He looked into his wife’s eyes and flatly stated, “I’ll put a gun to my head before I ever go to a nursing home.”  But the sad truth is this:  His wife will be the one to bear the burden caused by his long term care needs and her own aging challenges.

This couple are frugal people who worked hard all their lives.  They lived on two Social Security checks, his modest pension, and minimal investments.  They were able to pay their bills and enjoy simple luxuries—until the out-of-pocket expenses of long term care begin to drain what they worked a lifetime to save.

His wife selflessly provides in-home care for her beloved husband, until eventually the day comes when her strength is not enough to pick him up or keep him from wandering away from home.  On that day, it might be a doctor, a discharge planner, or a policeman who looks into her eyes and speaks the harsh truth to her: “I’m sorry, ma’am. You can’t take care of him by yourself any more.”

This poor woman now faces a nightmare as she walks the elder care journey with a frail and declining husband.  First she learns that neither Medicare nor their health insurance provide any payment for home health care costs.  Later, when her husband must be relocated to a long term care facility, she discovers that neither Medicare nor Medicare supplemental insurance will pay the facility’s $3,000 to $8,000 monthly cost.

Quickly, she also learns that Medicaid is not available because she has “too much money.”   Her husband’s care will be offset by Medicaid only if she and her husband meet stringent income and asset limitations.  If they have assets over approximately $101,000, they must “spend down” their life savings, which Medicaid defines as “excess assets.”  When all excess assets have been spent on her husband’s medical care, then Medicaid will also control her monthly income.  She is restricted to $2,500 per month; any income above that must be used to pay for her husband’s care.

Later, when her husband dies, she receives more bad news.  She loses his pension, and as the “survivor spouse” she loses one of their two Social Security checks.  She has spent nearly all of their assets to provide for her husband’s care, and now she can’t even afford to live in her own home.  The nightmare of long-term care has left her impoverished and stolen her independence.

She will now face her own elder care journey alone.  She will not have the luxury of a spouse who will serve her as she served him.  No one will be there to dutifully care for her at home and to delay the day that she must move to a long term care facility.  She will not have the financial resources that he had, because Medicaid called them “excess liquid assets” and she spent those assets on his care.  As a single person, she will not be provided with assistance by the State of Illinois or the federal government until she has become impoverished to the point of a paltry $2,000 or less in total assets. The indignity committed against her does not stop there, for now she must sign over all her income to the nursing home as well, except for a miserly “personal needs allowance” of $30 per month.

The loving wife who faithfully cared for her husband is now out of money and out of options.  $30 per month will not even give her the privilege of having her hair done.  She is alone—and living the nightmare of long term care in America.

“I am a lifer here at Countryside. When I need something, they are right there to help me and to relieve my fears. Yes sir, I love it here! This is my home. And Anthony is my friend.” --Bill Mueller, Cubs fan and long-term care resident

Many of our elder law clients live at Countryside Care Center in Aurora, Illinois. We hear from our clients and their families that great care is provided for both private pay and Medicaid clients.

When we are asked by families to recommend a skilled care facility, we often say, “Choose the care, not the curtains!”  In other words, investigate what it’s like to live in a facility—don’t just judge the place by the décor and the architecture.

Recently, I had the pleasure of taking a tour of Countryside Care Center to get to know the staff better.  Jean Bennett, Marketing Manager, greeted me and introduced me to Anthony Clark, R.N., Clinical Nurse Manager and Physician Liaison (pictured on the left in the photo above).  After telling me some of his favorite lawyer jokes, he showed me a whole new way to think about long-term care nursing.

Q:    Anthony, why do you serve here at Countryside?

A:    I had wanted to get an operating room position, but due to circumstances, I decided to apply here.  Actually, an operating room job can be easier, because you never get attached to the patients—and most of the time… you win!—the patient gets well.  But in a nursing home facility, you experience just the opposite.  You spend long periods of time building relationships with people, and then you face the reality of their inevitable death.  You have to learn how to deal with your grief.

That’s one of the real challenges of being a part of a long term care setting.  Ultimately, you will lose someone you care about.  I try to focus on providing our residents with comfort, care, and friendship.  I have a lot of friends who live here.

Q:    How do you and your staff find job satisfaction working in the nursing home at Countryside?

A:    One of the greatest things we have here at Countryside is our Reminiscence Boulevard; that’s our memory enrichment wing.  Our staff go out of their way to love and care for our residents.  They smile, joke, sing, and dance together.  The staff on the Boulevard take pride in what they do.  They do their work well, and the residents and the residents’ families come to trust each one of them.

Q:    What is one of the big reasons that you chose to work at Countryside?

A:    Formerly, I did work in a fancy and totally remodeled short-term rehabilitation center.  Before the new construction, it had been an older, smaller facility.  The nursing team had been able to provide the highest quality of care.  But, after the reconstruction, we had a state-of-the-art building in which it was physically impossible for us to safely serve our residents.  Here, we can see all of the rooms from either end of the hallway.

Q:    What is a special point of pride for you?

A:    The staff must be emotionally up each time they come through the door, or it will show to our residents.  I am proud that every day, this care team shows up emotionally ready for the day.

Many of us under-appreciate those who serve our frail, elderly and disabled, with both compassion and true friendship.  Thank you, Anthony, Jean, and the nursing teams like those at Countryside.

They say that when you meet a person, you know neither who they really are nor the path they have walked.  I am grateful to introduce you to a very inspiring young leader, Jeremy Amster, a wedding singer and nursing home administrator.

