Category Archives: Geriatric Care Manager

Alzheimer’s Treatment: Non-Drug Therapies That Can Help

Written by Evan Farr

There are treatments available now that most families coping with Alzheimer’s or other dementia never hear about that can significantly improve their quality of life.

Called non-pharmacologic therapies (NPTs), these treatments do not come in a pill. Instead, NPTs such as personal counseling and occupational therapy-based strategies are proven to improve the quality of life for people with dementia and their families. NPTs support families and teach them the skills they need to protect their own health and cope with the intense demands of caregiving and help people with dementia stay independent and safe for as long as possible. Some of the NPTs currently used are proven programs that are actually more effective than any known drugs for Alzheimer’s disease.

One example of an NPT, developed at NYU, includes individual and family counseling to reduce conflict and improve communication among family members. Those caring for a spouse with dementia who received the NYU Caregiver Intervention were more satisfied with social support and less depressed, less bothered by difficult behaviors, had better physical health and were able to keep their ill spouses at home longer than those receiving usual care.

Another model developed at Thomas Jefferson University in Philadelphia, employs occupational therapists to assess the patient with dementia and identify preserved capabilities as well as the caregiver’s needs. Families are then provided with strategies to manage day to day care, such as communication techniques, safe-proofing the home, establishing daily routines and engaging the individual with dementia in meaningful activities. Families who participated have reported feeling more confident and less upset, and found that their ill family member functions better and exhibits fewer challenging behaviors.

Another NPT that is now being used is a stimulator device surgically implanted into the brain of a patient in the early stages of Alzheimer’s disease. The implanted device is seen as a possible means of boosting memory and reversing cognitive decline, and has already been used in thousands of people with Parkinson’s. The surgery involves drilling holes into the skull to implant wires into the fornix on either side of the brain.  The wires are attached to a pacemaker-like device, which stimulates the brain with tiny electrical impulses generated 130 times a second. The patients don’t feel the current.

Lastly, another effective non-drug Alzheimer’s treatment used to jog memory is music. In nursing homes that use music, the personalized playlists are often meaningful songs chosen by loved ones.  According to Alzheimer’s experts, music helps patients become more alert, more cooperative, more attentive, and more engaged. In many cases, even if they can’t recognize loved ones and they’ve stopped speaking, when the patients hear music, they “come alive”.

Geri Hall, a clinical nurse specialist at the Banner Alzheimer’s Institute, explains how music activates a part of the brain that stays active despite the dementia. “There is something about music that gets through to Alzheimer’s patients right up until the very end of the disease,” she said, adding that “familiar music from the past can help people with dementia feel at home. It calms them, increases socialization, and even decreases the need for mood controlling medications.” Read our blog post about Alzheimer’s and Music.

Alzheimer’s slowly robs its victims of a lifetime of memories and the ability to perform simple daily tasks.  Instead of focusing on drug treatments, many of which have failed in clinical trials, it may be a good idea to try non-drug treatment options. These programs have been proven effective in randomized controlled trials. And, unlike drug therapy, there are no adverse side effects. There is also an economic argument to be made for better caregiver support. Nearly 11 million family and other unpaid caregivers provided an estimated 12.5 billion hours of care to people with dementia. This care is valued at nearly $144 billion. The country can’t afford the consequences of these caregivers becoming too burned out or sick to carry on. See our recent blog post about the rising cost of dementia.

Moving a person with dementia to a nursing home, while sometimes unavoidable, is expensive. The NPTs described have helped to delay nursing home placement for more than a year. Unfortunately, you cannot delay the inevitable forever, but what you can do is plan ahead for you and your loved ones. Do you or a loved one need nursing home care in the near future or are you looking to plan ahead? Call 703-691-1888 to make an appointment for a no-cost consultation at The Fairfax Elder Law Firm of Evan H. Farr, P.C.  We can meet with you, access your situation and determine strategies for your long-term care plan.

Important Medicare Change: Patients No Longer Need to Show Progress to Receive Nursing Coverage

Written by Evan Farr

Medicare coverage of short-term rehabilitation in a nursing home is about to undergo a major policy change, resulting in beneficiaries with chronic conditions such as Alzheimer’s disease, Parkinson’s disease, ALS (Lou Gehrig’s disease), diabetes, multiple sclerosis, hypertension, arthritis, heart disease, and stroke no longer need to show ongoing improvement to maintain Medicare coverage.

For decades, when short-term rehabilitation patients in nursing homes failed to show improvement but still needed skilled nursing in the form of custodial care or therapy, Medicare would routinely terminate their Medicare coverage, forcing these patients prematurely into private pay or, if they could financially qualify, Medicaid.  This need for ongoing “improvement” was a pervasive, though unwritten ”rule of thumb” followed by Medicare and by Medicare contractors when doing Medicare evaluations in nursing homes.  However, nothing in the Medicare statute or its regulations has ever stated that “improvement” is required for continued skilled care. 

A class action lawsuit, Jimmo v. Sebelius, was filed against the Obama administration in January 2011 in federal court. This case and a similar case in Pennsylvania aimed at ending the government’s use of the “improvement standard” were both settled by the Government.  This settlement should result in Medicare no longer focusing on “the presence or absence of an individual’s potential for improvement.”  Rather, Medicare must continue to provide short-term care whether or not the patient is improving, provided the patient needs skilled care.

It must be understood that Medicare coverage for nursing home care is still a very limited type of short-term benefit, as it only covers a maximum of 100 days per benefit period, and only if the patient requires skilled nursing care. However, under the new settlement, Medicare coverage should no longer be terminated just because the patient’s medical condition is no longer improving. On the contrary, coverage should remain available for services that are needed to maintain the person’s condition or to prevent further deterioration.

