I want to Stay in my Home – Medication Management

This week’s blog continues the discussion of an aging adult who wants to stay in his or her home.  The introductory installment (on February 11, 2016) discussed the emotional turmoil that can face the adult children in deciding whether to accede to the aging parent’s wishes to stay home.  The February 18, 2016 installment discussed home modifications that may make it easier for an aging adult to stay home.  Today’s installment will discuss medication management.

One of the most common reasons that an aging adult cannot stay in his or her home is failure to take medication as prescribed.  Not to be Captain Obvious (with apologies to Hotels.com,) but compliance with prescriptions is HUGE in a senior’s attempts to age in place.  There is help with medication management.

Any one older adult can have a complicated prescription regimen for any number of chronic conditions.  “Dad” might need a blue pill, a red capsule, a round white tablet, and an oblong white tablet at breakfast.  Then, he might need two red capsules, a yellow tablet, and two different white capsules at lunchtime.  Then, it’s a yellow capsule and two oblong white tablets in the afternoon.  Then, it’s more of the same at dinner and again at bedtime.  It’s hard to keep them all straight.

The older adult (or family) should seek out a prescription packaging service.  These services can organize all of Dad’s prescriptions and package them for easy identification of the pills necessary at each particular time.  The Monday morning pills are all in one sealed packet, and the packet is labeled for Monday morning.  The, the Monday noon pills are in another sealed packet labeled for Monday noon, etc.  Dad doesn’t have to sort his own pills.  The service has done the sorting and packaged pills together that need (based on day and time) to be taken together.

Also, the individual packets are in a tear-off strip, in order.  Monday morning’s pills are at the end of the strip.  When Dad tears off that packet and takes the pills, then the next packet (now at the end of the strip) is the Monday noon packet.  Then, the next packet has the pills for Monday afternoon.  Dad’s pills are sorted so that he needs to tear off just the packet at the end of the strip.  Dad has no confusion sorting pills and making sure that he gets all of them necessary at any particular time.  The service takes care of that.  Dad just needs to tear off the next packet (just like taking a number at the DMV or the deli.)

If Dad’s difficulty isn’t sorting the pills but remembering to take his pills at the appropriate time, there are prescription reminders available (often from the same companies that provide the panic button necklace for seniors afraid of falling.)  A reminder device can be placed in a conspicuous place in the house that will give an alarm when it’s time to take medicine.  These devices generally get the senior’s attention.  (Remember how annoying was the sound of your alarm clock this morning.  It got you out of bed at, more or less, the right time, didn’t it?  These reminders work on the same concept.)

A step above the medication reminder is an automated pill dispenser with its own alarm.  A dispenser will hold all of Dad’s prescription for a certain number of days at a time.  It will dispense Dad’s pills, pre-sorted, at the time necessary for him to take the pills.

A more sophisticated version of the pill dispenser will leave the pills available to Dad for a certain length of time.  If Dad doesn’t take the pills out of the dispenser during that time, it will close up.  (Each batch of pills necessary at a particular time are in one small drawer together on one model of such a dispenser.)  The closing of the drawer prevents Dad from catching up with his pills all at once.   Some models that close up the pills not taken on time can notify a family member when Dad fails to take some of his pills.

Now, someone needs to fill the dispenser.  That someone is usually an adult child.  To make filling the dispenser easier, the adult child can get Dad signed up for one of the sorting and packaging companies.  Then the children need only to open the packets in order and place the pills into the corresponding pots on the dispenser.

With these services, medication management (and compliance with medication’s requirements) becomes much easier.  Compliance with prescription schedules will make it far more likely that the older adult can stay home.

I want to Stay in my Home – Home Modifications

This week’s blog continues the discussion of an aging adult who wants to stay in his or her home.  The introductory installment (on February 11, 2016) discussed the emotional turmoil that can face the adult children in deciding whether to accede to the aging parent’s wishes to stay home.  Today’s installment will discuss home modifications that may make it easier for an aging adult to stay home.

If an aging adult has physical ailments but does not have significant cognitive issues, certain modifications to the home may make a big difference in ease of daily activities and quality of life.  This isn’t a remodeling to give the home updated decor.  These home modifications aim to make the resident’s daily routine (in elder law and long term care management, we refer to “activities of daily living) easier.

A primary concern is stairs.  As an adult ages, walking up stairs or down stairs is very risky.  To allow an older person to age in place, the tasks that the person must perform must be available on the main floor.  This includes a bedroom, full bathroom, kitchen, living room or family room, and laundry.

