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Caregiving Tips for Boomers: 5 Tips for Decreasing the Cost of Caring for Elderly Parents

by: Vicki Rackner MD

Over 30 million Baby Boomers provide countless hours of assistance to elderly parents at no charge. It is estimated that, using average hourly wages, the total amount of this uncompensated care is comparable to the entire Medicare budget. For the estimated 7 million Boomers who provide long distance care, actual out of pocket expenses amount to almost $5,000 per month. For caregivers who have, or are considering leaving the workforce to care for an ailing parent, the costs are even greater over $650,000 in forfeited salaries, benefits and pensions.

This stark economic reality shows only one dimension of the price caregivers pay for this act of love.

Caregivers pay with losses that extend well beyond their bank accounts. They often forego the activities that bring joy and richness to their lives, like meeting friends for dinner, or going out to the movies or taking family vacations. They pay with their time, the loss of professional opportunities and the erosion of personal relationships that result in isolation.

Sometimes, otherwise healthy loved ones need a short dose of care as they recover from an acute medical episode like a broken leg. Usually loved ones are on a path of steady decline with cascading assistance needs. Some caregivers sacrifice large chunks of their own lives as they help their parents and other family members and friends peacefully make their transitions. Caregivers can pay with their own health and well-being. In fact, we have evidence that some caregivers pay for their acts of care with their very lives.

You can decrease the personal and economic costs of caregiving. This means proactive planning rather than reactive responding. Planning saves money. You know this as you reflect upon your experiences of going to the grocery store with and without a shopping list. Planning also minimizes personal wear and tear and decreases stress. You will feel much better when you know your options and develop back-up plans before you jump into a challenging project.

5 Tips to Decrease the Cost of Caregiving:

1. Begin the conversation today. We have tremendous cultural resistance to the recognition of aging, disability and death. Just as the first few steps uphill are the hardest, so, too, you may meet the greatest resistance simply starting the conversation about their possible need for care. Say today, Mom and Dad, it would be great if you lived forever, but the discovery for the fountain of youth is nowhere on the horizon. What thoughts and plans do you have about enjoying your golden years?

2. Create a plan. Talk with your parents about their ideal plan if they are no longer able to care for themselves. Then, start to work toward that proactively. Investigate long-term care insurance. Draw up the appropriate legal documents. Find out who would make medical choices if they were not able to make them on their own, along with some guiding principles for the choices. You can anticipate and limit parental resistance by saying, Mom and Dad, I just got back from the lawyer’s office signing my will and durable medical power of attorney. I’ve asked Mitch to make my medical choices if I cannot make them myself. Just so you know, if I were in vegetative state, I wouldn’t want to be maintained on a machine. You probably already planned ahead too, right?

3. Use personal and community resources. Make caregiving a family job to which each member contributes. Even children can make grandmas life special with drawings and phone calls. Identify services that make your job as a caregiver easier. If you and your parents live in the same community, check with friends and neighbors and local organizations to learn about services and resources that will make your job easier. You say, Mom has just moved in with us, and she wants to find a card game with the girls. Do you know of any senior centers that have social events? How about transportation?

We’re a mobile society and millions of caregivers live more than an hour away from their parents. Executive William Gillis learned from his own personal experience how challenging it is to identify community resources from afar. As he was carving the path that ultimately led his on-line portfolio management service, he became the caregiver for his father. Talk about mixed emotions! Professionally, he was introducing a service that let millions manage their investments with one click of a computer mouse. Personally, he was investing untold hours just to find one bit of information to help his dad.

As with so many innovators, he used his personal and professional experience to launch Parent Care (www.parents-care.com), a service that he wished would have made his life as a caregiver-at-a-distance easier.

4. Gather cost-savings tips. This might mean something as simple as ordering generic medication or regularly inquiring about senior discounts. But, most cost savings opportunities aren’t as obvious. Mr. Gillis found, for example, that some states will pay for phones for hearing, visually or mobility limited seniors or fund home safety improvements. He said, we’ve invested heavily to locate time and money saving resources that most would have difficulty finding. I made it a personal mission to help other caregivers avoid some of the costs and frustration I encountered. You don’t have to re-invent the wheel. Tap into the resources others have collected.

