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Balancing ActsElderly Parents and Long Distance Care Giving
Get Ready
"There are only four kinds of people in the world - those who have been caregivers, those who are currently caregivers, those who will be caregivers, and those who will
need caregivers."
Rosalynn Carter
The Late YearsThree models: Measuring function across
time. The three most common ways to die
Getting Services Right for those Sick Enough to Die, by Sydney Dy and Joanne Lynn.
British Medical Journal, v. 334, no. 7592, Mar. 10, 2007, p. 511-513.
Twenty Percent
Organ Failure
The Final Forty
Long Distance Miles Away: Findings from a national study by the
National Alliance for Caregiving with Zogby International for the MetLife Mature Market Institute, July 2004.
Key Findings Average distance of 450 miles and 7.23 hours of
travel time one-way for those involved as long-distance caregivers.
Despite distance, LD caregivers report substantial regular personal contact with the person they were helping.
51% reported visiting at least a few times each month.
Caregiving Situation Nearly one-fourth (23%) of the LD caregivers
reported they were the only or primary care provider.
Nearly three-quarters were helping their loved one with instrumental activities like transportation, shopping, managing finances, cooking and were spending 22 hours a month on this help.
Almost half reported managing needed services and spending the equivalent of nearly one full day each week doing so.
Effect on Work More than four in ten had to rearrange their
work schedules in order to take care of their caregiving responsibilities, more than a third (36%) reported missing days of work, and 12% took a leave of absence.
Both men and women were equally likely to have rearranged their work schedules, left early or arrived late to work, taken unpaid leave as a result.
Women were more likely than men to report that they missed days of work and/or moved from full-time to part-time work.
Financial Contribution LD Caregivers spend an average of $392 per
month on travel and total out-of-pocket expenses.
Distance is a factor in total out-of-pocket expenses. Those living 1-3 hours distant spend an average $386 per month, while those who live more than 3 hours away spend an average $674 per month.
For the 10% of respondents who also paid for services the care recipient needed, women spent an average of $751 monthly, compared to men who spent $490 / monthly average.
Seeking Balance
Care PlanningThink of it as Due Diligence
A Chance to Get It Right
Few would deny the importance of planning for death – having a will, an estate plan, a health care proxy, an advance directive… Most of our elders have these.
Fewer still recognize the importance of planning for long-term or debilitating decline, yet most of our elders will experience significant diminishment before death.
Rarely do we plan for this likelihood… but recall those end-of-life graphs.
Timing
The best time to plan is well before there’s a need to have a plan. Plan when the need is
abstract. And remember that it’s not
your plan, it’s their plan. Your role is implementing it.
Where Do Things Stand
Relationships
Legal Issues
Financial Resources
Medical Management
End of Life Issues
Aspects of Daily Living
Housing
Care Network
Meals & Nutrition
Transportation
Stability “Everything’s just fine, dear”
Don’t just let sleeping dogs lie. Learn about aging
Discuss how decisions get made.
Evaluate Denial
Assess health habits with a 72 hr. visit. Admit your own slow slip.
Get to know their community members
Overcome generational isolation
Advance Directives An early discussion of legal and medical
issues.
Living Wills
Durable Powers of Attorney
Discuss how your parents would like to be treated if they lose the capacity to make their own decisions.
Observe decision making styles / behaviors
It can takes weeks or months to get comfortable with this when conditions are stable.
Aspects of Daily LivingAdvanced, Intermediate and Basic
Advanced ADLs These are the kinds of activities a person
needs to be able to do for herself in order to live as an active, participating member of the community. Participating successfully as a member of a
group – e.g., quilting, choir, volunteer projects
Leaving home to meet social needs – e.g., going to church, meetings, visiting friends, attending events.
Using public transportation, driving a car, traveling
Enjoying an out-of-home exercise routine
Assessing and coordinating home or care maintenance
Intermediate ADLs These are necessary for people to live by
themselves while having groceries and services delivered, and being accompanied on outings. Moving around adequately and safely at home
Making the bed, cleaning up, doing light housekeeping.
Simple cooking
Making telephone calls
Keeping track of bills and writing checks
Self-administering medications
Basic ADLs Activities people need to perform for
themselves to live independently in a bedroom/bathroom suite in a house with an attentive family member. Bathing
Dressing
Using the Toilet
Moving from Bed to Chair to Toilet (basic mobility)
Eating without assistance
Advocates
Spouse
Children
Grandchildren
Friends
Neighbors
Medical Providers
The Care Network If you’re at a distance from your family
member needing care, you’ll require others nearby to keep the plan on track.
Brothers, sisters, children, cousins, friends, church members, neighbors. These are in relation to the one who will need
care.
Health care professionals.
Geriatric case managers
From a distance… Re-engage the family
Get acquainted with HIPAA Health Insurance Portability & Accountability
Act.
Discuss with loved ones and medical staff your desire to be a parent’s advocate.
Confidentiality and involvement are not mutually exclusive.
In a litigious society, medical providers want / need release in writing.
Essential Legal Matters
A Care Crisis The triggering event to care giving.
Is your presence a “medical necessity”? Why is this important for the LD caregiver?
