Helpful Hints

 

Definition of Activities of Daily Living

Levels of Dementia

Financial Hints

Low-Income Hints

Veterans Hints

Continuing Care Retirement Community Hints

What Happens if you Run Out of Money?

Crime Statistics

 

DEFINITION OF ACTIVITIES OF DAILY LIVING

As you search for senior housing for yourself or a loved-one, you may run across the term, “Activities of Daily Living,” or ADL for short. This term is frequently used to determine whether or not someone is an appropriate fit for an Assisted Living Facility, or ALF, and what levels of care the person may need. Often an independent person enters an Assisted Living Community and as he or she ages, finds that they need help with one or more ADLs. Most ALFs are willing to assist residents in all aspects of ADLs for a structured monthly fee.

Here is a general guideline to assess how much assistance, if any, may be needed for the future resident. Each activity is defined with three levels of assistance: Independent, Some Assistance, and Dependent. You can talk to the Assisted Living Facility representative about these needs to determine an agreed upon cost for the required level of care.

Bathing

Independent: Can bathe or shower completely independently.

Some Assistance: Needs help cleaning one out-of-reach body area.

Dependent: Needs help on more than one area of body, help in and out of the tub/shower, or needs help in all aspects of bathing.

Dressing

Independent: selects, retrieves, puts on clothes complete with fasteners.

Some Assistance: May need help with shoe tying.

Dependent: Needs help with dressing other than shoes.

Going to the Toilet

Independent: Gets to toilet, on and off toilet, wipes without assistance.

Some Assistance: Needs some assistance with toileting.

Dependent: Incontinent. Doesn’t use the toilet, relies on bedpans and adult diapers.

Transfer

Independent: Completely independent getting in and out of chairs or bed.

Some Assistance: Needs assistance in getting in and out of chairs or bed.

Dependent: Does not leave the bed.

Continence

Independent: No incontinence.

Some Assistance: Occasionally has toileting accidents.

Dependent: Some or total incontinence.

Feeding

Independent: Able to transfer food from plate to mouth.

Some Assistance: Needs help in some areas, like cutting meat.

Dependent: Requires assistance to eat or uses feeding tube.

 

LEVELS OF DEMENTIA

Here’s a helpful guide describing the different levels of dementia. When looking for senior housing you can utilize this chart to determine if, and where, your loved-one falls on the dementia spectrum.

Level 1 – No Cognitive Decline

No subjective complaints of memory deficit. No memory deficit evident on clinical interview.

Level 2 – Very Mild Cognitive Decline (Forgetfulness)

Some subjective complaints of memory deficit. Most frequently in the following areas: (a) forgetting where one has placed familiar objects; (b) forgetting names one formerly knew well- No objective evidence of memory deficit on clinical interview. No objective deficits in employment of social situations.

Level 3 – Mild Cognitive Decline (Early Confusional)

Earliest clear-cut deficits. Manifestations in more than one of the following areas: (a) patient may have gotten lost when traveling to an unfamiliar location: (b) co-workers become aware of patient's relatively poor performance: (c) word and name finding deficit becomes evident to intimates: (d) patient may read a passage or a book and retain relatively little material: (e) patient may demonstrate decreased facility in remembering names upon introduction to new people: (f) patient may have lost or misplaced an object of value: (g) concentration deficit may be evident on clinical testing. Objective evidence of memory deficit obtained only with an intensive interview. Decreased performance in demanding employment and social settings. Denial begins to become manifest in patient. Mild to moderate anxiety accompanies symptoms.

Level 4 – Moderate cognitive decline (Late Confusional)

Clear-cut deficit on careful clinical interview. Deficit manifest in following areas: (a) decreased knowledge of current and recent events: (b) may exhibit some deficit in memory of one’s personal history: (c) concentration deficit elicited on serial subtractions: (d) decreased ability to travel to familiar locations. Inability to perform complex tasks. Denial is dominant defense mechanism. Flattening of affect and withdrawal from challenging situations occur.

Level 5 – Moderately severe cognitive decline (Early Dementia)

Patient can no longer survive without some assistance. Patient is unable during interview to recall a major relevant aspect of their current lives, e.g., an address or telephone number of many years, the names of close family members (such as grandchildren), or the name of the high school or college from which they graduated. Frequently some disorientation as to time (date, day of week, season) or to place. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. Persons at this stage retain knowledge of many major facts regarding themselves and others. They invariably know their own names and generally know their spouses' and children's names. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear.

Level 6 – Severe cognitive decline (Middle Dementia)

May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. Will be largely unaware of all recent events and experiences in their lives. Retain some knowledge of their past lives but this is very sketchy. Generally unaware of their surroundings, the year, the seasons etc. May have difficulty counting from 10, both backward and sometimes, forward. Will require some assistance with activities of daily living. e.g., may become incontinent. Will require travel assistance but occasionally will display ability to travel to familiar locations. Diurnal rhythm frequently disturbed. Almost always recall their own name. Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment. Personality and emotional changes occur. These are quite variable and include: (a) delusional behavior. e.g., patients may accuse their spouse of being an impostor. May talk to imaginary figures in the environment, or to their own reflection in the mirror (b) obsessive symptom e.g., person may continually repeat simple cleaning activities (c) anxiety symptom agitation and even previously nonexistent violent behavior may occur (d) cognitive ability i.e. loss of willpower because an individual cannot carry a thought long enough to determine a purposeful course of action.