In summary, Medicare coverage in the past has often been erroneously denied for individuals with chronic conditions, for people who are not improving, or who are in need of services to maintain their condition. With this new government settlement, it should no longer be necessary for an individual’s underlying condition to be improving in order to continue to get Medicare coverage!   I emphasize the word should because the people who implement these policies may not conform to the new settlement as quickly as they should, so coverage appeals may be necessary in the short run until the local workers on the ground all get educated about this new shift in governmental policy. 

Luckily, the Medicare program has an appeal system to contest improper termination of coverage. Beneficiaries and their advocates should use this system to appeal Medicare determinations that unfairly deny or limit coverage.

For more information about this settlement, see: http://www.medicareadvocacy.org/hidden/highlight-improvment-standard

To appeal what you believe is an improper Medicare termination in a nursing home, please download this self-help packet:  

MEDICARE SKILLED NURSING FACILITY SELF HELP PACKET

To appeal what you believe is an improper Medicare termination of home health care, please download this self-help packet:  

MEDICARE HOME HEALTH SELF HELP PACKET

 

 

Planning for Long-Term Care (Part 5)

Written by Evan Farr

The Veteran’s Aid and Attendance Pension Benefit

The best advice that I can give you when planning for long-term care is not to delay. We never know what the future holds. While we are able, we must prepare for a variety of situations, and so it is imperative not just to plan for long-term care, but to plan properly.

Part 1 of this five part series began showing why establishing a good Long-Term Care Plan is a necessary and urgent matter. Part 2 outlined the three most essential documents found in a good Long-Term Care Plan and Part 3 explained how long-term care insurance might enhance that plan. The last installment, Part 4, discussed how a trust that is unique to our firm, the Living Trust PlusTM Asset Protection Trust, can protect your assets from the hassles and expenses of probate PLUS the expenses of long-term care. The Living Trust PlusTM is the only type of self-settled asset protection trust that allows a settlor to retain an interest in the trust while also protecting the assets from being counted according to state Medicaid laws. What I have just described is the single most prominent feature of the Living Trust PlusTM and it is also what makes this type of trust be the preferred form of asset protection for most people.

The final installment of this series will now discuss an under-utilized, special monthly pension benefit available to wartime veterans and surviving spouses of deceased wartime veterans who are incapable of self-support and in need of regular personal assistance.

Who Is Eligible for the Veteran’s Aid and Attendance Pension Benefit?

To receive the Veteran’s Special Pension Benefit for Aid & Attendance, a veteran must have served on active duty, at least 90 days, at least one day of which occurred during a period designated as wartime.

 Periods Designated As Wartime:

  • World War II — December 7, 1941 through December 31, 1946
  • Korean Conflict — June 27, 1950 through January 31, 1955
  • Vietnam Era — August 5, 1964 through May 7, 1975; for veterans who served “in country” before August 5, 1964, February 28, 1961 through May 7, 1975
  • Gulf War — August 2, 1990 through a date to be set by law or Presidential Proclamation

There must have been a not dishonorable discharge. If younger than 65, the veteran must be totally disabled. If age 65 and older, there is no requirement to prove disability. However, the veteran or spouse must be in need of regular aid and attendance due to: inability of claimant to dress or undress, or to keep clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back etc.); inability to eat due to loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment.

Not all of the disabling conditions in the list above are required to exist. It is only necessary that the evidence establish that the veteran or spouse needs “regular” (scheduled and ongoing) aid and attendance from someone else, not that there be a 24-hour need.

Determinations of a need for the aid and attendance is based on medical reports and findings by private physicians or from hospital facilities.

What Is the Amount of the Aid and Attendance Benefit?

Effective December 1, 2011, the Veterans A&A Pension can provide:

  • $20,447 per year (~$1,704 per month) for a qualified veteran;
  • $24,239 per year (~$2,020 per month ) if the veteran is married;
  • $13,138 per year (~$1,095 per month ) for a surviving spouse of a qualified veteran;
  • $31,578 per year (~$2,631 per month ) if both spouses are qualified veterans.

Is Aid and Attendance Only For Low Income Veterans?

No, and this is the primary reason that this benefit is so widely misunderstood. If you speak to a Veterans Service Representative in a regional VA office and ask them about the Veterans Aid and Attendance benefit, they will typically ask for your household income. When you tell them your household income, they will compare it to a chart and most often tell you that you earn too much income to receive the benefit. While the information they provide may be technically accurate, what they typically don’t explain is the “income” for Veterans Administration purposes (sometimes called IVAP or “adjusted income”) is actually your household income minus your recurring, unreimbursed medical and long-term care expenses. These allowable, annualized medical expenses are such things as health insurance premiums, home care expenses, the cost of paying a family member or other person to provide care, the cost of adult day care, the cost of an assisted living facility, or the cost of a nursing home.

To be able to receive the Veterans Pension with Aid and Attendance benefit, the veteran household cannot have adjusted income (i.e., household income minus unreimbursed medical expenses) exceeding the Maximum Allowable Pension Rate — MAPR — for that veteran’s Pension income category. If the adjusted income exceeds MAPR, there is no benefit. If adjusted income is less than the MAPR, the veteran receives a Pension income that is equal to the difference between MAPR and the household income adjusted for unreimbursed medical expenses. The Pension income is calculated based on 12 months of future household income, but paid monthly.

How is the Aid and Attendance Benefit Calculated?

The monthly award is based on VA totaling 12 months of estimated future income and subtracting from that 12 months of estimated future recurring, unreimbursed medical expenses. Allowable medical expenses are reduced by a deductible to produce an adjusted medical expense which in turn is subtracted from the estimated 12 months of future income.

