Fong Law Group

What is Long-Term Care and Who Provides It?

Long-term care is the care you need if you can’t perform daily activities on your own for an extended period of time. There are a number of different ways that long-term care can be provided. 

Most long-term care involves assisting with basic personal needs rather than providing medical care. You are usually determined to need long-term care if you need help with two or more “activities of daily living” (such as bathing, dressing, eating, and going to the bathroom). Family members usually provide long-term care to start, but as an illness escalates paid care may become necessary. 

The following are the types of long-term care:

• Home care from family member. The most basic form of long-term care is when a family member becomes the caregiver. It can involve simple tasks like buying groceries or more complicated ones like bathing and dressing. Sometimes family members can be paid for their work.
• Home care aide. Home care aides provide companionship and socialization and assist with meal preparation, housecleaning, laundry, shopping, and errands. They are also called homemaker or chore aides.
• Home health care aide. Health care aides provide personal care (bathing, grooming, etc.), assist with range-of-motion exercises, provide some medically-related care (empty colostomy bags, dress dry wounds, check blood pressure, etc.), and provide assistance with housekeeping and errands. They are often referred to as personal care assistants
• Adult day care. Adult day care allows family members to get a respite from caregiving. In general, there are three types of centers: those that focus on social interaction, those that focus on health care, and special Alzheimer's care centers.  
• Assisted living facility. Assisted living facilities are a housing option for people who can still live independently but who need some assistance. Depending on the facility, that assistance may include help with meal preparation, housekeeping, medication management, bathing, dressing, transportation and some nursing care. Residents usually live on their own, in small apartments. Despite the emphasis on independence, supportive services are available 24 hours a day in order to provide different levels of help with activities of daily living. The level of medical supervision depends on the facility.
• Nursing home. Nursing homes are the highest level of long-term care. They provide 24-hour care to residents. Staff provide help with daily activities such as feeding, dressing, and bathing along with medical care and physical, occupational, and speech therapy.

Costs for care can vary widely, from a few hundred dollars a week to pay for coverage when family members are at work to $300,000 or more a year for around-the-clock home care or care in the most expensive nursing homes, perhaps with private aides hired on the side. 

Long-term care costs, whether at home, in assisted living or in a nursing home, are paid primarily from three sources: out-of-pocket, Medicaid, and long-term care insurance. Medicare, the health insurance for people over age 65, only pays for up to 100 days of skilled nursing facility care following a hospitalization, and only for so long as the patient is deemed to need skilled care. It will also pay for skilled care at home -- in theory indefinitely, but this may take some advocacy.

Can You Visit Nursing Home Residents After They are Vaccinated?

COVID vaccines are starting to roll out to nursing homes across the country, signaling the beginning of the end of the pandemic. Once your loved one has had both doses of the vaccine, you may be able to visit, but precautions are still necessary. 

The federal government entered into a partnership with CVS and Walgreens to deliver the vaccines to nursing home residents, who have high priority for being vaccinated, according to the Centers for Disease Control and Prevention (CDC) guidelines. The pharmacy companies began administering vaccines in 12 states in mid-December and will expand to 36 states before year’s end. Both the Pfizer the Moderna vaccines require two shots three or four weeks apart. 

Restrictions on nursing home visitors vary from state to state, with some states limiting them and others allowing more visitation. Currently, the CDC recommends that nursing homes allow indoor visitors if the facility has had no COVID cases for 14 days. Once vaccines have been distributed, restrictions may ease further. 

According to the New York Times, experts recommend that to be safe, you should wait until two weeks after your loved one gets the second dose of the vaccine before visiting. The safest time to visit would be after all the residents and staff have been vaccinated and you receive the vaccine as well. Even if you and your loved one are vaccinated, you should still wear a mask when visiting. As long as COVID is spreading in the community, mask wearing is still recommended. 

