Developing a financial plan for providing care is often the most challenging part of the care planning process. Paying for care out-of-pocket is expensive, ranging from more than $20 an hour for home care to over $10,000 per month for nursing home care. A wide variety of subsidy programs support services from home care to nursing homes, but the qualification requirements differ for each program. To make matters more complex, if you plan to meet the qualifications for one type of care subsidy, you may run into problems if your loved one needs a different level of care subsidy later on!
We have extensive expertise in understanding how to finance care in Massachusetts and how best to access appropriate subsidy programs. To explore the options, you need to gather information on your loved one’s income (and spouse’s income, if married), his assets (and spouse’s), and any transfers of assets that he (or his spouse) may have made in the past five years. Based on this and additional financial records, as needed, we will work with you to create a cost-effective financial plan for your loved one.
It’s often challenging to convince your loved one to listen to and understand your concerns. Underlying her refusal to accept help is the worry about losing control. We need to approach our loved ones with respect for their independence. A few helpful strategies:
- Pick your battles and focus on those issues of true concern.
- Find a good time for everyone involved and a comfortable place where your loved on feels secure to have the “talk.”
- Emphasize your understanding of your loved one’s need for control as well as your concerns for her health and safety.
That said, even if you do your best and still meet with resistance—and if your loved one is cognitively capable—we may have to respect her right to make a bad decision, and plan and wait for the crisis that will enable you to take appropriate action. We can help you to strategize how best to approach your resistant elder and how to plan, even without cooperation.
Family care contracts or agreements have become more popular in recent years, possibly due to the level of care that family members are providing to loved ones, often at the cost of their own employment and health. A family care contract is just what it sounds like—a formal agreement between your loved one in need of care (or surrogate) and you as care provider to deliver certain services in exchange for compensation. A written agreement protects all parties as well as clarifies the relationship for other family members and, perhaps, state agencies, if and when state subsidies are sought in the future for care. The Commonwealth of Massachusetts has programs that pay for certain family members (generally not spouses or persons legally obligated to provide care) to be caregivers. We can help you to understand and access these programs
While aging life care managers should not be writing these agreements, as they are legal contracts, the ALCM can provide a written assessment regarding the type of care needed, how it is provided and the financial value of the services provided. We have done a number of these assessments in concert with elder law attorneys. The assessment then becomes part of the family care contract.
Driving is an early marker of maturity and independence, and it’s often extremely hard for someone to give up willingly. When assessing your elder’s abilty to continue driving, ask yourself these questions:
- How comfortable you are in the car with your elder?
- Would you allow your children to be in the car with him driving?
- Would your elder know what to do if there is car trouble or a detour on a familiar route?
If the answer to any or all of these questions is “no,” then it’s time to act. An honest discussion of concern is always best. Your loved one may respond with his own concerns and describe ways in which he is already limiting himself, such as only driving locally or not driving at night. But if his problem is memory impairment, these self-imposed limits are often not enough.
We usually recommend a talk with a physician and a request for a driving evaluation. These evaluations are not covered by insurance; contact the agencies directly for pricing. There are two programs in Central Massachusetts:
Fairlawn Hospital Driving Evaluation (508-471-9322). A physician must write a referral for this evaluation (a note on a prescription pad is sufficient). The two-part evaluation begins with an in-office assessment by an occupational therapist who evaluates vision, strength and coordination, decision making ability, mapping ability and reaction time. If your loved one passes, then she progresses to the driving exam with a certified driving examiner. Her physician receives a formal report to share directly with your elder. If she does not pass this exam, her license will be taken and a recommendation for revocation will be sent to the Registry of Motor Vehicles.
Central Mass Safety Council (CMSC) (508-835-2333) Your elder undergoes a two-hour driving evaluation in a driver’s ed car (dual brake control) with an instructor who will provide feedback. The CMSC also provides driving evaluation and instructions to individuals who have sustained a medical event such as a stroke. There is no formal report included in this evaluation., and no report is made to the Registry of Motor Vehicles. This evaluation is not as thorough as the hospital-based approach, but may be more appealing to your elder.
There are many factors that go into the choice of an alternate care facility. We often recommend that your loved one move to a facility near family or friends. The presence of visitors and others to monitor care is critically important. If there are no available family or friends, your ALCM can be the liaison and surrogate family.
We also suggest that you consider your loved one’s religious or ethnic preferences. Word-of-mouth reports from others are useful as well—but take these with a word of caution: Two families or individuals can have vastly different experiences with the same facility, even at the same time. We have many stories of clients with positive and negative experiences at the same facility. An ALCM can also offer guidance for facilities to be considered for your loved one.
After identifying possible locations, you can check your state’s Department of Public Health website to locate annual reports on nursing homes. In Massachusetts, you can find these on the Health and Human Services website, following the link for Nursing Home Survey Performance Tool. The federal Medicare website also offers information and comparisons. The Massachusetts Executive Office of Elder Affairs (617-727-7750) has an assisted living ombudsman program which may offer some guidance regarding facility complaints.
It is important to realize, however, that these reports are snapshots in time. The decision makers (including your elder, as appropriate) should visit those facilities you are considering. It’s a good idea to take the formal tour with an admissions representative and then go back at a different time of day to get an informal sense of daily operations.
An early diagnosis of Alzheimer’s Disease or other chronic illness presents you with an opportunity to plan for the future. One of our first recommendations is to see an elder law attorney to review or implement an estate plan. If you haven’t done so already, this may include executing several key legal documents:
- Durable Power of Attorney—Your loved one names an agent or agents to act on her behalf with respect to financial and other matters.
- Health Care Proxy—Your loved one names an agent and an alternate to act on her behalf with respect to health care matters when she can no longer make decisions. This is also a very good time to discuss your loved one’s wishes, so that the agent will understand what decisions should be made.
- HIPAA Consent Form—Your loved one names an agent to obtain medical information or review medical records.
- Will—Your loved one directs what should happen with her estate after her passing.
There are other legal documents, such as trusts, which might also be part of an estate plan. We recommend that our clients see elder law attorneys who work exclusively with elders and persons with disability, who consider the entire family situation, and who will craft an estate plan that meets their loved one’s stated goals while leaving open the best option to obtain care in the future. Elder law attorneys should understand the various subsidy programs and work with you to arrange assets to maximize care options and eligibility for subsidy as needed. The rules around these programs are very complex and ever-changing; be certain to work with someone who specializes in this area and is up-to-date on its many intricacies. We can suggest local attorneys, or you can find an elder law attorney at www.naela.org.
For supportive services and education, we also recommend that you connect with the Alzheimer’s Association or call 508-799-2386 to speak with someone in the Central Massachusetts office. The Alzheimer’s Association offers a wealth of programs, training, support groups and written materials that can be most helpful. They offer a Care Consultation program—a free one- to one-and-a-half-hour consult with an Alzheimer’s Disease expert. One of their most popular free programs is called “Getting Started: A Primer After Diagnosis.”
Consultation with an ALCM can also help you to formulate a longer term care plan that can be implemented as the disease progresses.