The hidden role informal caregivers play in health care

Once a cared-for patient and now a caregiver himself, Scott Williams highlights the invaluable role of informal caregivers — those friends and relatives who, out of love, go the extra mile for patients in need.
From personal care to advocacy to emotional support, unpaid caregivers form the invisible backbone of health and social systems all over the world, Williams says — and without them, these systems would crumble.
“How can we make sure that their value to patients and society is recognized?” he asks.

Keeping the Bathroom Safe for People with Balance and Health Challenges

The bathroom is designated as the most dangerous room in the house for seniors. 

Numerous injuries and falls occur in the bathroom, causing an awkward (and sometimes embarrassing) situation for families. Because so many falls happen in the bathroom, it is encouraged for family members and paid caregivers to take a close look bathroom for safety concerns. A few simple changes will make the bathroom a safe and comfortable place for everyone.


  • Equip showers and surrounding walls with sturdy grab bars anchored to wall studs so they can support the full weight of an adult. Some portable safety handles use super strong suction cups and are easy to apply and remove.
  • A shower chair is also a safe solution that placed where balance is a challenge.
  • Flexible handheld shower wands with an on/off button might be easier to use than a traditional shower head. These are especially useful in combination with shower chairs.
  • Many medical alert buttons are waterproof to wear in the shower. Make sure you always have yours with you as it is the number one source of falls in the bathroom.


  • Replace an unused bathtub with a walk-in shower. The standard tub/shower unit in so many homes may be uncomfortably high for the elderly and disabled to step over, and too low to sit down into for bathing.
  • Check temperature settings on water heaters, as water hotter than 120 F can scald skin. No-scald faucets or a no-scald regulator may be installed as a precautionary layer of protection.
  • A spa-like walk-in tub. Installing a walk-in bathtub or shower system with a built-in seat brings back a measure of independence in self-care. Many walk-in tubs are designed to fit perfectly in the space of a conventional tub for easy installation and are now available with unique features.


  • Consider installing nonskid tape or mats on the floor of a shower or bathtub.
  • Make sure bath mats are slip-proof and don’t create a tripping hazard.


  • Toilets can be installed with a taller ADA-approved raised-height models to lessen the chance of a fall. Alternatively, raised-height seats can be installed on existing toilets.
  • Standard toilets have a bowl height of about 15 inches, but many manufacturers have recently introduced models that are an inch and a half higher. These taller commodes make sitting down and getting back up less stressful on the body.
  • Keeping an extra medical alert button near the toilet is a smart idea so they can summon help right away.


  • Some faucet handles are difficult for arthritic hands to grip and turn. These should be changed with an ADA-compliant faucet that is easier for seniors to use.
  • This faucet style also has an adjustable hot limit safety stop to help reduce scalding.
  • This simple and inexpensive alteration will make washing up more comfortable for elderly parents and grandparents and is also a great excuse to perk up the look of your bathroom.


  • Think about accessible storage. Keep bathing and grooming accessories neatly stowed out of the way to reduce trips and falls, and to keep them clear of wheelchairs. Accessibility and functionality are essential when planning for convenient storage options in the bathroom.
  • Vanities which offer ample storage space within a smaller footprint can hide hair dryers, towels, bath products and cleaning supplies, creating an uncluttered look to make the space appear larger.
  • The top of the toilet tank is valuable bathroom real estate, either on top of the tank or with a small cabinet attached to the wall.
  • Make it easy on the eyes. High-gloss paints and tiles can produce an uncomfortable glare, so introduce matte finishes for better visibility. Choosing wall and floor colors or patterns that contrast is another great way to increase visual perception of space and help older adults feel more confident as they move about the room.

What is an Advance Directive?

Advance Directive is a broad category of legal medical instructions for your healthcare. A Living Will, Health Care Proxy (Durable Power of Attorney for Health), Do Not Resuscitate Order (DNR), Do Not Intubate (DNI), Do Not Hospitalize (DNH) and POLST are all types of advance directives. 

