Dangers of Falling

We received an email from the folks at Bay Alarm Medical that has some interesting, if scary, facts:

• 1 out of 3 seniors will fall every year.


• 1 out of 7 women will break their hip; 50% of them will end up in a nursing home.


• 90% of fall victims responded to in the “Golden Hour” (the first hour) will return home to independent living.


• 97% of those that do not receive care for 12 or more hours will lose their independence.


• The average response time for a senior incapacitated in their home is 17.5 hours.

The message is one that we endorse at Support For Home.  If you are a senior living at home -- especially if you are living alone -- an emergency alarm system, with a pendant or bracelet button you can push for help, is a very important investment.

For that matter, such a system is a great idea, we feel, for anyone who is living alone, regardless of age.  Someone thirty years of age who falls down some stairs and breaks a leg needs help too!  If the phone is two rooms away, dragging yourself there is not the best plan.  I don't want to challenge anyone's sense of macho independence, but think about it. 

 :-)

Maximizing Long-Term Care Insurance Benefits

We have talked about long-term care insurance (LTCI) before.  It is a very good thing, in our view.  We strongly recommend everyone take a serious look at purchasing it, before something happens that would keep them from qualifying.  And, no, we do not sell insurance or get commissions!

Below are some questions that we think folks who are making a choice of which LTCI provider to buy from.  The questions are equally important for people who have already purchased long-term care insurance, as the answers will help them manage their use of the benefits, to maximize them.

The first question is -- Is there a waiting period before benefits can be used?

• This question has some definite twists and turns, depending on the insurance company involved.  Waiting periods can range from zero days (very rare) to 100 days, in our experience.  You want to find out from the insurance company what event starts the clock running.  Is it a doctor's order?  Is it such an order plus the actual start of privately paid care?  Within the waiting period is any agency-provided care required?  If so, is there a minimum number of days?  For example, if the waiting period is 30 days, does the insurance company mean 30 calendar days or does it mean 30 days of actual care?  Obviously, that makes a very big difference.

The second question is -- Does payment of the premium end when benefits begin?

• This sounds elementary, but you really need to confirm it with the company.  Premiums may end when the claim is made or when payment of benefits begin.  Continuing to collect premiums after benefits begin is non-standard.  If you are looking to buy, make sure your company does not do that.

Third question -- Is the benefit a purely daily amount, or is there really a monthly budget that you have the ability to manage?

• Most policies will state that there is a daily benefit.  For illustration, we will use $150 per day.  For some companies, they will pay up to $150 per day, maximum.  If you are authorized for care every day, you will receive up to that amount on any day you have care.  However, some of the better companies actually consider the benefit as a monthly budget.  In other words, if the daily benefit is $150 per day, that would create a pool of $4500 for use in a 30-day month.  In these cases, some days might use less than $150 and some days might cost more, but be managed on a monthly, rather than a daily basis.

Next question -- Whether it is a daily or monthly benefit budget, are unspent benefit dollars available for the future, or do they "disappear?"

• If the daily benefit is $150 and I only use $100, does the extra $50 go into the "bank" to be used in a future period?  Same question applies for a monthly pool -- if I only use $3000 of the $4500 available for the month, does the extra $1500 go back in my "bank" of benefits?

The inflation factor -- Does the benefit keep pace with inflation?

• Is there a guaranteed increase in benefits (either a specified percentage, say 5%, or tied to the Consumer Price Index) over time, or is the benefit fixed forever?  This is definitely something you want to consider.  $100 per day now, while you are healthy and 45, may not be nearly enough after 35 years of inflation.

Keeping the benefit coming -- Is there a recurring validation process required by the insurance company?

• Some companies will send out an RN periodically (every 6-12 months) to do an assessment of on-going need for care.  Others may want an updated doctor's order.  Find out how intrusive this process is going to be.  We have sat through some nasty ones with our clients.

