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As a Certified Guardian, I am often asked to act as a senior’s Power of Attorney for Health Care when s/he doesn’t have a family member who is willing or fit to act for him/her. Simply stated, the Power of Attorney for Health Care grants the designated “agent” control over the senior’s decision-making, including end-of-life decisions if the senior lacks the capacity make the decisions on his/her own. As a Power of Attorney For Health Care, you should be thoroughly familiar with a senior’s personal, financial, and medical history before accepting this serious responsibility. Please read the following real life story that makes my point.

REAL LIFE STORY

Five years ago,  I was called at the last minute to act as Power Of Attorney (POA) For Health Care for an 85 year-old  woman.  It was the day before she was to move to independent living at a retirement community. Independent living used to mean that the senior can basically function on their own with some assistance with meal preparation and housekeeping. Now there are a lot of ala carte services that can be brought to the senior’s independent apartment, allowing him/her to remain there without changing to the assisted living level of care. The woman’s former POA had moved out of state and had written her a formal letter of resignation. A trust company had been appointed to act as her Power of Attorney For Finances.

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My client was the son of a 72 year-old woman who had suffered a stroke within the last six months. She had been placed at an excellent assisted living community that I had used for several clients in the past. After the stroke, she needed some help with her activities of daily living. Her son had indicated that he wanted to move her due to the high price being charged at the community. He was bearing most of the expense. He asked that I come and visit with her in order to hear her side of the story.

When I went to assess her in the lobby of the current community (at the son’s request), I found a well-dressed woman who was totally independent and had all of her faculties. When I asked her why she was in assisted living, she told me about the stroke. The physician who practiced at the community originally would not release her to the independent living level of care.  She felt the woman needed medication supervision.  But, my client proved her wrong. Then on review of my client’s case, the physician reversed the decision and approved her her to live in the independent living area.

However, my client didn’t want to remain at the current community. She had met a boyfriend there, and he had recently moved to a competing independent living community. She wanted to move there too.  As the conversation developed, she shared that her boyfriend wanted her to move in with him because his memory was getting bad, and he wanted someone to take care of him.

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“There’s no place like home for the holidays,” sings Perry Como in the Christmas classic composed by Robert Allen and recorded in 1954. But despite the wonderful lyrics of writer Al Stillman, sometimes you can (and maybe even should) reconsider what best constitutes “home sweet home.” For a senior whose health or faculties are failing, or who would benefit from greater socialization and/or daily living support, the holidays can be a good opportunity for family members to bring up life planning for the new year. It is, after all, one of the few times of the year when loved ones gather and may pause to converse leisurely around the kitchen or dining table.

Here are three tips to consider this holiday if you are trying to convince a senior to move or even simply trying to bring up this often delicate subject:

Do not use words such as “nursing home” or “facility” or “institution” during a conversation with the senior. Instead, use the words “retirement community,” “continuing care retirement community,” or “alternative living option.” A lot of seniors have awful memories of a loved one living in an old-time nursing home, with few to no amenities, and little sophistication with regard to geriatric needs. Your older loved one might not realize how senior living communities have changed. They are not your Grandma’s nursing home anymore!

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20171031_141154-2-300x225How in the world are busy professionals who also have growing children supposed to find the time to handle their aging parents’ issues – both health and living arrangements?

More and more of them are turning to experienced professionals who have experience in the field and can assist with everything finding the most cost effective and person-centered elder care, to interviewing potential home caregivers, to dealing with legal and financial specialists, to acting as a liaison to Medicare and long-term care insurance companies and even to paying bills.

Chicago Senior Living Advisors, based in Inverness, provides personalized Geriatric Care Management which is designed to assist family members or other unpaid people who are caring for an elderly or cognitively impaired loved one, according to Andrea Donovan, president.

