Eldercare Articles

Article / Updated 02-19-2019

Copyright © 2014 AARP. All rights reserved. Assisted living as pertaining to long-term care for the elderly is a term that is often used as though everyone understands it in the same way. But that's not the case. Assisted living is just a generic term like hotel or automobile that covers a lot of options. Before getting into the specifics, start with a simple definition: Assisted living is a residence where groups of people share meals and other activities and where individuals can receive personal assistance to maintain their independence. People who choose assisted living typically would have difficulty living completely on their own but do not require constant medical attention. You can also think about assisted living as an intermediate step in long-term care. It is in the middle of the spectrum of long-term care, which often goes from independent living to assisted living to nursing-home care. Independent living can be in your own home, or the entry level of assisted living or in special housing for older people. About 70 percent of residents in assisted living come to the facility from their own home or apartment. Most definitions of assisted living come from industry or government sources and emphasize different aspects of this long-term care setting. It's important to keep the source in mind when you gather information. For example, the Assisted Living Federation of America, a trade organization, says: “Assisted living is a housing and health-care option that combines independence and personal care in a residential setting.” The Eldercare Locator, a free service connected with the federal Administration on Aging (AoA), has an even more specific definition: “Assisted-living facilities offer a housing alternative for older adults who may need help with dressing, bathing, eating and toileting but do not require the intensive medical and nursing care provided in nursing homes.” Living with a congenial group of people with whom to share meals, activities, and conversation is a potential benefit. Remember, though, that it is sometimes hard to make new friends in assisted living because they see a lot of turnover. According to the 2010 National Survey of Residential Care Facilities (assisted-living facilities), most people stay in assisted living for only 22 months. Nearly 60 percent move on to a nursing facility, a third die, and the rest move home or to another location. State governments, which license group residences, call assisted-living facilities by different names. Some examples of the state licensing categories are residential care facilities for the elderly (California), residential facilities for groups (Nevada), and personal care homes – assisted-living facilities (Pennsylvania). You may also come across the acronym ALF in your search. It is shorthand for assisted-living facility, not the old TV character. Similarly, ALP is assisted-living program, not a mountain. Owners of assisted-living facilities tend to shy away from that term in the name, preferring more appealing names like village, community, manor, or any phrase that evokes a secure and invigorating lifestyle. Your state's name for assisted living is not as important as its licensing requirements and its monitoring activities. Some states have detailed standards about what counts as assisted living and what must be provided, as well as building and safety regulations. When you check out your state's regulations, find out whether it has a bill of rights for assisted-living residents. Most states have such a document and generally require facilities to post it and give copies to residents. These documents may be lengthy.

Article / Updated 03-26-2016

Copyright © 2014 AARP. All rights reserved. Both the federal and state governments regulate long-term care services and facilities. The standards are set by agencies that pay for services, monitor quality of care, and establish rules for licensing staff. It is important to understand what standards are monitored and how a particular facility or agency measures up to the requirements. Particularly important, of course, is the number of problems noted by government surveyors or through public complaints. Home care agencies: There are different types of home care agencies with different regulatory oversight. In order for a home care agency to be paid by Medicare and Medicaid, it has to be approved by CMS (Centers for Medicare & Medicaid Services). These agencies provide skilled nursing care, personal care, and therapies from professionals such as physical, occupational, speech, and respiratory therapists. Social-work services are also available. Home Health Compare is a CMS website that gives you information on specific agencies and how they are doing with meeting federal standards. Many but not all states license home care agencies that provide personal care services. Check the website of your state department of health to see whether all home care agencies are licensed and what they require in terms of background checks and training. Most states do not regulate companion agencies that provide nonmedical services such as preparing meals, homemaker services, and personal care, although the number that do monitor them is increasing. You will have to exercise due diligence about the agency's practices regarding background checks of employees, training, and other issues. Assisted-living facilities: The federal government doesn't have standards for independent living or assisted-living facilities. (A final CMS rule of January 2014 sets standards for states that include assisted living facilities in their Medicaid home- and community-based services waivers. States have a transitional period to ensure that they meet the standards.) These facilities are subject to various state regulations, which include building and safety codes. Some are licensed under different categories of congregate living. Because they do not provide medical services (except in a specific nursing unit), they are not generally regulated by departments of health. Nursing homes: Nursing homes are subject to federal and state regulation, with specific requirements about staffing, training, prevention of abuse and neglect, reporting incidents of poor quality, and other standards. A CMS website, Nursing Home Compare, allows you to search by facility name. State governments also regulate nursing homes, and many department of health websites also provide information on the results of their surveys. This information is also available on Nursing Home Compare. Quality Improvement Organizations (QIOs): Part of the CMS structure, each state has a designated QIO that is responsible for ensuring and improving quality of care and for reviewing complaints. If, for example, you feel that you are being discharged from a hospital too quickly, you can appeal the decision to the local QIO. Most people don't know about these organizations, but they can be very helpful in resolving problems. This directory of QIOs will help you find the right one. Long-term care ombudsmen: Ombudsmen (the term comes from Swedish) investigate complaints and negotiate solutions to problems in nursing homes and assisted-living facilities. These or other comparison sites are useful as a starting point but they do not provide all the information you need, and the sources on which they base their reviews may be incomplete or outdated.