Family Medical Leave Act coverage
Absent an approved certification from your parent’s medical provider that your parent’s medical condition requires your assistance, time off from work to care for a parent is not covered by FML.
Approval provided by UAA Human Resources
FML Benefits Job protection for absences covered by FML
Claimant, once approved, is required to take all accumulated leave and remains in full pay/benefits status until leave is exhausted.
FML leave extents for 18 weeks. If paid leave runs out prior, employee must continue funding benefits out-of-pocket to maintain benefits.
Critical to coordinate with HR.
Note:
None of us qualifies for FML simply because our parents
are old and we need to travel to assist them from time to
time.
Medical necessity must be established to qualify for FML
protection.
Other Legal MattersThe Common Documents
Property: A Legacy The treasures accumulated over a lifetime,
whether large or small, are of great interest and concern to many parents who are focused on their legacy.
Wills and trusts are two legal instruments used to allocate property after death. These documents are in some ways the
easiest to discuss.
Recall that most have considered and taken steps to assure that their wishes regarding property are formalized.
Basic Terminology Wills
Intestate succession
Holographic wills
Probate
Trusts Revocable
Irrevocable
Avoiding Probate
Estate Planning Minimizing tax
consequences of property transfers.
Health Related
Legal Issues•Advance Directives
•Health Care Proxies
•Durable Powers of Attorney
•Living Wills
Capacity Presumed
Power of the “next of kin”
Conservatorships
Guardianships
Distinguish between Power of Attorney and Durable Power of Attorney Succession of powers
Governed by each state’s laws, not federal law.
Housing OptionsAsset Preservation
Housing Needs Independent Living
Senior Apartments
Naturally Occurring Retirement Communities
Continuing Senior Care Communities
Assisted Living Facilities
Skilled Nursing Care Facilities
In-home Care
Family Care
Aging in Place Most preferred by homeowners.
Home represents often the single largest asset owned by the parent.
NORCs
Family Care
Live-In Care
Asset Preservation Early discussions are most beneficial.
Scenario: Parent intends to bequeath the home to his children after death. Due to health decline, parent requires skilled nursing care in a facility.
Transfer to children?
Irrevocable trust?
Who gets the house?
“Spending Down Assets”
The idea is that the assets of the elder are legally transferred well in advance of the need for asset proceeds to pay for care.
Ethical issues abound.
Who pays for care associated with housing? Self-funded (“private pay”)
Long-term Care Insurance
Governmental subsidy (Medicaid).
The Five-Year Rule Transfers of property/assets for less than
reasonably equivalent value will result in an imposition of a penalty when one is institutionalized and seeking Medicaid benefits for nursing home expenses.
Note: Medicare does not pay for – in-home care, nursing home care, assisting living and the like.
IRS Implications Too Keep an eye on the tax man.
Gift taxes $13,000 annually gifted to child/spouse
without gift tax liability.
Tax on larger gifts, taxable to recipient.
Lack of gift tax has no bearing on Medicaid transfer liability. Estate planning lawyers vs. Elder care lawyers
Paying for care…As assets are depleted.
Health Care Medicare Part A
Hospitalization
Rehabilitative Care 120 midnights
Lifetime
The “three midnights” rule.
Medicare Part B Out-patient
Fixed reimbursements
MD cannot accept pay differential except through supplemental insurer.
Medicare Part D Prescription Drugs
The Formulary
Annual plan modifications
The Donut Hole
Paying for Rx while paying for coverage.
Closing slowly through 2018.
Pre-Certifications, Coverage Denials & Appeal 72-hr. expedited appeals
7-10 day normal time period
Long Term Care Insurance
Daily benefit amount.
Restrictions on use, especially in older policies.
Promotes live-in assistance and aging in place.
Most can be used to pay geriatric case managers.
Help on the horizon: the CLASS Act Part of PPAC of 2010
Not age or health restricted.
Nursing Homes New federal regulation prohibits skilled
nursing care facilities that accept Medicaid from discriminating among admissions based on entrant’s status as private pay, insurance pay or Medicaid pay.
Remember, Medicare does not pay for long-term skilled nursing care.
Beware of the transfer penalty, the 5-year look-back on any gifts from the individual in need of care.
Transfer Penalty Deficit Reduction Act of 2006 mandates:
A penalty – a set number of months during which an eligible recipient will be denied Medicaid coverage for skilled nursing care – is applied whenever Within 5 years of qualifying events
A transfer for less than reasonably equivalent value is made.
Calculate: Gift value / Ave. monthly cost of nursing home care in the state.
Calculation Total value of transfers (gifts) within 60
months.
Divide by the average monthly cost for nursing home care within the state (published by state HHS).
Quotient is the number of months the penalty applies.
Penalty is no Medicaid funding. Risks eviction
Out of pocket payment from external source.
Family?
Examples For instance, if the nursing home resident
transferred $100,00 in a state where the average monthly cost of care was $5,000, the penalty period would be 20 months ($100,000/$5,000 = 20).
Or, if the nursing home resident transferred $72,000 in Alaska where the average monthly cost of care is $7,000, the penalty period would be months ($72,000/$7,000 = 11 months because under these federal regulations we round up.
The EndContact Pamela Kelley for your copy of the Resource Manual.
Dedicated to Audrey RobertsMy Chance to Get It Right
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