Long Term Care Options

Although many of us would rather not think about needing long-term care, the federal government website http://longtermcare.gov/ notes that 70% of people turning age 65 can expect to use some form of long-term care during their lives.  The vast majority of care is provided by unpaid family caregivers, most of them women.  Those who can plan ahead are likely to get better results and place a far lighter burden on family members.

How does one learn about all of the options that may be available?   Just the terminology can be confusing, from “active adult” communities to “continuing care retirement communities” to “assisted living.”   In addition, there are many programs and services that may provide in-home assistance.

New Jersey has published a useful detailed guide at http://www.nj.gov/njhealthlink/ltc_guide.pdf.  The state also has tried to simplify consumer access to the various agencies and programs that may be relevant through New Jersey EASE (which stands for Easy Access Single Entry).  The State Information and Assistance Senior Helpline has a toll free number (877-222-3737).   All seniors and their families are eligible.

Where else can you access objective information about local options?  Medicare.gov has a website with a number of helpful tools for comparing nursing homes and home health care.

In researching nursing home care, the user inputs his or her zip code, which pulls up a list of facilities with overall ratings.  The user then can select several facilities to compare in greater detail. http://www.medicare.gov/nursinghomecompare/search.html.

Similarly, there is a tool for locating agencies that provide home health care services.  It includes patient survey results.  http://www.medicare.gov/homehealthcompare/.

There is an assisted living website sponsored by the industry.  An organization called ALFA has on online directory that includes reviews.  http://directory.alfa.org/.

An insurance company called Genworth publishes costs for various senior living arrangements. https://www.genworth.com/corporate/about-genworth/industry-expertise/cost-of-care.html.   The New Jersey “state median” statistics that they publish show the following annual costs:

Homemaker services: $46,904
Home health aide: $48,048
Adult day health care:  $20,800
Assisted Living (private one bedroom):  $71,928
Nursing Home (semi-private): $109,318
Nursing Home (private):  $121,180

Many assisted living and continuing care facilities will accept residents whose resources may run out, and will convert them to Medicaid when that time comes.  However, it is important to inquire closely as some facilities may appear to offer this option, but in fact have a very limited number of Medicaid “slots.”  Most will require a year or two of private pay (sometimes referred to as “key money.”)

Business Lawyer and Elder Law Attorney

Aging in Place By Design

Planning to Age in Place:  Should You Consider Home Modification?

Americans are living longer and overwhelmingly wish to stay in their own homes as long as possible.  At the same time, most housing in our area – whether newer or older – has not been well designed for people of differing heights, sensory abilities and physical strength.  Unfortunately, most people’s first association with home modifications is a mental picture of an ungainly wood ramp interrupting the curb appeal of a home, or other unattractive make-do solutions.  Fortunately, there are more and more professionals who are trained in the issues of making housing accessible AND beautiful.

Universal Design is – Well – Universal.   “Universal design” was developed by Ron Mace, a visionary architect who founded the Center for Universal Design at North Carolina State University,  http://www.ncsu.edu/ncsu/design/cud/. Mace was a wheelchair user who recognized that features designed to make life easier for people with disabilities tend to make life easier for everyone.  (Rosemary Bakker, Revitalizing Your Home:  Beautiful Living for the Second Half of Life (AARP and Lark Books, New York, 2010)).  Bakker explains:
“One of [Universal Design’s] primary goals is to create a house – the structure, everything that fills it, and the outdoor spaces that surround it – that is usable by everyone right now – boomers with knee replacements, young families with baby carriages, elderly parents, teenagers on crutches after a snowboarding accident, or anyone who uses a walker, scooter or wheelchair.”

Although it may not be possible to plan for every imaginable scenario, certain design features can improve safety, comfort and convenience for all users of the home – a mother carrying a child, an older adult or an individual with limitations on mobility or sensory issues.

How Do You Evaluate Your Home for Safety and Accessibility?
Where do you start in evaluating your home?  The state of New Jersey’s website includes a useful Home Safety Checklist: http://www.state.nj.us/humanservices/doas/documents/checklist.pdf, developed by a nonprofit organization, Rebuilding Together (http://rebuildingtogether.org/).    There are also many books on universal and accessible design that include checklists, photographs and design ideas, including Rosemary Bakker’s book described above. Another excellent book, The Accessible Home:  Designing for All Ages and Abilities, by Deborah Pierce, AIA (Taunton Press, Newtown, CT 2012) addresses the question, “Who Needs an Accessible Home?” and notes in part:
“People planning to stay put through their later years need accessible homes.   AARP surveys report that over 85%  of people want to age at home.  By age 75, however, it is estimated that 73% of the population will have some functional limitations.  Due to medical advances and healthy lifestyles, the portion of the population over age 55 is predicted to reach 35% by 2050.” 

Why Be Proactive?  Fall Prevention
Even if people may be interested in the idea of home modification to serve their long-term needs, they may think it would be preferable to wait until they need it.  On further reflection, though, none of the long-term accessibility solutions – whether home modification or moving to a different home – will be easier to handle in a crisis created by illness or injury.  Furthermore, hazards in the home can be the CAUSE of disability.

