Medicare A benefits

I want to explain one piece of the Medicare part A program today. One in seven medicare recipients will be in the hospital this year. Many will stay for three days or longer; and therefore be eligible for the part A benefit of rehabilitation. Please keep in mind that these programs do not guarantee a certain number of days for coverage; these benefits are based on progress within a program( or lack of progress) The primary diagnosis will play a role in particular with skilled nursing care on inpatient basis.

Part A covers inpatient hospital care, inpatient care in a skilled nursing facility, home health care services, and hospice care. Medicare Part A provides payment for post-hospital care in a skilled nursing facility. In order for a medicare recipient to receive Medicare benefits, a physician must certify that the resident requires skilled nursing facility care, and the care required by the resident must be available only as inpatient at a skilled nursing facility.
Skilled nursing facility (SNF) care is covered only if it occurs within 30 days of a three-day or longer stay in an acute hospital facility and is certified as being medically necessary. Individuals utilizing the benefits of skilled nursing facilities under Medicare are limited to a 100-day stay AT MOST) facility. Co-payments are required for the 21st through the hundredth day.

Home health care under Medicare Part A has no limitations on length of stay, no co-payments, and no deductibles. To qualify you must need skilled care and be considered home bound. Home bound has different meaning to different agencies- so check with the home health company in your area for clarification on this topic.

Medicare for hospice care: patients are required to relinquish their standard Medicare benefits for treatment of terminal illnesses in order to receive the hospice care benefits (they will no longer be eligible to pursue curative treatments with medicare coverage).

For those with Medicare advantage- the benefits will decrease!! Many will have co pays beiginning on the third or fifth day but at a lesser rate than the traditional medicare co pay. Medicare supplements will usually cover the copayment which begins on the 21st day of care.

Home Health care givers

Home Health Care has become big business. As the population ages; there is a need for caregivers to help people stay home longer. Sitters as they are sometimes called; earn from $8-20 an hour depending on where you live.
Quite a few families handle the care giving duties themselves. For those who work outside the home; caring for a dementia patient can be overwhelming and emotionally draining. Studies show that more than half of all caregiving for elderly is done by family members.
As a teenager I was one of those family members. My great grandma had "hardening of the arteries" Now we know it was Alzheimer's. My aunts and uncles hired a lady to live with her during the week; two of my cousins and I took turns staying on the weekends. Sometimes she could be a handful for a 15/16 year old. She set the kitchen towels on fire one night- she told me she was trying to turn on a light to see. She locked me out of the house many times. I could go on with stories all too familiar to those who have been caregivers. Elderly with dementia or Alzheimer's may have nontraditional sleep patterns. I often wondered if she had Sundowner's; it sure did seem thatway.

Private duty caregivers such as the one my family had are less expensive but do pose risks. What if your caregiver becomes ill; what is the back- up plan? Get a back up plan. IS this person able to lift, or help your loved one into and out of the shower? These questions must be asked no matter which option you choose. Also ask them about taxes- Will they handle it? Remember you need to file them on your tax deductions- if you have a doctors prescription it is deductible. Does this person have references you can call? What are their credentials? How many elderly with dementia have they cared for in the past? How many patients with diabetes/ or any illness that runs on your family.

Companies- there are national chains with franchises located throughout the US. Local companies are also an option. I have been approached my no less than 5 new home health companies in the last two months alone. The advantage to these organizations is the back up staff and the insurance they carry when problems arise. For example- I have a client with Alheimers whose caregiver accidentally set the kitchen on fire- it was a mess- the home insurance covered it- but the family felt good about having a professional organization involved in case there was a problem. If a valuable gets broken- the insurance these companies carry will pay for the item. Most of the national companies do a background screening on all employees; and often they hire licensed CNA's. I tend to refer to a few companies that I trust and have known to work through crises with families. Talk to your friends- talk too your church- find out if they can recommend respected people to handle the care for your loved one.
Another advantage to utiltizing companies is the option of part time help. The disadvantage of companies vs. individuals is the cost. Companies are more expensive. Finances often play a role in the choice to remain home. Unfortunately state programs often help in nursing home care but ignore home health care as an option.