5. Take care of yourself. You will be able to provide the best care as a caregiver when you’re at your best. Get good nutrition, enough sleep and regular exercise. Manage your stress and do a little something every day to nurture your soul. Understand that you are at increased risk for anxiety, depression, and weakening your immune system. Talk to your doctor if you see worrisome signs such as problems sleeping, changes in appetite or loss of interest in activities you enjoy.

Despite the costs, most caregivers say that they received much more than they gave. Most say they would do it again, and many do.

How To Find A Nursing Home That’s Right For Your Loved One

When people need more care than they can get at home or in the community, a nursing home may be the best choice. Nursing homes help residents with daily activities, like feeding, bathing, or dressing. They may also provide skilled medical care such as physical therapy or changing sterile dressings.

Nursing home care can be expensive and many types of health insurance don’t cover it. People pay for nursing home stays out of pocket, with long-term care insurance, or through their states Medicaid program. Medicare usually does not pay for nursing home care unless a person needs skilled medical care after certain hospital stays.

Nursing homes should encourage residents to stay active, doing as much as they can for themselves. Staying active can help residents feel better about themselves and lower their risk for other serious illnesses. Special equipment, like catheters and restraints, should only be used if a doctor says it is needed and not to make care easier for the staff.

Here are some of the things that you should consider in evaluating a nursing home:

· Daily activities such as feeding, bathing and dressing

· The amount of time spent in a bed or chair

· The ability of the resident to move around the room

· The nursing home policy on the use of physical restraints

· Control of bowels or bladder

· The nursing home policy on catheter use

· How the nursing home deals with moderate to severe pain and pressure sores

· The nursing home policy with depression or anxiety

· How the nursing home deals with Alzheimer’s

And here are some questions about the facility itself to consider:

· Total number of residents in the facility

· What is the nursing staff to resident ratio [very important in determining how much care the resident will receive?]

· Have there been any health deficiencies during its last inspection? (2)

· Have there been any fire safety deficiencies during its last inspection? (1)

· Does the facility have both family and resident councils? (3)

(1)    A finding that a nursing home failed to meet one or more federal or state fire safety requirements and other Medicare and Medicaid fire safety requirements

(2)    A finding as a result of the annual health inspection or a complaint inspection, that a nursing home did not meet a federal or state health statute or regulation based upon observation of the nursing home’s performance, practices or conditions in the facility.

(3)    Resident and family councils can facilitate communications with staff. The law requires nursing homes to allow councils to be set up by residents and families. If a nursing home does not have a resident and family council, ask the Administrator why.

When You Call and Visit The Nursing Home:

Visiting a nursing home several times can help you make a decision. It is important to talk with residents of the nursing home and their family members. Use this short checklist to help you decide whether the care meets your needs:

· Does the nursing home accept Medicare and Medicaid?

· Ask to see the nursing home last annual state inspection report? Notice any deficiencies and ask questions to see when they were fixed and how they were fixed.

· Does the nursing home have an active resident and/or family council?

· Does the nursing home look clean and free of odors?

· Does the staff treat the residents with respect?

· Is there information posted on how to reach the ombudsman? [An Ombudsman is an advocate for residents of nursing homes, board and care homes, and assisted living]

· Do the residents have the same staffers on a daily basis?

· Is there enough staff available to assist the residents?

· Does the staff respond quickly to calls for help from the residents? 

Plan Now For The Future

While it is important to be sensitive to privacy, asking them to share some personal information about doctors, medications, and medical histories will help you better plan for their health care and prescription drug needs.

Talk to the person you care for about what he or she wants and doesn’t want you to do.  Some people decide to authorize a family member or trusted friend to make the decisions about their medical care.  This is generally done through a Power of Attorney or a Durable Power of Attorney for health care.

Also, discuss a living will (a health care advance directive) with this person.  Living wills give directions about the kind of health care  they want – and who may speak for them – if they cannot speak for themselves.

Community Options

If you see yourself taking a greater role in caring for someone, now may be a good time to gather information about community services.  Take time to assess this person’s needs for care – and your own needs as a caregiver.  Consider getting help to manage meals, transportation, social activities, and service to assist with other daily needs.

