Concierge Physicians charge an annual fee (around $1,500 per year) to the patient, enabling the doctor to reduce their practice from about 2,000 patients to 500 patients. Now the doctor can be available for their patients who need to be seen right away, can take time to visit patients in the hospital and if needed, be on call 24 hours. Best of all, they can really spend quality time with their patients.

As a care manager, I offer this high level of service and I can do it because I do not have hundreds of clients. I appreciate the opportunity to work with concierge doctors who are available to the patients we have in common, immediately. If I visit a client and find that their new medication is making them sick, I want to have instant access to their doctor. I do not want to hear, ” Go to the emergency room”, like so many doctors now say to their patients.

In a perfect world, we would all have immediate access to our doctors. But in this world, if you want or need VIP treatment, you can have it, for the cost of one Starbucks coffee a day. If you do not think it is worth it now, wait until Medicare cuts physician billing AGAIN and they have to take on even more patients to make up the difference.

Many people think it should not be necessary to pay for extra service, but we do it all the time. We pay more for the box seats at the concert, we pay more for an upgraded hotel suite. We pay more for first class seats on a plane. If you feel you want upgraded medical care, it is now available and I feel, well worth it, especially if you have chronic medical conditions.

1) The only illegal aliens who receive Medicaid are those in the hospital ( coming through the emergency room), those remaining in the hospital due to brain injury or trauma, infants, pregnant mothers and frail elderly who are in nursing homes and have lived in the country documented for over five years. If they are illegal, documentation is often impossible to get, so this happens rarely. Every other illegal person who needs medical attention IS TURNED AWAY.

2) Medicare is a ” Public Option” for our aged citizens. They do not have to accept Medicare. They can keep paying for and using another private insurance. Most people choose their public option and then buy a supplemental policy to pay for what the government will not cover, or they pay out of pocket for those “extra” or “luxury” services. Medicare is for every senior regardless of income or assets. Our government, at the risk of seeming like a socialist entity decided to ensure that every elderly person had some basic coverage because they knew most people would not save for their own medical expenses. How much have you saved for your golden years?

3) Social Security is another socialistist government intervention initiated by a wise President who knew that unless the general public were forced to save for retirement, they wouldn’t do it or would not put away enough. Have you saved enough for your retirement?

4) A Public Option is an alternative for many hard working Americans who cannot afford health insurance, not even an HMO or who may have a pre-existing condition rendering them ineligible for insurance. Why is it that only the very poor, very young or very old in this country are allowed to partake in a government health care program? And yet it is the poorest and oldest people I know who are ranting against equal health care for all. All Americans deserve the option to have the most basic level of medical care. If we want more than the basics, we can pay for them. That is how Medicare and Medicaid work.

5) Some actually believe that there is not enough money in this country for Medicare, Medicaid and Social Security. To that I say only one word: NASA! We have billions, not millions, billions to invest in blowing up part of the moon to look for water, research on Mars and another planned moon walk. This country has a priority problem, not a money problem. We have a lobbist problem and a lawsuit problem and yes, an insurance problem. Allowing the health insurance lobby to become so powerful, our doctors to feel they are the elite and the lawyers to sue doctors and hospitals ad nausium, is a problem. Please do not worry this country will become socialist or communist. That would mean all citizens are seen as equals and there is no chance of that happening any time soon.

6) You can be a capitalist and still be your brother’s keeper. As a for -profit business owner, I charge for the health care consulting I do. That said, I have so many poor, pro bono clients that I formed a non- profit corporation to care for them and raise money for them. If every successfull capitalist started even a modest non- profit company to care for the less fortunate or those who are elderly and have no family support, they would be doing their part. We can all do our part and together help our communities. Visit www.EQOLPalmBeach.com  to learn more about what I am doing. Let’s loose the lables: republican, democrat, socialist, capitalist and just be citizens and take responsibility for ourselves and a few others

Prosecuting these crimes is difficult for the State Attorney because of how it is done. In my career as a Professional Geriatric Care Manager in South Florida I have noticed a definite step-by-step process, almost a formula, that these Exploiters use to separate elders from their life savings. In many cases the Exploiter actually gets permission from the elder to take their money. Because of this, it can be argued that the elder “allowed” their assets to be taken and therefore, no crime took place. Furthermore, to argue that an elder was easily influenced by the Exploiter is to imply that the elder is incompetent and perhaps should not be in control of any of their finances. Few elders want to admit that. Instead they justify the theft or even cover it up. Once the elder realizes that they have been victimized, they may feel responsible, guilty or embarrassed. Few will testify against the one who stole from them.