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I recently enrolled in the Certified Dementia Communications Specialist program offered by two of my colleagues in the senior living industry, Tami Neumann and Cathy Braxton of the Silver Dawn Training Institute. As a senior housing consultant and Certified Geriatric Care Manager, I am almost always hired by the children of the senior. The senior is usually a Person With Dementia (PWD). The child of the senior often asks me to interact with his or her loved one, particularly if the senior needs to be convinced that it is time to move to a long term care community.

What I found invaluable about the Silver Dawn Institute Program is that it is based upon the basic rules of improv, which are: 1) relinquishing your agenda; 2) making your partner look good; 3) Using “Yes…and”; and 4) the gifts.

I recently used the rules of improv to assist the adult child of a person with dementia. Here is what happened:

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As I have mentioned in the past, the lines between the levels of care provided by long-term care communities have become very blurred. As the number of assisted living communities providing specialized memory care seems to increase every week, here are some of the things you need to look out for if you are contemplating moving a loved one to one of them:

Last month, I was hired by a family to advocate for their grandfather who had recently turned 100 years old. He was living in an assisted living community that specialized in memory care. Please note that the level of care offered was assisted living only and did not include a third higher level of care, i.e., skilled nursing. When he entered the community a year ago, he had been totally ambulatory and able to take care of all of his activities of daily living with cueing. Shortly after he entered, the community physician decided to take him off of all of his memory-related medications (without the consent of the family), because the doctor felt the medications were adversely affecting the patient’s kidneys. The grandfather went into withdrawal and ended up in a wheel chair needing total assistance with all activities of daily living.

In addition, the absence of using one of the dementia medications made the grandfather combative. The staff at the community claimed that he was at times in need of a three-person assist. Normally, a two-person assist and beyond indicates that person should be in a nursing home. The staff requested that the family look elsewhere for a new community for their grandfather. The staff also requested that the family hire a private caregiver to assist Grampa with his activities of daily living and prevent him from getting out of bed. The cost of his care in assisted living was $8,300 a month, just as much as a nursing home, plus the cost of a caregiver. Since the grandfather was already 100 years old, the grandchildren did not want to move him. Upon the request of the grandchildren, I was asked to attend the quarterly care plan meeting (attended by the Administrator and representatives of dietary maintenance, social work and nursing). Here is what happened:

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I recall having a conversation 5 or more years ago with a colleague who was an Admissions director of a high–end assisted living community.   It was around the time when I observed assisted living communities were going beyond providing “stand-by” assistance with activities of daily living (ADLs = bathing, dressing, toileting, transferring, walking and eating) and providing “hands on” care to residents in need.  Hands on care typically had been handled at the intermediate nursing care level, when a resident needed 24-hour supervision and “hands on” care with ADLs.  My colleague looked across the desk at me and said, “Andrea, the days of skilled nursing as you and I know it are dead.”  I remember that my immediate, gut reaction was, “You are crazy. Nursing homes will never disappear.”

A recent article published in Crain’s Chicago Business (August 21, 2017), titled “Out with nursing homes, in with home health care,” showcased the fact that Northwestern-owned Lake Forest Hospital, located in the affluent suburb of Lake Forest, Illinois, has plans to replace its hospital but will not include plans for building a new long-term care unit.  The reasons cited were that the “Northwestern Medicine may have found the one market where investment in long–term care has not paid off.” A spokesperson from Northwestern’s partner law firm said that “Only the sickest patients end up in nursing homes.  People 65 and up tend to find home health care and assisted living more comfortable.”

Given such trends, nursing homes may start to diminish in a community as wealthy as Lake Forest.  But nursing homes will probably always exist in one form or another.  I have to admit that among the many senior housing placements that I have completed in the past few years, the number of assisted living placements is way up, and the number of nursing home placements has decreased.   I recently reviewed some pricing for assisted living in a northwest suburb that featured help with ostomy or catheter care (a service the assisted living communities wouldn’t touch a few years ago because it was considered a skilled nursing service), hands on service with ADLs, a 2 person assist in transferring, medication assistance including help related to diabetes, chemo or radiation therapy or dialysis, and assistance with a feeding tube.  The price for this kind of care in a studio assisted living apartment is under $6,500 a month.  That pricing is well under the price of nursing home care, which on the lowest end can start at $7,000-$8,000 per month in the Chicago metro area.  So why wouldn’t someone opt for assisted living in the comfort of a private apartment vs. a semi-private room in a nursing home setting?