Noting that the vast majority of older adults with chronic conditions live at home, long-term care consultant Howard Gleckman asserts that these vulnerable adults along with their caregivers should also be vaccinated as soon as possible.  As states ration their limited initial supplies of the vaccines, Gleckman says, "they should remember the millions of people who are at high risk of severe illness or death from the virus, but who are living at home."

For more information about the vaccine rollout to nursing homes, click here and here.

Caregiver Contracts: How to Pay a Family Member for Care

Although people are willing to voluntarily care for a parent or loved one without any promise of compensation, entering into a caregiver contract (also called personal service or personal care agreement) with a family member can have many benefits. It rewards the family member doing the work. It can help alleviate tension between family members by making sure the work is fairly compensated. In addition, it can be a be a key part of Medicaid planning, helping to spend down savings so that the elder might more easily be able to qualify for Medicaid long-term care coverage, if necessary.

The following are some things to keep in mind when drafting a caregiver contract:

• Meet with your attorney. It is important to get your attorney's help in drafting the contract, especially if qualifying for Medicaid is a goal.
• Caregiver's duties. The contract should set out the caregiver's duties, which can be anything from driving to doctor's appointments and attending doctor's meetings to grocery shopping to help with paying bills. The length of the term of the contract is usually for the elder's lifetime, so it is important to cover all possibilities, even if they are not currently needed. The contract can continue even if the elder enters a nursing home, with the caregiver acting as the elder's advocate to ensure the best possible care.
• Payment. Payment to the caregiver can either be made with a lump-sum payment or in weekly or monthly installments. For Medicaid purposes, it is very important that the pay not be excessive. Excessive pay could be viewed as a gift for Medicaid eligibility purposes. The pay should be similar to what other caregivers in the area are making, or less. To calculate a lump-sum payment, take the monthly rate and multiply it by the elder's life expectancy. (Note that some states, Georgia for example, do not recognize the ability to create a lump sum contract based upon life expectancy.)
• Taxes. Keep in mind that there are tax consequences. The caregiver will have to pay taxes on the income he or she receives.

Other sources of payment. If the elder does not have enough money to pay his or her caregiver, there may be other sources of payment. A long-term care insurance policy may cover family caregivers, for example. Also, there may be state or federal government programs that compensate family caregivers. Check with your local Agency on Aging to get more information.

Caregivers Are Getting Younger, Making Planning for Long-Term Care Even More Important

As baby boomers age, more and more millennials are becoming caregivers. Many are taking on this role while just getting started in their own lives, leading to difficult decisions about priorities. Proper planning can help them navigate this terrain. 

The term “sandwich generation” was coined to refer to baby boomers who were taking care of their parents while also having young children of their own. Now millennials are moving into the sandwich generation at a younger age than their parents did. According to a study by the AARP, one in four family caregivers is part of the millennial generation (generally defined as being born between 1980 and 1996). And a study by Genworth found that the average age of caregivers in 2018 was 47, down from 53 in 2010. Gretchen Alkema, vice president of policy and communications at the SCAN Foundation, told the New York Times that the rise in younger caregivers may be because baby boomers had kids later in life than their predecessors and many are divorced, so they do not have a spouse to provide care. 

Younger caregivers have different challenges than older caregivers. They may have younger kids to manage and careers that are just beginning, rather than established. In addition, more millennial men are caregivers compared to previous generations. The AARP study found that millennials spend an average of 21 hours a week on caregiving, and one in four spend more than 20 hours per week. More than half (53 percent) also hold a full-time job in addition to their caregiving duties and 31 percent work part time. Younger caregivers are also less likely to discuss their caregiving duties with their employer than previous generations.

Managing caregiving duties, family, and employment is stressful. Having plans in place can help alleviate some of the stress, and the earlier you plan ahead the better. The following are resources you can use to put together a long-term care plan: 

• Long-term care insurance can help lessen some of the costs of caregiving if it is purchased early enough. 
• A geriatric care manager can help determine what care is needed and where to find resources. 
• An elder law attorney can draft essential documents like a power of attorney and a health care proxy, as well as advise you on available benefits, such as Medicare, Medicaid, or Veteran’s Administration benefits. 
• Adult day care can give caregivers a much-needed break. 