When we think of someone who steals from the elderly, we conjure an image of the stranger lurking around the ATM machine or scam artist selling bogus products. Since Investment Broker, Bernard Madoff ”made off’ with his client’s millions, we have all become familiar with the term “ponzischeme”. But this type of financial exploitation is rare compared to the financial exploitation elder care professionals see every day which is perpetrated by an elderly person’s friends, family and caregivers. In cases I have worked I have seen that THIS type of exploitation achieved slowly, purposely and in FIVE PREDICTABLE STEPS. It is often done so artfully, that the elder and others around them see it happening but cannot believe it is true. They ignore all the small telltales signs. When the situation finally explodes, the FIVE STEPS are then seen as clear as day. By then it may be too late to do anything about it.

Here are the STEPs. Learn to recognize them and you may prevent this horrible crime from happening to yourself or someone you care about.

STEP ONE: The Exploiter comes to the rescue – they become a caregiver or helpmate when the person suffers a crisis. They may do extra favors for the elder without pay and refuse to take payment even when offered…at first. The Exploiter will later remind the elder of the favors and cause them to feel indebted to them.

STEP TWO: The Exploiter convinces the elder that they are the only one who cares about their welfare. The elder is brainwashed to believe that the true family only wants their money.

STEP THREE: The Exploiter separates the elder emotionally and physically from their family. They bring in their own family to be the “replacement family”. Next they tell the elder they are like family to them. The Exploiter may even start to call the elder ” Mom” or “Dad”. They may deny the true family access to calling or visiting the elder and cause others in the community to regard the true family as exploiters. The elder may never know about all the family’s attempts to reach them.

STEP FOUR: The Exploiter gets permission to use the elder’s credit card, ATM card or other money for a small purchase. Then they continue to use the elder’s assets and transfer assets little by little to their own account or distribute assets among the Exploiter’s family members. The Exploiter may shop for the elder but purchase items for themselves as well. They may take the elder out to dinner but also invite their whole family and have the elder pay for it. When the Exploiter’s car needs repair or gas, the elder is asked to pay for since that car is used to shop or transport the elder. The elder will feel they have no choice but to agree.

STEP FIVE: Finally, the Exploiter will attempt to take legal control over the person. They may become Power of Attorney, change the Will to disinherit the family and bequeath assets to themself and or their family. A few years ago, I had a case where an attorney changed the Will of a confused dying woman to give her home and assets to an aide whom she had only known for two years. This was especially heinous because that lawyer had previously written the Will for the family and knew that the heirs existed. This family fought the caregiver in court and had to settle for about one tenth of their original estate. I testified against the the attorney and he has tried to retaliate against me several times since. A few weeks ago I testified in a case where a caregiver in her forties married a ninety- four year old man. She was previously his maid for about two years. She had a notary perform the ceremony in their living room while her children served as witnesses. This act automatically disinherited the elderly man’s entire family. The marriage was challenged and annulled. The elderly man was deemed incompetent by a court of law and assigned a guardian of his assets.

The secret weapon these perpetrators use is LOVE, ATTENTION, FAMILY- LIKE CONNECTION and even SEX…all the things human beings need but may not get once they are aged. In South Florida, many seniors retire to this area only to find themselves thousands of miles from their original family when they need them the most. This isolation creates a dangerous opportunity for exploiters.

If someone you love has a person in their life, be it friend, family, caregiver, or even a trusted professional and you feel they are taking over that person’s finances, lifestyle and even thought processes, get professional help! Contact a professional such as a Geriatric Care Manager or an Elder Law attorney and make sure someone contacts Adult Protective Services. The reality is that the police and State Attorney’s office will need you to practically build the case for them in order for them to prosecute. The evidence may need to be gathered secretly in order not to cause the Exploiter to quickly move to STEP FIVE. Most importantly, take action immediately. Know that the elder will feel you are meddling and taking over. They will not thank you for this because they have already been convinced that the Exploiter has somehow earned their loyalty and their money. Act anyway because it is the right thing to do.