Nursing Homes - An explanation of state Audits

I spent several years working within the Rehab/ nursing home settings; and suffered through numerous state "rounds". Most nursing homes do not go by the Nursing Home title any longer. They are typically dually certified- which means that the facility takes state medicaid and is certified through the federal government to accept Medicare payments for Rehab. This being said- they often prefer to be called Health care and Rehabilitation facilities. This is a nationwide trend.

The federal government sets wide criteria for these facilities; and the state adds more detailed criteria for the facilities to receive payments. The state and federal programs are "tied together"; if a facility is not meeting state criteria they automatically lose the federal funding for the time allotted by the state.

Many websites encourage families to review the state findings which are available on the net as well as within each facility(this is required by law).

Facilities have state audits several times a year IF complaints have been made. Anyone can file a complaint (often disgruntled employees will call in complaints) the state is then obligated to investigate.

Nursing homes are highly regulated, more so than hospitals. This does not mean I am in favor of skilled nursing facilities for elderly. They are necessary on occasion; especially for Alzheimer's patients with wandering tendencies.

Each compliant results in an on site review by the government. The auditors or surveyors- as they are sometimes called- will review all aspects of the facility on each visit. They will occasionally decide to do a paper review and be gone in a day; but for the most part will remain for 3-5 days. These surveyors interview patients, staff, and families, they review admissions, discharges and will remain quiet about the actual complaint being made(to protect patients?).
At the end of the review they will tell the administrator and supervisory staff their findings, then write up a report which will be posted at the front of the building. The findings will reflect the initial complaint and any negative events that were not related to the complaint but need to be addressed.

A score is then given based on the findings from the past year of complaints. This score may not (in my opinion) reflect the daily events within a building.

It is more important to look at the cleanliness of the residents. Odors, it is against federal cover odors. SO the more often they are bathed and changed the better the building will smell. Friendliness of staff, do the CNA's know the residents by name- these are things to pay attention to. Check the bathrooms- my grandma taught me that- not for this reason- but it still applies- look in the corners of the rooms- On a tour you will see people that will yell out- they will appear confused, and those things can't be prevented. Also- ask a resident if they like the food. The audits are important but they do not tell you the whole picture.

Transient Ischemic Attacks- or TIA's

I get calls from families that are not sure how to handle loved ones with symptoms related to TIA's. This situation can be scary for the elder and confusing for the family.The most frustrating part is that by the time the elder gets to the doctor the symptoms have improved leaving everyone bewildered. Physicians will sometimes recommend changes in medications when TIA symptoms are exhibited; but may not explain the reasons very clearly. Here is an explanation about TIA's and how they relate to strokes.

Transient Ischemic Attack is abbreviated as TIA, often commonly referred to as “mini stroke”. It is caused by the changes in the blood supply to a particular area of the brain, resulting in brief neurological dysfunction that persists, by definition, for less than 24 hours; if symptoms persist then it is categorized as a stroke. *Patients will most likely return to previous level of function within 24 hours.
One third of the people with TIA later have recurrent TIAs and one third have a stroke due to permanent nerve cell loss.
TIAs are important in predicting if a stroke will occur rather than when one will happen. They can occur days, weeks or even months before a major stroke. In about half the cases, the stroke occurs within one year of the TIA.

Symptoms vary but most commonly include weakness, tingling, or numbness in the arms and legs on one or both sides of the body; vision and language problems; confusion; vertigo (the sense that either you or the room is spinning); poor balance; and lack of coordination. Remember these will typically have no lasting effect and the following day the senior will return to previous function.

3.6% of men age 75-79 will experience a TIA
4.1% of women age 75-79 will experience a TIA

According to the American Heart Association prevention includes:

Eliminate smoking. Smokers are two times more likely to have TIA's leading to strokes than nonsmokers.

