all different kinds can disqualify you. Some families have tried some very subtle techniques to transfer assets from their parents to others. Setting up a joint account with a son or daughter and then removing the parent’s account is one technique that is no longer allowed. Putting a home in the name of a son or daughter or other family member or friend fits into the same category. Purchasing a “life estate” in an adult child’s home by paying off their mortgage is also disallowed.

Use of Annuities

A technique that often worked in the past was for your parents to transfer their assets to an insurance company for an immediate annuity to pay a monthly income. They planned that this would no longer count the lump sum as a countable asset. The state has countered that by comparing the amount of the annuity with the life expectancy of the recipient. If the projected payout exceeds their life expectancy, this difference will trigger a period of ineligibility. Even if the annuity is taken on the life of the healthy spouse, the state will require that the government be listed as the beneficiary of the annuity.

In the Tax Relief and Health Care Act of 2006, the government made it clear that they are eliminating all the loopholes that families can use to qualify their parents for Medicaid unless they are truly destitute. Medicaid has become a very large part of each state’s budget and they know that they must control its growth in the future.

Government Programs-Part One

Veterans Benefits to Help Your Parents

The Department of Veterans Affairs provides three types of long term care benefits for veterans.

VA Health Care

The first type is benefits provided to veterans enrolled in VA health care who have substantial service-connected disability. These medically necessary services include home care, hospice, respite care, assisted living, domiciliary care, geriatric assessments and nursing home care.

Some of these services may be offered to veterans in the health care system who do not have service-connected disabilities but who may qualify because of low income or because they are receiving Pension income from VA. These recipients may have to provide out-of-pocket co-pays or the services may only be available to these non-service-connected disabled veterans if the regional hospital has funds to cover them.

Currently, veterans desiring to join the health care system may be refused application because their income is too high or they do not qualify under other enrollment criteria. Increased demand in recent years for services and lack of congressional funding have forced VA to allow only certain classes of veterans to join the health care system.

Veterans’ Homes

The second type of benefit is state veterans homes. The US Department of Veterans Affairs in conjunction with the states helps build and support state veterans homes. Money is provided by VA to help share the cost of construction with the state, and a subsidy of $71.42 a day is provided for each veteran using nursing home care in a state home. These facilities are generally available for any veteran and sometimes the non-veteran spouse and are run by the states, often with the help of contract management. Most state veterans homes offer nursing home care but they may also offer assisted living, domiciliary care and adult day care.  There may be waiting lists for acceptance into veterans homes in some states.

State veterans homes are not free but are subsidized; however, the cost could be significantly less than a comparable facility in the private sector. Some of these homes can accept Medicaid payments. A complete list of state veterans homes can be found at http://www.longtermcarelink.net/ref_state_veterans_va_nursing_homes.htm

Disability Payments

The third type of benefits for veterans is disability payments. These include Compensation, Pension and survivors death benefits associated with Compensation and Death Pension.

Compensation is designed to award the veteran a certain amount of monthly income to compensate for potential loss of income in the private sector due to a disability or injury or illness incurred in the service. In order to receive compensation a veteran has to have evidence of a service-connected disability. Most veterans who are receiving this benefit were awarded an amount based on a percentage of disability when they left the service.

However, some veterans may have a military record of being exposed to extreme cold, having an in-service non-disabling injury, having tropical diseases, tuberculosis or other incidents or exposures that at the time may not have caused any disability but years later have resulted in medical problems. In addition, some veterans may be receiving compensation but their condition has worsened and they may qualify for a higher disability rating. Veterans mentioned above may qualify for a first-time benefit or receive an increase in compensation amount. Applications should be made to see if they can receive an award. There is no income or asset test for compensation and the benefit is nontaxable.

Aid and Attendance Benefit

Pension is available to all active duty veterans who served on active duty at least 90 days during a period of war. There is no need to have a service-connected disability to receive pension. To be eligible the applicant must be totally disabled if he or she is younger than 65. Proof of disability is not required for applicants age 65 or over. Apparently, being old is evidence in itself of disability.  Pension is sometimes known as the “aid and attendance benefit.”