If you have other questions, comments or suggestions about LTCI, we would love to hear from you.  Drop me a line at bertcave@supportforhome.com.

Great Expectations

If you are serious about being in the homecare industry, rather than simply doing it instead of selling insurance, you learn a lot about the issues facing your clients and their families.  There is a wide range of such issues, from falls that lead to hip replacements to heart conditions to Parkinsons and many others. 

Two major conditions facing too many of our clients are dementia (including Alzheimer's) and MS.  We were delighted to have the opportunity to sponsor and participate in major events this year with the National Multiple Sclerosis Society (the Home Smart Home Expo) and the Alzheimer's Association Memory Walk.  Both events were huge successes in terms of raising the awareness of the community and even serviced providers.  These associations and others focused on different issues face huge challenges, but also raise great expectations.

With every client that we support, we are always looking at the total plan of care, the "pie" of needs, of which our homecare is one slice.  Without the proper plan of care partners, whether that's the Alzheimer's Association or emergency alert systems or fiduciaries or living space designers, our homecare will not succeed. 

We salute the more than 70 members of our Bright Lights team for the Memory Walk, and every other volunteer and association helping to create great expectations for the future.

I Hope Congress Actually Read It!

On September 14, 2009, a concurrent resolution was passed by Congress, on the topic of homecare.  We have posted the text and document on our Web site.  There are a number of excellent data points in the resolution, as well as a very positive recognition of "caregiving as a profession."

I don't usually care much for quoting dictionary definitions, but this one calls for it, in my view.  Dictionary.com says that a profession is "a vocation requiring knowledge of some department of learning or science". 

At Support For Home, we believe that our Home Care Aides are, indeed professionals.  Over 75% of our employees are certified -- Certified Nurse Assistants, Certified Home Health Aides or Licensed Vocational Nurses.  Others are certified as Direct Support Professionals.  These are not agency designations -- although some agencies will try to fake it, with similar titles.  These are actual State of California certifications.  Even our folks who have nto yet achieved certification are truly professional, in terms of knowledge and attitude, or we would not hire them.

The bottom line is that a professional caregiver is a person with character, dignity, passion and knowledge, all of which are applied within a structured, disciplined plan of care, to ensure the highest possible quality of life for the clients they serve.  These caregivers deserve respect and support, from us and from our clients.  They are the heart and soul of Support For Home.  Any homecare agency that does not feel that way and treat their Home Care Aides that way needs to find another business to pursue.

Bert and Siew Pheng, Support For Home

A Focus on IADLs

For most of us, if there is an issue with Activities of Daily Living (ADLs), such as bathing or dressing or eating, the need for support is very obvious.  We will return to this topic (ADLs) in a future blog, but today we want to talk about Instrumental ADLs (IADLs) as a basis for determining need for homecare support.  We have adapted an IADL discussion from an early gerontology article, because we think it is still one of the most useful.  We have provided just three examples, below, of the seven IADLs included in an Excel spreadsheet we have created that is posted on our Web site.

IADL Status

Ability to Use Telephone (4 points - highest - to 1 point)
Operates telephone on own initiative; looks up and dials numbers, etc.
Dials a few well-known numbers
Answers telephone but does not dial
Does not use telephone at all.


Shopping (4 points to 1 point)
Takes care of all shopping needs independently
Shops independently for small purchases
Needs to be accompanied on any shopping trip
Completely unable to shop.


Food Preparation (4 points to 1 point)
Plans, prepares and serves adequate meals independently
Prepares adequate meals if supplied with ingredients
Heats, serves and prepares meals or prepares meals but does not maintain adequate diet
Needs to have meals prepared and served

The idea, for each IADL, is that the more functionality I have, the higher my score will be.  In this particular scale, as we have implemented it, there is a maximum of 31 points, total, for all seven IADLs.  However, each IADL needs to be looked at by itself, as well as being part of an overall pattern.