The new income derived from subtracting adjusted medical expenses from income is called “countable” income or IVAP (Income for Veterans Affairs Purposes). This countable income is then subtracted from the Maximum Allowable Pension Rate — MAPR — and that result is divided by 12 to determine the monthly income Pension award. This cash benefit is paid in addition to the family income that already exists.

Filing a Claim

Filing a claim for the Veterans Aid and Attendance Pension Benefit is complex and time-consuming. If you want to do it correctly, it’s important to get qualified assistance. Just knowing which form to fill out and how to complete it is a complex endeavor in itself. Even if the proper form is completed, failure to check a single box may result in a complete denial of your claim.

The application process involves: obtaining evidence of prospective, recurring medical expenses; appointments for VA powers of attorney and fiduciaries; and a thorough understanding of the application process. Often, qualification for this benefit involves reallocation of assets and shifting of income in order to qualify, and these re-allocations may have significant impact on Medicaid eligibility.

Given that many veterans who need the Aid and Attendance Benefit will eventually wind up also needing Medicaid, this process should not be attempted without the help of a qualified elder law attorney who thoroughly understands both the Veterans Aid and Attendance Benefit and the Medicaid program, as well as the interaction between these two benefit programs.

We assist Level 4 clients of our firm, at no charge, in completing the required paperwork.

Conclusion

Evan H. Farr is an Accredited Attorney with the U.S. Dept. of Veterans Affairs, and the Farr Law Firm is an Elder Law and Estate Planning Firm that helps Veterans and their spouses obtain the financial assistance to which they are entitled. If you are a Veteran or spouse of a Veteran and you need assistance in your home, or are living in or considering moving into an Assisted Living Facility or Continuing Care Retirement Community, please contact us to see if you might qualify for the Veterans Aid and Attendance Special Pension Benefit. Call us today and take the first step towards gaining the peace of mind that comes with a good Long-Term Care Plan. 

If You’d Like More Information About Veterans Aid & Attendance,
Please Fill Out the Form Below to Receive our Veterans Aid & Attendance Special Report!

Planning for Long-Term Care (Part 4)

Written by Evan Farr

The most important thing that you can do in planning for future contingencies is to act now. The future may hold limited resources or health problems for you and either one of these may prevent you from taking care of the things that you can easily achieve today.

In Part 1 of this series, I showed how making a good Long-Term Care Plan is an urgent and necessary step in preparing for the future. In Part 2, I outlined the three most essential documents found in that plan, namely, a General Power of Attorney, Advance Medical Directive with a Long-Term Care Directive and a Lifestyle Care Plan. In the last installment, Part 3, I discussed using long-term care insurance as part of a Long-Term Care Plan.  As we saw in Part 3, Virginia’s Long-Term Care Insurance Partnership Program offers government-endorsed “Medicaid Asset Protection” to consumers who buy long-term care insurance.
Part 4 will now discuss how our Living Trust PlusTM Asset Protection Trust can protect you from probate (as does a Revocable Living Trust) PLUS protect you from the expenses of long-term care.

You Can’t Afford to Ignore Long-Term Care Expenses

Whether you’re rich, poor, or somewhere in between, you cannot afford to ignore the potentially devastating costs of nursing home care and other types of long-term care. Nursing homes are the most likely and one of the most expensive creditors that most Americans are likely to face in their lifetimes. Remember the following statistics that I cited in Part 1 of this series:

  • About 70% of Americans who live to age 65 will need long-term care at some time in their lives, over 40 percent in a nursing home.
  • As of 2008, the national average cost of a private room in a nursing home was $212 per day or $77,380 per year.
  • The average person age 65 today will need some long-term care services for three years. Women need care for longer (on average 3.7 years) than do men (on average 2.2 years). Twenty percent of them will need care for more than five years.
  • Long-term care is not just needed by the elderly. A recent study found that 46 percent of group long-term care claimants were under the age of 65 at the time of disability.

Contrast the above long-term care statistics with statistics for automobile accident claims and homeowner’s insurance claims:

  • Between 2005 and 2007, an average of only 7.2% of people per year filed an automobile insurance claim.
  • Between 2002 and 2006, an average of only 6.15% of people per year filed a claim on their homeowner’s insurance.

Revocable Living Trusts Don’t Help

A revocable living trust is a wonderful tool to protect your assets from the expenses of probate, but it does not protect your assets from the expenses of long-term care while you’re alive. Because you have 100% unlimited access to the funds in a revocable living trust, so do your creditors, including nursing homes and State Medicaid programs.

Living Trust PlusTMProtect Assets from Probate PLUS Lawsuits PLUS The Expenses of Long-Term Care

In response to this limitation of revocable living trusts, I have developed a unique solution – a special type of irrevocable trust called the Living Trust PlusTM that functions very similarly to a revocable living trust but protects your assets from the expenses and difficulties of probate PLUS lawsuits PLUS the expenses of long-term care while you’re alive, in addition to a multitude of other financial risks during your lifetime. The Living Trust PlusTM protects your assets from lawsuits, auto accidents, creditor attacks, medical expenses, and — most importantly for the 99% of Americans who are not among the ultra-wealthy — from the catastrophic expenses often incurred in connection with nursing home care. For most Americans, the Living Trust PlusTM is the preferable form of asset protection trust because, for purposes of Medicaid eligibility, this type of trust is the only type of self-settled asset protection trust that allows a settlor to retain an interest in the trust while also protecting the assets from being counted by state Medicaid agencies.
Even though the Living Trust PlusTM is “irrevocable,” it can still be terminated so long as all interested parties (typically you and all of your beneficiaries) agree to terminate it. Additionally, you remain in control of your assets because:

  • you can be the trustee if desired;
  • you retain the right to receive all of the trust income;
  • you retain the right to live in and use your real estate;
  • you retain the right to change trustees; and
  • you retain the right to change beneficiaries.