Advance directive – This document tells the medical community your wishes concerning medical treatments at the end of life.

  • Anyone 18 and older should have one, typically a living will and health care proxy, and it should be updated throughout your lifetime. An advance directive cannot be created by someone that has no decision-making ability or is developmentally disabled.
  • These are not good in an emergency. EMT’s can’t take the time to read or evaluate these long, multi-page documents. Once emergency personnel is called, they must do what is necessary to stabilize a person for transfer to a hospital. They do not have to honor living wills or health care proxy. Source: Caring Info
  • Advance directives can and do get lost in hospitals. Keep the original and give a copy to the hospital. It is supposed to stay with your hospital chart, but as your chart grows, it may rest with an earlier admission to the emergency room and not get passed to ICU, etc.

Living Will – This document allows you to approve or decline certain types of medical care if you are unable to make decisions and choices on your own. In most states, living will take effect only under the circumstances such as last injury or permanent unconsciousness.

  • Five Wishes – Written in everyday language, it was created by the non-profit Aging with Dignity and is best used as a conversation starter with loved ones. It approaches the end of life conversation in a non-threatening way by including questions on music or readings you might want to have a service after you die. 

Healthcare Proxy (Durable Power of Attorney for Healthcare) – In this document, you name a person to be your proxy (agent) and make your healthcare decisions if you are not able to do so. Your proxy can speak on your behalf and make decisions according to directions you gave earlier. The law does not allow the agent to be a doctor, nurse, or other person providing healthcare to you unless it is a close relative.

Do Not Resuscitate – This hospital order means that if you stop breathing or your heart stops, medical staff will not attempt to revive you by trying to re-start your heart and breathing. The attempt to resuscitate after death is very hard for the frail, older adult who usually winds up with rib fractures and punctured lungs.

  • The Do Not Resuscitate must be signed by the doctor.
  • There are several types of DNR forms:
    • DNR-A status indicates comfort care only; the comfort care order set should be completed routinely for all DNR-A patients. It is used to allow natural death to occur.
    • DNR-B status implies some active medical care is continued
    • An “Out of Hospital DNR” order is for outside the hospital; in an ambulance or at home, for example.
  • Any DNR is only good for the environment in which it was is created (e.g., hospital). If you move from another facility (e.g., nursing home), back to the hospital, you must redo the DNR for each treatment setting.
  • Some hospitals require a new DNR order each time you are admitted to the hospital. If you are hospitalized, ask if a new DNR is needed.
  • A DNR is not right if you are in an ambulance transport to another facility. If you code on the ride, EMT’s will do a full treatment unless you have given them a DNR and the hospital decides to accept it.

Do Not Intubate (DNI) and Do Not Hospitalize (DNH)– these are two more legal documents that give you control over your medical decisions.

  • Like the DNR, these documents are only good for the environment in which it is created. They are not portable documents.

How is the POLST form different from another end of life documents?
The POLST form is a medical order that must always be followed, in all places. These actionable medical orders complement your Advance Directive and Living Will. Doctors that follow the directions of the POLST form in good faith are protected from liability by the POLST law itself, while doctors and others that willingly ignore POLST directions will face the consequences, both legal and professional. Unlike the Advance Directive, the POLST form does not require the patient to have lost their decision-making process. There is no age limit on the POLST, and it applies immediately. Unlike the DNR, the POLST form is portable across settings.

  • Have these medical documents readily available in case of emergency: Medication list, POLST form and Advance Directives in a plastic bag that is attached by a magnet to your refrigerator. Having them in one place means you can quickly bring them with you in an emergency.
  • Create an electronic copy of all these documents so you can email them from your phone and have the hospital print it out.

Disclaimer: The material in this blog is for educational purposes only. It is not intended to replace, nor does it return, consulting with a physician, lawyer, accountant, financial planner or other qualified professional.