In my current baseline (as discussed in a prior blog), I'm doing okay and do not need home care.  However, for each IADL, I have set a lowest acceptable status before taking a very serious look at getting home care for myself.

We would be delighted to have your feedback and suggestions.  Thanks for listening.

They Have It Backwards

I just got a call from a daughter who had convinced her father to talk to us about home care, saying that he has changed his mind "again" and is not ready. We have seen this before and we will see it again. One of the big franchise companies in home care thinks they have the answer, with what they call the "40/70" rule: "The idea is that if you're 40, or your parents are 70, it's time to start talking - at least about certain senior topics."

We do not intend to take children of seniors "off the hook," but, frankly, we think this is a little bit backwards. It puts the onus on the children of seniors, rather than where it belongs -- with the parents. We see children of seniors, every day, willing and able to talk with their parents about aging and home care and other issues.

Too often, the parents' response is along the lines of "I know I will need help, eventually, but not now." The real problem is that the parents have too often not established the parameters of what "eventually" will look like.


So, here is some "Tough Love" for all of us seniors (yes, me too, I'm an AARP member!):

1. First of all, we need to remember that we are the parents, and act like it. When we are raising children, we would never think of putting them through the stress that they endure worrying about us when we do need home care, as we age. It is our responsibility to deal with our own aging, not make our children carry it around as a burden.
 2. That means we must define what the boundaries of "eventually" are, in determining when we do need -- and will accept -- home care. That means learning about the Activities of Daily Living (ADLs) and Instrumental ADLs (IADLs) and establishing clear lines for when we need support.  Please see the Gilbert Guide or Wikipedia for more information on this and other topics. 


ADLs:
 • Hygiene (bathing, grooming, shaving and oral care)
• Continence (bladder and bowel control)
• Dressing
• Eating (the ability to feed oneself)
• Toileting (the ability to use a restroom)
• Transferring (actions such as going from a seated to standing position and getting in and out of bed)


IADLs:

• Finding and utilizing resources (looking up phone numbers, using a telephone, making and keeping doctors appointments)
• Driving or arranging travel (either by public transportation, such as Paratransit, or private car)
• Preparing meals (opening containers, using kitchen equipment)
• Shopping (getting to stores and purchasing necessities like food or clothing)
• Doing housework (doing laundry, cleaning up spills and maintaining a clean living space)
• Managing medication (taking prescribed dosages at correct times and keeping track of medications)
• Managing finances (basic budgeting, paying bills and writing checks)

For each of these areas, we should take the time to establish a baseline (what can I do now) and an acceptable limit of competence that will tell me I need help in that area.  If I need to assign someone that I truly trust as an advisor in this, who can bring a second set of (independent) eyes, great.  Ideally, that should be someone other than my children, to help minimize their stress.

In a future blog, we will go into more discussion of how we might set those baselines and limits, with regard to our ADLs and IADLs.  Thanks for listening.

Long-Term Care Insurance - Don't Stay Home Without It!

Obviously, that title is an overstatement, as some families have the resources to self-fund home care - and the willingness to spend money to get the care they need to be able to safely live at home, when the time comes.

For the rest of us, building Long-Term Care Insurance (LTCI) premiums into our budgets -- and getting qualified while we're still healthy enough -- is something to very seriously consider.  That last point is an important one.  Siew Pheng and I recently applied for LTCI.  She got it.  I did not, because of my Diabetes.  Even though it is well controlled, the insurance company said, "No thanks," when it came to covering me.  I should have bought it five or six years ago.

Even for clients who can afford to self-fund home care, we at Support For Home have seen many instances where they are reluctant to do so.  They know they need care, but the idea of spending money on themselves (or having their families do so) just goes against the grain of a life time of independence and self-reliance.  If they have already paid for LTCI, the clients are much more likely to get the care they need, as they feel they have already paid for it, through premiums -- and they are right.