Another big concern is the bathroom.  The wet slippery surfaces make footing unsure.  Stepping over the side of a bathtub or over the raised edge of a shower can cause someone who is unsteady on his or her feet to lose balance and possibly fall.  Well placed grab bars can give the senior safe hand holds to overcome the slippery floor and the unsteadiness of stepping into or out of the bath or shower.  A walk-in tub can take away the high step over the side of a tub (but the person must sit in the tub while it drains before opening the door to get out.)  A shower can be redone to be level with the rest of the floor.

For someone who needs a wheelchair, a home can be modified to ease access to the home’s amenities.  Under counter cabinets can be removed to allow the wheelchair to fit under the bathroom and kitchen sink.  Storage can be provided within reach of the chair.  Doorways and hallways can be widened, if necessary (more often in older houses.)  If a door needs just a little more width, hinges are available that allow the door to swing all the way open.  (If you don’t understand what I mean about the hinges, take a close look at a door with “conventional” hinges.  The door itself blocks a couple of inches of the opening of the doorway.)

The modifications discussed above are just examples.  Many other possible modifications are available.

To find the modifications that make the most sense, the family may want to consult with an “aging in place specialist.”  Such specialists have training and experience that can help identify the most helpful modifications for the loved one’s particular needs.

I want to Stay in my Home

Seniors want to stay in their own homes as long as possible.  Given the choice where to live out their lives, seniors would rather stay in their homes than move to nursing homes or assisted living facilities to receive long term care.  No surprise there.

The home must be safe.  The home must be appropriate for the senior’s health status.  If the home is not safe or appropriate, staying home is horrible idea.

Let’s look at this issue from the point of view of an aging Mom and her adult daughter, for a moment.  Mom wants to stay in her home.  The daughter wants to allow Mom to stay in her home.  Mom may have forced her daughter to promise never to move Mom to a nursing home.  Mom may have been in a nursing home already on a rehab stay after a hospitalization and may have cried everyday wanting to go home, dumping an enormous load of guilt onto her daughter.  Now, as Mom is aging and becoming weaker, her daughter worries that she might have to move mom “to a home” or Mom might fall in the house and lie injured on the floor for hours.

Daughter spends every day wondering if she is doing the right thing, caught between worrying about Mom’s health and wanting to follow Mom’s wishes.

Then Mom falls.  Daughter questions her decision not to place Mom into a nursing home or assisted living facility.  Daughter’s guilt can consume her, weighing her down emotionally and making her question her judgment at every decision that she faces.

Unfortunately, there isn’t a clear cut way to decide where an aging parent should live.  What Mom wants emotionally may not be a good choice for Mom’s actual condition.  Mom and daughter (and the rest of the family) are caught in a tangled knot of Mom’s wishes (reasonable or not,) advice from Mom’s doctor (decisive and clear or not,) and the family’s worries (well-founded or not.)

I hate to say it, but there is no crystal ball on the best place for Mom to live.  There are rarely clear cut answers.

Still, Mom’s family members must do their best to find what seems the best place for Mom.

You may already be in a Medicaid Spend-Down

If you are married, and you or your spouse has been in the hospital and/or rehab and/or nursing home for more than 30 consecutive days, you may already be in a Medicaid spend-down for long term care coverage.  And you don’t even realize it!

Let’s start with a discussion of the amount of savings or assets that the “well spouse” can keep when the “ill spouse” asks Medicaid to pay for his or her long term care.  By savings or assets, I mean what is left at the end of the month after income is received and bills are paid.  Medicaid labels savings and other assets as “resources.”  The amount of resources that the “well spouse” can keep at the time the “ill spouse” gets Medicaid coverage is called the Community Spouse Resource Allowance, commonly abbreviated to CSRA.

For most couples, the CSRA is half of the assets at the time the “ill spouse” had to move out of the house for medical reasons and stayed out of the house for 30 days or more.  The first day of the month during which the “ill spouse” moved out is called the “snapshot date.”  (That’s not the official terminology, but I like that term because it’s the most descriptive of what happens.)

Please realize that, on the “snapshot date,” the “ill spouse” is almost always still at home and may not realize that, before the month is over, he or she will be out of the house for medical care and/or custodial care for an extended period of time.  (The “ill spouse” is out of the house on the “snapshot date” only if the “ill spouse” becomes ill or gets injured on that first day of the month.)  The “snapshot date” on the first day of the month seems illogical because, most of the time, nothing medical happens on that day.  It’s logical only when you realize that Medicaid works in whole months.  It’s just too difficult to break financial records down into individual days.

