Caring for aging parents replaces childcare as the top workplace concern.
Napa resident Suzanne Shiff is confident that her 81-year-old mother is comfortable and safe while living independently in her Arizona home. “I believe seniors should stay in their homes as long as possible,” says Shiff. “To be proactive, I bought her a two-bedroom, single-story townhome. Using the principles of universal design [a concept that makes a product or environment usable to the largest number of people, often those with disabilities], I had the tub replaced with a step-in shower and installed grab bars. The second bedroom will be useful if she ever needs full-time care. I know her neighbors and emergency contacts. My brother, who lives nearby, checks on her frequently and phones her every day.”
As the former director for the Public Authority In-Home Support Services (PAISS) in Napa County, Shiff knows the importance of planning. “My role [at PAISS] was to match low-income recipients of In-Home Support services—a county, state and federally funded program—with home care. People with older parents should have a conversation with them to create a plan. Is the parents’ home accessible, or can the downstairs be converted to include their bedroom with an accessible bath? They should become familiar with their city’s social services and agencies in case something happens and create a support system of family and friends.”
Who will care for me?
Most people don’t have Shiff’s foresight or knowledge—or they might simply be in denial.
“What people don’t realize is that, eventually, we’re all going to have to face this—and they keep putting it off,” says Yvonne Baginski, who has 25 years’ experience with senior advocacy issues and is the owner and publisher of Born to Age senior care directories. “Aging people often don’t self-identify as being seniors or needing help. In addition, they’re afraid of becoming vulnerable and dependent on others.”
Baginski says a lot of these fears are based on outdated notions.
“About 10 to 15 years ago, nursing homes were places where people went for long-term care. Nowadays, half the people who go into nursing homes are discharged; they’re considered rehab facilities.”
While nursing homes now are used for short-term physical rehabilitation for ailments such as a broken hip, there has been a rise in what’s known as assisted living communities, which offer a range of services from medication reminders to physical assistance in a community living situation. But Baginski says there’s usually no need to rush an elder into that environment.
“Often people start off needing just a little bit of help at home. You know what the most common need is? A ride to the doctor or someone to take out the garbage cans. Find people you can rely on and trust. Find ways to bring in some support so they can stay in their home longer.”
A little help, please
If it becomes necessary to move a parent into a long-term care facility, it’s helpful to understand the different terms. In the North Bay, the three most common types of assisted living communities are senior apartments that provide meals; assisted living communities (licensed as residential care facilities for the elderly, or RCFE) that have more levels of care and may accept Alzheimer’s or dementia patients; and board and care homes, which are small homes located in residential neighborhoods, usually with six or so beds.
John Zikmund is executive director of Avalon at Sonoma, an RCFE that opened in October 2005.
“There are varying levels of care,” says Zikmund. “The idea is to have people age in place, so they may come in needing just a little help, like medication management, then as time goes on and they need more assistance, they’re already here. The goal is to provide a social atmosphere as well as care for people and help them have the best quality of life during this period of their life.”
Zikmund explains that seniors may have difficulty adjusting to the new surroundings of an assisted living community. “Change is never easy because, oftentimes, they’re coming from a large home into a smaller space. It appears to them that they’re giving up independence when, in actuality, we’re creating more independence for them because we’re taking away the concerns of what they have to do on a day-to-day basis. All they have to worry about is enjoying life as much as possible.”
He has advice for those considering placing their parents in an assisted living community. “There’s a different place that’s right for everybody. What social activities are going on? Food is immensely important to seniors because a good portion of their day revolves around going to their meals. Without a doubt, try the meals a couple of times. Talk to residents. How’s the overall cleanliness? Is the staff friendly and pleasant? I tell my staff it’s fine to have a beautiful place, you can build that, but it’s the heart inside that matters most.”
Do you care?
A 2006 joint study by the MetLife Mature Market Institute and the National Alliance for Caregiving found the annual costs to employers for caregiving-related expenses totals $33.6 billion annually and include absenteeism, replacing employees and workday interruptions.
“Eldercare has replaced childcare as one of the top workplace concerns for employers and employees,” says gerontologist Michele Boudinot, geriatric care manager of North Bay Eldercare Options. “Finding time to handle this care can be overwhelming for adult children, who often have a working spouse and children of their own, demanding careers and numerous other obligations. Eldercare choices are complex and services are quite fragmented; it can be really stressful and time-consuming to figure out what to do and how and when to do it. Misguided choices can have very adverse
consequences for the parents.”
What is a geriatric care manager? “Private, professional geriatric care managers are, generally, registered nurses and licensed social workers with specialized training in geriatrics, or gerontologists with advanced degrees,” says Boudinot. “They typically charge from $80 to $150 an hour, however, after the initial assessment and care plan is implemented, periodic monitoring is usually all that’s needed to keep things moving along smoothly.
“Professional advice can actually save money in the long run by helping prevent costly mistakes such as inappropriate placement or a bad home care situation,” she continues.
