Assisted Living – What to Look For? What to Avoid?

Recently, a friend of mine, who works in this field, asked, “how do I advise friends and clients who are in the uncomfortable position of having to choose a new home for mom or dad?”

Assisted Living? What to Look For and What to Avoid

First of all, I want to point out that there are several other choices besides Assisted Living Facilities (“ALF”) and Nursing Facilities (“NF”). I encourage EVERYONE to look at those options before setting their sights on an ALF or NF. See also, my earlier post, here.

This blog post will not discuss Independent Living, Continuing Care Retirement Communities, Home Care or any other alternatives. I will not spend much time talking about Nursing Facilities either but, I think it’s really important to distinguish between ALFs and NFs. Here’s the important differences:

  1. ALFs are NOT medical facilities. They are NOT required to have a medical director (doctor), or even nursing staff on duty. It is possible that a resident’s attending physician will make a “house call” to the ALF. But, there is no requirement for medical staffing – not even for a nurse, RN or LPN. Many ALFs do have a Licensed Practical Nurse (LPN) on duty, particularly during the day. But they are not required to do so.  The majority of the staff are administrative, Certified Nursing Assistants (CNA), housekeeping and dietary workers, and Medication Technicians. There is NO requirement for a doctor to be present or see a residents at any time.  If a medical situation arises, typically there is no qualified medical staff there who can assess the situation and call a doctor for direction. The result is that your family member will be sent out to their physician, or more likely, 911 will be called and residents may be transported by ambulance to the nearest hospital.
  2. NF’s ARE medical facilities. They MUST have a Medical Director (an M.D.) and there are requirements for Registered Nurses (RN or NPs) They also staff with many Licensed Practical Nurses (LPN). They employ many CNAs and MedTechs. They will likely have an RN on duty who can at least assess and report to an M.D. who can make a determination of the urgency of care or issue medical orders and prescriptions by phone or fax. They can decide whether it can be addressed by the attending physician (often the Medical Director) if a trip to the hospital is necessary.
  3. Because of the above distinction, the two types of facilities are regulated differently. ALFs are licensed and inspected by Social Services. NF are licensed and regulated by several other agencies including the State Office of Licensure and Certification as well as Department of Medical Assistance (DMAS) and Federally, they are regulated by CMS (Center for Medicare and Medicaid Services) under the Department of Health &  Human Services.
  4. This difference used to mean that these facilities used to be priced differently. This is less and less often the case. The difference in cost is negligible if the level of assistance is about the same.
  5. One is initially placed in NF or ALF not because of what we “choose” – whether one goes to an ALF or NF will largely depend upon their level of care required. More on this below.

Since rarely does one have too much choice about NFs (it typically being a function of dollars & cents and available beds), the remainder of this discussion will center on ALFs.

Before I continue, I encourage readers, if considering an ALF, to first take the time to watch the outstanding production, Life & Death in Assisted Living, which aired on PBS “Frontline” in July of 2013. Please watch it. Note that it primarily addresses, “for profit” ALFs.

To be clear, a “non-profit” is not an institution that doesn’t make money. Non-profits differ from for-profit corporations only by how they distribute the money they make. For-profits have shareholders; profits are typically paid out in the form of “dividends” to the shareholders. For-profit corporations also have a Board of Directors, and officers (President, Secretary and Treasurer) as well as “operating officers” or executives – CEO, CFO etc. Often, these people command very high salaries at the corporate level. Non-profits, generally speaking, do not have shareholders. The money they earn is plowed back into the business in the form of capital improvements (buildings, equipment), more staff, higher salaries, better programs and training and the like. But they too have Boards of Directors, CEO’s CFOS and other “corporate” employees who command high salaries and money earned by the facility can, and often is, distributed at the end of the year to these folks in the form of salaries, bonuses and other forms of compensation or benefits.  It can also be “poured” into a Trust for later use or distribution.

One should also distinguish between Charitable Non-profits. Some, but not all, Non-Profits are “Charitable” organizations. Just because a “Non-profit” is affiliated with a faith community (e.g. the Catholic Diocese, Mennonites, Jewish affiliated, Disciples of Christ, Presbyterian Church) does NOT mean it is a “charitable non-profit organization.” A religious non-profit designation typically has to do with their tax status and means they are likely exempt from taxes. A Charitable Non-profit MAY be tax exempt, but that is not necessarily so.

None of this “corporate, legal, mumbo jumbo” should really be a concern in choosing a home for mom or dad except that on the whole, “non-profits” seem to manage their human and capital, resources better, and, as a result, provide better care. Faith-affiliated communities (no matter which faith) seem to have a better structure in place for using their much larger, more dedicated, pool of volunteers to good purpose. In our area, we have many faith affiliated facilities including Catholics, Mennonites, Mormons and Presbyterians to name a few. That does not mean you must BE Catholic, Mennonite, Mormon or Presbyterian to live there. It means it is run by or affiliated with, those communities.

Whew! I digress.

Getting to the meat of the subject, most people end up in an ALFs because they need “memory care” or because one cannot otherwise be cared for home, even though they are not physically debilitated enough to justify NF care.

I have been in many ALFs (and NF) both here in Virginia, and in North Carolina where we looked at various facilities for my mother. One thing I find they all tend to have in common is a good marketing director.

The marketing director is talented at showing you around, by appointment. Marketing Director will point out the lovely “restaurant style” dining room, the linen tablecloths and china, the “chef prepared” meals; the nicely appointed “common room” with big screen TV(s), fireplace, game area etc. You might also be shown a charming garden area that is “secure” where “memory care” residents are free to wander in and out. You may be agog at the lovely furniture, wallpaper, thick, plush carpet and beautiful tile or polished wooden flooring and vaulted cathedral ceilings. You will also be shown a selected “suite” or “apartment” which might even belong to an agreeable resident. You will probably be shown several “floor plans.”

At the end of your tour, you will probably be given a sheet that shows the cost for private and semi-private accommodations called “suites” or “apartments.” Indeed, many ALFs no longer even use the “F” word: “Facility”.

Usually these “suites” are rooms; single (“private”) or shared (“semi-private”). They may have a kitchenette area with sink and microwave, and a tiny area with counter space and storage cabinets. Typically rooms have one on-suite bathroom which has a pull cord for emergencies.