Planning for caregiving 25 years before it happens versus 25 minutes after you need care

Joel Johnson – Forbes Magazine

Long-term care insurance provides care for those who need long-term assistance in a nursing home, care at home or adult daycare. What it also offers is care support and assistance for yourself or loved ones. 

Long-term care insurance has been around since the late 1970’s; the popularity emerged during the 80’s and 90’s.  With more and more Americans needing this service, it is essential to know how LTC benefits will be of value to you, your family, and your lifestyle. 

Medicare covers only short stays in a nursing facility, Medicaid pays for care services in a care center because you have just social security and no retirement or other assets or you have depleted your financial accounts. Therefore, if you envision an assisted living center as your future home, you will need the necessary resources to fund this option. Are you prepared?

Long-term care insurance pays for services when you need care in your home or a nursing home. It provides a variety of services paying by reimbursement or cash payments to for Activities of Daily Living (ADLs) which include cognitive, bathing, dressing, continence, eating, toileting, transferring oneself from a seated to standing position and getting in and out of bed. There are varying levels of long-term care dependent upon each person’s assistance level needed.

There are 75,400,000 aging baby boomers in the United States.

Americans are living longer lives due to advancements and improvements in health products and health services. 

Baby boomers have also benefited from organ transplantations which are routine procedures at hospitals around the country. Heart, liver or kidney surgeries are performed saving thousands of lives every year. Also, a health-conscious society has also helped contribute to individuals living longer lives. Smoking, once considered a favorite pastime, has lost a little bit of its luster due to research emphasizing the many risks involved.

    1. 7 in 10 Americans 65 or older will need long-term care services.
We may be living longer; older individuals are not necessarily living healthier, more active lives. The health and well being of an individual affects everyone in the family. 
77% of caregivers missed time off from work and close to 1/3 of caregivers provided more than 30 hours of care per week.
  1. The median U.S. annual private room nursing home cost in 2016 was $92,378.

Fees for assisted living facilities are substantially less than private nursing homes, but at an approximate cost of $45,000 per year, those figures have a price tag if you haven’t planned. 

$166,845 is the projected median U.S. annual private room nursing home cost in 20 years.

It is essential for families to have these conversations before health becomes a concern to avoid a care planning crisis. 

There are traditional and hybrid long-term care insurance considerations. What’s appropriate for you depends on whether you are living along even if you have family and friends who may be available for your care or you are in a relationship, i.e., spouse/partner.

Begin the discussion early with family and develop a plan moving forward or you may want to speak with your wealth advisor who has a colleague relationship with LTC benefits agent to help assess what’s best for your caregiving plan. 


Why Self Assuring is better than Self-Insuring

My mother who is a retired estate planning attorney and has an income over one million dollars and assets millions comments about why owning care benefits if valuable: “No one has that much money.”

What she means, no matter how much income — care expenses if you are frail or if you need assistance because of activities of daily living will take significant sums of money away from your cash flow which funds your lifestyle.

I am certain that the people affected in the Montecito area of California which is affluent are calling their insurance agents about their homeowners’ insurance. There will be no happiness if they are obligated to pay for repairs from their income or assets. 

Why not have the conversation about an event which is a probably: Frailty, Dementia, or activities of daily living will occur and what is your plan for caregiving and how will you pay for it?

Veterans Benefits for Assisted Living and Nursing Home Care

For planning purposes, it is vital for families to know how VA benefits and Medicaid interact with assisted living facilities and nursing home care.

Traditionally, VA Pension with Aid and Attendance worked well as the transition through the continuum of care. An elderly individual who needed long-term care at an independent living facility or an assisted living facility might qualify for VA Pension benefits to afford the facility cost. If this individual later is necessary to go to a nursing home at a much increased monthly fee, they would apply for Medicaid. Medicaid would then take all of this individual’s monthly income, other than a small stipend, and provide complete care. In this circumstance, by statute, the VA would reduce the individual’s VA Pension benefits to $90 per month of which the individual is allowed to keep and use for incidentals. This path worked pretty well to afford essential care for Veterans and Surviving Spouses with limited income and net worth. 