Article / Updated 03-26-2016

Copyright © 2014 AARP. All rights reserved. When you plan a family meeting to discuss your long-term care options, present it as a preliminary discussion, not a done deal (unless a crisis has occurred). You may say to your adult children, for example, “This winter has made it clear to me that I really can't keep up the house and grounds the way I used to. I'm thinking about moving — maybe to assisted living, or maybe just to a smaller house or apartment. I've done a little research but I want to get your opinions.” Or, “Since your father died, I've been really lonely in this big house. I think it's time to make a move, but I'm not sure what to do. I don't want to move in with any of you but it would be nice to be closer.” Or to your siblings you might say, “You all know that Mom had a few bad falls recently. Her doctor is concerned that the next one might be even worse. Mom wants to stay here in the house she has put so much love into and that we all grew up in. But is that the best choice? Mom can speak for herself but she asked me to start the discussion with you.” You probably don't want to follow a formal agenda and parliamentary procedures, but it is a good idea to establish some ground rules. For example, Describe the purpose of the meeting and what you hope to accomplish. Make it clear that everyone will have a chance to speak and that all views are important. Encourage questions and concerns. Let participants know that personal gripes and problems are off limits. Set a time limit for the meeting. Meetings that go on endlessly are unlikely to resolve issues. Near the end of the designated time, sum up (or ask someone else to do it) and make a list of the issues that need to be resolved, who will gather more information, and when you will meet again. For example, if the meeting is to discuss a change in your own or your parent's medical condition, and this may mean additional help is needed, you may want the agenda to include: A concise description of the medical condition and recommended treatments (it is helpful to have a doctor's summary as well as a plain-language interpretation). Share any preliminary research you’ve conducted. Don't set yourself up as the expert, but try to counter opinions that you know are not based on fact. What the course of treatment will mean in terms of its physical impact on you or your parent and the extra help that will be needed (someone to help with household chores, someone to manage finances, someone to communicate with doctors). Likely length of treatment. Financial implications (what insurance will cover, what will have to be paid for out-of-pocket. What may be down the road, such as the need for full-time help or move to assisted living. Next steps and who will take on specific tasks. The most important part of the agenda is not the specific items you put on it, but the nonjudgmental and open-minded atmosphere you create. Even if no decisions are reached, you will have set the stage for further meetings and discussions. All too often a family meeting is something that happens in a hospital, with professionals guiding the discussion, with a focus on end-of-life care. Better start the process long before that and on your own terms. Unless you have to make an immediate decision (and you should try to avoid that), one meeting is not going to resolve the issue. The outcome of the first (and maybe the second and third) meeting should be a good discussion of the possible choices, with unanswered questions put on the table. Everyone should have an opportunity to speak and to be heard. Closing off discussion prematurely only causes problems later. Of course, this is easier said than done in families with a history of poor communication, but that is not a reason not to begin. Although long-term care planning includes consideration of end-of-life issues, such as advance-care planning, in my view it is best to separate these emotion-laden discussions. It is hard to go back and forth between discussing the merits of assisted living and the kinds of treatments one would want in a terminal illness. But both are important, and one can set the stage for the other. Use your judgment and your knowledge of family dynamics to decide where to start.