Take the case of Janet. She has spent the last fourteen years rising through the ranks of her company. She is known for her expertise and dedicated work ethic. When Janet’s mother first moved in with Janet and her family, everything seemed manageable. Janet’s staff and supervisors listened with compassion as she explained that she would need to take an afternoon off in order to bring her mother to the doctor. Six months later, the doctor appointments are more frequent and her supervisors’ compassion is waning. Her staff cannot help but notice all the personal phone calls she is receiving. It is apparent that others are beginning to question her commitment to her job. Her husband is also questioning her commitment. He is disappointed that Janet cancelled the family vacation for the second time. Janet cannot commit to a new vacation date because “Mom shouldn’t be alone right now”. To make matters worse, Janet is feeling resentment towards her siblings who live out of state. They are not available to help, yet they expect to be consulted on matters concerning Mom. The latest affront came last week when Janet’s brother called to ask for a financial accounting of their mother’s funds. Janet felt as though he was questioning her honesty and they had an argument. This upset Janet and her husband and then they had an argument.

Janet can see the problems are about to escalate and she is afraid she may lose her job and her marriage. She does not know where to turn. She promised her mother she would never put her in a nursing home but she is wondering if that is a promise she can keep. Janet called a local nursing agency and was shocked to learn that it would cost over sixty dollars per day to have an aide stay with her mother during the day. Her mother’s meager social security check would not even cover the cost. At this point, Janet is afraid to tell her husband that she must now help pay for her mother’s caregivers.

Thousands of employees are struggling with the issue of balancing family life, work life and caregiver responsibilities. Some of them lose their jobs because they simply cannot solve the problems of care giving without neglecting other important areas of their lives. Geriatric Care Managers specialize in consulting with elders and their families. First the Care Manager assesses the situation from a medical, social, psychological, financial, legal, government benefit, insurance and environmental perspective, so a Care Plan can be presented to the family. The Care Plan offers solutions to address the immediate needs but also anticipate the future needs.

Even if a family knows about the traditional community resources such as Assisted Living Facilities, Day Care, or Home Health Care, they often do not realize how much these services can cost. More importantly, families are not told about free programs and financial aid programs such as Veteran Special Pensions and Medicaid Diversion which could really make services affordable. Many elders and their families pay huge sums for services they never knew were available for free or at a discount. Families expect that hospital social workers, doctors and other health care workers will educate them about any appropriate programs. Sadly, many health care professionals are unaware of these programs or falsely assume that financial aide is only for the indigent. Geriatric Care Managers can determine which solutions are appropriate, access affordable or free services when possible and help elders and their concerned families plan for their future needs. The financial aspect is just as important as the medical aspect. While Geriatric Care Management services like these usually cost an hourly fee, most families find the information they receive saves them thousands of dollars. Of course, if the Care Manager can help a caregiver better balance their work, family and caregiver responsibilities, the value is priceless.

As it turns out, employees who are caring for an aging family member find that successfully managing the role of caregiver is much like managing a company. All of the “work” of caring for an elder must be broken down into separate tasks. The caregiver must see themselves as the manager and outsource and/or delegate any tasks that can be done by others. Your Employee Assistance Program can refer you to Geriatric Care Management consultants for professional advice and trustworthy, time-saving services. With the right help you can care for your aging loved ones and still maintain balance at home and at work.

The mere fact that nursing home care now costs over $60,000 per year explains why even middle income families must learn about Medicaid when someone they love needs a nursing home. Many American families have much less than $60,000 put away for a rainy day. In just one year, a life savings can be forever depleted. Many families are under the misconception that they must spend all their money BEFORE they can get Medicaid. In many cases, this is simply not true. ICP Medicaid (Institutional Care Program Medicaid) can be approved for nursing home residents who have assets, as long as the application has been done properly and the assets are titled and managed according to the rules. Hiring a professional Medicaid consultant such as a Geriatric Care Manager or Elder Law Attorney to assist with Medicaid Planning and Application is no different than hiring a good accountant to help you pay fewer taxes. What is the difference between a skilled Geriatric Care Manager and an Attorney when filing for Medicaid? About $300 per hour.

On February 8, 2006, President Bush signed into law the Deficit Reduction Act of 2005 which is a Federal attempt to eliminate many previously used techniques for sheltering assets for Medicaid applicants. The law is now under fire and may eventually be declared un-constitutional. In the meantime, Floridians are expecting to have to adopt the new rules as of October 2006. The new rules eliminate many opportunities for unmarried applicants to shelter some assets but married applicants will still be able to shelter almost any amount of money.

As the Medicaid eligibility criteria tighten, denials for Medicaid are on the increase. Some Geriatric Care Managers and Attorneys who specialize in Elder Law are helping families get qualified while protecting some assets. The simple truth is that ICP Medicaid has become difficult to get without professional help. Families who try on their own and fail, must then pay private fees to the nursing home for the months they were denied. In the State of Florida, that is at least a $5,000 mistake.