Having resources in place will help, but you also need to be mindful of when you need help. Recognize when you are being stretched too thin and consider your priorities. If possible, talk to your employer about flexible hours. Consult with other family members and do not be afraid to delegate tasks. Take care of yourself by eating well, exercising, and finding time to relax. For some tips on handling the caregiver/life balance, click here.

For an article on the unique caregiving challenges facing the women of Generation X, click here.

Will Restrictive Immigration Policies Cause a Shortage of Caregivers for the Elderly?

As the population ages, the need for caregivers is growing, but more restrictive immigration policities such as those being promoted by the Trump administration could have a negative impact on a caregiving industry that is already facing workforce shortages. 

The Supreme Court is currently considering the administration's decision to end the program that protected young undocumented immigrants from deportation, known as Deferred Action for Childhood Arrivals, or DACA. Among other policies, the administration has also ended Temporary Protected Status -- a program that gives immigrants who can't return to their home countries due to violence or natural disaster permission to work and live in the United States -- for several groups, including immigrants from Haiti, El Salvador, and Nicaragua.  In addition, another effort is to shift from "chain migration," where people enter the country based on family ties, to immigration based on skills, which are presumably not caregiving skills but more high-tech abilities.

While there is no data on specifically how many of the affected people work as caregivers, about one in four health care workers is an immigrant, according to the Paraprofessional Healthcare Institute (PHI), a nonprofit organization that studies the home care industry. That includes immigrants working as home health aides, personal care aides, and nursing assistants in home and community-based settings, nursing care facilities, assisted living facilities, group homes, intermediate care facilities, and hospitals. In addition, PHI found that immigrants constitute 31 percent of the home care workforce.

Meanwhile, the U.S. is already facing a growing shortfall of home health workers as 10,000 baby boomers turn 65 each day.  The Bureau of Labor Statistics estimates that there will be more than one million new caregiver positions created by 2028, a 36 percent increase. Caregiving jobs require hard work for low pay, so finding workers to take those jobs is difficult. Turnover is already high in the industry, and health care employers complain about the lack of available workers. Losing a large portion of the workforce will only make it harder to fill the positions. Experts also worry that a shortage of home-care workers will lead to more seniors being institutionalized. 

To read more about how immigration policies are affecting the caregiving industry, click here and here.

Aging in Place: Reality or Dream? 老有所屬：是現實還是夢想？ (中英對照)

“As lifespans increase, our elders grow in number, and government elder benefits become more politically tenuous, the need for empathetic family elder caregivers keeps increasing.

Seniors crave their independence and a sense of place. Almost all wish to remain in their own homes and to “age in place.” Being independent in your senior years benefits everyone. However, if aging brings illness, professional home caregiving may be unaffordable, says The Winston-Salem Journal in the article “Who will help me to age in place?”

Even though they want to remain independent, family member participation may be necessary for this to happen. Family caregivers may live with aging parents, serving as guardians, trustees or power of attorney agents on their parent’s behalf. They may perform many tasks, including cooking, cleaning and monitoring their medical or home care. They may take care of the home and take aging parents on outings.

Loyalty to aging parents runs the gamut, from daily contacts and living together, to children who vanish as soon as they are financially independent. While our biology may dictate that close family members are genetically predisposed to care for us most, it’s not everyone’s experience.

If your goal is to have parents, children and grandchildren all spend time together as the generations move through their lives, the time to start is while you are parenting. The most important thing you can do to increase the likelihood of having family members who value each other and care for each other, is to raise children with love and kindness.

You should limit the amount of time that children spend with electronic devices. Making family connections and teaching caregiving skills within the family, requires time and attention. Teach your children empathy and caregiving through gardening, caring for plants and pets and letting them see how you take care of siblings, parents, grandparents, friends and the less fortunate through volunteer work.