Level 7 – Very severe cognitive decline (Late Dementia)

All verbal abilities are lost. Frequently there is no speech at all - only grunting. Incontinent of urine. Requires assistance toileting and feeding. Loss of basic psychomotor skills, e.g., ability to walk. The brain appears to no longer be able to tell the body what to do. Generalized and cortical neurologic signs and symptoms are frequently present.

Reisberg. B.. Ferris, S.H., Leon, M.J. & Crook, T. (1982). "The global deterioration scale for assessment of primary degenerative dementia." American Journal of Psychiatry. 139:1136-1139.14

 

FINANCIAL HINTS

Don’t Be Afraid to Ask if there are Low-Income Options at Assisted Living Communities

When looking at Independent/Assisted Living facilities (also called RCFEs), ask if they have any below market rate or subsidized rooms.  When planning and building these communities, often the owners are required by their city government to include low-income, below market rate, or subsidized units along with market-rate units.  Often these units are not advertised.  It doesn’t hurt to ask!      

Tax Deductions for Assisted Living and Skilled Nursing Costs

Some of the costs of living in an Assisted Living or Skilled Nursing facility may be tax deductible if the expenses are more than 7.5% of the resident’s adjusted gross income.  Requirements are:

  1. The resident must be “chronically ill,” and a doctor or nurse must certify that they can’t perform at least 2 activities of daily living, or that the resident requires supervision due to a cognitive impairment like Alzheimer’s or dementia.
  2. Personal care services must be provided via a “plan of care” prescribed by a doctor, nurse or social worker (most assisted living facilities prepare these for their residents).

In some cases, adult children can get a tax deduction if their parents or other immediate family members live at an assisted living or SNF facility and qualify as their dependents.

Talk to your tax specialist to determine what portion of your care bills are tax deductible and look at the IRS information found at www.irs.gov/publications/p554/ch04.html.

 

How To Afford Senior Living

Life Settlement

You can sell your life insurance policy to a third party for a cash payment.  The purchaser then becomes the beneficiary of the policy and is required to pay the premiums.

Typically the purchaser is an experienced institutional investor, and policies will have amounts in excess of $250,000. Life settlements are usually only transacted when the insured person does not have a known life-threatening illness.

Gift Tax Exemption

The IRS offers a gift tax exemption if family members are financially able to make contributions toward senior care.  Consult with your tax professional.

Long-Term Care Annuity

As of 1/1/10, the proceeds from a long-term care annuity are tax-free if you use them to pay for an Assisted Living or Skilled Nursing facility.

Long-Term Care Insurance

This type of insurance covers assisted living, skilled nursing, and in-home care expenses.  The policy will pay a certain benefit amount per day, usually between $50 and $500 a day.

Cash-value Life Insurance

This type of insurance allows access to cash accumulations within the policy either through withdrawals, loans, or partial or full surrender of the policy (see above under Life Settlements for more detail).

Medicaid/MediCal

Find your state in this report: “State Medicaid Reimbursement Policies and Practices in Assisted Living,” by Robert L. Mollica, Ed.D. prepared for the National Center for Assisted Living, American Health Care Association in September 2009: http://www.ahcancal.org/ncal/resources/Documents/MedicaidAssistedLivingReport.pdf to determine if and how Medicaid/MediCal reimburses for Assisted Living (RCFE) facility costs.

Medicare

Medicare pays only for short term Skilled Nursing Facility stays, hospice care, and some home health care.

Veterans Benefits

See the Veterans Administration section, below.

 

LOW-INCOME HINTS

Different Types of Low-Income Senior Housing

  1. Public Housing = low cost housing in multi-unit complexes that require tenants to pay no more than 30% of their monthly income for rent.
  2. Section 8 Rental Certificates = allows very low income people to choose where they want to live, subject to HUD (US Housing and Urban Development) standards, by providing rental certificates that limit tenants’ rent to 30% of their monthly income.  You must have an income not over 50% of the median income for your area.
  3. Section 202 Housing = this type is for senior citizens, only, and usually provides services such as meals, transportation and accommodations for the disabled. These can be run by private, non-profit organizations or consumer cooperatives. One person in a household must be 62 years old or older.

 

Securing Low-Income Senior Apartments – Steps to Follow

There are often waitlists for low-income senior housing, which means there is a list of people who will be contacted, when an apartment becomes available. Sometimes waitlists are closed, which means that you cannot even leave your contact information with the apartment complex..  It is important to realize that obtaining low-income senior housing can be time-consuming and can take years to complete, so give yourself plenty of time.