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My father suffered a stroke at the age of 86. He had received diagnoses of Parkinson’s and Alzheimer’s at the age of 84. As the diseases can have similar symptoms, it was very difficult to pinpoint which disease was causing his behaviors. At times he was depressed, moody, lethargic, and verbally abusive.

After the stroke, he required skilled nursing home care.  That prevented my mother from bringing him home. My mother felt an obligation to place him at a nursing home that was owned by the hospital where he had practiced as a physician for many years. That was our first mistake. We assumed that since he practiced at the hospital well into his 80’s that he would have decent care. Much to our family’s dismay, it was quite the opposite.

My story is no different than anyone else’s nursing home nightmare. But at the time, I was not yet in the eldercare industry and didn’t know any better. I didn’t know that checking the ratio of the staff to residents, observing the staff’s attitude, and watching for possible language barriers were critical components in the selection of a community.

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An article posted in National Real Estate Investor has predicated that active senior living communities and Continuing Care Retirement Communities will be the most profitable in the future senior housing market.

I was trained in a faith-based, Continuing Care Retirement Community (CCRC) that offered independent living, assisted living, and a nursing home all on one campus.  A CCRC will allow the senior to move between the various levels of care without having to move out of the building or complex, thus saving the senior and his/her family the stress and heartache of having to move a second time.  In the case of a couple, if a husband or wife requires a different level of care, placement at a CCRC will allow them to remain together in the same home.  If a resident needs short term rehabilitation, most of the skilled nursing areas of CCRCs are certified by Medicare.  The necessary rehabilitation programs are offered right there without having to temporarily move to another community.  Therefore, I wasn’t surprised to see the posted article’s author predicating that CCRCs will be one of the most profitable options for senior housing.

REAL LIFE STORY

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A client who heard me speak a number of years ago decided to hire me for an interesting project. He and his wife live in a large beautiful older home (estimated over 5,000 square feet with three floors). The couple was wondering what the potential future costs of staying in the home would be if one or both of them became ill. I generated a report for them based upon three case examples. Although I didn’t know what the current costs of maintaining their home are, I included places in the report to “fill in the blanks.” I gave the couple some general ideas of what they might need to consider in the future. Many of the future costs would vary by the dimensions of their home and the models of safety equipment chosen (e.g., stair lifts, as they had three floors). The report was meant only to give them ideas of what the costs might be, and what they might need to think about for future safety. I ended the report with a ball park comparison of what it might cost to move to one of the higher end senior living communities. Here are the results:

Case Examples

Client M had been healthy until recently when s/he was diagnosed with a serious heart condition. The client was ambulatory, but now needs a walker. Because the disease has left the client very weak, s/he needs help with meal preparation, bathing, dressing, and standby assistance with toileting. In addition, the caregiver must run errands, provide medication reminders, do laundry, and light housekeeping. All of the necessary help can be obtained through a private caregiver from a licensed non-medical home care agency. The current cost for care of the individual would be $22 per hour. The non-medical home care agency estimated that the client would need at least 8 hours of care per day, 7 days a week so as not to exhaust the spouse. Therefore, the cost of the care would be $176 per day, and $1,232 per week. The total annual cost for the caregivers would be $64,064. In addition, the bedroom was on the second floor, so the stairs would need to be modified in order to accommodate a lift, the cost of which would start at $1,600. The bathroom needed to be outfitted with grab bars, and the shower needed to be modified to a walk-in model, with the addition of a raised toilet seat. A ramp needed to be fitted to the back door, with access to the driveway. Additional support had to be hired to keep the ramp and other areas free from snow and ice. The house needed to be canvassed for tripping hazards and slippery floors.

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