So, the bottom line is, if you can self-fund your future long-term care needs, great, but create a special account that you build up over time to provide that funding.  Set the money aside, invest it and let it grow.  If you cannot reasonably expect to self-fund, explore Long-Term Care Insurance, early, and do some research as to what real costs are going to be, when you will need home care.  Get enough coverage.  Get peace of mind for the future.  I wish I had!

The More Things Change... The More Things Change

As with every good homecare company, we take the process of client assessment very seriously.  Ensuring that we understand client needs is critical to developing the right plan of care, which includes assigning the right Home Care Aide from our staff.  In many ways, though, that is the easiest part of our job.

Once we have the right Home Care Aide in place, delivering the right services, the real work of being a great homecare company begins.

Each client's need is dynamic.  Not only does need increase and decrease over time, but the details also change.  We provide care in three different areas, associated with clients' activities of daily living (ADLs):

• Homemaker Care:
• This involves light housekeeping, such as changing bed and bath linens, laundry, meal planning and preparation.  Basically, it involves the activities of daily living (including what are called instrumental ADLs) that occur in the home.
• Companion Care:
• This area involves our interfaces with society, including health professionals (e.g., reminders and monitoring for medications), errands, shopping, appointments, and so forth.
• Personal Care:
• Our most intimate activities of daily living include dressing, bathing and toileting (including incontinence care).

Some times our job is to help our client recover from an injury, surgery, stroke or other crisis.  The client may need a high level of care in one or more areas, right now, with the expectation that need will decrease, over time.  That may mean that Home Care Aide #1 is the perfect answer, right now, but Home Care Aide #2 may be more appropriate in three months, as needs change.

Unfortunately, need can go the other way as well, with a client who requires more care over time.  If we do not catch those changes in need, we will fail to optimize our care.  If we are not constantly working to optimize our care for our clients, we will no longer be great at what we do.  In a future blog, we'll talk about what we do to stay on top of changing needs.

Homecare Employers - Who's on First?

Who is the employer of the caregiver supporting your mother's, father's or your activities of daily living (ADLs)?

This is a subject that just keeps coming up, because it continues to cause so many issues for families.  In the State of California, the law is actually quite simple about who is the employer of a caregiver or other household employee, but unscrupulous referral agencies try to avoid providing clients with information about the issue.  Some even intentionally -- well, I cannot find a polite word, but ...

First, let's make our position clear.  The employer of Home Care Aides / caregivers should be the agency that is sending them to the home.  For us, at Support For Home, that is the case.  We are the employer.  We provide liability insurance and bonding, pay payroll taxes, Workers Comp insurance, background screening, and so forth.  There are a number of other reputable agencies who are doing the same (we talk about certification by the California Association for Health Services at Home on our Web site).  Unfortunately, many referral agencies (sometimes called DRAs) operate very, very differently.

These folks simply will not raise the issue of who is the employer -- too often, it is going to be the client and / or the client's family or trustee.  Then, if something happens (the caregiver trips over an ottoman or is let go or commits a dishonest act, ...) the client is left holding the bag -- with the State of California wanting the bag to be filled up with taxes and fines and handed over.

One very good document on this subject from the Employment Development Department (EDD) is called "Household Employment."  This talks about the client's / family's responsibilities when hiring an "independent contractor" from a DRA.  Basically, the referral agency is off the hook, if they follow a simple set of rules, and the client is on that same hook.

The discussion starts with some definitions:


So, becoming the employer of your -- or your family member's -- caregiver is pretty easy.  Operating in that role, following all the rules of an employer, understanding the financial implications ...  That's not nearly as easy.  That does not mean that being the employer is always the wrong answer.  It just means when you are making that hardest decision -- about who is going to provide home care -- it needs to be an important factor.

If you have any questions, please feel free to contact us, by email at info@supportforhome.com or by phone at 916 482-8484 or 530 792-8484.
Good luck, Bert and Siew Pheng

Who is a Household Employer?

A household employer is someone who has paid $750 in cash wages to one or more individuals in a calendar quarter to household workers. You must register with EDD within 15 days after you pay $750 in total cash wages.

