March 2016

I want to Stay in my Home – Adult Child Moving in with Aging Parent

Posted on March 31, 2016 by Jim Koewler — No Comments ↓

This week’s blog continues the discussion of an aging adult who wants to stay in his or her home. The introductory installment (on February 11, 2016) discussed the emotional turmoil that can face the adult children in deciding whether to accede to the aging parent’s wishes to stay home. The February 18, 2016 installment discussed home modifications that may make it easier for an aging adult to stay home. The February 25, 2016 installment discussed medication management. The March 3, 2016 installment discussed hiring someone to help with activities of daily living. The March 10, 2016 installment discussed whether aging in place is an appropriate choice for someone suffering cognitive issues. The March 17, 2016 installment discussed services that can make it easier for an aging adult to stay home. The March 24, 2016 installment discussed the aging parent moving into an adult child’s home. Today’s installment will discuss an adult child moving into the home with his or her aging parent.

Many of the issues discussed in the last installment about the aging parent moving into the home of the adult child must be considered before an adult child moves into the home of an aging parent. Moving in with an aging parent requires the cooperation of the child’s spouse (if there is one) and the child’s children (i.e., the aging parent’s grandchildren) if any. The physical layout of the aging parent’s house might be very important to the parent’s ability to stay home. Of course, living in the parent’s home (grandparent’s home as far as the children are concerned) needs to fit into the lifestyle of the adult child’s family.

There is one big difference when the adult child moves into the aging parent’s house. The aging parent might be able to give the house to the child without creating a problem with Medicaid (if the aging parent later needs Medicaid to help pay for long term care.) There are some specific conditions that must be met, however, for a transfer of the house to be okay with Medicaid.

The short version of this rule is that Medicaid will reward the adult child that helps keep the aging parent out of a nursing home for two years.

So, to qualify for a transfer of the house to the adult child:
(1) the aging parent would need to move into a nursing home if not for the adult child’s help at home,
(2) the aging parent must have a level of care assessment indicating that the parent needs an “intermediate level of care” (usually meaning that the person needs help with two “activities of daily living” such as bathing, toileting, dressing, grooming, getting out of bed or a chair, walking around, or eating,)
(3) the doctor issues a letter stating that the aging parent would need to be in a nursing home if not for the child’s presence in the home,
(4) the child must live in the parent’s house for two years, and
(5) the parent must not move into a nursing home for at least two years.
(Note: This is only a Medicaid rule. It does not avoid possible IRS taxation of gifts. It also does not make the parent’s mortgage go away.)

Sounds easy, right? Maybe, maybe not!

The aging parent needs to get good care. The incentive of a home transferred from Mom or Dad should NOT create an incentive for failing to get the care that Mom or Dad actually need. Failure to take proper care of Mom or Dad should create a great deal of guilt. If extreme, it should prompt a visit from Adult Protective Services.

An adult child (with our without family in tow) moving into the aging parent’s home can sometimes help the parent age in place. The home and the child’s involvement need to be appropriate for the aging adult’s care. If everything falls into place (and that’s often a matter of luck,) the family may be able to protect the house from the parent’s long term care costs.

I want to Stay in my Home – Aging Parent moving in with Adult Child

Posted on March 24, 2016 by Jim Koewler — No Comments ↓

This week’s blog continues the discussion of an aging adult who wants to stay in his or her home. The introductory installment (on February 11, 2016) discussed the emotional turmoil that can face the adult children in deciding whether to accede to the aging parent’s wishes to stay home. The February 18, 2016 installment discussed home modifications that may make it easier for an aging adult to stay home. The February 25, 2016 installment discussed medication management. The March 3, 2016 installment discussed hiring someone to help with activities of daily living. The March 10, 2016 installment discussed whether aging in place is an appropriate choice for someone suffering cognitive issues. The March 17, 2016 installment discussed services that can make it easier for an aging adult to stay home. Today’s installment will discuss the aging parent moving into an adult child’s home.