Drink alcohol only in moderation. Heavy alcohol use also increases stroke risk, perhaps by increasing the viscosity of blood and making it more prone to clotting.

Exercise and maintain a healthy low-fat diet. These measures will help maintain proper weight and place less strain on the circulatory system.

Control blood glucose. This improves general health and reduces diabetes-associated complications.

Continue to ask questions when you are not sure if you understand the physician. It is important to have trust in the medical professionals caring for you and your loved ones. They are not volunteering their time, they get paid; become educated about the aging process so that you can be an advocate for your family members.

Organizing your Elder

Many older adults fear loss. The income has dwindled, and they do not want to go without necessities. Often their idea of useful means holding onto EVERYTHING.
Families get frustrated, and conflicts arise. Sometimes these people are known as hoarders.
I would say that the majority of homes I enter are cluttered. Grown children do not know how to stop their parents from keeping every bag, box, and leftover. Parents can become angry and ask their loved ones to leave. It happens.

Elders fear loss of friends, loved ones and possessions. The most common claim is memories. Or to pass it on.
Those with dementia or Alzheimer's may not understand why the family feels the need to make changes.

One suggestion might include creating a memory box- I have used Rubbermaid containers for several clients with great success. Ask them what makes the item special, and if they can't remember ask when they used the item. In the event they can't answer either, then keep a box for " donations" - explain that less fortunate could use this item. This week I have a client that has kept wrapping paper and bags for many years- I counted 50+ tubes of half used wrapping paper. the rubber bands had become attached to the paper or disintegrated. Once he understood that others could use this he felt better. " I just don't want things to be wasted".

Clothing is another area that created clutter- and shoes. Often the senior can't use the item because it is difficult to button or zip, maybe it needs repair. Letting the item go means admitting a decline in ability. Allow them to keep their dignity by showing them item that do work, show them that they have adequate clothing and these can be donated or used for rags. Challenge them to think without making them feel"old".

Papers another common item that collects and causes disruption of space.
Make three separate boxes- one for shredding, one for keeping, one for trash or donations. Allow the elder to participate in reviewing the items, often old tax records, newspapers, and mail pile up and take over the tables. Do not expect them to have patience to last all day- this process needs to be done in Small increments of time. Encourage them to show off special items or particular family history.

Make the experience as rewarding as possible, give positive feedback, and remember it may take several "rounds" to eliminate the majority of over- collections.

I am heading to a cluttered home as we speak, he needs to relocate to his family out of state, which means; at least looking at every piece of clutter in the house that he is putting up for sale. I am learning patience through this experience.

ER Visits: Preparedness

I could write every day on how to deal with hospitalizations. Why? Elderly adults often have multiple health issues which require a team; in the outpatient setting the individual physician is not able to interact as easily with other specialties.
According to Reuters there has been a 34% increase in ER visits among those over 65 in the last ten years.

I have one client who goes in at least once per month. In part his family physician does not know how to handle the natural aging and dying process. This client is 96. He was at home two weeks, and now back in the hospital again. This family knows the ER staff on a first name basis. He has not once been in critical condition. SO he sits for hours before getting admitted. His son misses work, and they both get hungry.

Here are a few tips to get thru the ER visit:

Medications- do not let the staff take the pills; it may be hours before you see the medications again. Keep a copy of the list and dosages for the staff.

Keep a supply of snacks handy; cheese crackers, small package of cookies, and a water bottle.

Keep on hand a book, deck of cards, or crossword puzzles- in large print. Boredom can effect your aging relatives mental state. Your senior loved one may appreciate activity not to mention the conversation.

Keep a pillow in the car- A long night may be in store.

Write down the names of staff members that have been helpful; let them know they are appreciated.

An ER visit is usually the first step to being admitted. Doctors forget what it is like to sit for hours with increasing anxiety over health.

To Take The Keys or Not to Take The Keys?

Knowing precisely when it's time to ask your elder to surrender their driving privileges is not an exact science. It's also traumatizing for the care giving son or daughter and potentially devastating to the loved one.