Their information sheet may, or may not, disclose some additional charges for instance:

  • Increased levels of care (“level II, level III etc.)
  • Upcharges for “continence” care
  • Upcharges for “memory care”
  • Upcharges for “medication management” (in addition to “pharmacy charges”)
  • Ancillary charges for all sorts of products: a box of Kleenex that is $1.49 at Walmart, will cost $5 at an ALF, the same for shampoos, soaps, hand lotion; often there are no controls on what the resident asks for no matter how demented they may be;
  • Pharmacy charges.
  • Charges for laundry and housekeeping service
  • Internet, cable TV and telephone charges
  • Charges for additional “private duty” nursing (!!)
  • Cost of meals not on “meal plan”
  • Charges for barber, beauty parlor, mani- or pedi- cure services
  • Charges for transportation or activities fees

How do these things add up? Well, let’s look at the pharmacy example. Naturally, you expect your loved one to have medications administered through the facility’s pharmacy. But your Mom also takes aspirin as a blood thinner. Or Ducolax (a very common stool softener). In the past, you probably purchased Aspirin from a retail pharmacy like Walgreens in 300 count bottle for less than $5. Ducolax (especially if its a store brand) is similarly priced. Now these items can only be provided through the ALF pharmacy because it must be “bubble packed” for administration by a med tech. Now you will pay $1.39 for EACH aspirin through the ALF pharmacy; instead of $5 for nearly a year’s supply. A year’s supply will now cost you $507 for the year. Ten times what it used to cost you! (these are examples taken from actual ALF prices, the prices paid at a particular ALF may be different)

The biggest “add-on” is going to be additional “care levels.” Let’s say the “base rate” is $3,000 a month for your semi-private “suite”. It is not at all unusual – after one is admitted – for the staff to do an “assessment” or “care plan.” After that assessment is done, the care planners will decide that a resident requires more care than originally planned for, for example, they may now need “medication management” or “continence care” or simply, more CNA hours than anticipated so they become a “Level II” care resident. Suddenly your bill went from $3000 each month to $4000 a month. Or even $5000 a month.

The savings one thought they were going to get by doing away with the expense of staying at home with home health, going to a nursing home and other seemingly more expensive alternatives has simply evaporated into thin air. To make matters worse, once mom or dad’s money runs out (as it will, pretty quickly at this rate!) Medicaid is not going to be available to pay for care in an ALF (except in very rare instances). Remember, it is not a “medical” facility so Medicaid won’t pay for it.

So now, all of Mom or Dad’s money has been spent at the ALF; where do Mom or Dad go? To the very nursing home you were trying to avoid all along. But, since you can’t afford to pay privately anymore, you’re at the end of a very long list of people waiting for a Medicaid bed to become available.

So that’s the money issue.

There is a far more substantial consideration than cost: The quality of care. And by that, I mean, the people who provide the care.

First of all, how many are there? Are there enough people on duty so that they don’t seem pulled in 15 directions at once? It’s useful to visit in the morning – unannounced – when Aides are typically busy getting residents up, bathed, dressed, fed and medicated. Are there enough workers to do this without leaving tasks undone or to keep some residents waiting for unreasonably long times for assistance? See if you can position yourself near the spot where the call-bell alarms light up. How many go on, and stay on, for more than a few minutes?

Do the aides seem to know what they’re doing? I’ve seen CNA’s try to get people into wheelchairs who didn’t know how to transfer the resident or position them in a wheelchair or position the chair’s appliances, pads and support pieces to keep them safe, stable and comfortable. I’ve seen them try to do this with the brakes off, such that the wheelchair keeps shifting (dangerously!) for everyone. Are they gentle and reassuring? Or do they shout maybe shove people along, oblivious to the pain or discomfort they may cause? In the case of bathing, toileting or dressing, do they take the time to shut the door or pull the curtain to protect and be cognizant of the resident’s dignity?

Where are the staff? Are they on the floors and in the rooms with residents? Or do they clustered at a “care center” (a.k.a. a nurses’ station) talking to eachother or on the phone? If you can, go visit a resident in their room. While there, ring their call bell. How long does it take until someone responds? And not just putting their head in the door, turning off the bell and saying, “I’ll be right back!” How long does it take to actually respond to resident’s need?

How do staff interact with residents? Do they talk “at them” and walk past like they are pieces of furniture? Do they address them respectfully and by name? Do they squat down so they can look them right in the eye if they are bed- or wheelchair bound? Or do they stand over them or behind them such that they are hard to see or hear which may frighten or startle? (Alzheimers and dementia patients almost always have a severely restricted field of vision. Most other frail and elderly people have deficits in sight and hearing too).  Are they overly patronizing or do they speak to them as if they were small children or in “baby-talk”?  Or do they gently touch a resident’s hand or knee to let them know they are there and care? Do they know and address visiting family members by name?

I recommend finding a “high traffic” spot in the facility – near a central work station, the activity room, the dining room – where you can simply sit and observe things for at least an hour. Take your time, get an accurate picture. You might even do this at different times of day if you can.

Have a meal in the dining room with the residents. Don’t call ahead, just show up unannounced. They can easily set an extra place. If they can’t accommodate that request, well, ask yourself why? You might have to pay a couple of bucks. But you will get a much more accurate picture of the quality of the food than the one you will get if the Marketing Director arranges for you to dine with them. Assisted Livings are a community where people live. You don’t have to make an appointment with the Marketing Director to visit.

Above all, use the smell test. If the place smells of urine, turn around and walk out. There is NO excuse for a facility to smell of urine.   Urine is mostly odorless when it leaves the body because it (under normal circumstances) is sterile at that point. If you smell urine it is because it has been exposed to air and bacteria for at least four hours. If it smells, that means someone(s) has been sitting in urine soaked diaper, bedding or it’s in the carpet for at least four hours. Aside from being embarrassing and uncomfortable for the resident, it can have very serious health consequences, not least of which is skin breakdown leading to “pressure ulcers” (bed sores). Feces is another matter. While I hope that’s not an odor you run into, it does smell strongly and immediately. As a result, it is usually addressed more quickly. But not always. Lingering fecal odors is of course unacceptable.

Lingering food odors – aside from not being very pleasant – can indicate that kitchen or dining room is not cleaned adequately or that air circulation is poor. If there’s a strong odor of Lysol or air freshener you can bet they are covering up other less pleasant smells.

Bottom line: ignore the “bricks & mortar” – it doesn’t matter how lovely the wallpaper, how smooth and classy the upholstery, how eye-catching paintings, how bright the linen tablecloths, nor how fancy the cherry furniture and granite countertops or any other décor; so long as it is clean, well furnished, and in good repair you’re probably going to be ok. Good lighting & fresh air are far more important than expensive trappings (who do you think will pay for that?). Study the prices with a cynical eye and ask many questions about “extras.”