The Living Trust PlusTM has no effect on your income or your income taxes.
If you’re a client or potential client who would like more information about the Living Trust PlusTM, please call us at 703-691-1888 to contact us for an appointment, visit the Living Trust PlusTM web site at http://www.livingtrustplus.com or click here to register for one of our upcoming Living Trust PlusTM informational seminars.
If you’re an attorney interested in more information about the Living Trust PlusTM or interested in the possibility of licensing the Living Trust PlusTM Asset Protection System, visit the Living Trust PlusTM web site at http://www.livingtrustplus.com and click on the link labeled “For Attorneys.”


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Planning for Long-Term Care (Part 2)

Written by Evan Farr

“Long-Term Care” refers to the broad spectrum of medical and support services provided to persons who have lost some or all capacity to function on their own due to a chronic illness or disabling condition, and who are expected to need such services over a prolonged period of time. Long-term care can consist of care in the home by family members (assisted by voluntary or employed help), adult day health care, or care in assisted living facilities or nursing homes.

In Part 1 of this series I mentioned that 60% of us will need long-term care at some point in our lives. When this statistic is put in perspective with the relatively low likelihood of making an automobile or homeowner’s insurance claim, the risk that you or I will need long-term care at some point in the future is shocking. Unfortunately, the majority of Americans are either unaware of these statistics or refuse to plan for the often catastrophic costs of long-term care. Part 1 of this series outlined the necessity to create a good Long-Term Care Plan in addition to, or as part of, your Estate Plan; Part 2 will now discuss the three most essential documents found in a good Long-Term Care Plan, as well as two additional documents that are often also part of a Long-Term Care Plan.

General Power of Attorney

A General Durable Power of Attorney (POA) containing Asset Protection Powers is the first essential document. Not all POA’s are created equal; it is crucial that this document be prepared by a knowledgeable and experienced Elder Law Attorney. One way to ensure the qualifications of your attorney is to look for one who is Certified as an Elder Law Attorney by the National Elder Law Foundation, the only organization accredited by the American Bar Association to certify lawyers in the specialty area of Elder Law. For a list of Certified Elder Law Attorneys, please visit http://www.nelf.org/findcela.asp.

A POA (always “durable” when used in connection with estate planning and long-term care planning) authorizes your “Agent,” sometimes called an “Attorney in Fact,” to act on your behalf and sign your name to legal and financial documents. It is an essential tool in the event that, due to age, illness, or injury, you are unable to carry on your legal and financial affairs. Asset Protection Powers written into the POA are essential in order for your Agent to protect your assets from the often-catastrophic expenses of long-term care. Attorneys who are not experienced Elder Law Attorneys often fail to put these essential Asset Protection Powers into the POA.

A properly-drafted POA is designed to avoid the need to go through a court-supervised conservatorship proceeding, which is a time consuming, expensive, and publicly embarrassing process whereby someone goes to court to have you declared incompetent and to be appointed as your Conservator. The Conservatorship process is often referred to as a type of “living probate” because the Conservator is subject to all the rules of the probate court, including the onerous requirement of filing annual accountings with the Court. State laws vary regarding the use and acceptance of a power of attorney.

Advance Medical Directive

The second essential document in a good Long-Term Care Plan is an Advance Medical Directive (AMD) containing a Long-Term Care Directive. As with General Powers of Attorney, every lawyer drafts AMDs differently, and most attorneys do not include a Long-Term Care Directive within the AMD. Therefore, it is again in your best interest to have your AMD written by an attorney who specializes in long-term care planning, such as a Certified Elder Law Attorney.

An AMD (also called a Medical Power of Attorney or a Health Care Power of Attorney) authorizes another person (called your “Medical Agent”), to make decisions with respect to your medical care in the event that you are physically or mentally unable to do so. This document includes the type of provisions that used to be in what was commonly called a “Living Will,” allowing you to indicate your wishes concerning the use of artificial or extraordinary measures to prolong your life in the event of a terminal illness or injury. In the AMD you will also appoint a “Medical Agent” and give that person the power to consent to medical and health care decisions on your behalf with regard to providing, withholding, or withdrawing a specific medical treatment or course of treatment when you are incapable of making or communicating an informed decision on your own behalf. A comprehensive AMD will also allow you to indicate your wishes with regard to organ donation, disposition of bodily remains, and funeral arrangements.

A properly-drafted AMD is designed to avoid the need to go through a court-supervised guardianship proceeding, which is a time consuming, expensive, and publicly embarrassing process whereby someone goes to court to have you declared incompetent and to be appointed as your Guardian, typically at the same time they are requesting appointment as your Conservator.

Long-Term Care Directive

Most importantly for your Long-Term Care Plan, your AMD should include a Long-Term Care Directive (or this could be drafted as a separate document), which will allow you to make your desires known in the event you need long-term care in the future. For instance, do you want to remain at home and receive home-based care as long as possible, regardless of cost, even if it drastically reduces or entirely depletes your estate? Or would you prefer to remain at home and receive home-based care only if it doesn’t drastically reduce or entirely deplete your estate? If nursing home care is absolutely required, would you like to protect as much of your assets as can be legally protected so that you can qualify earlier for publicly-funded Medicaid benefits? If so, do you prefer that the protected assets be used to enhance your quality of care, or to provide an inheritance for the beneficiaries of your estate?

In order to be easily accessible when needed, your AMD should be registered with an electronic archive service that can immediately fax the document to any desired destination. Some Elder Law Attorneys, including our firm, provide such registrations to clients at no charge.