Recently There have been two accidents on I-30 involving elderly drivers going the wrong way. One resulted in a head on collision between the elderly man and a semi truck. All those involved died.

The effects of age can't be avoided. Thinning skin, thinning hair, thinning memory.

Here are a few issues that affect elderly behind the wheel:

1. Peripheral vision

2. Distance Judgment

3. Speed and gap perception

4. Neck and shoulder stiffness

5. Slower response times

6. Individual medical problems

7. Not being able to hear sirens and horns


The above list should be taken into account when considering taking the keys. It is not easy. There is no magic age, health and reflexes should be considered; as well as memory. Recently one family took the key of a 96 year old client. He only recently began to decline in health and reflexes. I sat down with him, and the first thing out of his mouth was " I think we need to find someone to drive me around, I can't drive" He drives his lawn mower every where he can, but never his car.

To help in the adjustment period; create a plan for transportation. Is there a van that provides rides to appointments? Can a family member take your loved one to the store each week? Is there a church member to take your loved one to church each week?


As we and our parents age, our roles also change — sometimes subtly, sometimes in ways that turn our lives upside down. But in God's plan, honoring our aging loved ones is not negotiable. Pray for His strength and guidance as you take on the caretaking role. Honor your aging parent, and God will most certainly honor you, His faithful servant.

Auctions vs Estate sale

This past week I have learned a great deal about liquidating household items of clients. In the past I have simply recommended estate sales. The cost involved- and the strangers going thru the home for a week- can be emotionally challenging.

As I have been working with one client in particular I have attempted to think outside the box. His is widowed, a little paranoid, and very cluttered. He needs to relocate closer to his children but has been SLOW to eliminate anything from his cluttered home.
We interviewed Realtors several months ago. All said call after you get some clutter out of the home- if you want maximum price.

We look thru every item in one box, he tells stories, then gets rid of one item out of twenty. He is going from 2800 square feet to 1100 square feet, this is not working. He is fearful of people coming into the home for the estate sale- even though he will not be living there. The answer has come in the form of an Auctioneer. " John the auctioneer" came to the house, and we went thru many old items that could easily be seen. When my client realized he could make money from old toys, and furniture, he was ready to go thru his belongings much more quickly. Several toys are now going up for bid on a website this week.

Case management is for the entire family

One of my clients is a business owner trying to care for his parents. Nice guy. Well known in the community. He was heartbroken to separate his parents. His dad does not recognize his mom and had become aggressive to this "stranger" in HIS home. We tried more than once to reunite them. It always resulted in aggression.

Recently he called me and said to please help him with some paperwork. Early in the morning. During our phone call he told me that last week he was in an accident that resulted in a head injury and later death of an employee. He was obviously out of sorts- who would not be?

I realized that our meeting should not be about his parents, it should be concerning his mental health. He was not able to help his family unless he received counseling.

The point? Every one's mental health should be considered. Don't take care of parents and ignore your own needs and mental state. Families will become irritable and less supportive of one another when depression and anxiety set in.

Medicaid applications- Not for the faint of heart

Medicaid is the state run program for those in need of medical insurance or for the elderly- co-insurance.
Every state has some criteria set by the federal government- with a few variances on income guidelines.
The income guidelines are based on state and federal poverty levels.
While guidelines vary from state to state; basic issues remain the same. Medicaid programs are divided into categories for babies and children, disabled adults, and elderly.
Criteria typically includes reviewing finances, and property ownership; as well as medical criteria for the needed services.
Bank statements are required, as are ownership papers for homes and vehicles.
Time consuming tasks usually include gathering birth records, marriage records, and tax related paperwork. In some cases locating medical bills can become overwhelming. Most states ask for information from the past three to five years.
When beginning the application make sure to keep recent bank statements handy, and medicare information as well as any military information.
In order to minimize chance for lost applications, make copies of everything, and fax it to the main office or ask for the name of the staff member who receives the paper work.