If the couple had less than $47,688 on the “snapshot date,” the “well spouse” will be allowed to keep more than half of the resources because the “well spouse” is allowed to keep the first $23,844 of resources as the minimum CSRA.  (Unfortunately, if the couple has less than $23,844, Medicaid will not give money to the “well spouse” to bring him or her up to the minimum.)

If the couple has more than $238,440 in resources, the “well spouse” will not be able to keep a full half because the maximum CSRA is $119,220.  Any resources above the “well spouse’s” $119,220 will be attributed to the “ill spouse.”

Note:  The minimum and maximum CSRA are adjusted each year for inflation (if there is inflation.)  The Medicaid page at ProtectingSeniors.com is updated from time to time with these amounts and other related Medicaid eligibility figures.

If the couple has between $47,688 and $238,440, the CSRA is half of the resources.

Note:  Some assets, most notably the couple’s home, are not counted in “resources.”

So, after all that, the “ill spouse’s” resources at the time he or she asks Medicaid for help is the couple’s total resources above the CSRA (that the “well spouse” gets to keep) and the $1,500 that the “ill spouse” gets to keep (expected to become $2,000 in July 2016.)  All of the couple’s resources above the CSRA plus $1,500 must be spent-down before Medicaid will cover the “ill spouse’s” expenses for long term care.

So, why does all this minutia mean that someone might already be in a spend-down.  It matters because the “snapshot date” isn’t tied to long term care.  It’s tied only to the “ill spouse’s” absence from the home for medical reasons for at least 30 days.  The “snapshot date” from an injury or illness earlier in life (but still during the marriage) may be useful to save assets if the “ill spouse” later needs long term care.

I know, you’re still confused.  That last paragraph didn’t help, did it?  (Some people would describe that as a good lawyer’s answer:  entirely correct but completely incomprehensible.)  So, let’s tell this with a story.

For the rest of this discussion, I’m going to give names to the “ill spouse” and the “well spouse” in hopes of keeping further confusion to a minimum.  So, the “ill spouse” is going to be Ward, and the “well spouse” is going to be June.

Ward dropped a cleaver (sorry, couldn’t resist) on his foot 10 year ago, on January 6.  He needed surgery and several weeks of rehab.  He returned home on February 5 .  (As long as he was out for 30 days, additional days don’t matter for this discussion.)  Let’s say that Ward and June had $100,000 in resources on January 1 ten years ago (the “snapshot date” for his foot injury.)

Ward recovered and returned to work.  He continued to make money, and their savings grew.

So, now, 10 years later, Ward has a debilitating stroke.  June can’t take care of him by herself and needs to move Ward into a nursing home.  (By the way, this scenario also applies to home care and to assisted living.)  June would like to apply for Medicaid to help pay for Ward’s care.  At the time of Ward’s stroke, they have $200,000 in resources (on the first of the month.)

Based on the $200,000 in current resources, Ward would have to spend-down $98,500 (the amount left after half of $200,000 is reserved for June and $1,500 is reserved for Ward) before Medicaid will pay for Ward’s care.

BUT, Ward has already had a “snapshot date.”  Ten years ago, he was out of the house for medical reasons for at least 30 days.  At that time, he and June has $100,000 in countable resources.  As a result, Ward needs to spend down only $48,500 to get Medicaid coverage to pay for his nursing home stay after the stroke.  June was allowed to keep $150,000 rather than $100,000.  BIG DIFFERENCE.

Note:  The “snapshot date” resulting from Ward’s cleaver accident applies only to Ward’s future need for long term care.  If June, rather than Ward, has the stroke, the earlier “snapshot date” doesn’t apply.  Now, if June had a significant illness or injury of her own that resulted in her own medical stay out of the house for at least 30 days at some point in the past, that would create her own snapshot date.

So, if you’ve stuck with me during this 1,000 word shaggy dog story, here’s the payoff:

If you know a couple (maybe you and your spouse) in which one of them has had a 30 day stay out of the house for medical reasons, the couple should preserve all of their financial records from that time.  (For example, bank statements, investment statements, real estate values, IRA statements, life insurance cash values, and annuity statements.)  Those records might be very valuable in case the same person needs long term care in the future.

Boy, that installment was about as difficult to follow as War and Peace.  Sorry about that.  I couldn’t find a way to make it any simpler.