Having a loved one in a nursing home can be a confusing and emotional experience.   Understanding the various aspects of nursing home care and learning how to handle your concerns which may arise will greatly contribute to the success of your loved one’s stay.  These 12 tips will help improve your communication with the facility staff and help to clear up common misunderstandings.

1.   Have realistic expectations.

It is important to have realistic expectations about the nursing home environment and the amount of care your loved one will receive.  Although nursing home care (also known as skilled nursing facility care) is often referred to as “24-hour” care, it rarely means one-to-one care, 24 hours a day.  Certified Nursing Assistants (CNAs) will typically each need to care for eight to fourteen residents during a shift.  In addition, their extra duties required during meals and at change-of-shifts usually make staff even less available to help your loved one during those times.

Physicians do not make routine daily or even weekly visits to the nursing home and rarely have a set time to visit the facility, often making visits late in the evening or on the weekends after their general practice offices are closed.  However, the facility’s nurses are in constant communication with the patient’s physician by phone, reporting on the patient’s status, lab and test results and changes in condition.   If you need to speak to your loved one’s physician, ask the facility’s nurse to have him or her contact you.

2. Understand the purpose and extent of the care.

Some residents and family members believe that the nursing home staff should be personal attendants to the residents and do everything for them.  This is counterproductive to the goal of rehabilitation, which requires that each resident be encouraged to do as much as possible independently.    However, although independence is vital to self-esteem and crucial to meeting rehabilitation goals, safety is always a paramount concern.  Therefore, for example, if your loved one is at risk of falling, it will be important that that he or she not try to get up out of bed without the assistance of facility staff.

3. Important tips upon admission

 It is very important that you provide the facility with a copy of all of your loved one’s legal documents that relate to his or her wishes regarding health and personal care and that designate an agent for such care.  These documents include, but may not be limited to, an Advance Health Care Directive, Physician’s Order for Life Sustaining Treatment (POLST), Durable Power of Attorney for Health Care, and/or Conservatorship papers.

 The facility does not have the time to communicate information regarding your loved one’s care to multiple family members.  Therefore, it is important that one person be assigned as the “responsible party” to communicate with the facility.   If your loved one has executed an Advance Directive for Health Care or a Durable Power of Attorney for Health Care, the responsible party should be the person named as your loved one’s primary agent under that document.  If the primary agent consents to a different person being the contact person for the facility, the agent should nevertheless stay informed and available (at least by telephone) in case an emergency arises requiring the agent to make a medical decision.   The agent (or other contact person) should communicate any news regarding your loved one’s care to the other family members.

Do not bring valuable personal property to the nursing home as it may disappear for a variety of reasons, including getting misplaced, being taken by a confused resident, going down the drain in the shower, etc.  Also, label with your loved one’s name all of his or her personal items that will be needed while in the facility, including eyeglasses, dentures, and hearing aids.   Your loved one’s clothing should all be washable and not require ironing.  Document ALL of your loved one’s items that are brought to the facility on the facility’s inventory list and update the list when new items are brought in or items are taken home.

4. Know the Medicare rules.

Medicare will pay for a limited amount of care in a skilled nursing facility provided that certain qualifications are met.  In order to receive ANY coverage by Medicare, the patient must be admitted to the skilled nursing facility within 30 days following a qualifying minimum 3-consecutive-day inpatient hospital stay.  Qualifying days do not include any days in the hospital merely for observation or while in the emergency room. There have been cases where a patient has stayed in the hospital for a week or more without being officially admitted, so the hospital stay did not qualify the patient for Medicare coverage in a nursing home. The care in the skilled nursing facility must be for the SAME condition treated during the hospital stay and be needed for medical or rehabilitation purposes.

In almost all cases, Medicare will only continue to pay for care in the skilled nursing facility provided the patient is making progress and the potential exists for additional improvement.  As long as the above conditions continue, Medicare will assume full financial responsibility for the patient’s care in the skilled nursing facility for up to 20 days.  If progress is still being made and it is deemed medically appropriate to continue with the care plan past day 20, Medicare will continue to cover PART of the cost of the patient’s care from day 21 up to day 100.  The balance of the patient’s cost of care during these 80 days will be a co-payment charged to the patient or to the patient’s supplemental insurance carrier, if any.