IMPORTANT:  You can get help by calling your Area Agency on Aging, or the U.S. Administration on Aging.  You can also check with your county’s Department of Social Services.  It is listed with county government offices in your local phone directory.  And, your local library can usually help identify senior centers and other senior services available in the area.

Information For A Caregiver To Know

· Social Security Number

· Medicare Number and Medicare plan enrollment

·

Introduction to CARE options 

Even if the person you are caring for is receiving care not covered under the Original Medicare Plan, there are options for ongoing care.  Some Medicare Advantage Plans or Medigap policies may help with short-term care needs.  The State Health Insurance Assistance Program can help you determine choices and coverage.  

There are times when a person’s needs extend beyond the intermittent skilled care provided through Medicare.  Community-based services across the country support independent living and are designed to promote the health, well-being and independence of older adults.  These services can also supplement the supportive activities of caregivers.

Often, community-based senior citizens’ services offer companionship visits, help around the house, meal programs, caregiver respite, adult day care services, transportation, and more.  These support services may be funded by state and county programs or offered by church or volunteer groups.

Questions To Ask A Home Health Agency

·         Is your agency Medicare-approved?

·         How long have you served the community?

·         Does this agency provide the services my relative or friend needs?

·         How are emergencies handled?

·         Is the staff on duty around the clock?

·         How much do services and supplies cost?

·         Will you be in regular contact with the doctor?

Nursing Homes and Housing Options

Serious and chronic illness may create a need for full-time care outside the home.  It is a decision you and the person you are caring for should discuss with the doctor – as well as other family members.  

If long-term care is needed, you may want to consider in-home services from a home health agency in your community. 

Basic Information:  

Nursing home care can be very expensive.  Medicare generally doesn’t cover nursing home care.  There are many ways people can pay for nursing home care.  For example, they can use their money, they may be able to get help from their state, or they may use long-term care insurance.

Nursing home care isn’t covered by many types of health insurance.  Most people who enter nursing homes begin by paying for their care out of their own pocket.  As they use up their resources over a period of time, they may eventually become eligible for Medicaid.  

NURSING HOMES AND MEDICAID: 

Medicaid is a state and Federal program that will pay most nursing home costs for people with limited income and resources.  Eligibility varies by state.  Medicaid pays for care for about 7 out of every 10 nursing home residents.  Medicaid will pay for nursing home care only when provided in a Medicaid-certified facility.  For information about Medicaid eligibility, call your state Medical Assistance (Medicaid) Office.

MEDICARE COVERAGE OF SKILLED NURSING FACILITY CARE. 

Medicare does cover skilled nursing care after a 3-day qualifying hospital stay.  Skilled care is health care given when the person needs skilled nursing or rehabilitation staff to manage, observe, and evaluate his or her care.  Examples of skilled care include changing sterile dressings and physical therapy.  Care that can be given by non-professional staff isn’t considered skilled care.  

Care Options 

These are several categories of care available in most communities – ranging from daytime activities to full-time care: 

ADULT DAY CARE:  Daily structured activities and health-related and rehabilitation services for the elderly who need a protective environment.  Care is provided during the day and the individual returns home for the evening. 

ASSISTED LIVING FACILITIES:  Residential homes offering a range of services that usually include activities of daily living, supervision, and medication management.

CONTINUING CARE RETIREMENT COMMUNITIES (CCRC):  

A housing community that provides different levels of care based on residents’ needs. 

CUSTODIAL CARE:  Assistance with daily activities such as bathing, eating, and dressing.  

RESIDENTIAL CARE FACILITIES:  Settings designed for independent living while offering meals, social and recreational activities, and other support.

SKILLED NURSING FACILITIES:  Facilities with 24-hour supervision and medical and rehabilitative service for patients requiring a high level of care.  

Considering Hospice Care 

Hospice Care is a special way of caring for people who are terminally ill – and helping their families cope.  The goal of hospice is to provide end-of-life care, not to cure the illness.  This care includes treatment to relieve symptoms and keep the individual comfortable.  It includes medical care, nursing care, social services, drugs for the terminal and related conditions, durable medical equipment, and other types of items and services.

Call your Regional Home Health Intermediary (RHHI) for more information about Medicare hospice benefits.  A RHHI is a private company that contracts with Medicare to pay bills and check on the quality of hospice and home health care.

