Managing the care of a loved one is a perilous journey, often made more difficult by the obstacles of misinformation and bad choices. The beacon on the shore guides ships to safe harbor; we hope to be a beacon for families caring for their loved ones.
Dashed on the Rocks When Going It Alone for Medicaid
Families are sometimes tempted to go alone when applying for Long-Term Care Medicaid.
“Lawyers are just going to overcharge to help us.”
“How hard could it be?” they wonder.
Trying to navigate the Long-Term Care Medicaid process alone is akin to climbing Mt. Everest with no guide. The icy crevasses along the route are littered with the bodies of those who try.
The Medicaid Touch Stone
When a loved one needs long-term care, families often reach out to community resources for guidance with applying for Long-Term Care Medicaid. Inevitably most are told that they have too much income or assets to qualify. “You have to spend down the excess and then apply for Long-Term Care Medicaid” they are counseled.
If the family is fortunate enough to find their way to an Elder Law Attorney, they learn that the quintessential requirement for qualifying for Long-Term Care Medicaid is medical, not financial. The prerequisite for qualifying is that the applicant requires assistance with at least one activity of daily living, usually referred to as “ADL’s”. If there is no medical need, qualifying for the benefit is impossible. Thus, the need for assistance is the touchstone for Long-Term Care Medicaid qualification. It guides and shapes the family’s journey throughout the application process.
Let Go of Should’ve, Could’ve, Would’ve
(And take action now)
One of the biggest barriers to Estate and Long-Term Care planning is guilt over not addressing these important issues earlier. This is the could’ve, should’ve, would’ve syndrome. Or, they feel like it’s too late and they’re too far along with their choice. This is the sunk-cost fallacy. It’s hard to change course when you feel like you’ve invested so much into the decision, even when changing course would be more beneficial.
We all procrastinate because we are human beings, and we agonize over regrets and over lost months or years. Let it go. If you are reading this, you are just in time. In the words of Arthur Ashe, “Start where you are. Use what you have. Do what you can.”
Denial is Not a River in Egypt
At its extreme, dementia can cause the patient to say and do things that were once unimaginable for that person. When the patient threatens violence or actually becomes violent, the family has to take action. It’s one of those things that is easy to say. The hard part is doing it.
Family caregivers often endure dangerous and sometimes abusive situations because of love and devotion; especially a caregiving spouse. They soldier on hoping it will go away or at least get better. After all, they pledged “for better or worse.”
The adult children will become involved at some point because the parent caregiver will have to reach out for support. It is very typical for the caregiver to deny that calling the police or going to the emergency room for psychiatric help is necessary. But sometimes such action is the only reasonable, correct thing to do.
Acting out violently or threatening to hurt another person should not be ignored. Sometimes, adult children must intervene and get help from the police or the emergency room, even over the protestations of their caregiving parent. Denial is sometimes deadly.
Timing
A doctor’s finding that your loved one requires 24/7 care feels like sailing through murky, shallow waters. The first challenge is having to accept that skilled nursing probably is the only realistic choice for providing the care that is needed. The second is how to pay for such care on a long-term basis. The time frame for formulating a plan is short – maybe a week at most.
Managing the care of a loved one who is no longer independent with activities of daily living can be like steering through the fog of night. Like a lighthouse in the dark, we hope to share information that will help the caregiver avoid losing control when transitioning their loved one into skilled nursing becomes medically necessary.
- Nursing homes in Delaware charge between $12,000 and $18,000 per month.
- 90% of the senior population will exhaust their savings within the first year.
- Long-Term Care Medicaid is the only sustainable source of funding for most people.
The Medicaid application process is daunting. Assume that it will take at least six months for approval of the application. It is very difficult to find a nursing home bed unless the patient can self-pay until Medicaid is approved. This fact dictates that the caregiver must start when there is at least $100,000 left in savings to avoid a financial crisis.1
Watch to Warning
Predicting when someone will become dependent on others for assistance with activities of daily living is no more accurate than predicting the weather. The “watch” vs “warning” prediction model for the weather is useful, however, in the long-term care context.
A “watch” is issued when a family begins to notice mild changes in a loved one’s mental or physical condition that may affect their ability to remain independent with activities of daily living. Trends to watch include noticeable confusion, an active person becoming sedentary, unsteady gate or trouble with transferring, and social withdrawal.
A “watch” becomes a “warning” when the loss of independence with one or more activities of daily living is probably going to occur. Trends to look for include a decline in a decision-making capacity, an early diagnosis of a chronic medical condition such as Parkinson’s or dementia, incontinence, dependence on a walker or cane, falling, and one or more hospitalizations requiring inpatient rehab in a given year. The transition from independence to requiring assistance often takes place suddenly.
The question is, when does the family begin to prepare for a loved one’s predictable decline from independence? Just because the sun is out when the hurricane warning is issued, doesn’t mean the storm will miss your beach.
Where is the Dividing Line for Spouses Caring for an In-law?
Over the years we have had many cases where a person’s spouse becomes the primary caregiver for their in-law. This arrangement arises for any number of reasons: usually, the family wants to avoid having to pay home health aides, or the arrangement allows one spouse to continue working while the in-law stays home to care for mom, or the transition from “just helping out” to “being a caregiver” was too slow and subtle to notice in real time.
It works as a temporary stop-gap measure. It generally is not sustainable long term. The core reason shared by families is that the caregiving spouse married the adult child, not his parents. The adult child spouse should understand that the caregiving spouse is making significant sacrifices, both personally and professionally, to become a caregiver. Resentment tends to creep into the situation if the arrangement becomes long-term.
Once the parents cannot handle bathing or cleaning themselves after using the bathroom, it is time to hire a home health aide to relieve the spouse of this responsibility. This is the dividing line between what is sustainable and what is not. The disabled parent often finds this situation humiliating. The caregiving spouse becomes angry and resentful, even though they may deny having these emotions and feelings. Save everyone the upset feelings and start hiring professional help.
1 Don’t delay starting the Long-Term Care Medicaid process in the hope that your loved one might get better. This rarely happens. Based on the six-month timeline, available funds may not last that long. Let us warn you about the obstacles lying in wait, threatening to sink the ship: It is said that some facilities are willing to accept a new patient who has exhausted their assets on the basis of a Medicaid concept known as “retroactive payment”. The facility only requires the new resident to pay their monthly income until their application is approved. This creates a growing balance owed each month. The theory is that as long as the new resident has started the Medicaid application process, Medicaid will pay the facility up to three months retroactively once the application is approved. This is not correct. Please see our blog on this issue.