However, there is NO GUARANTEE that Medicare will pay for the entire 100 days of care.  In fact, patients rarely qualify to receive all 100 days of coverage under Medicare.  Usually, as soon as the patient stops showing progress, no matter how many days of care they potentially have left, Medicare will discontinue coverage.  If you disagree with the determination and believe that your loved one can still benefit from further therapy and that the care is still medically appropriate, even if only to maintain, rather than improve, his or her level of functioning, you may appeal the Medicare determination by calling  (800) 841-1602. You can also find information on how to appeal from the Center for Medicare Advocacy at www.medicareadvocacy.org.  However, if your appeal is denied, the patient will be completely financially responsible for the cost of the care from the date Medicare stopped coverage.  Also, supplemental insurance coverage will normally not cover any time after Medicare coverage stops.

5. Meet with the nursing home staff.

It’s important to be familiar with the Executive Director or Administrator, Director of Nursing (DON), Social Services Director, Head of Dietary Services, rehabilitation therapists, and nurses responsible for your loved one in the nursing home.  Know what their roles and responsibilities are in relation to your loved one’s care, and by all means, inform them of any special issues pertaining to your loved one.

 6. Get to know the Certified Nursing Assistants (CNAs).

CNAs provide most of the care to residents.  Be courteous to them but be clear about anything your loved one needs.  The better the relationship you establish with the particular CNAs caring for your loved one, the easier it will be to talk with them.

7. Understand dietary precautions.

 Always, always check with the CNA or nurse BEFORE giving any food or drink to your loved one or another resident. Some residents are on restricted or special diets, or require foods or liquids of a specific texture or consistency to prevent them from choking. Giving a resident the wrong type of food or drink (even water!) can be potentially dangerous or harmful.

Also be aware that what is considered a “diabetic” diet at the facility may not be as strict as the diet your loved one follows at home. Discuss any concerns regarding your loved one’s diet with the head of Dietary Services.

8. Respect your loved one’s rights.

Your role as a family member is to help communicate your loved one’s preferences to the staff.  It is recommended that you provide the facility with a written personal summary of your loved one’s daily routine, so that the staff can understand better how to accommodate and meet his or her needs.

However, a resident’s wishes always come before those the family may consider important.  For instance, if your loved one wants to return to bed but you disagree because you think he or she spends too much time in bed, the staff cannot violate your loved one’s personal rights and will allow and assist him or her to return to bed.

In addition, the resident has the right to be free from restraints, even if you’re worried about his or her safety. Restraints can be used only if a doctor determines them medically necessary.  Some examples of restraints are bed rails, seat belts, and even medications, when inappropriately used to control behavior, for discipline or for staff convenience.

Unless a court, as part of a conservatorship proceeding, has determined that your loved one lacks capacity to understand and make decisions about medical treatment, your loved one has a right to know his or her true diagnosis and prognosis and to be informed of any changes in treatment or care, and should not be given any medications without his or her knowledge and consent.

9. Respect other residents’ rights.

As neither Medicare nor Medi-Cal will cover the cost of a private room, it is likely that your loved one will share a room with one, two or sometimes even three roommates.  Although a resident should feel at home in the nursing facility as much as possible, it’s important to respect other residents’ rights regarding noise levels, privacy, and visitors.  Being considerate of your loved one’s roommate(s) is important to the well being of both your loved one and his or her roommate(s).  Know the facility’s visiting hours and be especially considerate when visiting outside of normal visiting hours.  It may be necessary to visit with your loved one in another room at the facility if the visit is too noisy or disruptive to the roommate(s).  This is especially true during night-time hours when many of the residents are trying to sleep.

If your loved one desires to watch TV or listen to music at a loud volume, especially when his or her roommates are trying to sleep, it may be necessary for him or her to use headphones.