Your “gut” will most likely be fooled by the very nice Marketing Director and the pretty building. Don’t listen to that. Your gut is looking at a Potempkin Village.

The single most important inquiry is “where is it?” followed by “where are you?”   If you are not close enough to visit regularly, Mom or Dad is not going to get the care they need. The proverbial “squeaky wheel gets the grease” goes double in Assisted Living. You – as caregiver or adult child of a resident in an ALF – must be prepared to visit regularly, as often as possible. You may not be daily caregiver anymore. But you do have a responsibility to make sure care is provided. You won’t do it if you have to drive any significant distance to visit. You don’t have to spend hours and hours. Just a few minutes puts staff on notice that you are keeping an eye on things. Be observant and ask questions rather than make demands. Are mom’s clothes coming back from the laundry? Can you see her Medication List? What is each medication for? Are her teeth been brushed? Is her hair done? Do her clothes match? Has she been to activities, did she eat all her meals (best to eat one with her!)

VERY IMPORTANT: be sure to thank staff for their hard work taking care of your family member. Theirs is not a pleasant job. They work long hours, weekends, nights, holidays; through snowstorms, hurricanes and all the resultant emergencies like power outages. Their feet and backs hurt. Your mother or father may cuss at them, throws food (or worse) at them, call them names, bite them, kick them, refuse medication; they make many unreasonable demands upon them. ALF staff do all this for somewhere around $8 – $10 an hour; many are part-time employees lacking any benefits. Some have been doing this work for 20, 30 and even 35+ years. Yes, they could pick another low paying job: they could pump gas, be a cashier, could cut lawns. But they choose to do this job. For most, it’s a labor of love. Thank them. Not just the nurses or CNA’s. The dietary and kitchen staff; the housekeeping people, the laundry personnel, the volunteers, the activities people, the social workers, the administrative staff, even the facilities guy (fixes everything! Including mom’s tv). And ok, the Marketing Director. They ALL come into contact with your family member daily and make the place a home for them. Please thank them even when they are not perfect.

Are Assisted Living Facilities my preferred solution? They absolutely are not. But I recognize that it may be the only feasible solution for your particular situation – especially in some of the more difficult dementia diagnoses. If the facility you are considering claims to have “memory care” or a “dementia unit” – then they better have properly trained and qualified people to care for those residents. Ensure that they do: ask to see the certifications and credentials of the people they claim to have on working on the “Memory Care Unit”. Ask about specialized activities or other factors that make it a “memory care” unit. Simply locking a unit up such that wandering dementia patients can’t freely go in and out is not  “care.” It’s a prison. Likewise, drugging a resident with “behaviors” due to Alzheimer’s or other dementia is actually the use of chemical restraints. The use of chemical restraints is dangerous and illegal.

If after all your exhaustive research, you find your loved one in a facility that does NOT meet the standards you expected or their care is just not up to par, call me. There are many ways to address it. I have likely been there before and will have some ideas how to go about fixing it. Often measures far short of have to move mom or dad again, or suing the facility – neither one an outcome I want to see happen.

Good luck on your journey. This is a difficult path you’ve been thrust upon as you become parent to your parent or other aging loved one. You are not alone, many of us are traveling it with you.






Nursing Homes, Assisted Living or…some alternative?

Multi-generational alternatives benefit everyone.
Multi-generational alternatives benefit everyone.

I’ve written a lot about the process of choosing an Assisted Living or a Nursing Facility or other alternatives. Actually what I’ve typically written about is the lack of choice we have in such matters and that most of us arrive at that weigh station through a medical crisis with a parent or loved one and our choices have become quite limited.

I’m sure many people don’t even realize there are alternatives to these options. I’m going to talk about several. These options exist or are in the works here in the Charlottesville, Virginia area or nearby. Many of these also exist in other communities or are being planned, so it is worth checking out even if you are living somewhere else.

Many of us are graced with the presence of an aging parent or other relative living in our homes.  Or, if they are able, perhaps still in their own homes. Some of them are able to care for themselves and others need constant supervision  and assistance 24/7.   The first and sometimes only option considered by most, especially if they must work outside the home, is home health or home companion care.  If you can afford it, that’s a great solution. However, agency personnel can be quite expensive with costs ranging anywhere from $ 18-30 or more depending on the type of service you need (or combination of services). The types of services are typically: Companion Care, someone to cook, do light housework, watch over someone to ensure they safety, give reminders for medications, perhaps do errands or drive for you:Certified Nursing Assistants (CNAs) can assist with bathing, dressing, shaving, feeding, toileting and the like, in other words, “personal care”  and then there are fully trained, professional nursing care, such as LPN’s or RNS and therapists such as physical, occupational or speech therapy.  Different agencies provide different levels of care and some may overlap. For example, the national company (generally locally owned and managed franchises), Interim Healthcare provides all sorts of medical personnel from therapists to CNA but no companion care.  Another nationally franchised company with locally owned offices is Home Instead which provides home care including CNAs plus companion care but no other medical professionals. Also worth noting is that most agencies have a minimum hourly assignment, typically 3 hours. As you can see this can add up very quickly.

You can also hire non-agency, non-certified, non-regulated assistance.  While this tends to be cheaper, it is also a much riskier proposition. Agencies are required to do background checks (including criminal background and sex offenders). This is not easy information for most private citizens to acquire.   If non-agency caregivers are licensed – for example a CNA or LPN – they should be able to present you with their credentials and hopefully, references. You can also check their license against online databases (in Virginia and most states) to make sure they are genuine and you should verify all references. On the flip side, freelance caregivers, because they are unregulated, are able to do more without worrying about the credentials. So a single caregiver could do both the companion work and the personal care piece for a single lower hourly rate. Private rates can run anywhere (in the Charlottesville area) from $14 upwards.

How does one pay for all this? If you’re lucky, your elder invested in a long term care (LTC) insurance policy that covers home care.  Barring that, most will expect you to pay privately. In some cases – for example after a hospital stay and with a doctor’s order – Medicare may pay for care and even therapy in your home. This is a great way to avoid “Rehab” – a nice word for a nursing facility stay though typically not permanent.  In other cases, particularly low income cases, you may be eligible for an Elderly or Disabled with Consumer Direction waiver orECDC Waiverfrom Medicaid. One advantage to working with an agency if that they typically have staff that will work with you to help figure out the financing of care.  If your elder is a Veteran who served during a “time of war” (not necessarily in “combat”) they may be eligible for cash assistance from the Department of Veterans’ Affairs (VA) known as Veterans Pension and “Aid & Attendance.”