Lifestyle Care Plan

The third essential document that is found in a good Long-Term Care Plan is a document called a Lifestyle Care Plan, also known as an Advance Care Plan.  The Lifestyle Care Plan is a document that is created by special software that gathers, organizes, stores and disseminates information provided by you in an interview, in order to guide those who you will depend or for future care. The Lifestyle Care Plan identifies your specific needs, desires, habits and preferences and incorporates all of this information into a document that your future caregiver can use to provide you with the best possible long-term care.

As an example, Alice wrote in her Lifestyle Care Plan that if Alzheimer’s disease or some other type of dementia inhibited her mental abilities to communicate or recognize her surroundings, she wished to be in a respectable facility and only asked that she be visited and brought chocolates. To her children this request seemed silly at the time, but when her mental capacities did diminish, the instructions were there. No one had to wonder if they should try to take care of Alice at home and how they would do it. Without guilt or question they placed her in a respectable facility that took care of her needs. All they had to do was make loving visits, and of course they brought chocolates.

Because of the importance of the Lifestyle Care Plan, the Farr Law Firm provides one to all of our clients as part our comprehensive Long-Term Care Planning services. To learn more about the benefits of having an Advance Care Plan, please click here or visit our Web site at:  www.farrlawfirm.com/advance-care-plan.htm

Living Trusts

A good Long-Term Care Plan will always include the three documents mentioned above, and will typically also include a Living Trust — either a Revocable Living Trust (RLT) or the  Living Trust Plus™ (LTP).

An RLT generally provides for the creator of the trust to have full use of the trust income and principal for life. On the death of the creator, the assets may continue to be held in trust (or may be distributed) for the benefit of the named beneficiaries, such as the grantor’s children. Although the most important benefit of the RLT is to avoid probate, a well-drafted RLT also can help protect from incapacity and can therefore be an important part of a Long-Term Care Plan. Similar to a General Power of Attorney, an RLT can provide uninterrupted management of your assets by your trustee if you become incapacitated, sparing you and your family from having to go through the expense and complexities of a court-appointed conservatorship. It is important to note that an RLT does not protect your assets from the expenses of long-term care. On the contrary, the assets in an RLT must be spent, if necessary, in providing long-term care, even if that means spending down all of the assets in the RLT to provide such care. For more information on RLTs, please click here or visit our Web site at: www.farrlawfirm.com/revocable.html

The Living Trust Plus™ is a living trust that is designed to protect your assets from probate PLUS lawsuits, PLUS nursing home expenses.  In other words, the LTP protects your assets from the complications and hassles of probate and from other financial risks, including the threat of lawsuits, auto accidents, creditor attacks, extended hospitalization, and — most importantly – the catastrophic expenses associated with nursing home care. Part 4 of this series will explore the LTP in detail.

Conclusion

A good Long-Term Care Plan will always include a General Power of Attorney, Advance Medical Directive, and Advance Care Plan, and will typically also include a Living Trust — either a Revocable Living Trust or the Living Trust Plus™.   However, as mentioned in Part 1, these essential legal documents are only part of the requirements for a good Long-Term Care Plan. The other important component is a plan for how to pay for long-term care. The next installment in this series will discuss protecting your assets by purchasing long-term care insurance.

The Farr Law Firm specializes in long-term care planning and we would be happy to assist you in your preparations. Please visit us at www.VirginiaElderLaw.com or call us at 703-691-1888.

New Hope for Diagnosing Alzheimer’s: Plus, Unlikely Team of Players Unite to Battle Disease

Written by Evan Farr

While it’s no secret that Alzheimer’s Disease can cause confusion in the estimated 5.1 million Americans directly affected by the disease, both researchers and the general public have spent years perplexed by the disease as well.  For a look at some of the most common misconceptions about Alzheimer’s Disease, see the Alzheimer’s Association‘s list of the top 8 Alzheimer Myths.

The Alzheimer’s Association, which calls Alzheimer’s Disease “the defining disease of the baby boomers,” points out that “too many of America’s baby boomers will spend their retirement years either with Alzheimer’s or caring for someone who has it.”  The Alzheimer’s Association also points out that although death rates for other major diseases — HIV, stroke, heart disease, prostate cancer, breast cancer — are declining, “Alzheimer’s is the only top 10 cause of death without a way to prevent, cure or even slow its progression.”

There is no question that Alzheimer’s Disease is a growing concern, especially as the number of America’s baby boomer and elders continues to rise.  But despite the disease’s prevalence, there are already two positive developments in 2011.  First, researchers seem excited about a new means to predict — and perhaps one day to diagnose — the disease with certainty in the living.  Second, an unlikely team of players  has unified on the front lines…from an NFL superstar to some of America’s largest pharmaceutical companies.

Three Recent Studies Suggest ‘Biomarkers’ Could Play Pivotal Role in Predicting Alzheimer’s Disease

What is a biomarker? AstraZeneca defines the term as:

“a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacological responses to a therapeutic intervention.”

In essence, a biomarker is an identifiable variable that can be measured in humans.   While this may sound like a very broad definition, the breadth of the concept is what makes it so promising.

A recent study, published in the Journal of the American Medical Association (JAMA) and reported by Senior Journal,  aimed to investigate a potential relationship between “plasma beta-amyloid 42 and 42/40 levels and cognitive decline in a large group of community-dwelling older adults without dementia.”

The study found that older individuals who do not suffer from dementia, but have lower levels of “blood plasma and biomarkers beta-amyloid 42/40 (protein fragments),” may be at an increased risk for experiencing cognitive decline later in life:

“[The use of] biomarkers to identify elderly persons at risk of developing dementia could be useful for early prevention, if and when such interventions are available, and treatment.”

In a different study, three specific proteins in cerebrospinal fluid were found to potentially “spot” Alzheimer’s disease.  That study appeared in The Archives of Neurology.  The BusinessWeek article on this study is available here.  Of note, the Senior Director of Medical and Scientific Relations at the Alzheimer’s Association had this to say:

“This just reinforces the recommendation by [Alzheimer's working groups] saying that biomarkers can actually be incorporated today into clinical practice in order to add a certain piece to the diagnosis if patients are already presenting with something that looks like Alzheimer’s.”

