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.