As you may have concluded by now, home care can be a pretty daunting and expense challenge both to manage and for which to pay. What other alternatives are there?

Another reasonable alternative for many working adults with elderly parents or others needing care is Adult Day Care.  The most prominent agency providing daycare programs in Charlottesville is JABA.  JABA offers a caring and safe environment for any adult (18 years +) who needs assistance with daily health or personal care activities and would like to engage in activities with other adults. JABA specializes in the care of adults with dementia.

Temporary or short term Home Care and Adult Day Care are also excellent opportunities for family caregivers to simply take a break and tend to their own needs for rest, recreation and relaxation.

There are two recent, very exciting developments that have come to Charlottesville!

The first, all ready up and running and signing up participants even as I write, is the brand spanking new Blue Ridge PACE which stands for Program of All-Inclusive Care for Elderly.  PACE is a collaborative effort between UVaMedicalCenter, Riverside Medical and JABA – our local Area Agency on Aging. PACE programs are operating all over the country and proving a very successful alternative model (they’ve had one in Lynchburg for a couple of years. Its associated with the Centra Health group).

PACE programs literally provide all the services the elderly need under one roof – or under your roof. Doctors, nurses, social workers, activities, day programs including breakfast, lunch and snacks, pharmacy, transportation, physical/occupation and speech therapy and more – all in one place. You must be a “dual eligible” (Medicare/caid) and over 55 to participate. You may also “join” and pay privately for membership (e.g. not Medicaid eligible) paying a flat fee for membership and using all services.  They deliver services both in their new facility at 1335 Carlton   Ave and in your home. Even if you need to have an in-patient stay at a rehab facility following an illness or surgery, your stay there is covered by your PACE participation.  Sounds too good to be true doesn’t it? Well, time will tell. but I am very excited about the prospect for Charlottesville seniors.  I hope you’ll take the time to stop and visit them and ask for a tour.

There’s another interesting project underway, this one a little further out in terms of its availability. It is called CharlottesvilleVillage.  This concept allows seniors with varying levels of need for assistance to stay in their own home and to – collaboratively – design the kinds of services they need to remain independent. Whereever possible, these services are provided by volunteers from within the community. For a good look at how a “Village” works, take a look at the recent PBS documentary on the subject, titled “There’s No Place Like Home: Seniors Hold on to Urban Independence into Old Age”  If you’d like to find out more about the Charlottesville Village project, you can visit their facebook page here.

Finally, for those seniors for whom living in their own home (or yours) is truly no longer an option and some sort of institutional care is the only route left, there is one more chance to avoid the traditional “medical model” we all hate.   It is called the Greenhouse Model and it has nothing to do with ecology or saving the earth. Except in a psychic sense!  The Greenhouse Model is also sometimes referred to as the “Eden Alternative” and was first conceived and brought to life by a doctor, William H. Thompson, in 2003. He decided to redesign long term care from the ground up.  Since that time, Dr. Thomas created The Green House Project a national non-profit organization dedicated to creating alternatives to traditional nursing home care. The project creates “caring homes for meaningful lives” for elders where each has a private room and bath, can move freely throughout the home, build deep relationships with each other and participate in preparing their own meals. It is based on a philosophy designed to reverse “enforced dependency” in a traditional nursing home by creating small intentional communities of 7-10 residents created to foster late-life quality of life and continued intellectual, emotional and physical stimulation and health.

Unfortunately, Charlottesville does not yet have a Greenhouse Model project (yet! Its my dream to bring one here!) However, they do have one just over the mountain in Harrisonburg. The Virginia Mennonite Retirement Community (VMRC), a 750 bed “Continuing Care Retirement Community” nestled in the Shenandoah Valley recently opened a Greenhouse community. While I’ve not had a chance to go see it myself, I’ve heard – from very reliable sources – that it is indeed a dream come true.

I’ll continue to explore the possibility of opening a Greenhouse Project in Charlottesville (the initial barrier is a licensing issue, but that’s another blog post and too boring). In the meantime, I just wanted to let people know that there are already several viable alternatives to traditional Assisted Living and Nursing Care facilities and that you should look into them before making any decisions.


“Choosing” a Nursing facility- troisième partie

It’s been more than a week, I know. Things got a bit busy and since I am chief cook, bottle washer and everything else around this office, I have to set some priorities. Blogging is way down the list when clients are demanding my attention. Would you want it any other way if you were my client?

Well, let’s return and see how Mom has fared in the nursing home shall we? When I left off in my last post, Mom had just been “de-certified” from Medicare and moved to “unskilled” nursing bed.  She is no longer receiving intensive therapy.

As the days and weeks go by, Mom becomes more depressed and hopeless. She seems dull and lifeless. Even her hair is limp and lifeless. When you visit she is often still in bed even though it’s the middle of the day. She’s not had a bath or brushed her teeth even.  When you visit she is both irritable and angry, or cries and begs you to take her home. Visits become something you dread.  More and more your visits are shorter and farther between.

One night, you get a phone call from the nursing home. Mom has taken a fall and hit her head. They think she’s okay, but it’s the nursing home’s policy that anytime someone falls and no one sees it happen they must automatically transport them to the E.R. to have them checked out.  At the time of the accident, your mother was in pain, confused and panicked. As the EMT’s arrived and tried to put her on a stretcher and into the ambulance, she started to shout and became combatative. In order to safely transport her, the  EMT’s needed to calm her down to prevent her from hurting herself (or them) so she is given a powerful tranquilizer and immobilized onto a stretcher.

Before you are able to arrive at the hospital, Mom is taken for an MRI. She is placed on a moving table and strapped down, then she is  slid into a large cylindrical machine for 45 minutes. The machine makes all manner of very loud clanking, buzzing and ringing sounds while disembodied voices tell her to lie perfectly still. She comes out dazed, completely disoriented and not sure where she is or what is happening.  It’s now 3 a.m. and the doctor decides to keep her “for observation.”  They give her a drug that is meant to help her regain herself, an antipsychotic called Seroquel.  It also acts as a sedative and knocks her out for the night.negative effects antipsychotics

The next morning she awakes and you are at her bedside. She has little or no recollection of what happened or why she is there. The doctor says she may have a concussion and wants to keep her for another day. She complains of pain in her hip and has severe bruising on her face.  The last thing she remembers is at the nursing facility. She recalls ringing the call bell repeatedly for assistance to go to the bathroom. She says that no one ever came and her need became so urgent that she decided to get up herself rather than wet the bed. She thinks she may have had an accident on the floor and may have slipped on the wet floor. She must have fallen then. She recalls nothing else.