Still another study carried out by the Texas Tech University Health Sciences Center and the Texas Alzheimer’s Research Consortium, reported by Ivanhoe Newswire, found that blood serum biomarkers PLUS other clinical information could be used to more accurately classify patients with Alzheimer’s.  Commenting on the importance of such studies, the authors say:

“There is clearly a need for reliable and valid diagnostic and prognostic biomarkers of Alzheimer’s disease, and in recent years, there has been an explosive increase of effort aimed at identifying such markers.”

The Texas Tech study authors are optimistic:

“With the rapidly evolving technology and the analytic techniques available, Alzheimer’s disease researchers now have the tools to simultaneously analyze exponentially more information from a host of modalities, which is likely going to be necessary to understand this very complex disease.”

Pharmaceutical Companies are Uniting to Fight Alzheimer’s Disease

CNN reported recently on Big Pharmaceutical companies uniting to share data in an effort to better understand the disease:

Numerous Celebrities Help Raise Awareness of Alzheimer’s Disease

Dozens of national celebrities have been helping to raise awareness of the devastating toll that Alzheimer’s Disease takes on our society.   Here’s a “Behind the Scenes” look at some of the Alzheimer’s Association’s Celebrity Champions:

This CNN story (and the video below) highlights the emotional toll that Alzheimer’s disease has had on one such Celebrity — NFL star Terrell Owens.  Mr. Owens’ battle against the disease on behalf of his mother has touched hearts and inspired many:

Recognizing Early Symptoms is Important: Top 10 Signs

The Alzheimer’s Association provides 10 ways to spot early-onset symptoms here.  Summarized by MayoClinic, you will find them listed them below for your convenience:

  1. Memory loss that disrupts daily life
  2. Challenges in planning or solving problems
  3. Difficulty completing familiar tasks at home, at work or at leisure
  4. Confusion with time or place
  5. Trouble understanding visual images and spatial relationships
  6. New problems with words in speaking or writing
  7. Misplacing things and losing the ability to retrace steps
  8. Decreased or poor judgment
  9. Withdrawal from work or social activities
  10. Changes in mood and personality

Have you Heard of Alzheimer’s Planning?

Many people are unaware that Alzheimer’s Planning is a sub-specialty of Elder Law.  It involves a unique and complex combination of estate planning, long-term care planning, asset protection, Medicaid planning, and nursing home planning, and requires a specialized knowledge of the legal and financial problems and issues that are unique to families dealing with this devastating illness.  We at the Farr Law Firm routinely assist clients with all of the financial and legal issues surrounding Alzheimer’s Disease.

One of the primary goals of Alzheimer’s Planning is to ensure the highest possible level of personal dignity and quality care for the remaining lifetime of the Alzheimer’s patient. To achieve this goal, it is often necessary to protect assets as quickly as possible, so that if the Alzheimer’s patient  must enter a nursing home, Medicaid can be obtained as soon as possible. Money that is protected through Alzheimer’s Planning can often be used to provide the Alzheimer’s patient with an enhanced level of care and a better quality of life while in the nursing home and receiving Medicaid benefits.

Conclusion

There is still a long way to go in predicting, diagnosing, and ultimately preventing Alzheimer’s disease.  But with help coming from all directions – the steady fight of the Alzheimer’s Association in leading the global fight for a world without Alzheimer’s, new research methods and tools, consolidated efforts from Pharmaceutical Companies, and the increased awareness created by dozens of celebrities who have been personally touched by this destructive disease — hopefully greater strides for combating this disease are in store in 2011 than ever before.

The Alzheimer’s Association, mentioned several times in this article, is the leading voluntary health organization in Alzheimer’s care, support and research. The Association’s mission is to eliminate Alzheimer’s disease through the advancement of research; to provide and enhance care and support for all affected; and to reduce the risk of dementia through the promotion of brain health.  If you have a question about Alzheimer’s disease, if you’re providing care for someone with memory loss, or if you’re experiencing memory loss yourself, the highly trained and knowledgeable staff of the Alzheimer’s Association can assist you at any time — just call their 24/7 Helpline at 1-800-272-3900.

Lastly, don’t overlook the quality of life and dignity that can be preserved through Alzheimer’s Planning.  Until there is a cure or vaccine for Alzheimer’s disease, the focus for many families is on ensuring the quality of life and dignity of those suffering with this disease.  For more on Alzheimer’s Planning, please visit us at http://AlzheimersPlanning.com.

Reverse Mortgage Rules Changing Again

Written by Evan Farr
money-question-markI’ve written several times over the years on the topic of Reverse Mortgages.  My first article explained the concept and requirements of a Reverse Mortgage and how seniors can use a reverse mortgage.  My second article, entitled Using a Reverse Mortgage to Pay for Home Care, explained how the Reverse Mortgage can be used as a tool to help seniors stay in their homes and age in place.  My most recent article, entitled Huge Problem with Reverse Mortgage Industry, raised a nationwide alarm about how the reverse mortgage industry is “shooting itself in its collective foot” (and, I believe, discriminating against disabled and incapacitated adults) by routinely second-guessing the legitimacy of every power of attorney document and therefore imposing unnecessary obstacles for, and sometimes turning away, the very people who need a reverse mortgage the most — those frail elders who are unable to care for themselves but wish to remain at home and age in place rather than being forced to sell their homes and move into a long-term care facility.  Here’s the link for the ElderLawAnswers article which picked up on my concerns and confirmed the enormous scope of this problem.
 