When an adult child sees Mom or Dad start to have trouble functioning with everyday activities, the adult child might consider moving Mom or Dad into the adult child’s house. Frequently, the parent and adult child have talked about this possibility in the past, usually at a time when the parent didn’t show any signs of ever needing help with routine activities. Even more frequently it seems, the parent has always assumed that he or she would move into the adult child’s house but has not discussed that assumption with the child.

Of course, the adult child must get agreement from his or her spouse (if married) before bringing an aging parent into the household. In addition, if the adult child has any children at home, their buy-in is certainly preferable if not absolutely necessary.

The adult child must consider the home’s physical layout before bringing an aging parent into the household. For example, if the aging parent cannot go up and down stairs, the house must have a place to sleep and a full bathroom on the main floor and may also need a ramp at one of the outer doors. As another example, if the aging adult needs a wheelchair or walker, an older home with narrow doorways and hallways may not be acceptable.

In addition, the adult child must consider his or her nuclear family’s lifestyle before bringing an aging parent into the household. If the adult child and his or her spouse work, will the aging parent be able to receive the supervision necessary to stay in the home? If the adult child and spouse are not “homebodies,” will either of them be willing to spend significant amounts of time at home with the aging parent (or in-law?) The care needs of the aging parent will put a strain on family relationships. How will the family deal with the strain?

Moving an aging parent into the adult child’s home sounds like it would solve most the the care issues for the aging adult. The devil is in the details, however. It is a much tougher situation than most people realize.

I want to Stay in my Home – Services Available

Posted on March 17, 2016 by Jim Koewler — No Comments ↓

This week’s blog continues the discussion of an aging adult who wants to stay in his or her home. The introductory installment (on February 11, 2016) discussed the emotional turmoil that can face the adult children in deciding whether to accede to the aging parent’s wishes to stay home. The February 18, 2016 installment discussed home modifications that may make it easier for an aging adult to stay home. The February 25, 2016 installment discussed medication management. The March 3, 2016 installment discussed hiring someone to help with activities of daily living. The March 10, 2016 installment discussed technologies that can monitor the well-being of an aging adult staying in the home. Today’s installment will discuss services that can make it easier for an aging adult to stay home.

One of the biggest needs for a senior to stay in his or her home is nutrition. Mobile Meals or Meals on Wheels is available in many areas for seniors of limited means. These services will deliver balanced nutritional meals to seniors in their homes. The meal delivery is also a social interaction for seniors, some of whom have very little contact with others. Many meal delivery volunteers get big smiles and hugs just because they show up at a senior’s home.

In many areas where there are a sufficient number of seniors, congregate meals are available at senior centers, community centers, or churches. These congregate meals (usually at lunchtime) offer a nutritious meal at little or no cost. Because it is a congregate meal, it also offers socialization. It’s a chance to visit with others. It is also a chance for others to see the senior on a regular basis. The people who host the congregate meal see the same diners on a regular basis. If someone doesn’t show up, the hosts will notice. If a diner is starting to have trouble getting around, trouble remembering, or shows signs of difficulties, the hosts can check with the senior and/or family members.

With luck, the senior lives in a neighborhood where the neighbors are friendly. If at least some of them are friendly, the neighbors can be a support “service.” Neighbors can check on each other or run errands together.

The telephone also helps. Someone calling a senior every day “just to talk” or to check in has the added benefit of knowing that the senior can get to the phone and “‘sounds okay.” It’s less immediate than a medical pendant, but it’s socialization and reassurance for both the senior and the caller.

If the senior has a disease that causes dementia, the Alzheimer’s Association can provide a great deal of advice and can put the family in touch with a great number of resources and other services. If the senior suffers from Parkinson’s, the Parkinson’s Association can provide advice, resources, and links to useful services. Likewise, a number of non-profit organizations can make advice and support available to the senior and family. Often, these organizations focus on a particular chronic condition. In some areas, a United Way agency may offer the same sort of advice and referrals without being linked to a particular condition.