Basic Medicaid Eligibility
Medicaid Eligibility is based on several basic criteria: Monthly income must be under the limit of $1,869. Assets must be under the limit of $2,000 or less for unmarried applicants and $101,640 for married couple (with one person in a nursing home). If both spouses live in a nursing home they can only have $3,000. The applicant must medically require nursing home care. The applicant must not have given away any assets within the last five years.

INCOME
A single applicant who lives in a nursing home is allowed to have up to $1,806/ month in gross income. If they have more than $1,869, they can still get ICP Medicaid as long as they pledge their entire income (except $35) to pay the nursing home or other health care expenses. This pledge is made in the form of a Qualified Income Only Trust. As long as the amount of income which is over $1,869 is deposited into the Income Trust and then paid to the nursing home, the applicant can remain Medicaid eligible. If any money is left in the Income Trust upon the death of the Medicaid recipient, it must be turned over to the State of Florida, not the heirs.

ASSETS
A single applicant may have up to $2,000 plus a house and in some cases investment properties, businesses, IRAs, life insurance, life insurance and other assets. The positioning, titleing and on-going management of these assets is critical. If not managed properly, these potentially “allowable assets” can cause an applicant to be denied or to have the Medicaid withdrawn after it had been approved.

IT PAYS TO STAY MARRIED
A married couple (with only one spouse living in a nursing home) technically is only allowed to have $101,640. However, with proper Medicaid Planning, a married couple should be able to keep any amount of assets. Why is this possible? Because in Florida, we believe a person should not become impoverished just because their spouse becomes ill and requires nursing home care. There is absolutely NO REASON TO GET A DIVORCE FOR THE PURPOSES OF MEDICAID QUALIFICATION. Any professional who recommends this option to a happily married couple is doing them an unnecessary injustice.

GIFTING:
After October 2006, gifting of any kind (including adding someone to the title of your home or donating to a church) will result in Medicaid ineligibility. The “look back” period is now 5 years which means all gifts over the last five years will be totaled and divided by 5,000. The result of this equation is the number of months an applicant will be unable to get Medicaid once they move into a nursing home. This is called the “In-eligibility Period”. The applicant will have to pay monthly rate to the nursing home out of pocket and cover all other medical costs not covered by insurance during this period. For some people, the nursing home fees plus medications and therapies total more than $10,000 per month.

EXAMPLE: A grandfather who gave up driving 4 ½ years ago gave his car, then worth $8,000 to his grandson. The grandfather now needs to live in a nursing home so he applies for Medicaid because he had no assets. The State can look back at that gift of a car which was worth $8,000 and divide that by 5000. The result is 1.6 months. That is how many months this grandfather will have to pay the nursing home before he can go on the Medicaid program. If the nursing home is charging $5,000/ month, the grandfather will pay $8,000 to the nursing home because he gave away an $8,000 car 4 ½ years ago. What if the grandfather does not have $8,000? The nursing home cannot evict someone without providing a safe discharge so they may have to keep him at no charge. For this reason, many have nicknamed the Deficit Reduction Act of 2005 the “Nursing Home Bankruptcy Act of 2006”.

PROPER PLANNING CAN AVOID COSTLY DENIALS
Now that the “look back” period is up to 5 years, the need for Medicaid education and pre-planning is more important than ever before. Because under the new law the penalties for un-approved gifting and title transfers are now being counted from the time the applicant enters a nursing home, the impact of these penalties is greater than ever before. But if families are willing to look at their future healthcare and financial needs, they can avoid costly mistakes. Many Accountants and Financial Planners who serve families with assets, are not knowledgeable about the specialty of Medicaid Planning. Frankly, many techniques they may employ to help families save on estate taxes are absolutely counterproductive to Medicaid eligibility. These well meaning professionals leap to the assumption that their well-healed clients will never need a welfare program. Well, now that nursing home stays cost over $60,000 per year, even middle income families need to know about Medicaid Planning.

Everyone seems to have an opinion about what is best, but sometimes these opinions conflict. The doctor wants to send the patient home. The  hospital social worker is arranging for nursing home or assisted living facilities to do an assessment for possible placement or rehabilitation. Your parents may be rejecting the idea of hiring a home health aide. Who will be your parents’ unbiased advocate? Even if concerned children rush to their parents’ hospital bedside, how will they know all of their options and most importantly, what these options will cost?  Geriatric Care Managers are professional elder care consultants hired by families to represent their interests and only their interests. A legitimate Care Manager takes no referral fees from any company or facility to whom they make a referral. They are paid by the patient to have an unbiased interest in seeing that the patient’s needs are met.