I must note that Medicaid offerings vary from state to state and I do not practice Medicaid planning law. I am only speaking to what I know from experience as aVA benefits lawyer. In recent years, states began to offer more varied care options through Medicaid programs. Although it is positive to have more care options for low-income elders, it has caused some confusion with how Medicaid interacts with VA benefits. 

Some states are offering Medicaid to cover assisted living facility costs. In these states, we have found that Medicaid requires that the individual applies for VA benefits before being considered for Medicaid. If the VA benefits are or have previously been approved, Medicaid counts the VA benefit as income, and it can disqualify the individual for this specific Medicaid program due to income level. Further, under this circumstance, the VA does not reduce the VA benefit to the statutory $90 per month amount because the facility is not a “nursing home,” under the statutory language. The VA benefit and all of the individual’s income is paid to Medicaid. We have had some clients who qualified for Medicaid to cover assisted living even with their VA benefits income, which has been a positive result for our clients!

When an individual is in an independent living facility, they must be contracting for nursing services at the independent facility from a third party for the fees paid to the independent care facility to be deductible from the individual’s income (which is how most qualify for Pension). The rub is that the VA has decided that within the definition of “contracting” is actually paying out-of-pocket for the care services. Therefore, if Medicaid is providing the nursing services free of charge, the individual will not qualify for Pension with aid and attendance, due to excessive income.

On a positive note, I would like to make sure that you know that a married couple with one spouse in a nursing home on Medicaid can still qualify for Pension with Aid and Attendance. In most situations, the non-Medicaid spouse does need to be incurring care costs, in-home or facility based, to qualify financially.

At the Center for Elder Veterans Rights we are dedicated to serving the needs of elderly disabled Veterans and their family members.

If you believe that you or someone you know might be eligible for this benefit, please contact us immediately for a no-obligation initial consultation – 800.394.1250 – or visit us on the web at:

VA Pension Plus Aid and Attendance Rates 2018

The Center for Elder Veterans Rights, PC

An independent law firm representing the interest of elderly Veterans and their Families

Maximum Pension Benefit Plus Aid & Attendance

Surviving Spouse $1176

Single Veteran $1830

Married Veteran $2169

Veteran Couple $2903

Qualifying Pension Service Dates:

12/07/1941 – 12/31/1946 – WWII

06/27/1950 – 01/31/1955 – Korea

02/28/1961 – 08/04/1964 – Vietnam I (must have been in country)

08/05/1964 ‐ 05/07/1975 – Vietnam II

08/20/1990 – Present – Mideast Conflicts

Call our paralegal department at 800‐394‐1250 for a no‐risk

pre‐filing consultation or email

Visit our website for an educational experience about VA Benefits

VA‐Accredit Attorney: Kristen Vanderkooi /

Office Manager/Senior Paralegal: Stephanie Boyd /

What family needs to do with helping with a parent’s finances

Josh Health – Financial Post


Take a close look at your parent’s income and expenses to make sure you know how they are funding their lifestyle and whether it is sustainable. If your involvement in their financial affairs is due to a physical or mental impairment that could result in higher medical or care costs, it is essential to get a sense of what those future costs could be and how best to fund them.


You should talk about whether care in the home or care in a facility is preferable. If a home is not sold, it may impact how you draw down on their investments, borrow against their home or provide support yourself.

Personal care workers can cost $20 to $35 per hour, and registered nurses can cost $30 to $100. There is typically a minimum number of hours required per visit. Full-time care can cost $2,000 to $10,000 per month — or more.