Now, having already maimed itself with the power of attorney fiasco, the reverse mortgage industry seems intent on digging its own grave.   According to Stephen Pepe, JD, a Reverse Mortgage Consultant with MetLife Bank, there are big changes coming soon to the HECM Reverse Mortgage programs, changes which for many seniors are going to significantly increase the expenses of obtaining a reverse mortgage after October 4, 2010, while also making the reverse mortgage counseling process “much longer and more involveddue to significant changes in HUD’s HECM counseling protocol.”
 
In an email sent to the members of the National Academy of Elder Law Attorneys, Pepe explained as follows:
 
“Congress and HUD have made some significant changes to the Home Equity Conversion Mortgage (HECM) reverse mortgage program that take effect on October 4, 2010. These changes impact any applicant that does not have an FHA Case Number assigned to his or her HECM application before that date.”

Specifically, Pepe says that HUD’s ongoing Mortgage Insurance Premium will be increasing from 0.5% to 1.25% (a 150% increase!), and that the size of new HECM reverse mortgages will shrink anywhere from 1% to 5% depending on the applicant’s age.

However, Pepe also points out that homeowners will soon have a second HECM reverse mortgage option, called the “HECM Saver.” According to Pepe, the HECM Saver is a smaller and less expensive reverse mortgage. Under the HECM Saver, a reverse mortgage applicant will gain access to significantly less money, but in return, says Pepe, “HUD will waive its pricey Initial Insurance Premium, saving the applicant up to $12,510 in initial costs.” 

Pepe did not mention whether HUD will be waiving or reducing the ongoing Mortgage Insurance Premium, so I’m guessing it won’t be.
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Who Was Supposed To Be Watching Grandma?

Written by Evan Farr

There is a popular tune played this time of year called “Grandma Got Run Over by A Reindeer” which relates that Grandma — after drinking too much eggnog — went out into the winter cold to get her medication and was run over by a reindeer. The question is . . .  “Who was supposed to be watching Grandma?”

Though this little tune is just for fun, it may very well raise alarms to many caregivers of the elderly. Caregivers know that even at a holiday party they cannot let down their diligent watch over their elderly loved one. As far-fetched as it may sound, with all the people and noise, an elderly family member with dementia or Alzheimer’s may be enjoying the family gathering and then suddenly become confused and walk to the door and leave.

For family caregivers the added stress of the holidays with decorating, shopping, parties and keeping up with all the family traditions is an overwhelming quest. Feelings of isolation, depression and sadness come with this added stress. There are millions of Americans who are caring for elderly frail loved ones and most of these caregivers will go through some of these emotions, especially this time of year.

There are some things you can do as a caregiver to help you and those you care for enjoy the holiday season.

First take care of yourself. Try to eat right, get plenty of sleep and exercise. This will help reduce stress and strengthen your ability to cope with caregiving responsibilities.

Prioritize your holiday traditions. Perhaps instead of cooking a large family dinner, have everyone bring his or her favorite dish. Use paper plates. Forfeit the traditional outside light decorating for a lighted wreath on the front door. Choose one or two parties or concerts to attend instead of trying to do it all.

Arrange for help. Call on other family members to help with the caregiving while you do your shopping or go out for the evening. If family is not available, ask your church group or a neighbor if they would donate a few hours.

Use community services. Many senior centers provide meals for the elderly and supervised activities, onsite, at no charge or a minimal charge. For locating senior services in your state, call your state Area Agency on Aging or check the national locator website at http://www.n4a.org/

Use adult day care services. Some assisted living facilities provide day activities and meals for seniors on a day by day basis. Other organizations called “adult day service providers” specialize exclusively in this sort of care support at a reasonable cost. These support services provide respite for caregivers from their caregiving responsibilities as well as social interaction for their elderly family members. There is a cost for adult day services, but the benefit for all is worth it.

Technology to the rescue. Here is a solution that would have kept “Grandma” from going out in the winter cold and getting run over by a reindeer. Companies that have created monitoring systems, security alarms and other safety equipment are “tweaking” them to adapt to the needs of seniors and their care givers.

Here are a few examples:

  • Ankle or wrist bands that monitor location and alert the provider when a person has gone beyond the designated perimeter, such as out the front door of the house.
  • Motion detectors. Set throughout the home, motion detectors allow someone outside the home to follow a senior as he or she moves through the house.
  • Smart medication dispensers. Live monitoring and dispensing of pills.
  • Emergency response alert. At a touch of a button on a desktop monitor, bracelet or necklace, emergency help is summoned.

Whether providing care in your home or helping senior family members in their own homes, your use of monitoring and “tech” help aids can provide extra safety for your loved ones, and peace of mind for you.

You are not alone. Join a caregiving help group. Your local senior center may have one or go on the internet to find one. Hearing about other caregivers’ problems and solutions and being able to share your own and ask questions is a great way to relieve stress and gain a new perspective. Check out websites like the National Family Caregivers Association at http://www.nfcacares.org/

Work with a Senior Care Professional. Recognize that you are doing the very best you know how. You are not a geriatric health care practitioner, geriatric care manager, home care nurse or aide, hospice provider or family mediation counselor, nor do you have the years of training and experience these professionals have, but you can definitely use their experience. In fact, using a senior care specialist will make caregiving easier for you and more beneficial for your elderly family member.

You can find a wide variety of care professionals in your area on the National Care Planning Council website at www.longtermcarelink.net and on our website at http://www.virginiaelderlaw.com/TrustedReferrals.htm.

One more thing to remember. As a family caregiver, the greatest gift you are giving this holiday season is “Love.”

Holiday Blues: Depression in the Elderly

Written by Evan Farr

The holiday season is quickly coming upon us. If you are a caregiver for an elderly loved one, you may notice a change in your loved one’s mood as the holidays approach. Perhaps you are one of many who live a distance away and visit elderly parents and family during the holidays. When you visit, you may notice that your loved one is not as physically active, or is showing symptoms of fatigue or sadness and has no interest in the holiday or in their surroundings.