It is common today for people to leave the family home town and retire in resort areas like Florida and Arizona. The problem comes ten to twenty years later. The now aged parents have needs, but their children are living far away. The first time the kids hop a plane to respond to a family emergency, it is no problem. When the problems escalate and that child is now taking significant time away from work and family to assist their parents, the situation can become critical. As a Care Manager I have met many couples whose marriages are strained by caregiver duties. Not only are their marriages strained, their wallets are strained. Most are unaware of financial programs which may help offset expensive health care costs. When costly services are needed, families need to know what is a reasonable amount to pay. Children who care enough help their elderly parents often find it is not easy. Depression Era parents sometimes distrust their children when it comes to financial and medical decision making. They either think of them like an eleven year old or have negative opinions about the way their children have spent money in the past. Either way, the concerned children can be dismayed to find that their parents will listen to the advice of a stranger rather than the advice of their own family. Care Managers can be that concerned outsider whose expert advice will be heeded.

A Classic Example:
Rose and Morris were married nearly sixty years and their mindset was shaped by the Great Depression. In their day, it was inappropriate to tell their children how much they earned or saved. When Rose entered a nursing home, Morris was uncomfortable with his daughter’s attempts to get involved in the financial discussions. Once he learned that Rose would have to stay in the nursing home, he knew he would need help applying for Medicaid. Once his daughter found a Geriatric Care Manager who seemed to “know her stuff” he let his new team help him. The Care Manager and the daughter worked together to gather all the financial documents. They worked within the Medicaid guidelines to shelter a little money and apply for his Veteran benefits. Because of the extra financial assistance, Morris was able to maintain his standard of living. The Care Manager thoroughly assessed their medical, social, financial, insurance and housing needs, and was able to help Rose and Morris maximize their finances to provide the best possible quality of life for both of them. Their daughter was able to return to New York and sleep well at night knowing she had a Care Manager to be her partner in the care of her parents. The Care Manager visited Morris and Rose regularly and gave their daughter informative updates. When problems arose, the Care Manager responded quickly and appropriately. Their daughter was able to spend her visits creating special memories with them instead of flying down for crisis after crisis. When Rose and Morris finally passed away, their daughter was left with fond memories and comforted by the knowledge that she helped her parents make informed decisions so they could live their final years in comfort, with dignity and on their own terms.

Independence vs. Isolation
Many of my elderly clients who were trying so hard to maintain their independence by living alone at home actually maintained nothing more than an isolated existence punctuated by the occasionally call or visit from friends and family. This type of isolation was also coupled with medication errors or abuse, self-neglect and unsanitary housekeeping. A person living in this situation will often “bloom like a flower” in the right retirement facility environment. It is amazing what three hot meals a day, social interaction, clean sheets and regular administration of medications can do for a person’s mind, body, and spirit. A person who lives alone is more likely to fall and lay alone on the floor for days without being found. A person who lives alone may make poor choices such as keeping (or worse, eating) spoiled food in the refrigerator. If a person lives alone, there are many signs of illness that no one will notice during sporadic short visits. Medical appointments may be missed and prescriptions left unfilled. Many people feel that they are honoring their aging loved one by letting them live alone, even though all the tell tale signs of self neglect are apparent. There is no honor or dignity in being found on the floor after one has lain in his or her own excrement for three days. Unfortunately, many families will wait for this type of incident before insisting on either home health care or facility placement. If an elder is physically or verbally abusive to family and caregivers, they are much more likely to be left alone to make their own decisions, regardless of how dysfunctional their situation may be. Elders with difficult personalities are many times more likely to be abused by caregivers. They need more supervision, not less.

American Family Dynamics and the Pressures of Today’s World
I hear people say “Americans don’t take care of their elders like other countries do.” Well that is not my experience. The adult children who consult with a Geriatric Care Manager or other eldercare professionals are very concerned about their parents. They love them and they want the best care their money can buy. That’s the clincher: what their money can buy. In America, caregivers, maids, etc, are expensive. Perhaps in another country where slave labor is commonplace, people can afford plenty of care. But in this country it costs $12.00 per hour (or more) for a home health aide. At eight hours per day, that is $96.00 per day. That is $2,880 per month or $34,560 per year – more than the average working American earns per year. The average woman gets a social security check of less than $500.00 per month. Do the math and you will soon see that unless you are wealthy, many people cannot afford to keep their elders in their own home with a part time caregiver or even in their children’s home with a caregiver.