Do not hesitate to notify social services if there are serious roommate incompatibilities. A room transfer may be possible.

10. Visit and Participate as much as possible.

The best way to monitor your loved one’s care and identify any problems or concerns is to visit your loved one often and participate in the care process as much as possible.  Find out when he or she is receiving rehabilitation services and come in to observe them.  Your frequent presence helps to reinforce to your loved one and to the staff how much you care.

A full-care plan is created by the facility’s interdisciplinary team upon your loved one’s admission to the facility and is updated at a “Care Conference” meeting held for him or her every three months.   During these quarterly meetings, your loved one’s medical condition, rehabilitation progress, diet, activities, and other important information will be discussed.  If possible, it is recommended that you attend these Care Conference meetings.  Find out when the next one is scheduled for your loved one.  As the meeting will be fast paced, prepare a list of your questions and concerns ahead of time and bring a copy to share with the team and discuss.  If you cannot attend the scheduled Care Conference for your loved one, ask if it can be held at another time or if you can join in by phone.

Many facilities also have Family Council meetings where you can discuss issues about living in the nursing home.  In addition, if your loved one is capable, he or she could participate in the Resident Council meetings at the facility.  A Resident Council is an organized group of active nursing home residents who meet regularly to voice their concerns, offer their input on decisions, present suggestions for improving services and plan social activities.  Ask when the Resident Council meets and, if appropriate, encourage your loved one to attend.

Most facilities will also allow and may even accommodate visits by a patient’s pets.  However, before bringing the pets, you should find out and follow the facility’s policy on pet visits.

11. Communicate your needs and concerns.

Voice any concerns about your loved one’s care and life in the nursing facility promptly to the CNAs or the charge nurse.   Keep a notebook to remember specifics, especially dates and times, of situations that you want to address. The more detailed you are, the greater the possibility that any problems you identify will be corrected.  Just saying “the food is terrible” or “the care is awful” makes it difficult for the staff to know what you mean and how they can correct the situation.   Act as a problem-solver or option-creator, not a complainer, by answering the following questions: Can I prioritize the issues?  What is unacceptable? What do I really want?  What can I live with?  By doing so, realistic outcomes are achievable.  If you do not get a satisfactory resolution after addressing the problem with the staff most directly involved, then go up the chain of command.

However, before complaining about something, be aware of who is being upset by the situation.  Is it you or your loved one?  For instance, if your loved one’s clothes are not color coordinated, does it matter to him or her?  Or, does it really just matter to you? As the old adage goes, pick your battles.

If your loved one does have a complaint (or even a minor concern) ask him or her how he or she wants to deal with the situation.  Does he or she simply need to air feelings rather than have you confront the staff?  Sometimes, simply listening is the most effective response you can give.  Your loved one has to live in the nursing home, so it’s important that his or her wishes be respected.

Finally, and most importantly, be polite and friendly.  A nursing home staff is comprised of people doing a very challenging job.  Lifting and moving adults who are unable to help themselves is physically demanding.  Understanding the needs of residents who may be confused or unable to communicate for a variety of reasons is emotionally exhausting.   Recognize that the facility has many residents and the staff is very busy all of the time.  Nursing home staff members work hard to do a good job. Thank them for their efforts. You will accomplish more by being polite and friendly, rather than nasty and demanding, when requesting changes or bringing problems and/or concerns to the staff’s attention.  If you continue to have difficulties resolving a concern, contact the Long Term Care Ombudsman Program for assistance at (800) 231-4024.

In summary, immediately document and report concerns to the staff directly involved; clearly state your concerns and the outcome you would like; and be respectful in your interactions.

12. Tips about discharge

When it is determined that your loved one will be leaving the nursing facility, if you have any questions or concerns about how to care for him or her at home, arrange for training with the rehabilitation team several days in advance of the day of discharge from the facility. It is also important to set up an appointment with your loved one’s regular Primary Care Physician within 24-48 hours of discharge so that any changes in medications or care can be discussed.

