• Helps dispel fears about what will happen.
• Helps avoid potential problems such as running out of money.
• Ensures wishes are respected.
• Identifies appropriate persons to assume specific roles.
• Ensures personal business is in order.

• A Directive to Physicians
• Durable Power of Attorney for Healthcare
• General Power of Attorney
• A Will · A burial policy
• Health insurance, Medicare
• A log of financial information such as bank accounts, investments 

• Identify a place for important information and documents.
•  Make sure all family members, trusted neighbors, and/or friends can access this information in an emergency.
• Distribute copies of important documents to family, physicians, attorneys, etc. 

• Everyone should visit a physician at least yearly.
• If your loved one does not have a physician, make an appointment immediately. 
• It is not uncommon for doctors to have waiting lists. It could be several weeks before your loved one is seen.

• List all concerns and questions.
• List all medications, including herbals, vitamins and over-the-counter medications.
• List all known allergies.
• Prepare a complete medical history including mental health issues.
• Copy advanced directives as Directive to Physicians and Durable Power of Attorney for Healthcare.

• Go with your loved one so that you can be his/her eyes and ears.
• Let your loved one talk when asked questions, and interject if needed.
• Tell the doctor about any specialists being seen.
• Be respectful of the doctor`s time and don`t give frivolous information.
• Get to know the nurse and office staff. Ask if you can contact the nurse directly with questions.
• Find out if the physician will see patients in a nursing facility.
• Find out how the doctor feels about end of life issues.

• Decline in ability to perform activities such as dressing, bathing, etc.
• Change in appearance, looking unkempt.
• Bills unpaid, mail unopened.
• Leaving iron or stove turned on.
• Problems with incontinence/odor.
• Apathy and depression.
• Ruined food in refrigerator.
• Missing appointments/events.
• Becoming paranoid or suspicious.
• Not eating well.
• Unable to take medication properly.
• Social isolation.
• Unexplained dents in car.
• General safety concerns.
• Change in behavior.

• Listen to neighbors, friends, relatives.
• What have they observed?
• Observe for yourself, but be aware that your loved one may appear more oriented when you are present.
• Make unannounced visits at different times of day.
• Spend extended periods of time in the home to observe their ability to function independently.
• Respond; don`t react.

1. You pick Mom up for a visit to a local tearoom and her clothes are dirty. What might be the problem?
   1. Washing machine is broken
   2. Poor lighting in house
   3. Problems with eyesight
   4. Depression and/or apathy

    

2. Uncle Joe doesn`t want to get out anymore. What might be the problem?
   1. Fear of falling
   2. Incontinence
   3. Can`t hear/enjoy activities
   4. Depression
      
3. Aunt Mabel isn`t taking her medication properly. What might be the problem?

1. Doctor`s orders are unclear
2. Medication makes her feel worse
3. She can`t remove cap from bottle
4. She can`t read the label on medication
5. She`s trying to save money by taking medications at a lesser dose and/or less frequently

4. You visit Ms. Smith and notice a strong urine odor. What might be the problem?

1. Incontinence
2. Urinary tract infection
3. Afraid to get in shower
4. Unable to smell odors
5. Not remembering to shower

• What is the doctor`s opinion?
• Is your loved one a hazard to him/herself or someone else?
• Is the situation creating a burden for the spouse of your loved one?
• Are you intervening too often?

• Sleeping poorly?
• Missing work or often late?
• Feeling resentful toward your loved one?
• Feeling overwhelmed?
• Suffering from physical or emotional illness?
• Being a caregiver is a balancing act. If the reason you are considering moving your loved one is your mental and physical health, don`t feel guilty. YOU CAN`T DO IT ALL!

• In-home Services
• Moving your loved one into your home
• Residential properties

• What`s really out there?
• There are multiple services that you can access in the home.
  • NOTE: It may be necessary to work with multiple service providers to meet the needs of your loved one

• Personal assistance
• Light housekeeping
• Meal preparation
• Transportation
  • NOTE: Some agencies are also licensed to provide hands-on care such as dressing, bathing and incontinent care.