Meanwhile, back at the nursing home, the business office tells you that if your mother doesn’t pay for her bed, that is, put  a “bed hold” on it,  they will discharge her. With mother in the hospital again, your boss complaining that you’re taking too much time off, and the kids needing picked up from school,  you can’t worry about this and set that aside so you concentrate on the urgent needs like the kids and mom in the hospital.

As it turns out, Mom has only bruised her hip and does have a concussion but its mild.  However, the neurologist who treated her after the MRI of her head has also diagnosed her with vascular dementia (brought on by mini-strokes) which, while relatively mild now, will get worse over time. She ends up staying one more night in the hospital under observation.

The discharge planner comes around the next morning and starts discussing plans about where to send mom now. Come to find out that her bed at the nursing facility is now gone. Her belongings have been packed up and stored. She was “discharged” from the nursing facility to the hospital.  However, the hospital never “admitted” Mom as an inpatient. She was only there on observation.

While this may seem to be mere bureaucratic technicalities,  they have very significant consequences.

To discharge your mother to a nursing facility now means that she will NOT be eligible for Medicare for any rehab because she did not have the requisite 3 night inpatient stay  she was merely there on observation..  Mother’s resources are nearly tapped out for privately paying for long term care. She has no long term care insurance. No Veterans or other benefits. That leaves very few options. In such cases, the only choice may be to find a “Medicaid” bed.

Medicaid rates (the rate at which Medicaid reimburses a nursing home) are substantially lower than the private pay rates. If a person comes into a nursing facility while eligible for Medicare treatment, the reimbursement rates are higher.  But if a person has fewer resources and will be quickly dependent on Medicaid – public assistance – most nursing homes are reluctant to take them.

Nursing homes typically want to bill every penny they can to Medicare or other 3rd party source (supplemental, long term care insurance etc.) and/or if they can, they want the person to privately pay (out of their own pocket).   These sources are usually quickly depleted by the monthly rates which average about $7,000 a month.

In your mother’s case, she used Medicare in her initial admission following the stroke, thereafter, she paid from her own funds but now that money is almost gone.  Had she stayed where she was, she would simply have depleted her resources and an application for Medicaid would have been filed and she would have stayed right where she was.  But that didn’t happen – instead she was discharged from that nursing facility.

The hospital’s discharge planner begins seeking a facility that will accept a Medicaid resident from the outset – no private pay, no Medicare billing. Almost all nursing homes are “dually certified” – that is, they accept Medicare and Medicaid patients. However, many of them limit the number of beds available to Medicaid patients. There is a therefore a shortage of certified Medicaid beds and the need is great.

But the discharge planner manages to find a bed for your mother after you indicate you can pay their private pay rate for two more months. So off mother goes to a new nursing facility. She is discharged from the hospital (to which she was never actually admitted!)  and transported to the new facility.

Along with the little ditty bag of stuff from the hospital she carries is a discharge order and a list of medications. The med list now includes some things that were not on her regular regimen before. Among them are the antipsychotic medication, Seroquel.  You notice that mom is much more agreeable, calmer and sleeps a lot more.  That seems helpful to you.  What no one notices is that Seroquel – and most of the other medications of this sort – carries a specific “black box” warnings about use in older adults.  The warning reads something like this:

Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel is not approved for the treatment of patients with dementia-related psychosis

There are many potential negative side effects listed as well. Among them, are the increased risk for falls.

However, in a nursing home, the drugs are not administered in the same form we get them from retail pharmacies. Nurses never see the box or bottle the drugs come in, or the sheaf of fliers that come with them. Nursing facilities get “bubbled paks” for each patient from their own pharmacy or contracted pharmacy. So they never see the warnings.

The new nursing home is older, the carpet worn and dingy, the furniture nicked and upholstery faded. The walls are painted a dull blue and stained and marked up.  It’s noisy, smelly and the only activity that is available on a regular basis is a big tv blaring very old movies and bingo every afternoon. The hot food is served on ice cold dishes and the cold food —  iceberg lettuce masquerading as salad, jello, sherbet, cottage cheese and the like —  is served on steaming hot dishes. Everything is stewed or looks like its stewed. All of the food is either over-salted or completely tasteless.

Mom is very complacent though. She sleeps a lot but doesn’t complain much. She has a lot pain so whenever she asks for it, they give her a narcotic painkiller for which her attending physician has written a PRN order or “as needed.” She is also labeled “high risk for fall” so she is no longer allowed to stand or try to walk and is restricted to a wheel chair and completely dependant on nurses aids to transfer her from bed to chair or chair to toilet.  Her lack of activity and complacency about the food means she as begun to put on weight. She eats and snacks on sweets at every opportunity. To please her, you bring in more such treats when you visit.

The nursing facility is trying to turn a profit. They are limited by the fact that so many of their residents are Medicaid payors only. So, even more than any other nursing facility, such nursing homes attempt to make money by reducing expenses. The biggest expense is staff. They keep staffing levels so low that only the barest of care is able to be provided.

Lately, your mom has been having “accidents.” You mom is not incontinent. She can control her bladder fine but, because she must wait for aids to assist her to get to the toilet on time, she is wetting herself and the bed. Soon she is labeled “incontinent.”   Rather than get her on the toilet on a regular interval, and unwilling to regularly change her and the bed, the aids now put her in an adult diaper day and night. Your Mom has become very docile and complacent on the drugs therefore they have no sense of urgency to see to her, she rarely rings the call bell anymore and never yells as she used to – she sometimes lays in a wet diaper for hours.

A year has come and gone since Mom first had her stroke. Mother’s Day is coming. You decide it would be a good idea to take Mom out for an outing, have a change of scenery, get some fresh springtime air.  When the appointed Sunday arrives, you stop for some flowers at the grocery store and go to the nursing home early to help get Mom up and dressed.  The aid has arrived to get her out of her diaper while you choose something nice to dress her in. Together, you and the aid turn her to sit her up and put her clothes on and to your horror you see large, gaping, raw sore on her tailbone.  It is the size of coffee coaster, red and angry looking, seeping fluid.

Thanks to the lack of repositioning or movement, the constant weight on her backside, the skin breakdown from the urine and lack of cleaning or moisturizing of the skin, your mother has a giant bedsore.

This is completely preventable. Bedsores,(also called “pressure ulcers”) except in very limited circumstances, can be avoided by good skin care, repositioning and constant attention and inspection. Mom obviously has received none of this.

You race down to the nurses’ station and demand to speak to the unit manager. You raise holy hell. The Unit Manager, while sympathetic, is distracted by 3 phones ringing and several call bells going off, nods, says they’ll look into it and blows you off.