Basic Information Regarding Hospice Care

Medicare’s hospice benefit provides for support and comfort to terminally ill patients – including services not usually paid for by Medicare.  To be eligible for hospice care, the patient must have Medicare Part A and 

·         the doctor and hospice medical director must certify that the patient is terminally ill and has probably six months or less to live.

·         the patient must sign a statement choosing hospice care instead of routine Medicare-covered benefits for their terminal illness.

·         the patient must receive care from a Medicare-approved hospice program.

Be aware that Medicare hospice benefits don’t include treatment to cure terminal illness.  If the patient’s health improves or the illness goes into remission, he or she always has the right to stop getting hospice care and go back to the regular Medicare health plan. 

Hospice Care

Most hospice patients get hospice care in the comfort of their home and with their families.  Depending on the patient’s condition, hospice care also may be given in a Medicare-approved hospice facility, hospital, or nursing home.  Hospice volunteers are available to do household chores, provide companionship, and offer support to the patient and family.

Medicare pays for inpatient respite care (short-term care for hospice patients) so that the usual caregiver can rest.

Introduction For The Caregiver 

As your parents, grandparents, relatives, or friends face health care decisions, they might need to rely on you for help.  Medicare can be an important factor in many of those health care decisions.  But at this point, you may not be familiar with Medicare basics or other senior services.    

Articles within this section detail certain “decision points” related to the health or overall well-being of senior citizens.  For each of these decision points, you’ll find basic information about Medicare and suggestions on finding more detailed information.    

Getting Medicare

If the person you care for is turning age 65 and is already getting Social Security benefits, of if those benefits will start at age 65, he or she will be enrolled automatically in Medicare. 

A Medicare card will be mailed about three months before their 65^th birthday.   The card will show this person has Part A (hospital insurance) and Part B (medical insurance) coverage.  Most people don’t have to pay a monthly premium for Medicare Part A when they turn age 65 because they or a spouse paid Medicare taxes while they were working.  Most people do pay a premium each month for Part B.  Part B is optional.  However, there may be a late enrollment penalty if the person you care for doesn’t join when he or she is first eligible.   If the person you care for isn’t getting Social Security benefits when he or she turns 65 (for example, if this person is still working), this person will have to sign up for Medicare.  Call Social Security to find out more.   Your state has programs that pay some or all of the Medicare premiums for people with limited income and resources.  Call your state’s Medical Assistance (Medicaid) Office to learn about Medicare Savings Programs.  

Learning The Basics

It will be necessary to learn what kind of health coverage the person you care for already has.  First, find out if the person currently has Medicare.  If he or she does have Medicare, find out which parts of medicare he or she has – Part A (hospital insurance), Part B (medical insurance), or Part D (prescription drug coverage).  You will also want to find out whether the person is in Original Medicare, in a Medicare Advantage Plan (like an HMO or PPO), or in any other type of Medicare health plan.  This information is on a person’s Medicare card.  If the Medicare card for the person you care for is not available for you to look at, you can either call medicare together, or the person you care for can complete an authorization form to allow you to get Medicare information released to you.  To get an authorization form, call Medicare at 800-633-4227.  If the person you care for does not presently have Medicare, find out when he or she will be eligible to enroll.  

Note:   It is essential to find out if the person you care for has other health coverage in addition to Medicare, such as a health plan with a former employer, Medicaid, or other insurance that can help pay for health care needs.  If the person is enrolled in Original Medicare, also find out if he or she has a Medigap (Medicare Supplement Insurance) policy.

Did You Know: 

Medicaid isn’t the same as Medicare.  Medicaid is a joint Federal and state program that helps with medical costs for some people with limited income and resources.  Medicaid programs vary from state to state.  A person may have both Medicaid and Medicare.

Medicare is health insurance for people age 65 or older, under age 65 with certain disabilities or ALS (Lou Gehrig’s disease), and any age with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

Medicare Options

Today’s Medicare is about choice.  Medicare gives people different ways to get Medicare benefits, as well as tools to help people with Medicare make the best choice.

Medicare has Part A (hospital insurance) and Part B (medical insurance).  People with Part A or B can also enroll in Part D (Medicare prescription drug coverage).  Medicare prescription drug coverage may help lower the person’s prescription drug costs and help protect against higher costs in the future.