Our children learn more from what they see, than what we say. By teaching your children to respect and care for those they love, you will be creating a family legacy based on your values. This will be as much a part of them, as any inheritance you can leave them.

Part of caregiving is taking care of the legal and financial side of your life. Ensure that your family members have an estate plan in place, including a will, financial power of attorney and health care power of attorney. Caregiving for others involves preparing for the ups and downs of life. This shows your children that there are things we do for ourselves and for others that make life easier for those we leave behind. It is an important life lesson for each generation.

Reference: The Winston-Salem Journal (March 5, 2019) “Who will help me to age in place?”

“隨著人的壽命越來越長，老人的數目也日漸增加，政府老人的福利變得更加政治化，對理解老人的家庭護理人員的需求不斷增加。

老人渴望有一個獨立及舒適環境。幾乎所有人都希望可留在自己的家中終老。在你年老時可獨力照顧自己則令家人受惠。然而，如果年老帶來疾病的話，專業的家庭護理費用可能負擔不起，The Winston-Salem Journal在文章“Who will help me to age in place?”中說。

即使他們想獨立，也可能需要家人幫助。照顧老人的家庭成員可以與年邁的父母一起生活，代表其父母擔任監護人，受託人或財務代理人。他們可以執行許多任務，包括烹飪，清潔和監控他們的醫療或家居護理。他們也可以打理房子，並帶年邁的父母外出。

對年老父母忠誠的幅度可以從日常接觸和共同生活到在經濟上獨立後就消失的子女。雖然在生物學角度上親密的家人是最關心自己的，但並不是每個人都一樣。

如果你的目標是讓父母，子女和孫兒一起度過，那麼應在你養育子女的時候開始。如果你想能讓家人互相尊重並互相照顧，最重要的就是要用愛及仁慈去撫養子女。

您應該限制子女花在電子設備上的時間。在家中建立關係和教導互相照顧的技能,透過園藝，照顧植物和寵物教導你的子女同情心和如何照顧其人，這都需要時間和精神。​​讓他們看看你如何照顧兄弟姐妹，父母，祖父母，朋友和當義工照顧不幸的人。

我們的子女從他們看到的東西中學到的東西比我們說的多。通過教育子女懂得尊重和關心他們所愛的人，你便可以用自己的價值觀創造你的家庭遺產。這將是其中的一部分，因為他們將繼承你留下給他們的任何東西。

處理好你法律和財務方面也是照顧的一部分。確保您的家人有資產計劃，包括遺囑，財務授權書和醫療授權書。照顧他人包括為人生的高低潮作準備。這讓您的子女看到你是如何為自己和其他人做事，讓在生的人生活可以更輕鬆。這對每一代人來說都是重要的人生課程。

參考: The Winston-Salem Journal (March 5, 2019) “Who will help me to age in place?”

Senior Scams Range from Promised Luxury Cars to Stolen Homes

“Police Detective Rosalee Reid told of one scammer who tried to entice her to give up her personal information, so he could attempt to drain her bank account by promising her she’d “won” $750,000 and a white Mercedes Benz.”

Too bad this particular scammer had no idea to whom he was speaking. The officer played along, asking when she could get the car, and telling the scammer it was snowing and she didn’t want to get that on her brand-new Mercedes. After too many questions, the scammer hung up on her, reports the New Haven Independent in an article “Senior Study Scam Avoidance 101.”

Unfortunately, not every senior is that savvy, when it comes to being scammed. According to the Federal Trade Commission, Americans lost more than $900 million in 2017 – that’s $63 million dollars more than in 2016 — to fraud, and many of the victims are seniors, who are routinely targeted.

Some of the cases are debt collection fraud, where a phone caller says they are calling from the IRS or the U.S. Marshall Service, stating vehemently that the person they are calling owes money to the government. The threat of jail time is frightening to enough people, that they fall for it.

Seniors are advised over and over again: the IRS does not call to make threats, and it’s definitely not calling to demand payment in gift cards from a major retailer. However, the scammers speak with authority and are extremely convincing. As a result, many people fall into the traps.