In 2013 New Jersey sponsored a Falls Prevention Awareness Week, and created a fact sheet including the following:

  • More than one third of adults 65 and older fall each year in the United States
  • In 2010, 338 older New Jersey residents died in a fall
  • In New Jersey, each day an average of 194 older adults 60+ are treated in emergency departments or as inpatients due to a fall
  • Falls are the #1 cause of brain injury among older adults


The CDC (Centers for Disease Control and Prevention) has published a Home Fall Prevention Checklist:  http://www.cdc.gov/HomeandRecreationalSafety/Falls/pubs.html.

The university-based, nonprofit organization website http://www.homemods.org/ is a service of the Fall Prevention Center of Excellence, funded by the Archstone Foundation. The web site is headquartered at the University of Southern California Andrus Gerontology Center.  The authors explain why  there are good reasons to be pro-active on safety enhancing modifications:

“What is the role of home modification in fall prevention? The addition of supportive features can help reduce accidents such as falls, a leading cause of death for older Americans. Six out of 10 falls occur in homes which typically contain a high prevalence of hazards such as loose throw rugs, the lack of tub/shower grab bars, and obstructed pathways. Home modifications can reduce the demands of the environment while making the home safer and more supportive.”  (http://www.homemods.org/.)


There are some qualifications that indicate completion of specific training in home modifications.  For example,  an Executive Certificate in Home Modification is offered by homemods.org.  Five courses with challenging assignments are required to obtain the Certificate.   Students include professionals such as occupational therapists and social workers, as well as consultants, designers, builders and architects.

The National Association of Home Builders has a two-part training course for Certified Aging in Place Specialists (CAPS).

Many home modifications are simple, unobtrusive and relatively inexpensive – improved lighting and floor treatments, better handrails, easier to operate switches, doors and locks, and strategically placed grab bars (which, by the way, can look just like a towel bar, rather than the big ugly pipes we are accustomed to seeing in public “handicapped” bathrooms.  For example, see http://www.us.kohler.com/us/Bathroom-Accessories-Grab-Bars/.  Proper installation is the critical issue.)  Other projects, such as kitchen or bath remodeling, may be a bigger investment – but are areas where many homeowners may already be considering a remodel or update (so why not include features that will enhance your ability to stay in your home?)  Financing options may include some public as well as private sources.

Assistive technology also may make a significant difference in the feasibility of staying in your home.
“Assistive technology is any service or tool which can help an older person or a person with a disability perform activities that might otherwise be difficult or not be possible.

Such technology may be something as simple as a walker to make moving around easier or an amplification device to make sounds easier to hear (for talking on the telephone or watching television, for instance). It could also include a magnifying glass that helps someone who has poor vision read the newspaper or a scooter that makes it possible to travel over distances that are too far to walk. In short, anything that helps the elderly continue to participate in daily activities is considered assistive technology.”

Accessible design can empower people to remain in their homes longer, in greater safety.  We would be happy to help you with the legal details of contracts or financing.

Business Lawyer and Elder Law Attorney

Long-Term Care Commission Issues “Call to Action”

On September 20, 2013 the federal Commission on Long-Tem Care issued a “Call to Action” in its report to Congress.  Noting that over 12 million Americans currently rely on some form of Long Term Services and Supports (which it abbreviates to LTSS), it projects that this number will more than double to 27 million by the year 2050, as the “baby boom” ages.   http://www.ltccommission.senate.gov/Commission%20on%20Long-Term%20Care-%20Final%20Report%209-26-13.pdf

Medicare covers very little of long-term facility expenses, contrary to popular belief.   It will only cover 20 days fully (IF you have had a 3-day hospitalization, require skilled care and meet certain other criteria); you pay your own expenses up to $140 per day for days 21-100, and Medicare pays the balance; and coverage ends after 100 days.   http://longtermcare.gov/medicare-medicaid-more/medicare/In 2011, 21.6% of long-term care expenses were paid out-of-pocket; 11.6% were other private sources (long term care insurance, primarily); Medicaid paid 62.3% of such expenses; and “other public” sources made up the remainder.

The so-called “sandwich generation” of workers with aging parents (and in many caeses, also children they are supporting wholly or in part) are caught in the middle.  Most families need to combine family caregiving with other programs while addressing the fact that eventually, assisted living or nursing home care may be necessary.

Although many long term care facilities do have Medicaid patients, there are often a limited number of beds resulting in waiting periods.  Others will accept clients that they know will become Medicaid patients, provided that an initial period is paid out-of-pocket (referred to as “key money.”)

Medicare will pay for various home care services for a limited period of time, but a doctor must certify them as “medically necessary” every 60 days.  A helpful handbook about Medicare coverage is available from the Department of Health and Human Services.  http://www.medicare.gov/publications/pubs/pdf/10050.pdf

Elder and disability planning includes – but is certainly not limited to – helping families understand what would be involved for a family member to qualify for Medicaid or other available programs.  Some families may have certain types of assets that can be transferred or put into a properly drafted trust without a penalty (although Medicaid may have a lien against the beneficiary’s estate).  Social Security and long-term care insurance are also potentially important and the process for each is more difficult than one might expect.  We will make note of some of the many sub-topics in this blog.

Business Lawyer and Elder Law Attorney