The Original Medicare Plan is a fee-for-service health plan that lets people with Medicare go to any doctor, hospital, or other health care provider who accepts Medicare.  Medicare pays its share of an approved amount and the person with Medicare pays the rest, up to certain limits.  People in the Original Medicare Plan must choose and join a Medicare Prescription Drug Plan if they want to get Medicare prescription drug coverage.  

Medicare Advantage Plans such as Medicare Health Maintenance Organization (HMO) Plans, Medicare Preferred Provider Organization (PPO) Plans, medicare Private Fee-for-Service (PFFS) Plans, Medicare Special Needs Plans (SNP’s), and Medicare Medical Savings Account (MSA) Plans are available in many areas of the country.  If the person you care for joins one, he or she will get all Medicare-covered benefits through the plan.

If the person you care for joins a Medicare Advantage Plan, the plan will usually provide Medicare prescription drug coverage.  A person who joins a medicare Advantage plan does not need to (and is not allowed to) join a separate Medicare prescription drug plan.

More Options For The Caregiver 

Medigap (Medicare Supplement Insurance) policies are sold by private insurance companies to fill “gaps” in Original Medicare Plan coverage, such as out-of-pocket costs for Medicare coinsurance and deductibles, or for services not covered by Medicare.  A Medigap policy only works with the Original medicare Plan.  If the person you care for joins a Medicare Advantage (MA) Plan, he or she generally doesn’t need (and can’t use) a Medigap policy.

MEDICARE PART A                                                         

Usually No Premium.  It helps pay for inpatient hospital care, skilled nursing facility care following a hospital stay, hospice care and some home health care.

MEDICARE PART B

There is a monthly premium.  It helps pay for doctor's services, outpatient hospital care, and some other medical services when they are medically necessary.

Not covered by Part A or Part B: long-term custodial care in a nursing home.  This is the need for long term care insurance.

Medicare Drug Plans  

Medicare drug plans are run by insurance companies and other private companies approved by Medicare.  Each plan can vary in cost and drugs covered.  To get Medicare drug coverage, the person you care for can join a Medicare drug plan. 

There are two ways to get Medicare prescription drug coverage:  

·         Join a Medicare Prescription Drug Plan (PDP).  These plans add drug coverage to the Original Medicare Plan, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.        

·         Join a Medicare Advantage (MA Plan, like a Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO), or another Medicare health plan that includes prescription drug coverage.  You get all of your Medicare coverage, including prescription drugs, through these plans.

If the person you care for joins a Medicare drug plan, he or she usually pays a separate monthly premium in addition to his or her Part B premium.  The amount of the monthly premium isn’t affected by the health status of the person you care for or how many prescriptions he or she uses.  IMPORTANT:  Joining a medicare drug plan when he or she is first eligible means the person you care for will pay the lowest possible monthly premium.  If the person you care for doesn’t join a Medicare drug plan when he or she is first eligible and he or she goes without creditable prescription drug coverage for 63 continuous days or more,

he or she may have to pay a late enrollment penalty to join a plan later.  This penalty amount changes every year, and the person you care for will have to pay it as long as he or she has Medicare prescription drug coverage.  If the person you care for qualifies for extra help, he or she may not have to pay a penalty.   

Coverage Options

Most Medicare drug plans charge a monthly premium that varies by plan.  The person you care for pays this in addition to the Part B premium.  Costs and coverage for particular drugs will vary depending on which drugs the person you care for uses, which Medicare drug plan he or she chooses, and whether he or she gets extra help from Medicare to pay for prescription drug costs.  Having a variety of plans to choose from gives people with Medicare the chance to pick a plan that meets their unique needs.  Help the person you care for choose a plan that will allow the person to get the coverage he or she wants at the best price possible.  

In most cases, if the person you care for joins a Medicare drug plan, coverage is effective the first day of the month after the month the person joins.  Enrollment is generally for the calendar year.  The person you care for can switch plans from November 15-December 31 each year if his or her coverage changes or his or her needs change.  In this case, coverage begins January 1 of the following year. 

