Long Term Care

• The Caregiving Component.  Check if care is on-campus or off-campus.  Also, if your family has a history of a medical problem, like Alzheimer’s, make sure your CCRC has good care for that.
• The Costs.  CCRCs normally have an entrance fee depending on the apartment size and a monthly fee to cover needs.  They are also dependent on other factors, including health, the number of residents living in the facility and the type of service contract (fee-for-service or all included).  Remember that many current expenses, like groceries and home maintenance, will be covered at the CCRC.  A general suggestion is to have your monthly income be one and a half times the monthly fee.
• The CCRCs Finances.  If the occupancy rate is below average (90%), the number could reflect poor management.  Also, look at the sponsoring companies and the CCRC’s track record.  Have a lawyer or geriatric care manager check the community’s status, too.  Make sure your CCRC can keep any promises they make.

Many times, the cost of providing a full time skilled caregiver (which is estimated at $5,531 out of pocket expenses) causes a family member (or members) to step in a serve as a caregiver.  But even this can cause financial issues, as the caregiver will lose his or her paycheck once pulled away from his regular job.  He or she might fall behind of retirement savings, also, and there could be some difficulty returning to the workforce.

Fortunately, there are some options available for compensation for caregivers.  Pennsylvania has a Caregiver Support Program that includes supportive services such as counseling, education, financial information, and monthly reimbursements depending on your needs if you care for a person over 60 with chronic dementia.  If your loved one is a veteran, you can receive a monthly stipend if the veteran was injured in a military conflict after 9/11.  Other benefits include access to health care insurance, mental health services and respite care of 30 days a year.  For veterans of other wars, caregivers may be eligible for the VA's Aid and Attendance Pension Benefit.  If your family member has long-term care insurance, it may cover some home care.  Some policies permit family members to be paid, but you should ask your family member's insurance information to explain this benefit and its conditions.

If none of these other options apply to you, you can still be paid if your family member has some savings or assets.  In a method that is becoming more popular as more children are caring for aging parents, a caregiver contract writes out the services that will be provided as well as the pay he or she will provide.  A simple, written personal care agreement can help every party involved understand what is supposed to be done and when.  It can also help avoid misunderstandings with other family members and can prove the validity of the pay and the services for the state and Medicaid if you family member ever needs to enter a nursing home.

A caregiver agreement should include when the care will begin, the tasks that will be performed (be specific and thorough, but also provide yourself with some flexibility by including a statement like "or similar tasks to be mutually agreed upon by the parties), how often you will provide the care, how much you will be paid (and when), and how long the agreement will stay in effect (again, you can provide yourself with some flexibility by saying "This agreement shall remain in force until terminated in writing by either party").  You should also include a statement that allows for the contract to be changed only by mutual agreement in writing by both parties.  Once everything is written, both you and your loved one should sign and date two contracts, one for each of you.

For an example of a contract that was upheld in Missouri during a Medicaid dispute, see this example provided by Survivorship A to Z.  However, just because it was upheld in Missouri does not mean it will be in Pennsylvania, and you should seek an elder law attorney to verify that it meets all tax requirements.

If a personal care agreement is not a viable option, and you are still facing financial hardship, consider seeing if your family member is eligible for programs that send an outside caregiver to the home so the responsibility isn't solely yours.  Also, look into finding a job that allows you the flexibility needed as a caregiver, or try working from home.  You can also hold a family meeting with siblings to discuss ways you can all share the financial burden, or even discuss receiving a larger portion of inheritance to help cover the finances of caregiving.  Whatever you do, make sure your loved one, family members, and yourself are all in agreement.
 

Caregiver Program Links:
Pennsylvania Caregiver Support Program
VA Caregiver Support Services
 

The role of caregiving can be both rewarding and exhausting.  To handle those exhausting times, it is important to incorporate some down time in your schedule to take care of yourself.  A study from Penn State and Virginia Tech showed that adult day services (ADS), which can provide services to allow for down time, significantly lowered stress levels of the caregiving family members.  Adult day services can give caregivers respite by providing a center where elderly parents can be taken for a couple of hours or the entire day and picked back up later. The day programs include social activities, meals and general elderly supervision.  Older adults who cannot be home alone can go into a safe supervised setting that can administer medications, provide hot meals and fun activities, and give caregivers a break.  In Lancaster County there are six facilities and all give tours to caregivers to determine whether ADS is a good fit.  To find out more about the adult care centers, contact one of the six in Lancaster.