According to the National Institutes of Health, of the 35 million Americans age 65 or older, about 2 million suffer from full-blown depression. Another 5 million suffer from a less severe forms of the illness. This represents about 20% of the senior population — a significant proportion.

Depression in the elderly is difficult to diagnose and is frequently untreated. The symptoms may be confused with a medical illness, dementia, or malnutrition due to a poor diet. Many older people will not accept the idea that they have depression and refuse to seek treatment. 

What causes depression in the elderly?

It is not the actual holiday that causes depression, but the fact that holidays tend to bring memories of earlier, often happier times. Additional contributing factors that bring on depression may be the loss of a spouse or close friend, or a move from a home to assisted living, or a change with an older person’s routine.

It is not the actual holiday that causes depression, but the fact that holidays tend to bring memories of earlier, often happier times. Additional contributing factors that bring on depression may be the loss of a spouse or close friend, or a move from a home to assisted living, or a change with an older person’s routine.

Depression may also be a sign of a medical problem. Chronic pain or complications of an illness or memory loss can also cause depression. In addition, diet can also be a factor when proper nutrition and vitamins are lacking.

Symptoms to look for in depression might include:

- Depressed or irritable mood
- Feelings of worthlessness or sadness
- Expressions of helplessness
- Anxiety
- Loss of interest in daily activities
- Loss of appetite
- Weight loss
- Lack of attending to personal care and hygiene
- Fatigue
- Difficulty concentrating
- Irresponsible behavior
- Obsessive thoughts about death
- Talk about suicide

How do you know if it is depression or dementia?

Depression and dementia share many similar symptoms. A recent article on Helpguide gives some specific differences.

In depression there is a rapid mental decline, but memory of time, date and awareness of the environment remains. Motor skills are slow, but normal in depression. Concern with concentrating and worry about impaired memory may occur.

On the other hand, dementia symptoms reveal a slow mental decline with confusion and loss of recognition of familiar locations. Writing, speaking and motor skills are impaired and memory loss is often not acknowledged by the person suffering dementia.

Whether it is depression or dementia, prompt treatment is recommended. A physical exam will help determine if there is a medical cause for depression. A geriatric medical practitioner is skilled in diagnosing depression and illnesses in the elderly. If you are a caregiver of an elderly person, it may be beneficial for you to seek out a geriatric health care specialist.  

Treating depression in older people.

Once the cause of depression is identified, a treatment program can be implemented. Treatment may be as simple as relieving loneliness through visitations, outings and involvement in family activities. In more severe cases antidepressant drugs have been known to improve the quality of life in depressed elderly people. Cognitive therapy sessions with a counselor may also be effective.

Once the cause of depression is identified, a treatment program can be implemented. Treatment may be as simple as relieving loneliness through visitations, outings and involvement in family activities. In more severe cases antidepressant drugs have been known to improve the quality of life in depressed elderly people. Cognitive therapy sessions with a counselor may also be effective.

As a caregiver or family member of a depressed older person, make it your responsibility to get involved. The elder person generally denies any problems or may fear being mentally ill. You can make the difference in and remove the Holiday Blues from seniors suffering from depression.

The Geriatric Mental Health Foundation offers a “Depression Tool Kit.” To read more about the tool kit and depression in the elderly go to:

http://www.gmhfonline.org/gmhf/consumer/depression_toolkit.html

For more information on senior health services, see the following lists from Evan Farr’s book, the Virginia Nursing Home Survival Guide:

List of Geriatric Physicians
List of Geriatric Care Managers

Care Management for Your Child With Special Needs

Written by Evan Farr

When establishing a special needs trust (SNT) for your child, it’s important to consider how much care the child may need in the future and who will oversee any arrangements related to that care. In many cases, either a family member or the SNT trustee can assume responsibility for care management. But when care needs are significant or family members cannot be available, parents may wish to include instructions in the SNT documentation for the trustee to retain a professional care manager. This can help ensure that care decisions will be handled professionally and consistently throughout the beneficiary’s life while allowing the trustee to focus on other responsibilities.

What Is a Care Manager? 

A care manager is a professional with the expertise necessary to develop, implement and monitor a plan for all aspects of an individual’s care. Often trained in nursing or social work, care managers are available primarily through private care management companies, many of which also deliver services to the elderly. Generally, a care manager will be knowledgeable about everything from health care and rehabilitation options to residential alternatives. Care managers also should be familiar with the alternatives for funding an individual’s care — both private resources and public benefits.

What Does a Care Manager Do?  

A care manager coordinates, monitors and advocates for services to help ensure that an individual with special needs can maintain the greatest possible degree of independence, safety and comfort at the most reasonable cost. Working closely with family members as well as financial advisors, attorneys, health care providers, the SNT trustee and others involved in the individual’s care, the care manager may:

- Assess the individual’s needs based on visits to the home and one-on-one interviews.

- Develop, or help the family develop, a care plan covering living arrangements, medical and therapeutic needs, social preferences, educational opportunities and other relevant issues.

- Implement the care plan. This may include coordinating physical therapy, medical care, social services and equipment needs; improving the home’s safety and comfort through repairs or modifications; and hiring home health aides or training family caregivers.

- Work with the SNT trustee to ensure that private and public resources are used appropriately, helping to preserve trust assets and avoid improper distributions that could jeopardize the beneficiary’s eligibility for benefits.

- Address emergency or crisis situations.

- Consider housing alternatives and oversee placement, handling such details as admissions paperwork and moving arrangements.

- Monitor care in the home or at residential facilities and recommend changes as necessary.