What Are Wages?

Wages are all payments made to employees for personal services, whether paid by check, cash, or the reasonable cash value of noncash payments, such as meals and lodging.

Home Care Sometimes Means Mourning

Support For Home provides in-home care for our clients and emotional and respite support for their families.  In fact, our clients and their families are really part of our own extended family.

There is very little that can surpass the emotional gratification of being successful in extending our clients' ability to live at home, safely and with good quality of life. 

When, as occasionally happens, a client moves to another area or needs to move to a skilled nursing facility, we are saddened, but we understand such choices are sometimes the right answer (see our recent blog on making such decisions).

However, when a client passes away, the pain is intense and the mourning is very real.  Losing a member of our extended family isn't just a phrase, it's very personal.  We run a professional operation, exercise professional judgment and so forth, but we are with our client sometimes every day of the week.  The connection is not simply a business relationship.  It's a personal bond.

Do we continue to provide in-home care, in spite of losing extended family members, on occasion?  Of course we do.  The rewards are immediate and the memories are forever.  Seeing the smile on a man's face, on his 87th birthday, because we took him some of his favorite custard tarts, is worth every bit of worry -- and potential eventual pain -- associated with developing that emotional bond.

So, to our clients and to their families, thank you for being part of our lives and letting us be part of your extended families.  Bert and Siew Pheng

Is Home Still the Right Place?

At Support For Home, our mission is to help people live at home just as long as they want to and safely can. We, along with the courts and gerontologists, believe that home is normally the place where quality of life is the highest. However, we believe that every individual and every family should, in advance, determine the criteria which establishes home as a viable living space.

In this blog and future ones, we will talk about what we consider some of those criteria. There are very few solid lines ("if I'm on this side of the line, all is OK; on that side, I need assisted living or ..."). However, there are a number of factors we feel individuals and their families need to bake into a fairly formal plan.

Many of us have or are developing living wills or Advance Health Care Directives (AHCDs) -- whatever we may call them. These AHCDs specify when we want treatment and when we don't, to prolong life, for example. They don't usually cover, however, the decisions about where we should live, under what circumstances.

What we're talking about, then, is a sort of "Advance Living Directive" -- under these circumstances, I should / must be allowed to live at home; under other circumstances, I should / must be placed in (a) assisted living or in (b) a skilled nursing facility. Identifying the "circumstances" as clearly and precisely as possible is the key to making sure the right decisions will be made (by me, a trustee, or the courts), when the time comes.

What we want to do is to eliminate as much "gray area" or "overlap" of conditions as possible, to reduce ambiguity or confusion for whomever is making the actual decision about where we live. The cleaner the lines, the happier we are all going to be -- and that includes our families.

What are the factors that need to be considered in making that Advance Living Directive real?  Some are obvious -- state of health, finances, etc.  Others are less so.  We'll talk about these more in future blogs.

Please give us feedback.  This is not about our ideas -- it's about solutions.  Help us share those.  Thanks.  Bert and Siew Pheng, Support For Home

Help With Homecare Costs

Paying for homecare for our family members is not always an easy task. Since medical insurance and Medicare do not pay for non-medical in-home care, recipients of care are in a "private pay" situation. Our family is doing this, right now, in fact.

When the economy dips and people's income is impacted, it gets harder. We even had a client or two have to stop receiving professional care when a family member is laid off and returns home. They know, and we do, that the level of care -- not love, but care -- is going to be reduced, but reality is reality.

To try to help with this issue of affordability of homecare, we've posted some information and documents on our Web site, concerning two major sources of financial support -- Long-Term Care Insurance (LTCI) and Veteran's Aid and Attendance benefits.

If either the client or the spouse is a veteran, it is important to check out Aid and Attendance, from the VA. There are income and asset criteria, but there are good sources of help to determine eligibility (again, you can check our Web site).