Now couple this financial problem with another very real problem. Most middle income women in their fifties who are caring for their elderly parents, are also trying to hold down a job, help their young-adult children and maintain a marriage. If a middle-income woman stops working to care for her parents, she and her husband either cannot pay their bills or they must significantly reduce their standard of living. I know a few husbands who are fifty-something and feel they have worked too hard and too long to have their dreams of retirement evaporate because someone else’s needs are suddenly more important than their own. Now that Americans have come to grips with the concept that it takes two incomes to live well in this country, they are more determined than ever to have a retirement. Paying $35,000 per year for a caregiver can take a huge chunk out of the retirement savings. Frankly, most people couldn’t afford to do it even if they wanted to. Because most Americans’ net worth is in the equity of their home, selling the family home is the most common way to finance elder care services. If the family home sells for $100,000.00 and the average cost of an Assisted Living Residence is $36,000.00 per year, an elder can afford to live in that Assisted Living for 2.7 years. Coincidently, the average amount of time a person lives in an Assisted Living before moving on to a nursing home is 2.5 years.

Many adult children, who do have the desire and financial means to bring their elders to live with them, still cannot. They cannot because the medical or psychological needs of the elder are beyond their capacity to manage. For example, if Grandma is sweet and docile by day, but “sundowns” or grows agitated as evening falls, this poses a difficult problem for the caring family. When some people experience dementia or other medical issues, they may stay awake all night. They sometimes wander out of doors or rummage through drawers and closets. This behavior will keep the whole family awake at night. If a working family cannot sleep at night, this situation will become intolerable very quickly. Some adult children have been raised by violent, aggressive parents who are now violent aggressive elders. Children who have been raised under these conditions need not feel obligated to bring their parents to live with them, despite the pressure they may get from outsiders who do not know the real story.

Elders and their families who are trying to make difficult choices about elder care benefit from a professional assessment from a geriatric specialist. Professional care managers can offer an objective opinion based on a clinical evaluation of the physical and cognitive status of the elder. Physicians, hospital case managers, facility admissions coordinators and social workers can also offer advice about appropriate placement of an elder or even suggest how to set up services in the home to best meet the elder’s needs.

Home Health Care – Stay Home Without Being Alone
At the very least, any elder living alone should have a medical alert system. This is a necklace or wristband with a panic button that can be pushed in case of emergency. If the button is pushed a dispatch center receives the signal and makes and attempt to communicate with the elder through a speaker placed in the home. If the elder needs help or does not respond to attempts to communicate, emergency services will be dispatched to the home. Many services will also contact friends and family to notify them that assistance is needed. A good candidate for this device is one WHO DOES NOT have memory loss, as memory loss makes it difficult to learn to operate new appliances.

There are two basic types of home health care services: Medicare and Private Duty:

Medicare Home Health is free but can only be accessed if ordered a physician. Medicare will only authorize the free home health services if specific events have happened such as a recent hospitalization lasting three or more days, or a recent change in health status, etc. Medicare will send a Registered Nurse to evaluate the elder and that nurse decides if other professionals such as physical therapists, social workers, dieticians, etc. should perform evaluations. Each professional will determine what services they will render and for how long. Medicare services are temporary in nature and are not offered on a full time basis. The average visit by the nurse, aide and therapist is less than one hour each. Even Medicare home health aides only stay long enough to bathe and dress the patient.