• Therapies
• Nursing services
• Personal care
  • NOTE: Medicare will pay for some home health services if there is a need for skilled care. However, this is generally short-term.

• Adult day care centers are classified as either “social” or “medical.” Both offer a secure setting for seniors who have physical or mental impairments, meal service, and activities. In addition, “medical” adult day care centers offer:
  
  • Meal service
  • Medication administration
  • Activities
  • Nursing supervision

• Nutritious meals
• Activities
• Games
• Educational opportunities

• Medical service used when a person has been diagnosed with a terminal illness and, generally, has less than six months to live.
• These agencies provide physical, emotional and spiritual support to the client and family.

• Transportation
• Meals on wheels
• Bill payer programs
• Case management

• Does agency conduct criminal history checks and reference checks on employees and volunteers?
• Does it have a drug testing policy?
• Is the agency licensed? If licensed, what is its inspection history? · Is it bonded and insured?
• How does it resolve complaints and concerns?

• Some in-home services are covered by Medicare, Medicaid and private insurance.
• Ask questions before you sign any contracts.
  • Will the agency expect payment in advance?
  • Will it bill your insurance?
  • How often does it bill?

• Fear of running out of money
• Fear of strangers
• Fear of nursing homes
• Fear of being forgotten
• Fear of losing independence

• Friends and family
• Physical health
• Roles such as spouse, employee
• General feeling of independence
• Identity
• Car and home

• Home
• Memories, life history
• Neighborhood, community
• Sense of security
  

• Finding the right place can be a challenge.
• There are multiple choices representing a continuum of care.
• You will likely need to visit several properties to find the right fit.

• Center with independent living, assisted living and nursing care on the same campus.
• This is a good option for married couples who need different levels of care.
• Some CCRCs will guarantee placement for the remainder of a person`s life even if the person runs out of money.
  

• Properties that are federally funded for the aged and disabled.
• Regulated by the Department of Housing and Urban Development to serve independent residents.
• Additional services can be contracted such as health care, transportation, meals and housekeeping.

• Private apartments or cottages.
• Good option for people able to care for themselves.
• Provide opportunities for socialization and a sense of security.
• Properties generally provide housekeeping, laundry, meal service, and transportation.

• Assisted Living – Type A
  • Licensed facility.
  • Provide supportive services while allowing seniors to maintain their independence.
  • Type A facilities will accept residents who are able to leave the building unassisted in case of emergency.
    
• Assisted Living – Type B
  • Licensed facility.
  • Type B properties can accept residents with more complex medical problems.
  • Services may include transfer assistance and incontinent care.
  • Residents who cannot leave the building unassisted in case of an emergency can be accepted.
    
• Assisted Living – Special Care
  • Licensed facility.
  • Designed for people with dementia.
  • Generally locked units.
  • Special activity programming for people with dementia.
  • Daily personal assistance service.

• Nursing Facility
  • Licensed facility.
  • Provide therapy services, nursing care and custodial care.
  • Residents may be there for respite, rehabilitation or long-term care.

• Special Care Unit – Nursing Facility
  • Licensed facility.
  • Providing specialized care for persons with Alzheimer`s disease and other types of dementia.
  • They may have locked units with special activity programs for the residents.

• How much does it cost?
• Is there a second person fee?
• Is there a deposit? If so, is it refundable or non-refundable?
• Is there an application fee?

• Most properties will raise the rent at least yearly.
• Ask about the history of rent increases.
• When does the increase usually takes place?
• Are you locked into a lease for a year?
• What happens if your loved one gets ill and must move?
• Annualize cost and plan for an increase of 5% or so per year.

• Make an appointment.
• Make a list of all your questions.
• Prepare the marketing representative by telling what is important to your loved one.
• Go at a time when your loved one can see activity in the building such as meal time or game night.

• Make sure all questions are answered.
• Get activity calendar and menu.
• Get brochure with prices.
• Get copy of lease agreement and other legal documents.
• Observe staff and residents.
• Talk to residents and their family members to see how satisfied they are.
• Observe how people access the building for security purposes.