If the person you care for decides to join a Medicare prescription drug plan, it is best to enroll early in the month.  This gives the plan time to mail his or her membership card, acknowledgement letter, and welcome package before his or her coverage becomes effective.  This way, even if the person you care for goes to the pharmacy on the first day of coverage, he or she can get prescriptions filled without delay.  

Help With Hospitalization and Billing Questions

Medicare covers inpatient hospital care when all of the following are true: 

·         A doctor says the person with Medicare needs inpatient hospital care to treat an injury or illness

·         The person with Medicare needs the kind of care that can be given only in a hospital

·         The hospital has an agreement with Medicare.

·         The Utilization Review Committee of the hospital approves the stay while the person with Medicare is in the hospital

·         A Quality Improvement Organization approves the stay after the bill is submitted

Medicare helps pay for the following services:  

·         Care – general nursing

·         Room – semiprivate room

·         Hospital services – meals, most services and supplies   

Knowing about deductibles, coinsurance, and co-payments can help you understand Medicare billing.  

The deductible is the amount that a person must pay for health care or prescriptions, before the Original Medicare Plan, the person’s prescription drug plan, or other insurance begins to pay.   

Coinsurance is the amount the person you care for may be required to pay for services after he or she pays any plan deductibles.  In the Original Medicare Plan, this is a percentage (like 20%) of the Medicare-approved amount.  The person you care for will have to pay this amount after he or she pays the deductible for Part A and/or Part B.  In a Medicare Prescription Drug Plan, the coinsurance will vary depending on how much the person you care for has spent.

In some Medicare health and prescription drug plans, a copayment is the amount the person you care for will pay for each medical service, like a doctor’s visit or prescription.  A copayment is usually a set amount, $10 or $20 for a doctor’s visit or prescription.  Copayments are also used for some hospital outpatient services in the Original Medicare Plan. 

IMPORTANT:  When a person with Medicare is covered by more than one health insurance plan, there are rules about whether Medicare or the other insurer pays health care bills first.  This is called “coordination of benefits.”  Sometimes, the other health insurance pays the person’s health care bills first, and the person’s Original Medicare Plan or Medicare Advantage (MA) Plan pays second.  Other insurance that may pay first includes an employer’s or union’s group health plan coverage, no-fault insurance, liability insurance, black lung benefits, or workers’ compensation.  If the person you care for has other insurance, it is important that you tell his or her doctor, hospital, and pharmacy so that his or her bills get paid correctly.     

Home Health Care and Community Services

The right kind of support can go a long way to help people continue to lead independent, productive lives at home.

Together, you and the person you care for should start by checking with his or her doctor about what services are needed and who provides them.  To find out if a patient is eligible for Medicare’s Home Health Care services, call the Regional Home Health Intermediary (RHHI).  A RHHI is a private company that contracts with Medicare to pay bills and check on the quality of home health care.  Home health care under the Original Medicare Plan is short-term skilled care at home after hospitalization or for the treatment of an illness or injury.   

Home health agencies provide home care services, including skilled nursing care, physical therapy, occupational therapy, speech therapy, medical social work, and care by home health aides.

Medicare Home Health Care benefits are available to patients if they meet four conditions:    

·         Their doctor decides the patient needs medical care in the home and makes a plan for their care at home, and

·         They need reasonable and necessary intermittent skilled care or physical therapy, continuing need for occupational therapy, or speech-language pathology ordered by the doctor and provided by a Medicare-certified home health agency.  Home health services may also include medical social services, home health aide services or other services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), and medical supplies for use at home.  

·         The person is homebound.  This means they are normally unable to leave home and that leaving home is a major effort.  When he or she leaves home, it must be infrequent, for a short time.  The person may attend religious services.  He or she may leave the house to get medical treatment, including therapeutic or psychosocial care.  The person may also get care in an adult day care program that is licensed or certified by his or her state or accredited to furnish adult day care services in his or her state, and

·         The home health agency caring for the person must be approved by Medicare.

Note for Women with Osteoporosis:  Medicare helps pay for an injectable drug for osteoporosis in women who have Medicare Part B, meet the criteria for the Medicare home health benefit, and have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis.  The person you care for must also be certified by a doctor as unable to learn or unable to give herself the drug by injection, and that family and/or caregivers are unable or unwilling to give the drug by injection.  Medicare covers the visit by a home health nurse to give the drug.