• Landis Homes (Eden East and Eden West) - 717-581-3939
• Lancaster Regional Medical Center - 717-291-8055
• Garden Spot Village - 717-355-6226
• Lancaster Generations - 717-656-8783
• Masonic Village - 717-361-5353

Being the caregiver of an elderly parent can be a tiresome job by itself.  If you have kids to worry about, it becomes that much more difficult.  While worrying about getting your mother to her doctor appointments, giving her her medications on schedule, making sure her kitchen is stocked if she's still living at home, etc, you have to make dinner for your kids, drive them to soccer practice, and make sure they get their homework done.  In a 1990 article, Newsweek reported that the average American woman will spend 17 years raising her kids and 18 years helping her aging parents or in-laws.

Family caregivers worry about spreading themselves too thin and their own ability to cope with all the responsibilities that face them.  So how can a family caregiver handle caring for their parents and their kids?  Here are some tips that might help you feel a little less sandwiched:

• Hold a family meeting.  Family meetings are a time to discuss conflicts and propose solutions together.  They allow everyone to contribute their thoughts and may encourage feelings to be shared that would otherwise go unspoken.  If family meetings seem to go nowhere, bring in a friend or other family member to moderate.
• Educate teens about their grandparent's condition.  Talking to them honestly about their grandparent's situation, both abilities and disabilities, can help kids, especially teens, better cope.  Illness can be scary, and some, like Alzheimer's, can impact them as well.  Kids will be better able to cope if they understand the nature of the illness and how it should progress.
• Ensure that family members have their privacy.  This is especially important for teenagers, so if your mom or dad moves in with you, give them their own space.  Ideally they should have their own room as well as a TV, phone or computer.  And make sure that your parent knows that the kids need their space and alone-time as well.
• Expect your kids' help, but be realistic about what they can do.  Kids should understand that they are a part of the family and will be depended on to help.  Prepare a list of all the things you do on a daily and weekly basis, then ask them which of those things they can do for you.  And most importantly, hold them to it!
• Don't ignore the quiet ones.  Some kids are louder than others, but that doesn't mean that the quiet ones aren't struggling.  They may just not want to further stress you out with complaints or don't know how to express their feelings.  Regularly ask your kids how they are feeling and acknowledge that this is a difficult situation for everyone.
• Focus on your marriage.  Set aside time each week for your spouse to do something you both enjoy.  Also, talk about the situation and don't let your marriage suffer because of it.  Your spouse can provide the comfort you need, and you want to nurture that relationship.
• Prepare a long-range financial plan.  Do you have kids heading to college soon?  How are you going to fund your parent's long-term care?  These are questions that you should be asking yourself to better prepare for the future.  A professional financial planner can help you figure out your parents' assets and how to use them to finance their care.
• Look for the blessings.  It may seem stressful to care for an elderly parent, but it can be very rewarding, too.  Many caregivers report great satisfaction due to the closeness they achieve with their parent.  This can also be a great experience for kids as they learn to sacrifice their own needs for the family.

Whether you have hours, weeks, or months to find a nursing home for an elderly loved one, the task is going to be daunting.  But this will be the task for a majority of the population, as two-thirds of people over 65 will need the care given by a nursing home, according to AARP.  Just as you wouldn't move into a new house without visiting and inspecting it, you should do research on nursing facilities ahead of time if possible.  And when researching, there are several key considerations you should take.

First, look at the official stats.  Medicare rates and compares nursing homes on their website (medicare.gov/nhcompare).  Some facilities are even certified by Medicare, meaning they are inspected every year and all complaints are investigated.  Read these ratings and recent inspection reports, but don't just take them at face value.  Check out the ratings for health inspections and for staffing and see if you can find why they rank as they do.  What are the citations for and how often do they occur?  One patient accident isn't a big deal, but frequent falls could be a red flag.  If you want more opinions on the nursing home, your local Area Agency on Aging (the Lancaster County Office of Aging) or a hospital discharge planner can give you referrals on nursing homes.  Furthermore, the state's ombudsman and licensing agency should be able to tell you about consumer complaints.

Check to see how staffing is at the nursing home.  How much time are residents receiving with the nurses?  The Centers for Medicare and Medicaid Services (CMS) recommends at least 2.8 hours a day of nursing aide time and 1.3 hours with an RN or licensed practical nurse.  Ask specific questions of the staff and about care, ask how personal preferences are accommodated.  Also see whether staff work with the same patients each day because when staffers know the patients better, the quality of care is higher.  Finally, make sure to ask how the staff will deal with an unexpected event, like a power loss or a situation which requires evacuation.