Article / Updated 03-26-2016

Copyright © 2014 AARP. All rights reserved. If you need to step in to help take care of an older person’s finances while planning their long-term care, an alternative to holding a joint bank account is receiving financial power of attorney. Two types of power attorney are available: conventional and durable. Conventional power of attorney Conventional power of attorney is granted by a document, signed by one person, giving another person permission to take care of different kinds of financial affairs, like signing checks, agreeing to pay a contractor for home repairs, handling bank accounts, and taking care of other tasks. The power of attorney may be limited to specific tasks, such as paying monthly bills, or it may be general and all encompassing (allowing everything including selling property and assets like stocks, filing taxes, or managing a retirement account). Depending on state laws, some powers cannot be assigned to another person. Those include the power to make, amend, or revoke a will; change insurance beneficiaries or vote. The person signing the document is known as the principal, and the person who is designated to act in the principal's name is called the agent or attorney-in-fact. Typically, a power of attorney goes into effect right away, but the principal can set it to expire on a certain date, and the principal can revoke the power of attorney at any time. Furthermore, conventional power of attorney ends if the principal becomes legally incapacitated, which means he or she is unable to understand and make decisions. If you are the agent, be sure you sign a check, for example, as John Brown (your name), attorney-in-fact for Mary Brown (your mother) to avoid personal liability. Durable power of attorney Because a conventional power of attorney ends when the principal (the person who signed away some powers) becomes legally incompetent, many people choose what is known as a durable power of attorney, which continues even if the person becomes incapacitated. Therefore, durable power of attorney lets the agent remain in control of certain financial and legal matters even if the principal is no longer able to understand the decision to be made or its implications. For example, a person with advanced dementia would be considered incapacitated, as would a someone in a coma. All states recognize some form of durable power of attorney, but the specifics vary. Another version of durable power of attorney is called a springing durable power of attorney. It sets conditions under which the durable power of attorney goes into effect; for example, when a doctor certifies that the person has become incapacitated. The springing durable power of attorney may be more acceptable to an older person and avoids the lengthy, costly, and emotionally difficult process of guardianship. However, the document must be very clear about what counts as the springing event so that the principal, agent, and other third parties who need to rely on the power of attorney can easily determine when the principal intended the agent to take over. Without clarity, a court may have to decide. This would negate one of the benefits of having a power of attorney, which is that financial and legal matters can be handled without going to court. Even if you have a durable power of attorney in a form approved by your state, your bank or other financial institution may require its own form. Even the Social Security Administration requires its own version of a power of attorney. Be sure to ask your bank whether it honors the standard form or requires its own. Just as in joint bank accounts, as the agent in a durable power of attorney, you are required to act in the person's best interests, maintain accurate records, and avoid any conflict of interest. Most people are not well versed in the fiduciary responsibilities that accompany being named an agent in a durable power of attorney. The same temptations that can occur in a joint bank account are present with a durable power of attorney, and here the stakes may be even higher. Therefore all financial actions taken on behalf of the person who is incapacitated must be transparent, and all family members involved in the care of the older person be apprised of significant outlays. There may be disagreements, but better to have them resolved early rather than cascade into serious trouble. A durable power of attorney for financial affairs does not include making healthcare decisions. That requires a separate document, which can be called by different names but is usually termed a healthcare proxy or a durable power of attorney for healthcare.

Article / Updated 03-26-2016

Copyright © 2014 AARP. All rights reserved. More than 60 percent of nursing-home admissions come directly from hospitals, so it's not surprising that most people face the decision about entering a nursing home in a crisis or just after one. The crisis might be a stroke, a bad fall, or a worsening of a chronic condition. Going home from the hospital may be the preferred choice, but the family may not be able to provide the needed care, even with the home healthcare and rehabilitation therapy that Medicare and other insurance coverage provides. A short stay in a skilled nursing facility rehabilitation program is one option that can give the person and family time to adjust to the new requirements and be better prepared to manage at home. Don't panic if the hospital nurse or social worker says, “We're sending you (or your parent) to a nursing home tomorrow.” Although this information should not come at the last minute, it often does. What it usually means is that you are being referred to a rehabilitation program at a nursing home, not being sent to a nursing home permanently. In these situations, you will be asked to make a quick decision about which nursing home rehab program to choose, and the choices may be limited. The discharge planner at the hospital may hand you a list of five nursing homes in the area and say, in effect, “You choose.” The discharge planner will then see what is available right away. Your choices may be limited by the facilities’ bed capacity, their ability to provide the kind and level of care needed, location, and other factors. Frequently the list includes only those nursing homes with which the discharge planner works on a daily basis; it may not include the full range available and appropriate. If you are interested in nursing homes not on the list, you can ask that specific nursing homes be put on the list, but the hospital will not keep your parent until a bed in your preferred nursing home becomes available. You can try to push the hospital to delay discharge for a few days, and you can file a formal appeal to postpone it. (If you lose the appeal, however, you will have to pay the costs of the additional hospital days.) The push to move patients quickly from hospitals to nursing homes is in hospitals’ and nursing homes’ economic interests. Hospitals want to ensure that they can discharge their patients quickly, and nursing homes want to maintain that source of new income. Medicare pays for the initial episode of nursing-home rehabilitation services if the person has been discharged after a minimum three-day hospital admission, but patients don't always get to stay for three days. Original Medicare pays for the first 20 days of each benefit period; you pay a coinsurance of $152 per day for days 21–100 (in 2014), and you pay all the costs for each day after day 100. You must be hospitalized for three days to start a new benefit period. If you have a Medicare Advantage plan or private insurance, check with the plan. To be eligible for Medicare coverage for short-term rehabilitation services, you must have been formally admitted as a hospital inpatient for three days. If the hospital makes a referral to a rehab program for further treatment in a nursing home – for example, to improve your ability to walk after a fall – after an observation stay, no matter how long the stay lasted, Medicare will not pay. Check to make sure your family member has actually been admitted to the hospital. You can also complain to the hospital if you are not given accurate or timely information. There are steps you can take without the pressure of an imminent hospital discharge or a rapidly deteriorating situation at home. The first step is to look broadly at the options in your area. Then you can be more focused on specific nursing homes and how to evaluate them. Sometimes a person admitted for a short-stay rehab program is unable to return home as hoped, and then another decision point is reached: to stay in the same nursing home as a long-stay resident or move to another facility. There may be interim steps to prepare for going home, for example, home modifications or hiring extra help.