What makes scammers more frightening, is when they use a small piece of the senior’s identity. They may read the home address and insist that they will come to their home to collect the debt. They could also mention a family member, one who has passed away lately, and claim that they know everything about the person.

Another scam is to call and say that a beloved grandchild is in prison or has been kidnapped and needs money fast to pay ransom or bail to get out of jail. If this occurs, immediately hang up and contact the person or someone who can verify their safety, to make sure they are okay.

If someone has been arrested, they have the right to make one phone call. Authorities are not likely to be calling a person’s grandparents for bail money.

Another major source of fraud comes from those who know the senior or befriends them, solely to get their money or even their home. There are tales of caregivers, who become more and more involved in a senior’s life, often pushing their family members away and isolating the individual, so they can’t ask for help. Be wary of new people who are pushy about being helpful, especially if they ask to use your credit card or debit card to run errands for you.

Sadly, there are also many instances of family members who are charged and convicted for financial elder abuse, using their relationship with aging parents or other relatives to gain access to their finances. Be wary, warn experts, even when it is a family member. Read your credit card bills and bank statements carefully, to make sure that your money isn’t disappearing. Keep personal finance information secure.

Reference: New Haven Independent (Feb. 5, 2019) “Senior Study Scam Avoidance 101”

Getting Paid as a Family Caregiver Through Medicaid

Caring for an ailing family member is difficult work, but it doesn’t necessarily have to be unpaid work. There are programs available that allow Medicaid recipients to hire family members as caregivers. 

All 50 states have programs that provide pay to family caregivers. The programs vary by state, but are generally available to Medicaid recipients, although there are also some non-Medicaid-related programs. 

Medicaid's program began as "cash and counseling," but is now often called "self-directed," "consumer-directed," or "participant-directed" care. The first step is to apply for Medicaid through a home-based Medicaid program. Medicaid is available only to low-income seniors, and each state has different eligibility requirements. Medicaid application approval can take months, and there also may be a waiting list to receive benefits under the program. 

The state Medicaid agency usually conducts an assessment to determine the recipient's care needs—e.g., how much help the Medicaid recipient needs with activities of daily living such as bathing, dressing, eating, and moving. Once the assessment is complete, the state draws up a budget, and the recipient can use the allotted funds to pay for goods or services related to care, including paying a caregiver. Each state offers different benefits coverage. 

Recipients can choose to pay a family member as a caregiver, but states vary on which family members are allowed. For example, most states prevent caregivers from hiring a spouse, and some states do not allow recipients to hire a caregiver who lives with them. Most programs allow ex-spouses, in-laws, children, and grandchildren to serve as paid caregivers, but states typically require that family caregivers be paid less than the market rate in order to prevent fraud. 

In addition to Medicaid programs, some states have non-Medicaid programs that also allow for self-directed care. These programs may have different eligibility requirements than Medicaid and are different in each state. Family caregivers can also be paid using a "caregiver contract," increasingly used as part of Medicaid planning. 

In some states, veterans who need long-term care also have the option to pay family caregivers. In 37 states, veterans who receive the standard medical benefits packagefrom the Veterans Administration and require nursing home-level care may apply for Veteran-Directed Care. The program provides veterans with a flexible budget for at-home services that can be managed by the veteran or the family caregiver. In addition, if a veteran or surviving spouse of a veteran qualifies for Aid & Attendance benefits, they can receive a supplement to their pension to help pay for a caregiver, who can be a family member. 

All of these programs vary by state. Contact your attorney to find out what is available in your state. 

Add This to Your New Year’s Resolutions

“It’s one of the most important conversations that none of us want to have.”

The conversation with loved ones about growing older and the chances that we or our spouses are going to need help with the activities of daily living, is something that needs to be talked about before being faced with that situation. It’s difficult at best, says The Des Moines Register in the article “In 2019, resolve to have a difficult conversation,” but very necessary.