More and more Adult Day Care services are opening. Adult day care services offer a chance for the senior to get out of the house (i.e., a little variation on the daily routine) and socialization. Lunches and sometimes breakfasts, as well as snacks, are available. Adult day services provide activities, and many times those activities are forms of covert rehabilitation for the senior’s chronic issues.

A local senior center may offer a number of services similar to Adult Day Care. There will be less structure than Adult Day Care, but still senior centers many times offer a great deal of structure. Structured or not, senior centers offer companionship and someplace to go outside the house. (Senior Centers with pool tables seem to attract a great deal of men, I’ve noticed.) As mentioned above, senior centers often have a congregate meal. Also, they frequently offer informational programs or support groups for seniors and family members.

Companion Care services are also available. These services are similar to in-home care, but they don’t provide actual hands-on care. Companion Care doesn’t offer (or rarely offers) help with bathing, dressing, toileting, feeding, getting in and out of bed or a chair, or other “activities of daily living.” Help with those needs falls under non-skilled home care (as discussed in the March 3, 2016 installment.) Companion Care may offer meal preparation, medication reminders, laundry, light cleaning, and (as the words “companion care” imply) companionship for the senior – someone in the house spending time with the senior.

A one-stop-shop that can put the family in touch with the many of the services described above as well as a great number of other services is the local Area Agency on Aging or the county Department of Aging. These organizations attempt to “know everyone” who can help seniors. Area Agencies on Aging and Departments of Aging do an incredible job connecting seniors with support services.

I want to Stay in my Home – Technology

Posted on March 10, 2016 by Jim Koewler — No Comments ↓

Perhaps, the most well known device that helps aging adults stay in their homes is the pendant monitor. (If you’re old enough, you remember “I’ve fallen, and I can’t get up.) The older adult wears the pendant. If he or she falls, the pendant has a button to push that allows the person to talk to a base receiver in the home. (Push the button, and talk is much like a walkie-talkie.) As the older adult talks into the pendant (well, actually, talks into the air and the pendant picks it up,) the pendant sends the message to the base. The base is connected to the phone line (or to a cell number, if the house doesn’t have a land line.) When the senior pushes the button on the pendant, the base places a phone call to a designated monitoring service. The monitor will hear what the senior says “into” the pendant and can initiate a response, like calling an ambulance, for instance. The monitor can also speak to the older adult through the pendant, keeping him or her up to date on what is happening. (It’s kind of like GM’s On Star system that way.)

Of course, if the older adult suffers from some form of cognitive impairment, he or she may not remember to use the pendant to summon help. (I worked with a family in the past in which the mother’s ability to remember her pendant was a big issue among the adult children.) A pendant isn’t much good when the wearer doesn’t remember to use it. Likewise, a pendant isn’t much help if a fall knocks the person unconscious and incapable of pressing the button. To avoid these problems, there are pendants now available that detect when the wearer has fallen. The pendant will call the base itself if it detects a fall. (Unfortunately, these systems sometimes detect a fall when the person has not, in fact, fallen.)

With the availability of security cameras and video feeds over the internet, adult children can keep an eye on aging parents from their computers. With one or two cameras, children can check whether their parent is moving around the house. With a number of cameras, children can keep an eye on their parent anywhere in or around the house.

In addition, if the parent has a cell phone or something else that he or she keeps close all the time, the children can attach a gps locator, allowing the children to check the parent’s location at all times. While gps locators may not be sensitive enough to follow movements in the house, they are useful to find the aging adult if he or she has wandered away from the house. (If the parent has a medical monitoring pendant, a gps locator may be attached to it.)

If the aging adult lives in a “smart house” (or in a house that can be updated with smart technology, the house’s technology may be used to keep the adult safe. Smart houses can often monitor for a stove left on too long. The can monitor the temperature inside the home (to make sure the aging adult isn’t living in an overly cold or overly hot house.) Motion detectors can check whether the parent is moving around. Contact switches can monitor doors to see if they’ve been opened.