Long-Term Care Insurance is something that most people are just learning about. We think it is a critical piece of planning for the future. We purchased LTCI for ourselves -- and no, we don't sell it :-). There are good sources of information (there is an AARP link in the page on our site) and a number of good companies. Like all insurance, you have to buy it before you need it.

The bottom line, whether a family turns to VA Aid and Attendance or LTCI or other forms of budgeting for future care needs, making a plan is critical -- as earlier as families can do so. Good luck from Support For Home. Bert and Siew Pheng

Emergency Alert System - Don't Be Home Without It

One of the simplest things that we can all do, to protect ourselves at home -- especially if we live alone, is to wear a bracelet or necklace with a button we can push if we fall or have some other medical emergency. There are many such personal alarm products / services on the market, just as there are many alarm systems for our houses.

For our own clients, believe in this service so strongly that, if we provide at least 20 hours of care per week, we actually pay for the installation and monthly fee for the personal alarm. When we are not with our clients, we want to know -- and their families to know -- that help is a simple button push away. If anything happens, after emergency services are notified, so are we. We can then provide fast help, ourselves.

You can find a link to a company we work with on our Useful Resources page, on our Web site. In addition to the alarm bracelet or pendant, most companies have a lockbox service, where you can put a key to the home. Emergency services gets the lockbox code from the alarm company, so nobody has to break down a door! :-)

If you have any questions about these services or other areas of living at home as a senior, give us a call (916) 482-8484 or send an email to info@supportforhome.com.

Comprehensive Plan of Care

We were talking with some folks on Saturday, about all of the questions involved in hiring an in-home care provider. We'll talk about this list soon, although you can look at our recommendations on what questions to ask on our Web site. However, one of the most over-looked issue is making sure that whomever you are talking to can help the family build a comprehensive plan of care. As we tell families, unless all of the needs of someone requiring home care are addressed, the in-home care "slice" of the plan of care "pie" is likely to be less than adequate.

When we talk about a comprehensive plan of care, we mean a wide variety of potential needs, inclusing things like home safety (grab bars, ramps, transfer poles, ...), medical emergency alerts (a necklace or bracelet), a private fiduciary or conservator, home health (for skilled nursing), and there are many more possible needs that should be discussed with the family and client.
For each of these needs, we make sure we have a great resource who can help the family, if they do have those requirements. Obviously (well, with some agencies, not so obviously), we do NOT have any financial ties to those resources. Either they are the best, most ethical resouce or we do not work with them. Agencies providing in-home care that take commissions, are completely out of line, as far as we are concerned.

Bottom line, make sure that the agency you select can help you identify all needs and can help satisfy them with top-notch resources.

The Hardest Job in the World

Some people think the hardest job in the world might be serving as President of the United States. Well, we admit we haven't worked closely with him, but we're sure it's a tough assignment. However, we are truly convinced that the hardest job in the world is actually that of being a family caregiver. It is so hard, in fact, that the statistic that reinforced our own desire to start an in-home care agency (http://www.supportforhome.com/) is that 65% of family caregivers die before the person they are taking care of at home.

That statistic is frightening. Family caregivers need help -- not just from agencies such as ours, but from friends, other family members and, strange as it may sound, from themselves.

What we mean by that last comment is that family caregivers must first take care of themselves, if they are going to be successful in caring for others. That means rest and respite. It means fun and relaxation. It means support groups, for sharing, when the person being cared for is suffering from dementia or a chronic physical condition.

More than anything else, it means that the family caregiver must act with a bit of what might feel like selfishness, once in a while, in order to be the best caregiver he or she can be.

Making sure that you get adequate respite care is the starting point. If there is someone else in the family who is competent and able to provide that respite care, great. If not, look for a very good in-home care agency, whose employees can provide you with the breaks you need. That will allow you to come back to that hardest job in the world refreshed and ready to go.

If you are ready to look for help, check out a list of questions you want to ask, before you decide who is going to provide care to your family.