Monday morning, you call the director of nursing for an explanation. You leave three messages; all go unanswered.  You call Mom’s attending physician’s office. They tell you they will send out the nurse practitioner to have a look and will call you back.

What are you to do now?


Tune in for Part IV!  In which we explore the resources available to help you advocate for Mom.


“Choosing” a Nursing Facility Part Le Deux: They tried to make me go to rehab but I said ‘no, no, no’

Patient wearing respirator
How we left mom at the nursing home last week….

Last week, I wrote about how it is that we really have very little to say in the matter when the decisions are made about taking our aging loved one to a nursing or rehabilitation center when they have a serious health issue arise.

In fact, there’s plenty we can say and do, it’s really about knowing in advance that you have plenty of choices, that you could and should ask many questions and offer input into the healthcare decisions of your loved one. Unfortunately for most of us, these decisions are made when both our loved one and we, as caregivers and family members, are completely depleted – physically, mentally and emotionally.

At the conclusion of the last segment, we had arrived at the “Health & RehabilitationCenter” and Mom had been admitted.  Let’s revisit the “Rehab” and see how Mom’s getting along shall we?

So let’s say, a week has passed. In that time, the staff of the nursing home – nurses, social workers, recreation/activities, physical, occupation and speech/language therapists, (pt, ot, slt) nutritionist or dietary and so on – have all had a chance to do their part on a “baseline” assessment which is done for each and every patient who goes to a Medicare/Medicaid qualified nursing facility (that would be most, not all, there are a very few exceptions). This is called the “MDS” assessment or “Minimum Data Set.”  Medicare and Medicaid keep careful track of every patient and it is from these assessments that

a)      Billing is done for Medicaid

b)      “Quality Measures” are assessed by Medicare.

The first is pretty obvious – Medicaid pays for certain things at certain rates and MDS codes tell them what to reimburse.

The second might seem a bit more mysterious until you understand that nursing home staff are required to continuously update their assessments so that changes are documented for every resident at regular intervals. For instance, if a patient arrives and on their initial MDS assessment, they report no pressure ulcers (bed sores) and 90 days later, the same resident now has bed sores, there has been an decline in the quality of care.  If patients report chronic pain and classify it as a “number 2” on a scale of 1-10, but it gets worse, say the patient later takes a stronger painkiller and self-reports his pain is now a “5” – that too is reported. Things like Urinary Tract Infections (UTI), occurrences of Depression and other things are also carefully monitored. This set of statistics forms a picture of the “quality” of the care patients are receiving at any given facility.

This information is also readily available, to the public, online – for free! You can access it by using the 5-Star Quality Rating System provided by the Center for Medicare/caid Services (CMS).  There’s a very readable set of documentation available on what it is and how best to use the system (click on the link). You can search for data on a particular facility or compare several facilities at the Five Star Rating System. (click on the link). You can also see reports on staffing levels and recent inspection reports (“surveys” in nursing care parlance) including the actual reports of problems as cited by the surveyors.

So your Mom has now been “MDS” assessed and from that a “Care Plan” has been designed in conjunction with her care team.  First up at bat are likely to be the PT/OT/ST team who will try to get Mom into as much therapy as possible. She will have been assessed and orders written by her physician to try to get Mom to the “least restrictive alternative” for her care – that means discharged home, discharged to another facility such as an Assisted Living or to a “unskilled” nursing facility.

Lets say Mom has had a stroke and is “hemispherically” (one side, lets say left) impaired. She has trouble walking, talking, seeing, swallowing and doing most everything that engages her motor system on the left side. She also suffers from some “aphasia”  – that’s a condition where, due to the damage caused by a stroke (in this case) the person  may make mistakes in the words they use, or perhaps using the wrong sounds in a word, choosing the wrong word altogether, or putting words together incorrectly. Its a problem not of motor skill, but of the brain’s ability to handle language and communication. Your mom’s case is not bad and the SLT thinks they can correct it with some intensive therapy.

So your mother’s days are full up with intensive therapy to help her physically – to strengthen the weakened and impaired left side, and to work on balance; in Occupational Therapy – to help her figure out new ways to do tasks that she used to do without a thought: putting on her socks & shoes, getting things down from the pantry shelf, dressing, bathing and getting on and off the toilet by herself. Then hours of very intensive therapy to improve her swallowing and language. At the end of each day she is exhausted and discouraged. When you come to visit at dinner time she is depressed and irritable. She hates the semi-liquid food she’s given because of her impared with swallowing. Her roommate (she can’t afford the upcharges for a private room) watches TV all day and all night at full volume and with the lights on. When she finally does fall asleep, she is awakened by the constant noise from the nurses station down the hall or someone coming to draw blood or check on her roommate. You try to cheer her up by reminding her “its only temporary Mom, you’ll be going home soon.”

Nursing home mom
Mom’s a bit irritable, hopeless and depessed now.

Won’t she?

Well she has 100 day right? That’s what the hospital caseworker said, “Medicare will pay for Rehab for up to 100 days.”  Yes, that’s what they said. Note that it is “up to” 100 days. And she didn’t say that Medicare would pay for ALL the charges. Indeed, right around day 20 you will start hearing the Administration of the facility start making noises about “discharge planning.”  What?  Mom is ready to come home?  Well, not exactly. They don’t necessarily mean discharging Mom home. They mean discharge from therapy, or more accurately, discharge from “Skilled Nursing.”  Again you say, “what?!”

There’s a fly in the Medicare ointment. And it has little to do with your mom.  It has to do with Medicare’s reimbursement schedule. What they actually pay – at 100% reimbursement – is the first 20 days  of rehab. After days 1-20, you pay a co-pay (depending on whether you have traditional Medicare, or an Advantage plan – all of these are moving targets, but basically it comes out in the end).  On days 21-100 you’ll pay $144.50 “co-pay” each day and Medicare picks up the rest.

(By the way, if you find yourself in the hospital in advance of such a situation, one critical question to ask is if you’ve been “admitted” to the hospital as an inpatient. Well of course you were admitted! You were there for 4 days!  Except, today, hospitals routinely bring patients in on “observation” and in fact, unbeknownst to most,  they are not admitted as inpatients.  To go from a hospital to a skilled nursing, or rehab facility and have Medicare pay for it, you must have been admitted for a three inpatient day stay, not including the day you leave. What if you were on ‘observation’ on day one, stayed two more days as an inpatient and left on the fourth? No, Medicare won’t pay for your rehab because you only had a two day inpatient hospital stay. Sneaky huh?)

