I always find it interesting to see how other cultures and countries approach elder care. Several news stories came out recently about China’s plan to support its aging population.

Family ties are a tremendous part of Chinese culture, and for centuries, Chinese families have come together to care for relatives young and old. But just last year, on Seniors Day, one social scientist noted that the responsibility of elder care was shifting towards the government.

China currently has 167 million people over the age of 60, 19 million of whom are over the age of 80. Half of them live alone, though the number is closer to 70 percent in the cities.

While it was often considered a moral obligation to care for your aging parents, the country’s economic boom bringing time-consuming jobs and changing migration patterns have weakened familial ties in both rural and urban areas.

But this new social problem is clashing with an old social problem.

China’s one-child policy, in place since 1978 as a means of controlling the population growth, has created a generation without siblings.

Today, this means that there are fewer workers, and thus fewer incomes, to support aging relatives. A typical household then may be supporting 3 nuclear family members (2 parents and 1 child), as well as 4 grandparents (husband’s two parents and wife’s two parents). And, longevity is even imposing a greater burden – called the 4-2-1- Problem – on young people. A single adult child could be responsible for supporting his or her two parents over the age of 60 as well as any living grandparents.

In response to calls for greater government aid to the aged, China is looking to codify a practice that used to be a mere cultural tradition. The proposed law would give the elderly a right to sue their children in court to enforce their right to be physically and emotionally cared for.

While it’s a praise-worthy law, Chinese lawyers are already saying it lacks teeth and may be unenforceable because it violates personal liberty.

James D. Perry

Finding a quality long-term care facility can be a daunting task. The options are many, so how do you know if one is better than any other?

Starting in the New Year, you may be getting some help.

In 2011, California nursing homes will be required to publicly post their federal ratings and information explaining the ratings. They will also have to tell patients and family members how to obtain information about the nursing home’s state licensing record from the California Department of Public Health’s website.

The federal Centers for Medicare and Medicaid Services oversee the rating system. Facilities are inspected annually and judged on a number of licensing factors, including the quality of medical care, staffing levels, sanitation, and bedsore mitigation.

The star system went into effect in 2008, but California is the first state in the nation to mandate posted rankings about the quality of care in nursing homes. Currently, California has 1,235 federally rated facilities, of which 195 got the lowest rating – one star – and 187 got the highest rating of five stars.

The ratings are not perfect, though. Patient advocates and nursing home officials have found fault with the system and are appealing to the federal government for reform.

California Advocates for Nursing Home Reform initially supported the state legislation that mandated the public disclosure of the star ratings, but the group is concerned that the system encourages nursing home administrators to cover up their facilities’ flaws to boost their ratings. And officials with the California Association of Health Facilities say that ratings tend to skew against facilities with larger populations of chronically ill residents.

Imperfect though they may be, the star system at least provides a starting point for patients and families wading through their long-term care choices.

James D. Perry

There has been much news in recent days about the need for Long Term Care (LTC) Insurance and the recent reports of large increases in premiums and big insurance companies announcing that they will not sell any new policies.

The subject deserves more time and space than one blog article, so today I will touch on the need. I will follow this blog next week with interviews with Long Term Care Insurance Brokers and Financial Planners discussing the problems the LTC insurance industry is going through.

People are living longer these days, but the human body still continues to break down.  As such, more and more seniors – an estimated 9 million in 2008 – need long-term care.  But do you need long-term care insurance?  It’s a smart way to defray the enormous costs of care, but really, it depends.

Premiums this year cost individuals an annual average of $2,180, but the average rate this year for a private nursing home room is $229 per night, or $83,585 a year, and the average rate for a home healthcare aide is $21 per hour.  The New York Times had an article last week (“Ignore Long-Term Care Planning at Your Peril”) reporting that some major long-term care insurance companies are looking to raise premiums by as much as 40 percent.  And, the longer you wait the more likely rates will rise, and the older you get, more likely you’ll develop a so-called pre-existing condition that affects plan availability and premiums.

There is a misconception that Medicare will cover long-term care costs.  While Medicare may pay for short-term nursing home stays in certain circumstances (for example, while you are convalescing after surgery or undergoing rehabilitation after a qualified hospital stay), it will not pay for long-term care.  And, Medicaid will cover nursing home costs, but only after you’ve expended most of your own finances, and then your access and options in care providers becomes severely limited.

The new Class Act, passed under the health care bill, provides long-term care insurance through the government, but enrollment doesn’t start until 2012 and benefits aren’t likely to exceed $100 a day and then only after you’ve paid premiums for 5 years prior.  However, it may be easier to qualify under the Class Act, as some private plans won’t cover care for certain pre-existing conditions.

One up-side is that there are tax breaks available for qualified long-term care insurance premiums where benefits received under such policies are tax-free.

So, how likely are you to need care to make purchasing an insurance plan worth it?  It largely depends on your family’s health history and your financial situation.  If you’re at risk for a serious illness that requires regular care, and you want to leave something to your children or grandchildren upon your death, it’s probably smart to at least investigate the specifics of a LTC policy.

Next time, update on the Long Term Care Policies and Insurance Companies.

