Best Laid Plans -- Oh, Well

At Support For Home, we urge families -- whether they will be working with us or some other agency -- to plan ahead, in terms of homecare for loved ones.  That planning involves a number of factors, including:

1. What is the budget? 
• What will homecare cost, at several levels of care, from perhaps 4 hours a few days per week to 24 hours, 7 days per week?  That is a wide range of care, and it corresponds to very different costs.
• How will homecare costs be paid?  Is there Long-Term Care Insurance?  Is the loved one eligible for Veteran's Aid & Attendance benefits to subsidize homecare costs?
2. What is the "tolerance" for homecare?
• While it may be clear that assistance with ADLs (Activities of Daily Living) and Instrumental ADLs is critical to success in aging in place, we all have different levels of tolerance for that assistance.  We have each been independent for a long time.  There are issues of pride and privacy that need long and sensitive discussions.  Often it is better to start with a smaller schedule, to allow adjustments, if #3 allows it.
3. What is the goal of implementing homecare?
• This is actually a big deal.  In our view, homecare support should be started before there is a major crisis, such as a fall and a broken hip or a stroke.  Our goal is to begin supporting our clients early enough that we are able to help maintain a safe environment and high quality of life for them, avoiding crises to the extent possible.  If we are already in a crisis, the immediate well-being of the senior is the key, always.

One of the reasons it is so important to have these discussions and make plans early enough is that we do not know when the crisis will arise.  A family called us in last Tuesday, to begin a schedule of 4.5 hours per day, Monday through Friday.  By Thursday, when we met with the senior and her family, the need had changed to seven days per week, starting the following Monday.  By Sunday morning, the need had changed to 24-hour shifts, seven days per week, starting that day.  The crisis was here.

Neither the family nor the client have had time to adjust to homecare or the costs of it.  That means more stress than they need, but ...

So, plan ahead, but be ready to move quickly, as the situation changes.  Need for homecare goes up, down and sideways.  We can help you deal with it.

Best wishes, Bert

Stair Lifts and Homecare

I saw a tweet this morning about how stairlifts reduce the need for homecare.  At Support For Home, we think stairlifts can be extremely helpful, but, frankly, I think that is the wrong point, entirely. 

If seniors need to utilize a stairlift to stay in their multi-story home, they almost certainly need other help, as well.  Stairlifts can absolutely make it possible for seniors to stay in the home they love, providing they have support for ADLs (Activities of Daily Living) and Instrumental ADLs.

When we bought our current two-story home, we knew that visits from my mother were going to be very difficult for her, without a stairlift, because her mobility would not be sufficient to climb the stairs.  So, we had one installed.  It made it possible for her to enjoy our home any time she wished.  It did not remove the need for support with other ADLs / IADLs.

Stairlifts are not cheap, but they can still be less expensive -- and traumatic -- than disrupting our clients' lives and homes and forcing a move.  It is something we always look at as we do homecare client assessments, putting together a comprehensive plan of care.  We do not sell or install stairlifts, or make a penny from them, but we make sure we know great resources for our clients, to help them stay at home.

Licensing Homecare Providers?

In virtually all states, skilled nursing homecare or "home health" agencies are licensed by that state's government.  When it comes to non-medical homecare, however, the situation is much more mixed.  Slightly more than half of the states do license non-medical homecare companies, but exactly what that means varies greatly.  There is a fairly current reference page at Private Duty Today of what licensing requirements exist, state by state.

In Oklahoma, for example, the agency sends a letter and a form and $1 to the Department of Health.  That's about it.  Like every business, you need state and federal employer ID numbers and you have payroll responsibilities, but there is not much substance to the requirements in terms of quality or safety for the clients and their families.  The fee for the license, to me, indicates the seriousness with which it should be taken.

In Oregon, on the other hand, applications cost $1500 and renewals cost $750.  Right there you have an indication of a rather more serious approach, in that state.  From colleagues operating there, Oregon does, indeed, take homecare seriously.

In California, on the other hand, there is no licensing involved for non-medical homecare, at all!

So, what's the big deal?  Well, in our view, it does not make any sense at all that home furnishings business are licensed (Bureau of Electronic Appliance Repair, Home Furnishings and Thermal Insulation), but the people who take care of folks in those furnished homes are not!

As owners of a homecare agency in California, we would welcome a change to that situation.  Seniors need as much protection as anyone having landscaping done or a car repaired.  Will it cost our business money to implement the needed licensing overview?  Yes.  Is it an important investment in the safety and quality of care of our clients.

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.

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!

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.

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.