Veterans’ service to qualify for Pension would include World War II, the Korean Conflict, the Vietnam Conflict Period and the Gulf War conflict. The veteran did not have to serve in combat but only had to be in the service during that period of time and only one day of the 90 days of service had to occur during the period of war.

The purpose of this benefit is to provide supplemental income to disabled or older veterans who have a low income. If the veteran’s income exceeds the pension amount then there is no award.

Submission of Claims

Compensation and Pension claims are submitted on the same form and VA will consider paying either benefit. Generally, for applications associated with the cost of home care, assisted living or nursing home care, the Pension benefit is a better option.

Pension can pay up to $1,843 a month to help offset the costs associated with home care, assisted living, nursing homes and other unreimbursed medical expenses. The amount of payment varies with the type of care, recipient income and the marital status of the recipient. There are income and asset tests to qualify.

VA claims this benefit is only for low income veterans but a special provision in the way the benefit is calculated for recurring medical expenses (long term care costs associated with home care, assisted living or nursing homes) could allow veteran households earning between $2,500 and $5,000 or more a month to qualify.

There are also death benefit payments associated with Compensation and Pension that are available to surviving spouses of veterans or surviving dependents.

The National Care Planning Council estimates that up to 33% of all Americans over the age of 65 might be eligible for a Pension benefit under the right circumstances.  That’s how many war veterans or their surviving spouses there are in this country. If your mother or father served in the armed forces it is definitely worthwhile to check into the benefits that may be available to them.

The 4 Steps of Long Term Care Planning

Planning for Eldercare

The Importance of Planning for Eldercare

According to some sources, 60% of us will need long term care sometime during our lives. It is important for all of us to prepare for that day when we will need to help loved ones with care or we will need long term care for ourselves.

We may prepare financially for unexpected disasters by covering our homes, automobiles and health with insurance policies. But no other life event can be as devastating to an elderly person’s lifestyle, finances and security as needing long term care. It drastically alters or completely eliminates the three principal retirement dreams of elderly Americans:

1. Remaining independent in the home without intervention from others
2. Maintaining good health and receiving adequate health care
3. Having enough money for everyday needs and not outliving assets and income

Yet, it is our experience that the majority of the American public does not plan for the devastating crisis of needing eldercare. This lack of planning also has an adverse effect on the older person’s family, with sacrifices made in time, money, family lifestyles and even affecting the family’s or caregiver’s medical and emotional health.

Because of changing demographics and potential changes in government funding, the current generation — more-than-ever — needs to plan for long term care before the elder years are upon them.

What Is Long Term Care?

The need for long term care arises when an individual requires, from someone else, assistance with medical care, daily living activities, comfort, supervision or advice. This need for care may be caused by an accident, disease process, or frailty. Such conditions may require help with the ability to move about, dress, bathe, eat, use a toilet, medicate, and avoid incontinence.

Also care may be needed to help the disabled person with household cleaning, preparing meals, transportation, shopping, paying bills, visiting the doctor and answering the phone. Oftentimes, long term care in the form of supervision or confinement is needed due to cognitive impairment from stroke, mental retardation, depression, dementia, Alzheimer’s, Parkinson’s Disease and so on. Most long term care is provided at home by family members.

What Is Long Term Care or Eldercare Planning?

For seniors, the terms “long term care” and “eldercare” are synonymous. For younger people, “long term care” is the more appropriate phrase.

For the uninformed family member, eldercare or long term care might appear to be a very straightforward and easy-to-understand process. Unfortunately, the reality is that long term care is very complicated and finding care systems and providers is a frustrating and time-consuming process. There is no one single source to help caregivers find services or solve problems with a simple phone call or a single community contact. For this reason, planning for care requires a great deal of prior knowledge in order to avoid operating in a crisis mode trying to find help when the need for care suddenly arises.