Visit the nursing homes you are considering, and visit more than once.  Observe lifestyle details, like do the nurses greet patients in the hall?  Are meal eaten in the dining room and are residents enjoying the meal?  Does it smell pleasant and homey and are residents smiling?  Check rooms for cheerfulness and safety, use the bathroom to check for hot water, and inspect the kitchen for cleanliness.   Ask about anything that could affect the well being and happiness of your loved one, like are there organized outings and visits?  What activities are listed on the bulletin board?  Are there stimulating offerings like exercise classes and a library?  Snoop around (and be wary of any place that objects) and try visiting unannounced on a weekend when staffing is likely to be tighter.

Another important consideration is how close the nursing home is to you.  The biggest influence on care quality is the frequency of visits by friends and family.  Make sure you're allowed to visit when you want to fit your schedule, and to monitor care at different times.  Drop by often and sometimes without notice.  Stay late sometimes after your loved one has fallen asleep.  By coming at different times, you can see how quickly a staff member respondes to a ring for assistance, whether residents are enjoying interesting activities together in the afternoon or staying cooped up in their rooms and how much your mom or dad eats at meals.

One of the biggest factors in your decision will be cost.  The median annual rate for a semi-private room in Pennsylvania last year was $89,425.  If the move is years away, consider getting long-term care insurance.  If your loved one already has long term care insurance, find out the daily rate it covers.  This could be far less than your preferred homes and most policies don't kick in until after a 60 or 90 day "elimination period."  To keep costs down, determine if it's possible to keep your loved one at home a bit longer through a combination of health aides, adult day care, and family help.  You can also consult an elder law attorney for help with nursing home planning.  The Law Office of Shawn Pierson can help with the planning and can help get you qualified for Medicaid, known as Medical Assistance in Pennsylvania.  However, not all facilities accept Medical Assistance, so make sure your preferred facilities accept payment or else you might have to move when payments switch.

If you find that your loved one is not receiving the care he or she deserves, don't hesitate to move him or her.

For more ideas on what to look for in a nursing home or long term care facility, use the checklist found here by AARP.

In our latest e-newsletter, there was an article titled "Son Liable for Mom's $93,000 Nursing Home Bill Under 'Filial Responsibility' Law."  The same day our newsletter went out, local attorney Patti Spencer had an article in the Lancaster newspaper regarding the same topic, that a son was responsible for his mother's nursing home bill.  Because of these, we've had some questions regarding filial responsibility, namely what is it and what does it mean?  Well, here's a quick run down on what Pennsylvania's filial responsibility law entails.

Pennsylvania, as well as 29 other states, has a filial responsibility law.  Although these laws vary from state to state, they all say generally the same thing; they require adult children to provide financial support for their indigent or poor parents.  In Pennsylvania, not only do the children have the responsibility of maintaining their mother or father, but the spouse of and the parents of the indigent person hold the responsibility as well.  Caring for a person also includes financially assisting him or her, however there is an exception in the case that an individual does not have the ability to support the person financially.  Additionally, A child shall not be liable for the support of “a parent who abandoned the child and persisted in the abandonment for a period of ten years during the child's minority,” meaning a child who was abandoned for 10 years while under the age of 18 is not responsible for his or her parents' care.

In order for the filial responsibility law to be enforced, a civil lawsuit must be filed to get court-ordered judgment. The amount of the liability will then be determined by the judgment from the lawsuit.  Civil action may be taken by the indigent person or any other person, public body or agency who has interest in the care and well-being of the indigent person.  Most commonly, it is the nursing home who takes civil action.

If you are found liable and fail to comply with the order, the court will schedule a contempt hearing.  If the court determines that the individual found liable has intentionally failed to comply with the order, that individual could face 6 months of jail time.

In the past 30 years, there have been only 3 cases discussing the filial responsibility law.  However, in wake of the recession and budget woes affecting state-funded nursing home programs, nursing homes and other care facilities may turn to filial law to recover the lost funding.  You can protect yourself and your parents now through estate planning, long-term care insurance and knowing home Medical Assistance works.  Legal action for filial responsibility isn't all that common now, but the trend may change.  If you are at all concerned about this, or have more questions, call our office at (717) 560-4966 or email us at questions@piersonelderlaw.com and we will be more than happy to help.

Want to read more?  You can find our newsletter article here or the article by Patti Spencer here.  Additionally, to read the current Pennsylvania statute on filial responsibility, click here.