Private Duty Home Health can be arranged on a full time, part time or live-in basis. Many Long Term Care Insurance policies will pay for home health care. The amount of care one can get and the duration of the service varies depending upon which policy they purchased. If someone does not have insurance, they must pay out of pocket (or private pay) for any services. Typically a private home care agency will offer services at a minimum of four hours per day. Typical eight hour shifts are 7am-3pm, 3pm-11pm and 11pm – 7am. Many elders complain that an agency sends them a different caregiver each day. In order to avoid that as much as possible, order care every day for at least eight hours. This will allow the agency to schedule the same person for all your shifts. Because labor laws do apply and the agency would have to pay overtime for time, which exceeds 40 hours per week, you will most likely have at least two to three caregivers on a full time case. The average hourly rate is $14.00 per hour. A live-in will cost about $150.00 per day. A live-in lives in your home and drives your car (or theirs for a mileage fee) and you are expected to feed them as well, even if you go out to dinner. By law, a live-in is entitled to two hours per day of free time. They can do what ever they like, including leaving the house during their break. If this arrangement will not work for your situation, consider hiring an aide around the clock. Around the clock care is typically delivered in two twelve-hour shifts, which are done by two different caregivers. One aide comes to the home from 8am until 8pm and is relieved by the second caregiver at 8pm until 8am. Around the clock care can be delivered in many schedule formats. A live-in is expected to have their own private bedroom and bathroom although many agencies are flexible on this issue. The live-in is expected to be awake all day and have at least 7 hours of sleep at night. If the elder does not sleep at night, a live-in arrangement will not work. One option is to have the live in ($150/day) plus hire a caregiver to come to the house and stay up all night with the elder ($14.00. hour for eight nighttime hours). This costs $112 + $150= $262.00 per day. The only other alternative is to have around- the-clock care which will cost $14.00/hr X 24 hr=$336/day. Adding the eight-hour night shift to the live in saves about $3,000 per month. The Veterans Aid and Attendance Pension is available to qualified veterans who need a caregiver in their home on a regular basis.

Types of Adult Housing and Facilities:

Independent Living Facilities usually offer small apartments with some meals included in the price. A person who lives in an Independent Living Facility is expected to manage their daily care needs on their own, but the staff would readily recognize if needs increased and assist the resident in obtaining the needed help. Some facilities have extra care services available for additional charge to help the resident “ age in place.” Others may ask a resident to move out if their needs exceed the scope of that particular facility. Limited transportation is usually provided although many residents are still driving when they enter an Independent Living Facility. These facilities may cost anywhere from less than $1,000 per month to over $5,000 per month depending upon the luxury amenities and location.

Assisted Living Facilities usually offer hotel size rooms with the option to share a room or pay extra for a private room. Three meals and snacks are usually provided as part of the price. Residents are expected to need some assistance with their daily care needs. Medication administration is strictly supervised. The State laws dictate who can live in an Assisted Living. The State does not want Assisted Living facilities to house nursing home candidates or Nursing Homes to admit people who could function just as well in an Assisted Living Facility. Assisted Living residents must be able to walk and transfer (from bed to chair or chair to standing) with the assistance of only one other person. An Assisted Living resident can be left alone in their room for two hours or more. Nurses aides are on duty around the clock. Registered nurses or Licensed Practical Nurses are on duty at least during the daytime. Many medical services may make rounds and visit residents at least monthly. It is not uncommon for an Assisted Living resident to never have to leave the building for a medical or beauty appointment. Prices may range from under $1200/month to over $8,000/ month, once again depending upon the amenities. Medicaid has a program called the Medicaid Waiver, which can pay part of the cost of the Assisted Living. However, funds have been historically limited and waiting lists can be long. The Veteran Aide and Attendance Pension is designed to financially assist qualified veterans who need the services of an Assisted Living facility.

Dementia Specific Facilities are designed especially for the memory impaired resident. The building, floor plan, furnishings, décor, activity program and even the lighting have been scientifically engineered to enhance the lifestyle of residents with dementia. Many Assisted Living Facilities and Nursing Homes offer a dementia program or dementia unit, but there are entire facilities that specialize in this unique population. Dementia Specific Facilities can be either Assisted Living Facilities or Nursing Homes. They are secure in order to prevent residents from wandering off the property and getting hurt or lost. The price for this extra level of care is usually about $1,000 to $2,000 more per month than a non-specialty building.

Nursing Homes are State regulated and are inspected at least annually. A person who needs a nursing home generally cannot live safely in an Assisted Living environment. A typical resident is either wheelchair bound or bed bound. Those who can walk around freely may need the nursing home environment because they need constant medical supervision. The medical component of this environment is similar to a hospital or hospice setting. The emphasis is on rehabilitation or custodial care rather than socialization and activities. The ICP Medicaid Program (institutional care program) will pay for the room, board and medical costs of those residents who meet the financial and medical criteria. It is possible to plan in advance to help an elder meet these strict criterions.

Financial Realities
Keeping an elder at home with a caregiver can be the most expensive option of all. Many families feel keeping their loved one in the comfort of their own home is priceless. If a paid caregiver cost $14.00/hour, eight hours per day is equal to $2,880.00 per month. Around the clock care exceeds $10,000 per month. Independent Living Facilities cost an average of $2,300.00/ month and provide no personal assistance. Assisted Living Facilities range from about $2,500/month to $5,000/month and provide limited care. A Nursing Home (without ICP Medicaid assistance) can cost from 5,000.00 to $7,000.00 per month and will provide total care.