Temporary, part-time, and limited Home Health Services needed by your loved one when he or she returns home will be covered by Medicare.   To arrange for these services you will need the facility physician to write an order for the services that will be needed.  Once you have that recommended order, the home health agency that you choose must contact your loved one’s regular primary care physician to write the order for the continuation of services.  It is your responsibility to make sure this contact with the primary care physician happens as, without the primary care physician’s order, Medicare will refuse to pay for the continued home health services.

 Final Thoughts…

Remember, no matter how good the nursing home, issues may still arise.  More than one person will be looking after your loved one, making communications and systems difficult to manage at times. One of the challenges you will face is figuring out the system and how it works, otherwise you will be setting yourself, your loved one and the nursing home up for failure.

* The information contained in this Blog is intended for general information and educational purposes only and does not constitute legal advice or an opinion of counsel.

A big concern for most of us is how to financially manage to stay at home as we age, despite ever increasing care needs.  For those that are fortunate enough to have adequate savings, care costs may not be much of a concern.  However, care costs are quite high, with average hourly rates around $25 per hour, and many find paying for care in their home outside of their means.  It is not unusual for 24/7 care to cost $10,000 – $20,000 per month.  Thus other resources need to be located in order to keep our elders in their home, with the proper care.

For those that were forward thinkers and purchased Long Term Care insurance, that insurance can provide payments to help offset the costs of long term care in your home.  The policy typically will begin payments once the elder is unable to perform two activities of daily living.  Most policies have a stated maximum payout per day, and while this will cover some basic level of care, most policies will not cover the cost of 24/7 care.  However, the policies many times will provide enough funds to enable elders to remain at home with a minimal level of care.

In order to stay in their homes, some elders opt to obtain a mortgage on their home, but as a “forward” mortgage does require repayment, and has income requirements to qualify, many elders may not qualify or may not be able to maintain the monthly mortgage payments as their care costs increase.   In these situations, a reverse mortgage may be a good option.  A reverse mortgage allows elders to access the equity in their homes to pay for care and no repayment is required until the elder leaves the residence or passes away.  While fees and interest rates on a reverse mortgage can be high, this can still be a good option for elders who are “cash poor” and “house rich”.  The reverse mortgage primarily provides three payment options, with one being a set monthly payment, one being a flat amount up front, and the third option similar to a home-  equity line, where the senior can draw on the funds up to a stated maximum when those funds are needed.

For our totally and permanently disabled Veterans and their spouses, or those Veterans and spouses over the age of 65, funds may be available to pay for care costs if they qualify under the asset and income limitations.  Funds for Aid & Attendance are designed to supplement your resources to pay for care as the Veteran’s Administration wants you to pay for the care for which you can afford to pay.  The Aid & Attendance program (pension) is not widely known, and can provide up to a maximum of $1,703 to a single Veteran or $2,019 to a married Vet, for those that qualify under the asset and income tests.  These funds may be just enough to keep the Veteran and his/her spouse in their home with the necessary caregivers.

Other community resources are available to help our Elders remain in their home, and ensure that they are safe.  Resources include Outreach or other transportation services, to assist with transportation when the Elder no longer drives, Meals on Wheels and other meal services, to bring hot meals and easily prepared meals, Day Programs which provides needed respite for the family caregivers and for socialization for our Elders, with many programs specific for certain conditions, for instance Alzheimer’s.  If the Elder qualifies, In Home Support Services (IHSS) administered through Medi-Cal can provide limited funds for caregivers to come to the home to provide needed services.

* The information contained in this Blog is intended for general information and educational purposes only and does not constitute legal advice or an opinion of counsel.

On or before April 6, 2012 the California Department of Public Health will require  all nursing homes to use a State issued Standard Admission Agreement (SAA). This means that all skilled nursing facilities and intermediate care facilities will use the same standard agreement and attachments to the agreement, which will replace admissions contracts or agreements written by individual nursing home operators . The SAA defines the rights and obligations of each party to the agreement.