However, knowledge of long term care systems is not enough. Because it can happen suddenly, at any time, you must take action now to prepare for the day when you will need to deal with eldercare for your loved ones or for yourself. This action involves:

Determining the care settings and services you or a loved one most likely would want.
Providing funding for paying the cost of care, especially when government support programs are lacking or require sacrifice of assets.
Completing a survey to determine necessary financial and legal arrangements to be made.
Completing a written long term care planning document to provide instructions to caregivers and to your care coordinator in advance of needing eldercare.
Assigning a care coordinator and determining the role of other family members, friends or advisers involved in caregiving.
Holding a planning meeting and drawing up a written agreement for involvement between all those who are willing to participate in future caregiving for you or a loved one.
We have defined four crucial steps necessary in this process for long term care planning. These four steps will be described below. The four steps are based on the following four concepts:

1. Knowledge and preparation are the keys to success.

2. Having funds to pay for care greatly expands the choices for care settings and providers.

3. Using professional help relieves stress, reduces conflict, and saves time and money.

4. Success is assured through a written plan accepted by all parties involved.

STEP 1-Understanding the Nature of Care, Care Settings, and Government Programs (Knowledge and preparation are the keys to success.)

This step requires an understanding of 12 different living arrangements and four different settings under which care is provided. In addition, understanding the provisions and limitations of government programs is essential because the public generally has a misconception that the government will step in and provide care when the time is needed.

Government programs are limited and according research by the National Care Planning Council (www.longtermcarelink.net), only 16% of all long term care services are provided by government programs. The other 84% is provided free of charge by family members, friends, charity, church groups or volunteers or paid for by private funds.

STEP 2-Funding the Cost of Long Term Care

(Having funds to pay for care greatly expands the choices for care settings and providers.)
Much emphasis is being placed on purchasing long term care insurance or arranging for reverse mortgages in order to fund the cost of care. These are two excellent tools for providing funding but in reality, this approach for planning is not working that well.

After 30 years of being touted as the ultimate solution, less than 2% of the American public and only 9% of seniors own long-term care insurance policies and using reverse mortgages may be a good strategy but in practice, few seniors are using them to pay for care. Our new book definitely covers these two funding options but also addresses at least 30 other strategies that can be used when trying to provide funds to pay the cost of long term care.

STEP 3-Using Long Term Care Professionals

(Using professional help relieves stress, reduces conflict, and saves time and money.)
Long term care services are complicated and provider contacts are fragmented throughout the community. For the majority of Americans, eldercare becomes a frustrating do-it-yourself process. This approach is unnecessary. Using care professionals is the most cost effective and efficient way to provide help for a loved one.

Those people who need help with long term care and use the services of professionals often find they save money over doing it themselves. They also reduce their stress and they free up a considerable amount of their personal time. Another benefit with using professional help, such as a care manager, elder law attorney or mediator, is to help you alleviate or avoid family conflicts that often arise as a result of caregiving.

Hiring professional advisers or providers to help with long term care is no different than using professionals to help with other complex issues such as car repairs, dealing with taxes or dealing with legal problems With their education and training, long term care professionals also bring experience that only comes from dealing with countless hands-on, caregiving challenges.

In much the same way that a three legged stool needs all three legs to be useful, the care planning approach needs at least three key entities in order to be successful. It needs YOU, LONG TERM CARE PROFESSIONALS, and GOVERNMENT LONG TERM CARE PROGRAMS. Our new book describes this team planning approach in more detail and outlines 13 vital professional services necessary for a successful long term care plan.

STEP 4-Creating a Personal Care Plan and Choosing a Care Coordinator

(Success is assured through a written plan; accepted by all parties involved.)
The first three steps in the planning process are designed to give you a wealth of information about long term care. It is important for you to have an understanding of care systems and the resources you can turn to when the need arises. However, knowledge of long term care systems is not enough. You must take some tangible action now to prepare for the day when you will need to deal with eldercare for your loved ones or for yourself.

The final fourth step in the planning process will help you make a care plan. If you follow our instructions and prepare a written plan for you or a loved one, the challenge of dealing with long term care will unfold for you in a more manageable manner. You will experience less stress, have fewer costs, require less time committed and have fewer family conflicts.