“But one of the most important benefits is the peace of mind that comes from knowing a caring and competent professional is monitoring the situation. This frees up the adult children to spend their valuable time actually visiting with their parents rather than getting bogged down in handling the details.”
Professional geriatric care managers look at the whole picture, explains Boudinot, including environment, function level, social, emotional, legal, financial, cultural, nutritional, hydration, even spiritual needs and caregiver stress. “We help the elder function at the highest level possible and help them find pleasure and purpose in their remaining years. Everyone benefits.”
According to Boudinot, there are many caregiver options to sort through and match to a family’s specific circumstances. “Medicare-certified home healthcare agencies for doctor-ordered, short-term skilled care; private duty home care agencies that supply caregivers for companion, personal or skilled care—these agencies act as employers and are responsible for taxes and deductions. Hourly, shift or live-in caregivers can either be independent contractors or employed by the family. This can be less costly, but families need to know about the liability pros and cons, tax issues and other considerations.”
A recent AARP survey (“The Costs of Long-Term Care: Public Perceptions Versus Reality in 2006”) indicated that 63 percent of those polled underestimated long-term care costs.
“In the North Bay, four hours of home care per day, three times a week, will run from $7,500 to $16,250 annually,” says Boudinot. “Round-the-clock, in-home care can range from around $50,000 to $200,000; assisted living in both small, board-and-care homes and larger assisted living communities can run from $28,000 to $78,000; skilled nursing can cost $42,000 to $120,000 a year and range from rooms with up to five beds to private accommodations. And very low-income folks may qualify for In-Home Support Services (IHSS), which provides basic and minimal assistance to frail older adults.
“Continuing care retirement communities and Life Care communities offer a continuum of care as your needs change, but they can also involve considerable buy-in and monthly rental fees. Prices for a unit in a continuing care facility can range from $265,000 to $1.5 million, with monthly fees from $2,200 to $4,000.” Granted, that’s a lot of money, but some continuing care facilities sell their units then allow the resident (or resident’s heirs) to keep the equity when the unit is sold again due to death or failing health (many continuing care facilities don’t provide skilled nursing or dementia care).
“Only facilities designated as ‘Life Care’ must provide for all levels of care for the duration of the resident’s life, from independent and assisted living levels up to skilled nursing and hospice care. Entrance fees range from $65,000 to $650,000, and monthly fees from $2,350 to $4,000. When only minimal care is needed, dependent living retirement facilities can provide meals and basic housekeeping services from about $1,950 a month and up.”
Confused yet? “The important thing to remember when considering any type of long-term care is there’s a huge range of quality, cost and preferences. Be sure to read the fine print and have significant contracts reviewed by an elder law attorney,” Boudinot says.
The financial burden of aging
Joe Fischer is the owner of Fischer Financial Partners in Napa. “We specialize in working with business owners to build wealth, but we also look at risks,” says Fischer. “Long-term health is one of the risks we focus on. When people in their late 30s and early 40s come to us, one of the things we ask about is their parents. If either of your parents were to become ill, would they be able to take care of themselves? If not, who will do it?”
There are several alternatives to pay for long-term care, Fischer continues. “People can buy long-term care insurance. I, personally, feel a properly designed long-term care contract is a good investment. But all long-term care insurance contracts aren’t the same. Consumers need to be mindful of the different provisions and make sure they get what they want.
“What we find is that most people have a significant amount of wealth tied up in the equity of their home. One alternative, if one partner has to go into long-term care and they’ve drained their assets, is a reverse mortgage.”
Another more controversial manner of financing is “MediCal Planning.”
“Some people consider MediCal planning—getting long-term care paid by the government and keeping the residual wealth for the heirs—morally wrong,” says Fischer. “And it’s not something I advocate. Aside from the financial issues, there’s the question of care for the individual. MediCal slots [the number of beds available to MediCal patients] are very difficult to find, and some people may not be happy with the accommodations—although I commend providers who participate in the program. They’re caring individuals who do everything in their power to create the best environment they can.”
Insuring your care
Let’s look at a couple of financing options for paying for long-term care, long-term care insurance and reverse mortgages.
Ed Ritch, senior partner at Ritch Insurance Services in Santa Rosa, says, “Long-term care insurance is about protecting a person’s dignity. Asset protection hasn’t been as big an issue as the ability to stay in the home environment and have quality care.”
There have been a lot of changes over the years, says Ritch. For example, some older policies didn’t have a home care provision, and had short benefit periods. Many required a hospital stay before benefits began.
“The new policies are much broader. They’re pricier because of it, but you can design with a lot of leeway as far as definitions go. Some companies will allow zero-day elimination, which means there is no waiting period before benefits begin, or a specific waiting period before coverage kicks in; a lot of times, people will opt for a 90-day waiting period. The longer the period, the lower the premium.”
The younger the insurance applicant, the lower the premiums, and Ritch says he’s started to field a lot of inquiries about long-term care policies from people in their 50s.