Anyone considering hiring home health or moving an elder into a care facility of any type should have their elder’s current needs assessed by a qualified professional who can ascertain the elder’s current medical/psychological and financial needs and anticipate future needs/solutions. With careful, realistic planning, caring for an elder does not have to be a financial or emotional nightmare. Making the right choices for you and the elder you care about is easier when you enlist the help of people who know the eldercare community and all that it has to offer.

The Aid and Attendance Pension is the government’s best kept secret. I cannot tell you how many seniors have told me that they called the Veterans’Administration and were actually told that this pension does not exist or that they do not qualify. For twelve years, I have assisted veterans and widows in obtaining these funds – they really do exist.

To get the maximum pension amount, a veteran must qualify medically and financially and must have served their country for at least one day during “War Time”. Also the Veteran must have been honorably discharged. Every case is considered individually. If a Veteran or Veteran Widow feels they may qualify, they can apply for the pension. The pension can take many months to actually be approved. The average waiting period is three to eight months. The first check will be retroactive to the date the application arrived at the Veterans’ Administration, therefore the first check may be for thousands of dollars. Subsequent checks will arrive monthly for the approved amount. This pension money can mean the difference between affording adequate care for an aging Veteran/ Widow or having no care at all.

As with any governmental program, success is all in the paperwork. The pension application is seven pages long and some of it is in essay form. It is the exact wording used in the essay areas that mean the difference between approval and denial. Also, the Veteran’s Administration does not tell Veterans about all the supporting documents that they would like to see. The better the medical and financial records, the better the chances are of approval. Including the right medical forms signed by a doctor is very important for approval. Also typical of governmental red tape is the frustrating lack of communication. Once the application is filed and in the process of being reviewed, it is nearly impossible to get an update or check on the status of the application.

In a perfect world, financial assistance for those who qualify should be easily accessible and easy to get. But the reality is that government agencies are inherently complicated and their application processes are never self explanatory or simple. Ignorance of the rules is no excuse and no one will tell you the rules. The rules are written somewhere, but the Veterans Administration is not allowed to give them to you. Seasoned Eldercare professionals can often navigate these processes for you. They may charge for their services, but to attempt to do it yourself and have your application denied, will cost much more money. The Veterans’ Administration supposedly employs staff to help Veterans and their Widows apply for these pensions for free, but it is these very people who have told so many seniors that they do not qualify, when in fact, they could qualify if they made one small change. Perhaps the Veteran’s Administration is afraid that if they made it easy for every Veteran to apply, the pension fund would go broke. Given that War Time includes the Gulf War Era which began in 1990 and has not ended yet, I anticipate the pension fund will one day be either broke or impossible to get. For now, the money is very much available and attainable.

Here are the Aid and Attendance eligibility criteria for the year 2005.

1. Veteran served in the Military for at least one day during War Time or had a spouse who served at that time. Spouse’s are people whom you never divorced.
2. Honorably Discharged from the Military.
3. Currently has medical or psychological condition which make the Veteran or Veteran widow dependent on the aid or assistance of a non- family member in order to meet their daily care needs or they reside in an Assisted Living Facility ( not a nursing home). This claim must be supported by physician signed forms and medical records.
4. Financial: Have assets in their own name below $80,000 (if married) or below $50,000 (if single). The car and house does not count as an asset. Annual income below $16,955 (if single) or $ 20,099 (if married) after all medical expenses such as Assisted Living fees, paid caregiver salary, medications, medical transportation/ supplies, certain housing expenses, etc.

In many cases, if a person has a paid care giver, such as a nurse’s aide, or they pay an Assisted Living Facility, those expenses impact so greatly on a person’s net income, that they will meet the criteria for the income level.
If a Veteran or Veteran Widow has cash assets above the limit, they are allowed to place those assets into certain investments in order to have them “sheltered”. This sheltering does not have a penalty or “look back period” associated with it. Proper asset sheltering for Aid and Attendance should be done under the supervision of an Eldercare professional or Attorney well versed in Medicaid planning because one could easily ruin the chances of ever getting Medicaid if the VA pension planning was done incorrectly.

With a little professional planning, many Veterans and Veteran Widows can receive pensions that make a significant difference in the amount of care they receive. After all, the reason for this particular pension is to assure that a Veteran or Veteran Widow does not live in a substandard environment in their old age. It takes a little work to apply for this pension, but anything worth having usually does..