The SAA and attachments are available at California Department of Public Health Website. The form number for the  SAA and its attachments  is CDPH 327. The form and its attachments contain a lot of useful consumer information, including the contact information for the Ombudsman program and lists of the supplies and services that are covered by Medi-Cal and Medicare. The final attachment is The Resident Bill of Rights,  created by the State of California Department of Public Health.  The Resident Bill of Rights is a compilation of law from a number of sources, which are now conveniently gathered into one document.

The rights are found in state laws and regulations under California Health and Safety Code Section 1599; Title 22 of the California Code of Regulations, Section 72527 for Skilled Nursing Facilities, and Section 73523 for Intermediate Care Facilities; and Chapter 42 of the Code of Federal Regulations, Chapter IV, Part 483.10 et seq. The California Health and Safety Code is abbreviated as “HSC,” Title 22 of the California Code of Regulations is abbreviated as “22CCR,” and Title 42 of the Code of Federal Regulations is abbreviated as “42CFR.”

* The information contained in this Blog is intended for general information and educational purposes only and does not constitute legal advice or an opinion of counsel.

One of the hardest conversations to have with someone who has Alzheimer’s disease is the conversation about when they should stop driving.  Since driving requires the ability to make quick decisions and fast motor reactions, there will come a time when every person with Alzheimer’s will be unable to drive.

In our culture we often equate driving to independence. To preserve dignity, avoid isolation, and prevent the loss of independence, a plan needs to be in place for alternative forms of transportation.

Fortunately, there is a good resource for facilitating this discussion and discussing the alternatives.  The Alzheimer’s Association  now has a number of resources in their Dementia and Driving Resource Center, including safe driving checklists, resources for transportation alternatives, and videos to help families prepare for dealing with this difficult issue.

* The information contained in this Blog is intended for general information and educational purposes only and does not constitute legal advice or an opinion of counsel.

Do you ever wonder how attorneys keep current on the law and consider unique and difficult issues?

All California attorneys have to take a certain number of continuing education classes and report those units to the State Bar.  We attend various seminars to complete the required units and typically have hundreds of hours of classes between us.

However a unique type of program is called the Un-Program.  Rather than attending classes with a formal speaker, we meet with attorneys from all over the country and have the opportunity to discuss actual and complex legal situations in an informal setting.  We recently attended the National Academy of Elder Law Attorney’s (NAELA) Un-Program in Grapevine, Texas.  We spent three days meeting in small groups to discuss a variety of issues, with just general topics as the guide for the group.

This was a great way to discuss complex elder law issues including upcoming changes in Medicaid (Medi-Cal here in California), Veteran’s benefits, Special Needs Trusts and disability issues for our clients.  We had the opportunity to discuss cases and brainstorm options for those clients with the best elder law attorneys in the country.  We also have the ability to continue with the Un-Program format by discussing cases on the NAELA Listserve and in future conference calls that will be established.  We found this to be a wonderful resource for us and a great benefit to clients who have increasingly complex issues with federal benefits.

* The information contained in this Blog is intended for general information and educational purposes only and does not constitute legal advice or an opinion of counsel.

I had the opportunity to participate in a dementia reality tour that our firm co-sponsored at Pacific Gardens.  The premise behind the tour is to experience what it is like to have dementia and to gain compassion and understanding from the experience.

The tour began by dividing the participants into small groups and outfitting us with shoe inserts, special gloves, goggles and headphones.  The affects were uncomfortable and a little disorienting.  We were then led to a typical efficiency apartment with the expected furnishings and personal items.  A voice in the headphones gave each individual a series of daily tasks to complete.

It was hard to complete the tasks and no one in the groups that I met with was able to complete all of the tasks that they had been given through the headphones. Most of the participants were very surprised when they had the opportunity afterward to read the actual instructions that they had been given.  The written list did not match their recollection of the verbal list. In the debriefing afterward some of the participants were adamant that the tasks had been impossible to complete because the necessary items were not available to complete the task.  It turns out that everything that was necessary was available to complete the tasks, but we experienced the frustration of perhaps not finding things where we expected them to be.