Most nursing facilities know perfectly well that most of us can’t afford to self pay from our own pockets for rehab. So, ready or not, they’ll begin making noises about “de-certifying” Mom from rehab because they don’t believe she can pay. Will they ask you about it? No. If there’s no second payor insurance (e.g. a private or supplemental policy that picks up where Medicare leaves off) they will start making noises such as, “your mom is no longer getting better” or “your mom doesn’t seem to be motivated in her therapy anymore” and the next thing you know you’re either frantically making plans to put mom elsewhere – your house, an assisted living, home with a home health agency coming in – or heaving a huge sigh of relief when the social worker at the “Health and Rehab” Facility offers you the option of simply moving mom to an “unskilled bed.”  There she’ll be taken care just as she has been all along (for better or worse!) but without all the pressures to participate in therapy to get her back on her feet. Indeed – she might be very hard pressed to get any therapy at all. Often we hear about “restorative therapy” that is meant to keep residents from losing whatever physical gains they’ve made. (notice they are now “residents,” no longer “patients”). Generally, that will consist of a Certified Nursing Assistant (CNA) walking with a resident and perhaps doing some mobility work with them (manipulating arms in legs in bed or shower).

Mom has now gone from a temporary “Health and Rehabilitation” patient, to a full-time, long term care resident.  And if you think she was unhappy before, wait until you see what starts happening next!

Tune in next week, same time, same place….. for Part III – “Choosing” a Nursing Home





Cash Assistance for Veterans – Help Offset the Cost of Long Term Care

Lately there’s lots of “advisors” out there talking about Veterans Benefits. Many are also hawking annuities and “planning services” (creating trusts etc.) to make Veterans Eligible for these benefits. Meh!

This guy deserves some long term care from the country he served!

The VA Enhanced Pension – often erroneously referred to as “Aid & Attendance Benefits” is meant for certain Wartime Vets who are in need of cash assistance. It is not meant for people wanting to leave all of their accumulated wealth to the next generation. In that way, it is like Medicaid — a program designed for citizens in need of assistance as they age.Unfortunately, many of the “planners” (largely insurance salespeople, financial advisors, and yes, lawyers) don’t really have any idea what they are doing with regard to these vulnerable elders and their need for assistance in paying for Long Term Care (whether at home, in nursing facilities or assisted living).  Or maybe they do and just don’t care? By “planning” for VA benefits (divesting the senior of assets to make them eligible for benefits) they inadvertently may cause the Vet or his widow to become ineligible for other benefits – particularly Medicaid.

If you, or someone you know is a Vet (our surviving spouse of a Vet!) and you believe s/he might be qualified for Pension and Enhanced Pension benefits, you might want to talk to a qualified advisor. And to be honest, it is difficult to tell who actually is qualified. (I am certified to practice before the VA and any lawyer that is offering to do VA Benefits work that is not, probably is not a good choice – I can’t speak for the other professions) The Dept. of Veterans’ Affairs allows you to search their list of qualified representives here: – but you do not need to have a lawyer or representative to apply. But I will warn you that it can be a long and complicated process.

If you’re a Vet and have no idea what I’m talking about, but want to know more, see if you can fit into the guidelines below then give me a call. I can help.

General Guidelines to Qualifications for Veterans Affairs Enhanced Pension


Served at least ninety (90) days active duty

At least one day served during a qualified wartime period:

  • WW2 12/7/41 through      12/31/46
  • Korea 6/27-1950 through 1/31/1955
  • Vietnam: if served inside Republic      of Vietnam,      2/28/1961 through 5/7/1975, if elsewhere then 8/5/1964 through 5/7/1975
  • Gulf War: 8/2/1990      through some future date TBD.

Any discharge not categorized as dishonorable;


Assets owned by claimant must be limited. Amount claimant may hold depends on age and health of claimant. No “hard & fast” rule on maximum assets although generally if they exceed $50,000 readjustment of claimants holdings may be necessary. WARNING: do not give away or divest of assets without consulting a professional planner familiar with both VA Benefits and Medicaid. Planning for one set of benefits may result in disqualifying claimant for the other!

Assets that are NOT counted: Primary residence, car, personal effects.

Income: gross income evaluated after reduction by total out-of-pocket annual medical expenses (including pharmacy, Medicare/insurance premiums and typically, the entire cost of Assisted Living is deemed “medical expense”)


Basic Pension for those over 65 and meet above criteria –  pays the difference between countable family income and the yearly income limit (see chart below). This difference is generally paid in 12 equal monthly payments rounded down to the nearest dollar.


Tom is single and has no dependents. He has an annual income of $5,000 from his union pension. His annual income limit is $12,465. To determine Tom’s V.A. Pension subtract his annual income of $5000 from the $12,465 income limit . This comes to an annual V.A. pension rate of $7465. This translates into a monthly VA pension check of approximately $622.

If the claimant is housebound, the amount increases as does the income allowed. Likewise if the claimant requires “aid & attendance” (with activities of daily living such as dressing, bathing, eating, toileting) – the amounts increase. In the case of Aid & Attendance, a doctor’s statement will be required.


Veteran, no dependents $12,465 $1,038
Veteran, one dependent $16,324 $1,360
Veteran, no dependent & housebound $15,233 $1,268
Veteran, one dependent & housebound $19,093 $1,591
Veteran, no dependent, and Aid & Attendance $20,795 $1,732
Veteran, one dependent, and Aid & Attendance $24,652 $2,054
Each additional child $2,093 $174
Widow, no dependent $8,359 $696
Widow, no dependent and housebound $10,217 $851
Widow, no dependent and Aid & Attendance $13,362 $1,113
Surviving child $2,129 $177
Veteran married to Veteran, Both Aid &   Attendance $32,100 $2,675




New Year – New Committment to Improving Long Term Care

I long ago stopped making impossible New Year’s resolutions.  I quit smoking when I was ready to quit (I think it was in September, no New Years involved); I’ve never succeeded at dieting at any time of year. Ditto exercise though I do swim regularly in the summer – still nothing to do with New Year’s resolve.  But I am recommitting myself to something: improving the state of long term care in our community

When I was preparing to open my Elder Law practice, one of the things I did to get familiar with the issues elders face and the regulatory schemes that are associated with them, was to volunteer with our local “Ombudsman” program. In the Jefferson Planning District (5 counties: Albemarle/Charlottesville, Nelson, Fluvanna, Louisa and Greene), JABA is responsible for providing Ombudsmen in local nursing and Assisted Living facilities. You can read more about the federally mandated Ombudsman program here.