James D. Perry

One of the most frequent questions I get from my clients is “Why should I spend the money to create a trust?”

The easiest answer to that question is that for the price you pay now, you save far more money down the road. But that answer doesn’t satisfy everyone. So here is one serious money-sucking situation that might make you think twice before dismissing your need for a trust.

In the event of your incapacity, the court may impose a conservatorship because the individual can no longer handle his or her own finances. Anytime you have to initiate court proceedings, you’re looking at a significant investment of time and money – more of both if the proceedings are contentious.

Also, nearly anyone can petition the court to become your conservator if they can show that you no longer have the capacity to manage your affairs. We have seen this most recently where an advocacy group for child actors, A Minor Consideration, petitioned the court to take control of the finances for the 14 children of OctoMom, Nadya Suleman. An Orange County judge has given the green light to the group to proceed with their case.

However, you might become incapacitated for any number of reasons in your life having nothing to do with the Hollywood scene, including dementia, illness, disease, or accident.

By creating a revocable living trust, you designate ahead of time a successor trustee who you want to be in charge of your affairs should you become incapacitated. Moreover, you can designate exactly what property that person can control and choose different individuals to manage multiple assets. Most people transfer the title to their house into a living trust so that the successor trustee would be able to manage the affairs of the home.

Your life is probably not as crazy as the OctoMom’s, and you may never have Lindsay Lohan or Britney Spears’ problems (both have battled conservator petitions in court), but you may one day be struck by Alzheimer’s disease, or an accident or illness resulting in a coma, any one of a number of mundane real life disasters that strike regular people.

You and your estate planning attorney have tools available to prevent confusion in your family and keep them from fighting for control should you become incapacitated.

James D. Perry

Having a pet in the house has a number of benefits to our overall physical and emotional health. But I’ve heard many friends and clients question whether it would be better to remove a pet from their aging parents’ homes to prevent injuries or to eliminate the added responsibility of caring for an animal.

Carolyn Rosenblatt of AgingParents.com wrote recently for Forbes about the problems pets can present in the home of an elderly person.  If your parent has a large dog or a cat that is old and can’t see or hear a human coming to get out of the way, there is the risk that your parent could trip and fall sustaining serious injuries. And if your parent suffers from dementia, there is concern for the pet that it won’t get fed or taken outside for walks.

But whatever the risks, it is likely they can and should be mitigated to preserve the parent-pet bond.

According to research in the Journal of the American Geriatrics Society, caring for a pet serves as a buffer against isolation and loneliness. And further studies suggest that petting a dog for a few minutes a day can relieve stress, lower a person’s blood pressure, and alleviate depression. Pets also aid elders in their socialization with others, serving as a conversation starter.

If the pet is unruly, offer to pay for training, Rosenblatt suggests, or shop together for a collar or harness that provides more control. If your parent is frail, find someone to walk to dog to prevent falls or suggest that your parent’s home care worker go along on walks to monitor your parent’s safety.

Whatever the risks, it is probably more beneficial to your parent’s health to protect that owner-pet bond. Safety is a family issue, but don’t forget that Fido or Fluffy is family, too.

James D. Perry

Open the newspaper and on any given day you can find a cautionary tale of an elderly person losing thousands of dollars to his or her caretaker, a scam artist, or some final friend.

The sad fact is that the elderly make easy targets of financial abuse, and you may be their first line of defense against scammers. If you have a parent over the age of 70, you should have a conversation with him or her about what would happen if they could no longer manage money.

Approach your parent respectfully, asking permission to talk about the subject. Your parent is likely to feel vulnerable – relinquishing money means relinquishing control.

You’ll want your parent to sign a durable power of attorney. And, if your parent is already showing signs of mental impairment, you need to act fast. A durable power of attorney must be signed and notarized while your parent is still competent.

If possible, you should include the whole family in the conversation and decision-making. Put all agreements in writing so that there is no argument or second-guessing.

If you already are in charge of your parent’s bank accounts, try not to micromanage. If possible, keep just enough for monthly expenses in a joint checking account and protect the rest in another account. Pay the bills together or help your parent set up automatic bill-pay to prevent forgotten bills.

The change in power can be a tough, emotional transition, but you don’t want to put off protecting your loved ones.

James D. Perry

It is estimated that by the year 2020, 12 million elderly Americans will be in need of long-term care.  Many of them will have to rely on their adult children as caregivers.

This imposes a heavy emotional and financial burden, even on happy and willing caregivers, and financial assistance for long-term care is sparse.

Medicare generally does not pay for long-term care, which assists people with daily living activities such as cleaning, meal preparation, dressing, bathing, using the bathroom.  Medicaid may pay for some long-term care services, but its eligibility is limited to people with low incomes and limited assets.  Private long-term care insurance can be pricey, especially if you wait until you are over the age of 50 to begin paying premiums.

The new Community Living Assistance Services and Supports (CLASS) Act is an attempt to close the gap between people too rich for government assistance, but not rich enough to afford they care they need.  It goes into effect January 1, 2011 and enrollment is expected to begin in 2013.