• Once you tour several properties they will probably start to look a like.
• Make a notebook with checklist and questions. Take notes during tours.
• Keep brochures.
• Once you have toured all the properties, you will need to narrow down your search.
• Tour properties again.
  • You may want to go in the evening when management staff has left for the day.

• The Texas Department of Human Services has a web site designed to help you in the search for a nursing facility. It gives a comparison to other facilities in the county or zip code area.
  http://facilityquality.dhs.state.tx.us

   

  • NOTE: This report should not take the place of visiting a property.

The Long-Term Care Ombudsman may also be able to tell you about facilities’ complaint histories. 

• Choosing a nursing home is much like choosing any residential setting.
• You should ask many of the same questions you asked when touring a more independent setting.

• What do your senses tell you?
• Do residents appear well care for?
• Do employees interact positively with residents?
• Do employees interact positively with other staff?
• Is the building clean and odor free?
• Is the facility accessible by public transportation? If not, staff may have a hard time getting to the facility, and there may be more problems with short staffing.
•  What is the facility`s staff turnover rate? This reflects how satisfied employees are with their work. 

• Adjustment takes time
• He/she may need to grieve the loss of the house, community, independence
• Don`t sell the house immediately
• Continue to visit with regularity but don`t hover
• Plan times to visit when you can share a meal or attend an activity
• Make sure he/she doesn`t feel abandoned 

• Visit often.
• Take things to discuss such as pictures, books, church bulletins.
• Discuss your daily activities.
• Encourage participation in activities.
• Join them for activities.
• Bring small gifts such as flowers or plants.

• Attend care plan meetings.
• Be realistic.
• Pick your battles.
• Catch staff doing things right.
• Learn chain of command.
• Get to know staff by name.
• Seek to understand staff.

• Talk to the person who can resolve the problem. 
• Follow chain of command.
• Contact the Ombudsman. His/her phone number should be posted in clear sight.
• As a last resort, file a formal complaint with Texas Department of Human Services.
  • NOTE: Write down concerns and give them to appropriate staff. It is also good to keep a record of your efforts

• Medicare
• Medicaid
• Private Insurance
• Private Pay

• Medicare Part A – pays hospital and nursing home costs. Eligibility is automatic for most people when they turn 65.
• Medicare Part B – pays physicians, labs, ambulance costs, etc. It does require you to enroll and pay premiums, unless your income is very low and you qualify for assistance through the State. 

• Part A covers …
  • Inpatient hospital care.
  • Skilled nursing facility care.
  • Home health care.
  • Hospice care.

   

• Criteria for Skilled Nursing Facility Care.
  • Three day hospital stay.
  • Skilled need must exist.
  • Need inpatient facility.
  • Access services within 30 days of discharge from the hospital.
    
• Misconceptions about Medicare:
  • AA person can be covered for up to 100 days provided if he/she has a skilled need and continues to improve. 
  • If a person plateaus or stops improving, Medicare will cease. 
  • Many people think they will automatically get 100 days of nursing facility care. However, this is not true.

• Assistance program administered by State.
  • Eligibility is based on financial and medical necessity.
  • Different component of this program.

• Medicaid - Community Based Alternatives.
  • Purpose is to direct Medicaid funds into community based care to allow people to stay at home. 
  • Services include but are not limited to: personal care and attendant services, therapies, medical supplies and adaptive equipment.
    
• Medicaid - Nursing Facility Benefit.
  This benefit covers:
  • Nursing services
  • Room and board
  • Medications
  • Medical supplies
    • NOTE: A person must meet certain income requirements and “spend down” to a specific level of assets. Currently, Medicaid recipients who are singly are allowed no more than $2,000 in assets (excluding the homestead).

• Supplemental Insurance – also known as “Medigap” functions as a supplement to Medicare Part A and covers most co-pays.

• Long-term Care Insurance – covers people who may have chronic illness such as strokes, dementia, and arthritis. 
  • The coverage is generally a daily rate and may cover home care, assisted living and nursing home care.

• Many services and residential settings are not covered by any type of insurance or entitlement program.
• Some of these services will require you to pay up front or at the time service is delivered.