If there are insufficient financial resources to fund future expenses, it is of value to have a care giving plan before there is a need. The idea may be for family members to help pay for care costs or for a parent to move in with you or a sibling. And if the best alternative is for a parent to move into a government subsidized long-term care facility,  it is important to note that wait lists can be long and priority if to to those who are most in need of care services.


Make sure your parent’s tax returns are up to date. Some seniors are prone to owing money on their tax filing since neither investment income nor minimum withdrawals from a Registered Retirement Income Fund (RRIF) are required to have tax withheld at source. Some seniors may also be entitled to government benefits that are based on their annual tax filing. Benefits will not be paid if taxes are not filed.

There are other tax deductions and credits related to medical expenses, caregivers or modifications to a home that you should investigate as well.


A parent will be able to authorize your involvement with their bank or investment adviser, whether you all take part in discussions, they give you trading authority, or you formally take over accounts as power of attorney for property.

The first thing you should do with your parent’s investments is taking inventory of what they have in the first place. Statements are a good starting point, but review their past tax returns to see if they had tax slips from companies not included in their investment statements.

Once you have everything summarized on one page, you can take stock of whether they have enough money to fund their future expenses, whether on your own or with the help of a professional. You can also get a sense of what is invested and whether they have a proper overall asset allocation.

My experience has been that older investors are more prone to having their savings stashed in high-fee mutual funds that were the only investment game in town in the 1980s and 1990s. The available alternatives have significantly evolved over the past 20 years. You should be considering whether your parents are paying a reasonable fee for their investments and whether their asset allocation is appropriate.

If you find yourself solely responsible for their investments or you have the green light from a parent to consider alternatives, avoid the habit to do things  because that is how it has been done. 

Be mindful of tax considerations from selling investments and most importantly, treat the money like it belongs to your parent. Some children tend to treat what could someday be their inheritance like it belongs to them before it does.


Make sure your parent’s will and powers of attorney are up-to-date.

If a parent is still of sound mind, they can change their beneficiary designations, so make sure account, and insurance beneficiary designations are all accurate.


Determine life insurance policies that are in-force and confirm anyrequired ongoing premiums.

Review health and long-term care insurance policies to see which medical expenses are covered now or are covered in the future.


There is a good chance you will be called upon someday to assist with a parent’s finances. It may be a role you play for many years or it may be more short-lived.

A parent’s money belongs to them until they give it away or until they die. Respect this fact and respect if they choose not to talk to you about their finances. I think it is essential for children to try to talk to their senior parents about money, even if it is short, sweet and high-level. You do not necessarily need to know all the details.

And for parents out there who think they are going to manage their financial affairs well into their 90s. 

Consider the possibility that time will come when you least expect it, and your family will be managing your financial affairs. They may want to talk to you about it, but not know where to start. You could always be the one to begin the discussion.

Will You Outlive Your Money?

Methuselah is fortunate. The Biblical stalwart lived 969 years without any reported money worries. Like him, Americans live to an advanced age—although nowhere near the record set by the man who might have been the only true millennial.  People have a fear of outliving their financial assets. Sometimes, that concern is justified; often, it’s irrational. But, in the minds of the worriers, it’s always palpable and, frequently terrifying.

A 2016 survey of 4,500 people by TransAmerica, found that the top retirement fear of respondents, regardless of age, was exhausting their money before death. The second and third most common concerns were related to the first: Social Security going bust, or their health deteriorating, leading to medical expenses that would pauperize them.

Kathleen Gurney, a psychologist, and authority on behavioral finance, “These fears are much more prevalent today than they once were. People live longer. They don’t have defined-benefit pension plans. Health insurance is another challenge. People once felt that Medicare would be enough to take care of them if they got needed health care services. That’s not the case anymore.”

Lengthening lifespans compound the retirement challenge. According to the Social Security Administration, anyone who reaches 65 now can expect to live past 85. And by 2035, the agency estimates, there will be 79 million Americans at least 65 years old, versus 49 million today.