The government program acts like long-term care insurance – you pay premiums for five years (working at least three of those years) and it will provide cash to pay for care when you need it for as long as you need care.  No tax dollars are to be used to support the program.

The CLASS Act is not meant to cover the full cost of 24-hour in-home care or a nursing home, but to supplement your personal contribution.  The Congressional Budget Office has assumed a cash benefit of $75 a day, but the Department of Health and Human Services has until October 2012 to hammer out the rules.  But, to put this in perspective, the national average cost last year of an assisted living facility was $37, 572; $75 a day would pay almost three-quarters of that expense.

The best thing to do is to plan now as if long-term care, for yourself or for your aging parents, is a financial inevitability.

James D. Perry

A living will – called an advance directive for health care here in California – is an important part of your estate-planning arsenal. In the event of an accident or life-threatening incapacitation, an advance directive dictates your medical care and treatment preferences. This is especially helpful to family members and care providers because where there is uncertainty and disagreement, the court may have to step in.

An advance directive for heath care can fail its essential purpose, though, if it is ambiguous about treatment options and does not provide enough detailed guidance.

A recent MSNBC article highlighted this problem in the story of Bunny Olenick, an 87-year-old from Boston who became incapacitated by a severe stroke. She had a living will and a medical power of attorney, but her sons were left with questions about assisted breathing devices and feeding tubes and the quality of life she would sustain because of them.

She had stated that she didn’t want to be intubated or hooked up to a respirator, but did that preclude temporary nasogastric tubes for nutrition or a short-term oxygen mask?

Bunny’s sons were able to take advantage of palliative care counseling, which helped them navigate her legal documents and the preferences she had shared with them prior to her stroke.

However, had the sons gotten into a disagreement about Bunny’s wishes, they might have ended up petitioning a judge to appoint a medical proxy. The legal process is costly and ultimately may prolong an incapacitated individual’s life or suffering where he or she would not want it.

No one really likes to ponder their own death, but appropriate advanced planning can save you and your family pain and confusion in a time better spent saying goodbye.

James D. Perry

An Alameda Superior Court judge decided this month not every felony conviction will disqualify you from helping the elderly or disabled.

Gov. Arnold Schwarzenegger originally wanted to ban everyone with a felony record from working in the In-Home Supportive Services program (IHSS). As the law stands, workers are barred from the program for 10 years if they have been convicted of child abuse, elder abuse, or defrauding MediCal or any patient.

Outside those restrictions, though, Judge David Hunter says in-home patients can employ anyone they want.

IHSS helps pay for in-home care to 430,000 low-income elderly and disabled Californians. It allows patients to remain in their homes under the care of individuals of their choosing, as approved by the state, to render help with daily tasks, such as bathing, house cleaning, meal preparation, laundry, grocery shopping, personal care services, accompaniment to medical appointments, and protective supervision for the mentally impaired.

The state argues that its interest is protecting Californians and preventing fraud.

One of the plaintiffs to the suit is a Sacramento woman who provides in-home care for her 90-year-old-mother. She was initially disqualified under the governor’s plan because of a 1976 conviction for felony grand theft.

The program costs about $5.5 billion annually, half of which is paid for by the federal government, 35% by the state, and 15% by individual counties.

“We are following the court order, but we do not believe convicted felons should be eligible to care for elderly and disabled Californians in their homes,” said Lizelda Lopez, spokeswoman for the Department of Social Services.

The state could appeal the ruling, and Ms. Lopez says the Department is already reviewing it.

This is tricky ground. The state has a legitimate interest in protecting its citizens and taxpayer dollars, but how long should it punish people for their crimes at the expense of the elderly and disabled?

James D. Perry

I recently came across a truly heart-warming story about a neighborhood initiative in the Washington, D.C. area.

Harry Rosenberg and his wife, Barbara Filner, along with nine of their neighbors started an aging-in-place “village” in their Bethesda, Maryland community to help their elderly neighbors with basic services such as transportation and home maintenance, helping them to stay in their homes longer as they aged.

Their first request for assistance came in November 2008: they helped an 81-year-old widow take out her trash and drover her to the doctor. The organization has a budget of $4,000 collected solely through donations. It charges no dues and has about 65 “friends” who volunteer, receive help, or are otherwise are associated.

And while it doesn’t receive many requests for assistance Harry and Barbara say it is still a viable presence in the community hosting neighborhood walks and restaurant outings. There are now six similar “villages” in the city itself, two in the Virginia suburbs, and eight others in the planning stages in the Maryland suburbs.

The first such aging-in-place community on record was called an “intentional community” in Boston’s Beacon Hill neighborhood to which members paid dues to provide collective services. The idea spread and “intentional communities” popped up in California, Illinois, Colorado, Florida, Hawaii, New York, and other states, and the first international intentional community was in Australia.

Retirement communities are expensive and aren’t always the best option. Not every older adult needs the care of trained staff but could use, perhaps, the helpful hand of neighbor every now and then. If you are interested in learning more about aging-in-place initiatives or starting one in your community you can learn more at http://www.aginginplaceinitiative.org/.

James D. Perry