New technology can be used to help keep an aging parent home. To be fair, the technology is more reactive than proactive. The technology allows a monitoring company or the family to respond more quickly to a problem or to an usual behavior pattern. The technology won’t get the aging adult up and out of bed. It can, however, let family know when the parent is staying in bed overly long (possibly indicating a problem.) Technology allows the aging parent to stay in his or her home longer by making the family less scared of emergencies.

I want to Stay in my Home – In-home Care

Posted on March 3, 2016 by Jim Koewler — No Comments ↓

When an older adult is no longer able to perform the routine daily tasks that he or she could easily perform when younger, it is time to consider how to help the older adult. The routine daily tasks that people who work with seniors usually considers are:

bathing,
grooming,
toileting (including bladder and bowel control and cleaning up afterward,)
moving around (often broken down into “transferring,” meaning the ability to get into and out of bed or a chair, and “ambulating,” meaning the ability to walk around,)
eating (not cooking, but the actual ability to put food into one’s mouth,) and
dressing.

These “activities of daily living” or ADLs are crucial in allowing someone to maintain health and hygiene. When someone has trouble carrying out one or more of these activities, it is time to figure out how the family can make sure that the senior gets help performing them.

Someone who is trying to stay in his or her home but is having difficulties with one or more activities of daily living can hire help. Professional caregivers are available who will help someone with these activities. Such caregivers can be found through a commercial home care agency, and there are many such agencies. Such caregivers can also be hired directly by the aging senior or by his or her family.

Commercial home care companies can be expected to provide oversight of the caregivers as well as to manage the business relationship with the caregiver. The caregiver should be an employee of the company, so the company handles insurance, bonding, payroll, taxes, and accident liability. The actual person who acts as caregiver may change from time to time. Commercial home care companies are currently watching a Department of Labor proposal that would force higher pay for the caregivers because of the application of rules on length of the work day and overtime pay.

When the older adult or family hires the caregiver directly, the adult or family must manage payroll and taxes. The adult and family takes the risk that the caregiver is not up to the task of providing care or is not trustworthy. Admittedly, many (maybe even most) directly hired caregivers are friends (especially church friends) willing to help out. In addition, much of the pay for directly hired caregivers is done “under the table,” without proper tax and payroll compliance. (I cannot recommend such an evasion of tax and labor laws.)

For some older adults, the Medicaid program and/or the Veterans Administration’s Pension (more commonly called Aid and Attendance) program can help pay for such home care services.

Please note, despite what TV shows and literature, these home caregivers are rarely nurses. They may be most often called home health aides. Nurses provide medical care (in the way that “medical” is used by hospitals, doctors, and health insurance companies.) Home health aides provide more personal care or “custodial” care. Nurses in the home are more highly paid priced than aides, but their costs are usually covered by Medicare and health insurance. Home health aides are paid less than nurses and are rarely covered by insurance (other than long term care insurance.)

(As an aside, I try to call nursing services “skilled care” and call home health aides “non-skilled care.” I do not want to imply that home health aides are not skilled. They are great! Often, people who work with seniors call them “medical home care” and “non-medical home care.” I try to avoid the “non-medical” label because of the rules for VA Pension.

The VA Pension program covers “medical” costs for certain veterans and surviving spouses of certain veterans. The rules for VA Pension defines “medical” costs in a way that includes the services of home health aides. Some of my friends who help with VA Pension applications have encountered difficulties with the review of applications if the home care provider describes itself as a “non-medical” provider. (This description has most often been in the letterhead of the care provider. The VA sees the letterhead because the paid care provider must provide a letter explaining the services that it provides or the Pension applicant.) A reference to “non-skilled” care does not seem to trigger the same difficulties in the application process.)

If the older adult has funds available to pay for home care services and is willing to accept a “stranger” coming to the house, home care support can allow the older adult to stay in his or her home.