I think that for me the hardest part was to remember all of the instructions that were given quickly amidst the distractions that were caused by the equipment I was wearing, especially the noises from the headset. The point that came across most strongly to me was that I need to be patient with someone with dementia.  I need to give them time to respond to one thing at a time and understand that I may need to repeat an instruction when they are bombarded by distractions, some of which may not be distractions to me. I can also imagine how isolating it must be to live in this disorienting world and how much I would need the patient assistance of others.

* The information contained in this Blog is intended for general information and educational purposes only and does not constitute legal advice or an opinion of counsel.

Since 1999, the Social Security Administration (SSA) mailed annual Social Security Statements to you three months before your birthday.  These statements were a way to inform you about the amount of Social Security benefit that you would be entitled to receive at different retirement ages (based upon your current earnings), the disability benefit that you, your spouse, and dependents would receive if you became permanently disabled, and the benefit available to your survivors in the event of your death. They also showed a record of your annual earnings.

Depending on the month of your birth, you may have noticed that you have not received the statement. In April 2011, the Social Security Administration decided to stop mailing annual Social Security statements to workers to save money. By suspending mailings for all workers over age 25, SSA is expected to save approximately $70 million in annual printing and mailing fees.  For several months the only way to obtain this information was to go to the social security office.

SSA plans to eventually resume mailing statements to people age 60 and over. In the meantime and for those under 60 going forward, the SSA website has recently added calculators that can be used to compute these values. The tool is an estimator and does not show the actual values that were available on your statement.  The SSA has provided a number of tools at the website to assist you in planning retirement, but has not yet included a feature to access the actual values associated with your social security number.

For those who are currently receiving SSA/SSI benefits, there is an electronic form now available at the website to obtain a Proof of Income Letter that can be used as proof of your income when you apply for a loan or mortgage, income for assisted housing or other state or local benefits, current Medicare health insurance coverage, retirement status, disability, and/or age.  You will have the option to select the information you would like in the letter. This form is a request for the letter, so it will take at least 10 days after submitting the form to receive the letter.

* The information contained in this Blog is intended for general information and educational purposes only and does not constitute legal advice or an opinion of counsel.

Hearing loss affects 50% of people over age 85, most commonly men.  Poor hearing diminishes quality of life. It may bring on frustration in daily interactions with others. It can even be at the root of withdrawal from social activities. Hearing loss also carries risk, because you may not notice a shouted warning or may misunderstand a doctor’s instructions. Fortunately, there are some solutions.

HEARING AIDS  – The current generation of hearing aids bears little resemblance to those of old.

• Appearance. With new technology, hearing aids today are barely visible. Even the traditional behind-the-ear style is smaller. Only a slender tube extends into the ear canal.
• Quality of improvement. According to Consumer Reports, 73% of people with hearing aids are satisfied with their purchase. Behind-the-ear, open-fit designs are ranked highest for the most difficult hearing situation: loud, social gatherings.
• Comfort and use. Many styles and types are available. Choose a provider who offers follow-up service to fine-tune fit and volume. Be sure the purchase includes a trial period and refund.

Cost remains a challenge. A pair of hearing aids costs $1500 – $7000 (average $3000). Medicare covers the diagnostic exam but not the hearing aids. A supplemental health plan may provide coverage.  Help is available to Veterans through the VA.

ASSISTIVE DEVICES – A number of stand-alone assistive devices are also available. These support hearing in specific situations. Look for personal amplifiers, which fit in the pocket. They are an easy, inexpensive first step. You might also consider TV earphones and special telephone options.

If you have a relative that has hearing loss that has not been corrected, you can also try these tips to improve communication:

• Face your relative.
• Speak a bit slower than usual.
• Turn off or avoid background noise. Move to another room if need be.
• Stop shouting! Volume is only part of the problem. Seniors with hearing loss tend to have difficulty with high tones (pitch) and certain consonants. If you can, make your voice lower and only slightly louder.

Learn more at the website of the Hearing Loss Association of America.

* The information contained in this Blog is intended for general information and educational purposes only and does not constitute legal advice or an opinion of counsel.