Each apartment may do things differently, so it is advisable to contact each directly by phone for availability and application details.

Be prepared so that your application process is as seamless as possible:

  • There will be fees to pay to process your applications.
  • Your credit, as well as a criminal background check, will be conducted on each applicant.
  • If you are applying as a one-person household, be sure to indicate you are the “head of household.”
  • You will be rejected if you cannot pay the full security deposit.  
  • Apply to many different places to improve your chances.
  • Call the apartment contact every 4-6 months to let them know that you are still interested in an apartment, and if there are any changes to your personal contact information so there is no delay in reaching you, when an apartment becomes available.

 

To see the housing waiting list for San Mateo County, go to http://housing.smcgov.org/waiting-list.

To see what housing is available and the status of waiting lists for San Francisco, go to http://sf-moh.org/index.aspx?page=153

To see what housing is available and the status of waiting lists for Santa Clara County, go to http://www.hacsc.org/section-8-housing-programs/waiting-lists-applicants/; and http://scchousingsearch.org/

 

 

VETERANS HINTS

Veterans Administration Benefits can Include Home Loans and Money for Assisted Living and In-Home Care Veterans Administration benefits include home loans. Close to 90% of all VA home loans do not require any down-payment. In addition to 100% financing, federally guaranteed VA home loans have flexible credit standards to make qualifying easier.  You can apply for a VA loan with any mortgage lender that participates in the VA home loan program. At some point, you will need to get a Certificate of Eligibility from the VA to prove to the lender that you are eligible for a VA loan.

The unmarried surviving spouse of a veteran who died on active duty or as the result of a service-connected disability is eligible for the home loan benefit.  Also, a surviving spouse who remarries on or after attaining age 57, and on or after December 16, 2003, may be eligible for the home loan benefit.  Loan limits vary; if you’re not buying in a high-cost county, the maximum home loan is $417,000, but high-cost county maximums are greater.  Go to www.benefits.va.gov/homeloans/ for more information.

Additionally, if a spouse of a veteran, or the veteran is in need of assisted living or the services of an in-home care provider, the “Aid and Attendance” benefit can be applied for.  Certain requirements must be met, but this benefit can pay up to $1949 a month.  Go to http://benefits.va.gov/pension/aid_attendance_housebound.asp for more information.

 

CONTINUING CARE RETIREMENT COMMUNITY HINTS

What to Know Before You Buy

Go through the CCRC (Continuing Care Retirement Community) contract with a lawyer. CCRCs have lawyers, and you should, too - preferably a lawyer who specializes in senior housing.  It is important to understand what happens to your down-payment if you move or die and what happens if it takes months or years to rent or sell your unit.  Be sure to go over all costs, fees, monthly rental fees, real estate costs, and any other considerations with your lawyer.

Consider a CCRC for your Short-Term Rehabilitation Needs

If you are in the market for a Skilled Nursing Facility (SNF) for Rehabilitation purposes after being released from the hospital, consider the SNF unit at a local CCRC.  Many of them will accept out-of-community patients in their SNF level if a bed is available.

 

WHAT HAPPENS IF YOU RUN OUT OF MONEY?

No one can predict how long they will live and everyone is concerned with having enough money. The best plan is to have a lot of money saved and long-term care insurance, but not many people have the luxury of both, and even if they do, they can outlive their savings.

To give you an idea of the kind of costs you can expect, look at this website  https://www.genworth.com/corporate/about-genworth/industry-expertise/cost-of-care.html which shows the average yearly price, by state, for in-home care, assisted living and skilled nursing facilities.  

If you live in a CCRC (Continuing Care Retirement Community) and are unable to continue monthly payments, you may have lived there long enough that a reduced monthly rate can be worked out for your situation.  The CCRC has your entrance fee, so they may possibly have more flexibility than other types of communities.

If you run out of money while living in an Assisted Living/Independent Community, you will probably have to move out and rely on family, friends, or the government (social services) for assistance.  Before moving into a community, look at their policies for this particular situation and see if you agree with them.  An Assisted Living Waiver (ALW) uses Medicaid/MediCal money for assisted living.  Unfortunately, at this time in late 2013, only Fresno, Los Angeles, Riverside, Sacramento, San Joaquin and Sonoma counties have this program, and it is only in limited use.

If you run out of money while in a Skilled Nursing Facility, you may qualify for a Medicaid/MediCal bed. If the SNF participates with Medicaid/MediCal, you may be able to stay on in the community at the much-lower rate. If the SNF does not participate with Medicaid/MediCal, you may have to move to a SNF that does. (Medicare will only pay for a short amount of an SNF stay (see options for paying above). Before moving into an SNF, find out if they have Medicaid/MediCal beds for this particular situation.

 

CRIME STATISTICS

Crime Statistics for California Cities

Before moving to a different city, check this website: http://www.cityrating.com/crime-statistics/california/#.UoVXk-PZ_Wo. Once the page has come up, scroll down to the end to select the city that you are interested in.