An expensive illness: dementia, now the sixth most common cause of death in the U.S. The elderly aunt of a friend of mine pays more than $15,000 a month at a memory-care facility in Massachusetts. (Medicare doesn’t cover long-term care.) 

After being diagnosed in 2009, he cared for her in their Sarasota home, with the help of aides. But after he suffered bouts of heart disease and cancer himself, his children convinced him that he couldn’t do that anymore.In the last nine months of her life, Helen lived at Arden Courts at Sarasota, a small memory-care facility.

“It cost $5,600 a month,” Pell says. “She insisted, about 15 years ago, that we buy long-term care insurance, which we did. 

The fear of losses increases as investors age and have fewer years left to recoup from setbacks like those inflicted in the vicious bear market from late September 2007 to early March 2009, during which stocks fell by more than 50 percent. The math is merciless: Lose 20 percent on $10,000, and you must make 25 percent on the remaining $8,000, just to break even. Lose 50 percent, and you need to make 100 percent. 

Ironically, that dizzying climb seems to have scared some investors as much as the devastating plunge did. Those investors have convinced themselves that, like Icarus and Daedalus of Greek mythology, stocks are flying too close to the sun and is primed for a vertiginous tumble, and they’ve stayed out of the market. A recent Gallup poll found that only 52 percent of American adults have money in the stock market, directly or indirectly (as through a pension plan or mutual fund). In 2007, before the Great Recession and market slump, the figure was 65 percent.

When will you and your family have the conversation about your caregiving and your exit strategy?

Is Long-Term Care Insurance Worth It?

$255.1 billion. That is the staggering amount Medicare and Medicaid paid in 2016 for long-term care. Home health care accounted for $92.4 billion; $162.7 billion for nursing home care and continuing care in retirement communities.

Based on 2013 data, Kaiser Family Foundation estimated that Medicaid pays 51 percent of long-term care expenses. Ultimately, the American taxpayer.


As astounding as the figure is, it is an incomplete picture of long-term care spending. Insurance carriers paid an additional $8.65 billion in long-term care claims on behalf of 280,000 long-term care insurance beneficiaries. These reimbursed expenses do not include the unpaid care provided by family members.

54 percent of new LTCi claims are for home health care services. The family offers much of home health care. On average, caregivers contribute $10,000 to care expenses. Then there is the opportunity cost of caregiving due to lost wages for unpaid time-off to provide care.

Taking a look at who pays for long-term care gives a different perspective. For those who plan to rely on a combination of Medicare, Medicaid, and family help, it becomes clear, that others shoulder the cost of failing to prepare for an inevitable situation for 70 percent of those 65 years and older. By 2050, a little more than 30 years, twenty percent of the population is expected to be 65 or older.

Now, let’s turn to the increasing cost of long-term care. Over the last seven years, the price of care rises. Reviewing the chart below, rates of change accelerate and decelerate, but continues to rise, year after year.


There is only one solution that will protect financial to provide reserve funds to pay for care services. In 2016, AHIP (America’s Health Insurance Plans) commissioned a study of satisfaction levels of long-term care claimants. In virtually every category, long-term care insurance beneficiaries indicate LTCi made a significant difference in their lives and the level of long-term care provided.

  • 93 percent believe policy benefits are sufficient to cover the cost of care
  • 88 percent are satisfied with the amount of coverage purchased
  • 75 percent say that without LTCi, they would receive less attention
  • 64 percent say that without LTCi, they would have to rely on family and friends for care

The most overwhelming evidence of the wisdom of purchasing long-term care insurance is the policy value. The per-person average total claims paid by insurance carriers participating in the survey is $118,986.

Conversely, the average long-term care expense for the general population is $140,000, $72,000 of which is compensated by families.

The premium-paid to benefit-received ratio tells the story. For every dollar in LTCi premium paid, $2.78 is paid in benefits. That is an excellent return on premiums paid by extended care benefits.