As a volunteer ombudsman, I was assigned to a local nursing home to visit with residents and talk to them about questions, concerns, problems or any issues they might have with the facility where they resided. As a neutral 3rd party we could try to help advocate and intercede on their behalf, often anonymously so that the staff could not “retaliate” against the patient or resident who “complained” about their care. In that capacity I met many residents and their family members as well as a large variety of the staff from housekeepers to executive directors. We solved problems whereever the problem lay.

But many problems were so intractable that there seemed to be no solution. Confounding and infuriating. Some residents seemed broken, miserable and unable to be helped. Many were depressed, some were suicidal.

One of those residents died earlier this year.  I’m writing this blog post to honor her.

In my practice area (elder law) I lose clients all the time. Its to be expected when when you deal with the elderly. I always grieve for their passing, but I generally take it in stride as the natural order of things.. But Anita was different. She was not old. Well, not compared to most of my clients or the other residents of the nursing home.

brain trauma
Residents of LTC facilities with traumatic brain injuries – are they properly treated?

Anita was in her late fifties, perhaps early sixties. Under normal circumstances one doesn’t find many people that young in nursing homes. But Anita was had suffered a traumatic brain injury some years earlier. After being in a coma for several months, she awoke to find herself on life support. Her condition improved and after she had undergone many rounds of reconstructive surgery, her horrific automobile accident left her alive, but unable to care for herself.By the time I met Anita, she had been in a nursing home for several years. When I first met her, she was able to wheel herself about in a wheelchair. By late spring of this year (almost two years later) she could barely move and needed to be lifted from bed to chair with a Hoyer lift (sort of a person-sized block and tackle used by nursing staff to save their backs from injury in hoisting patients who cannot transfer themselves in an out of beds, chairs, toilets etc.) Anita required the aid of two people to assist her on and off the toilet or was left in adult diapers. Her looks had been destroyed in the accident despite reconstructive surgery; almost all her teeth had had been removed as well. Her hair was either a tangle of uncombed knots, or cut so short she resembled Sinead O’Connor. She had barely a shred of dignity left and no desire to live.  Perhaps the most heart breaking aspect of Anita’s story was when I learned that before her accident, Anita had worked a registered nurse. She was extremely smart and capable. She worked in ICU and knew all about trauma victims. She knew what good nursing care was supposed to be. And she knew she was never going to get it in the situation she was in.

I discovered that despite her injury, Anita’s mind was still plenty active. And she had a very sharp – if dark – wit. Regardless of the motor skill deficit and behavioral issues, she liked to read, especially science fiction. She also became an avid member of the “Science Club” which we created for another severely brain injured resident (this one by stroke) who’s scientific mind was clearly genius level (he was a nuclear engineer in a previous life). Anita kept right up with him.  Otherwise her days were a dull hum of endless bingo and relentless daytime TV as it is in most nursing homes.

Anita had many issues related to her brain injury – some of them behavioral. Many people don’t know that brain injuries – from trauma, stroke or other reasons – can cause severe emotional, psychological and behavioral changes in addition to physical impairments.

Bloomberg News service recently published a powerful expose on the care of brain injured individuals in nursing homes and it is well worth a read. The article is Brain-Injured in Nursing Homes Without Care Giffords Had. Click on the link to read it.

We tried desperately to get Anita some much needed physical, speech, and nutritional therapy. We tried wheelchair yoga and other alternatives. The staff was willing to make an effort but the universe and Medicaid were not.  The director of therapy told me plainly that they were not equipped to deal with brain trauma-injured patients who require much more specialized care than the average nursing home can accomodate.

I’m not criticizing the nursing home (although I think it and most others can do far better than they do with what they have). I understand that they really are not equipped to deal with brain injured residents’ needs in the way that they should be addressed.   This is a giant gap in our healthcare structure. And another ugly stain on our national health system.

This is not relevant only to brain injuries. I had occasion to represent a family earlier this year with a severely disabled adult son.  His disability was not a brain injury but a genetic condition with truly catostrophic symptoms that could not be managed at home.  He too was being warehoused in a facility not equipped to deal with his (admittedly) very demanding needs. Indeed, the only available solution was to spring him from a state psychiatric hospital and to admit him to a nursing home!  He is still with us and, because he is geographically closer to people who can check on him and ensure that he is getting care that is up to snuff, his quality of life has improved somewhat.

I would like to honor Anita  who died this past summer. Anita and all the other residents of long term care facilities that we lost prematurely in 2012. As I go into 2013, in her memory, I rededicate myself  to continue to fight for improved long term care. Not just for seniors, but across the spectrum of our community.

I hope you will take note of the conditions we are warehousing these people in – our brothers, sisters, mothers and fathers – and put your shoulder to the wheel too.

Happy New Year to all.



Long Term Care — Planned For It?

Typically, the first time someone calls me it is because they need a Will or other estate planning documents.

In the course of our initial consultation, I ask lots of questions, some of which is intended to draw out what their plans are for making sure their care needs are taken into consideration as they age – no matter where that may be — at home, with family or in a facility.

The second situation in which I’m usually called is when there is already a medical emergency or event and it is basically to late to do any planning for long term care – it’s a matter of stanching the flow of money and resources and that is sometimes just not possible.

Recently, the New York Times published a great piece on Long Term Care Insurance and you should read it whether you have Long Term Care Insurance or not.  This is relevant if you are yourself reaching an age when you are concerned about your care, if you are a “planner” and need some insight into how these things work, or if you have aging parents and are trying to figure out how you are going to finance their care.

One shortcoming in the NYTimes piece is that it doesn’t cover the role that an attorney can play in planning for long term care. For that, you will have to call me.


BREAKING: New “Nursing Home Compare” System released by

This has always been a useful tool, but it has recently be substantially upgraded and now provides much better data in easily navigatible screens. You can search for nursing facilities by any number of means, state, county, within a specific zip code or by name. You can compare several at a glance and you can “drill down” to very detailed information INCLUDING the most recent survey and inspection reports! Extremely useful tool, Check it out here:


ObamaCare and Medicare — what’s the REAL Impact?

Medicare — as we know it

Now that the dust is beginning settle, and hopefully, some of the political posturing will subside, its time to look at what is actually in “Obamacare” (or, more officially, the Affordable Care Act) Most of us in the field of Elder Law are concentrating our energies on what the law does with regard to Medicare. Way back in February of 2011, then-adminstraor of CMS (Centers for Medicaid/care) Dr. Donald M. Berwick testified before congress as to what the implementation of the law would do and gave special attention to Medicare and the improvements we could expect.  Here’s a transcript of Dr. Berwick’s testimony. Very readable. I recommend it!