The person who is contemplating needing help, may want to start the conversation but the person who may be called on to help may find it too difficult to consider. Who wants to think about their parents getting frail and needing help going to the bathroom? No one.

The person who is starting to feel the impact of aging, may already be aware of some limitations. However, talking with their children or potential caregivers, may change the conversation from “someday” to “soon.” The loss of independence is one of the big milestones, just as gaining independence is a milestone earlier in life. That’s a hard thing to accept for both sides.

Those who have lived through this process of needing to become caregivers, say that it would have been easier, if they would have known what their loved ones wanted. So, would have been knowing what kind of help their loved ones could afford. It’s better to have time to research available resources in advance, rather than operating in crisis mode.

This is what your conversations need to address:

• Medications, physical health, emotional well-being and health care providers
• Their wishes, if their health declines slowly or rapidly. Do they want to stay at home? Who would they want to help with daily care?
• Finances: Can they afford to pay for care at home? Has any Medicaid planning been done? What government programs are they eligible for? Do they have a CPA or financial advisor?
• Estate plan: Where is their Last Will and Testament? Is there a Power of Attorney, Living Will or Medical Directive in place? Who is their estate planning attorney?
• Documents, including birth certificates, Social Security, insurance cards, safe deposit box keys, computer passwords, etc.

We prefer to think we’ll live a long healthy life and then die peacefully in our sleep, with no advance notice. However, that is not what happens to most Americans. Seven out of 10 people over age 65 will need help from others at some point, and most will need it for at least three years. Therefore, make having this conversation part of your New Year’s resolutions. When the time comes, you and your caregivers will be glad that you did.

Reference: The Des Moines Register (Dec. 19, 2018) “In 2019, resolve to have a difficult conversation”

Lessen the Stress of Becoming Widowed

“It is no surprise that dealing with the emotional impact of the death of a spouse is overwhelming. For many widows, handling the financial implications of her husband’s death may be too much to bear. However, that is what most widows must do.”

A recent study from Merrill Lynch and Age Wave on widowhood shows that a mere 14% of 3,300 respondents said they were making financial decisions on their own, before their spouses passed away. That is a very low number of women in charge of their financial lives as married women, says Press & Guide in the article “Financial planning can help ease impact, stress of widowhood, study shows.”

Widows are tackling major challenges in the days and weeks after the loss of a loved one. That includes everything from funeral costs, mortgage or rent payments, other costs of running a household and for many, medical costs. With nearly half of those in the study reporting a household income drop of 50% or more after the death of a spouse, that is an enormous burden to take on during a time of great grief and upheaval.

The women are also facing the tasks of juggling Social Security, pensions, life insurance and making sure that their late spouse’s retirement accounts are all correctly transferred into their names.

There is often a lack of preparation for this situation. Many are simply not prepared for how complicated it is to deal with the loss of a spouse.

The study reports that couples who plan for this situation, have their level of worry cut in half. Only 38% of the widows in the study who had conducted financial planning, worried about not being able to support themselves immediately after the death of their spouse. That compares to 64% of widows who had not planned at all.

Widowers (men whose wives have passed) face unique challenges. If their wives pass first, they may be faced with taking on their own caregiving. Statistically, women outlive men, so the widowers have to adjust to losing a caregiver. There may be new financial costs they would not have had to bear, if their wives were still alive.

The first step: meet with an estate planning attorney. Make sure that a will and power of attorney are created, along with any other necessary planning documents. Both spouses should be familiar with all accounts, and both names should be on the accounts and all deeds. Don’t forget to organize all important papers in a file drawer at home or in a safe deposit box. Know where everything is and how to access it.

Having long-term care insurance in place and making sure there are assets available for caregiving, should be a part of everyone’s plan for longevity. Even if you don’t need home health care or to live in an assisted living facility, someone will eventually need to provide some level of care.

Reference: Press & Guide (Nov. 19, 2018) “Financial planning can help ease impact, stress of widowhood, study shows”