“That’s an age range where you can design a ‘Cadillac plan’ that’s affordable for most folks. Take that same individual at 70 years old, and we often have to reduce the contract to fit the budget.”
But if an individual is 50 now and doesn’t use the plan for 25 years, won’t health care solutions have changed? “I don’t think it’s appropriate to hold off on long-term care insurance because we don’t know what the future will bring,” says Ritch. “I doubt it’ll get easier or better. What’s changing is that the bigger companies are coming in [to long-term care insurance] now. You want to deal with a larger company because you want them to be around longer than you.”
Reversing isn’t going backward
“A reverse mortgage is a unique type of home loan that lets an older homeowner [aged 62 and above] turn home equity into cash without having to leave their home or make regular loan repayments,” explains Jeff Taylor, vice president of the Senior Products Group for Wells Fargo Home Mortgage.
“There are four ‘nevers,’” says Taylor of reverse mortgages. “You never have to make a monthly payment. You never relinquish title or ownership of your house. You’ll never owe more than the value of your home at death, sale or move-out; and there are no restrictions on how the tax-free proceeds can be used.”
After death, an estate has an initial six-month period to satisfy the reverse mortgage debt, followed by the potential for two 90-day extensions pending HUD approval.
An FHA-insured Home Equity Conversion Mortgage (HECM) is capped on the maximum FHA lending limit by county. “The maximum lending limit of $362,790 remains the FHA lending limit on the HECM for Marin, Sonoma and Napa counties,” says Taylor. “If a 70-year-old has a home valued at $362,790, they could get 62.7 percent of that at what we call a ‘principle limit’ of $227,469. The interest rates change every week. If it was a $700,000 house, they can still only get $227,469 because of the FHA lending limit.”
Taylor admits the reverse mortgage isn’t right for everyone. “If a senior doesn’t intend to remain in the home for two or more years, I would recommend they look for other options. First of all, as with any mortgage, there are closing costs and origination fees, and there’s a mortgage insurance premium that’s paid to the FHA. That premium is what guarantees seniors they’ll never owe more than the value of their house.”
When the family can’t agree
Elder law attorneys specialize in legal analysis, planning for incapacity, drafting legal instruments such as health care directives and powers of attorney, establishing trusts, and in meeting client goals such as preserving and protecting assets, paying for long-term care and finding public and private health insurance. They also represent clients in court conservatorship proceedings.
“Clients typically seek advice on such questions as designating a trusted agent to make financial decisions, preserving assets and meeting housing and health needs with dignity and autonomy,” says attorney Lenore Ellen Gerard of Gaw Van Male counselors at law, which has offices in Napa, Solano and San Bernardino counties.
Sometimes, a conservator is needed to manage assets and care. “When there are no prior legal instruments or when misuse or mistrust is involved, the matter may be brought to court,” explains Gerard. “A conservatorship is a protective court proceeding. There are two types. In a conservatorship of the person, a court-appointed fiduciary, or conservator, steps in to manage the care of someone who’s been determined unable to properly provide for his or her own personal needs. In a conservatorship of the estate, a court-appointed conservator manages the financial affairs of a person who is unable to manage his or her own resources or who is unable to resist fraud or undue influence.
“A diagram of financing and paying for long-term care looks like a patchwork quilt. It’s comprised of out-of-pocket payments from elders or their adult children; private health insurance; and federal, state and local sources from many different programs. The complexity of piecing together various programs—each with different criteria and funding sources—can be like a puzzle. Seeking professional advice can make a big difference.”
Ultimately, it’s all about quality of life. Investment adviser Fischer says the most important thing is to face the truth. “Doesn’t it make sense to sit down and figure out how you want to live the rest of your life?” he asks. “You want to be in an environment that you choose. It’s inevitable, after all. It’s funny how many times I have people come in and say, “Now, if I die….’ Take care of yourself and take care of your family. Figure it out and take action. It’s gut-wrenching for your family if you don’t.”
Eldercare Resources
There are many local and national resources for seniors. For more information:
• Council on Aging for Seniors in Sonoma County
730 Bennett Valley Road
Santa Rosa, Calif.
(707) 525-0143 or (800) 675-0143
www.councilonaging.com
• Division of Aging, Marin
10 North San Pedro Road, Suite 1012
San Rafael, Calif.
(415) 499-7396
www.co.marin.ca.us/aging
• Area Agency on Aging, Napa and Solano Counties
601 Sacramento Street, Suite 1400
Vallejo, Calif.
(707) 644-6612
www.aans.org
• Born to Age Senior Care Directories in Napa and Sonoma
(707) 226-7127
www.borntoage.com
• Ombudsman Service of Northern California, for complaint investigation, resolution and monitoring in long-term care facilities
(800) 644-4194
• AARP
www.aarp.org
• The National Academy of Elder Law Attorneys
www.naela.com
• Elder Law Answers
www.elderlawanswers.com
• The California Partnership for Long-Term Care
www.dhs.ca.gov/cpltc
• California Assisted Living Association
www.caassistedliving.org