Recently I conducted my own personal investigation of Tower Hill Healthcare Center in South Elgin, Illinois.  I wanted to find out how they earned the coveted 5-Star Medicare Nursing Home Quality Rating.  Skilled nursing home care is provided to both private-pay and also quite a few Medicaid-qualified senior residents.  (There are two certainties about State of Illinois Medicaid nursing home reimbursement: it is too little and always too late.)

When I arrived in the lobby, I saw an award to 33-year-old Jeremy Amster called “The Friend of Seniors Award.”  The award states that Jeremy’s leadership demonstrates “quality, creativity, enthusiasm, and care built into every life he touches.”   

Jeremy is the proud husband and the father of Avery, Naftali, and Adir.  His office is an art gallery of the boys’ artwork.  One of his sons told a friend, “My dad helps old people and does payroll.”  The boys are frequent visitors who love to meet and greet the senior residents.  One such visit coincided with the arrival one Sunday morning of some nursing home inspectors.  The inspection team leader suspected that someone had “tipped off” Jeremy, and he was furious!  Jeremy countered by saying, “Do you think I would be here with my 5-year-old son if I knew you were coming?”

Jeremy is very involved in Chicago area Jewish community events.  He tutors kids for their Bar Mitzvah lessons.  He works long hours at Tower Hill—but on Fridays he leaves on time to celebrate the Shabbat.  He quietly stated, “I believe that Orthodox Jews have the luxury of rest.  From sundown Friday night until sundown on Saturday, my wife and sons know that I will be there for them.  My kids know that no matter how busy I am, on Friday evening… Daddy is coming home.”

Regarding the 5-Star Rating, Jeremy credited that award to the ownership and the staff.  He humbly stated, “The secret to keeping great staff is to give people a place to serve and to be proud of.  We have low turnover, strong loyalty, and our team believes in this place.”

Jorie Gustafson, Jeremy Amster and Pam Hilderbrand

Later I asked Pam Hilderbrand, marketing director, and Jorie Gustafson, admissions director, what was the secret to the 5-Star Rating.  They credited Jeremy and the ownership of Tower Hill.  They all agreed when Jeremy said, “Most facilities have a box that all residents must fit in—but we shape our box to fit what our residents actually need.” 

Then they really got to my heart when they told me their “Christmas story.”  “We don’t hold back when we give our Christmas dinner.  Many of our residents will never again go home for the holidays.  So we go all out!  We lavish upon them.  They are encouraged to invite two family members to join them for a sumptuous dinner complete with carving stations.”

As I finished my investigation, it was obvious to me that Tower Hill’s success is due to acting in accord with the Golden Rule: “…you shall love your neighbor as yourself.” (Leviticus 19:18)

**For more information contact:
Tower Hill Healthcare Center
759 Kane St. South Elgin, IL 60177
Phone: 847-697-3310
www.towerhillhealthcare.com

This blog is not about strangers lurking in an alley.  Nonetheless, nursing homes are routinely “invaded” in the wee hours and weekends, because they are subject to unannounced night and weekend visits by trained teams of Medicare inspectors.

These snoopy night stalkers show up and  “camp out” in the facility for days.  These teams have full authority to review and audit over 180 different items covering all major aspects of care in a skilled nursing facility.  They inspect the buildings, the medical records, the residents, the cleanliness, the staffing hours per resident, and much, much more.  These investigators are there to find deficiencies, note them, and  report them to the Center of Medicare and Medicaid Services (CMS).  The report is used to provide a rating which is available to the public at the Nursing Home Compare website. 

The website lists each nursing home and assigns a quality rating between 1 and 5 stars.  A 5-star nursing home is heavenly! Unfortunately, a 1-star nursing home is a probably a living hell.

CMS has created this rating system to help seniors and their loved ones see behind the scenes and beyond the nice décor to find a safe and nurturing care facility for a frail senior.
 
The most coveted score is a 5-star Medicare quality rating.  That score is received by only 10% of all skilled nursing home facilities.  There are very few facilities who receive such an award even when they are in the luxury market.  It is even more impressive when a facility which accepts Medicaid residents qualifies as a 5-star-rated Medicare facility.  Recently Tower Hill Healthcare of South Elgin, Illinois announced in their newsletter that they had received a 5-star award.  I was impressed!  Tower Hill is a 206-bed Medicaid-certified skilled care facility with a 31-bed Alzheimer’s wing.

In my next blog, you will be introduced to a 33-year-old orthodox Jewish synagogue cantor and  wedding singer, Jeremy Amster, whose leadership skills have earned the 5-star rating.

Two weeks ago, at a local hospital, I taught a two-hour continuing education course about advance directives for an audience of hospital administrators, nurses, and social workers.  “Advance directives” are documents such as the Living Will, the Do Not Resuscitate Order (DNR), and the Health Care Power of Attorney.  A primary goal for people who sign these forms is to avoid unwanted resuscitation and other “heroic measures” when there is no hope of recovery and returning to an enjoyable life.

Often, older adults have told me stories of doctors and/or hospital staff who ignored the refusal of life-prolonging care wishes of a now-deceased loved one.  They tell me that they had insisted that their loved one did not want life-prolonging treatment, but nonetheless a doctor ordered feeding tubes, ventilators, and other life-prolonging measures.  I have wondered—is this fear of wrongful resuscitation real or imagined?  The short answer appears to be that the fear is real.

Recent studies show a real “lack of regard” for patient’s preferences in life-sustaining treatment decisions by doctors and hospital staff (National Quality Forum: Safe Practices for Better Healthcare 2009 Update). 

Another 2008 published study (Pieracci) reviewed life-sustaining treatment decisions that occurred between hospital medical staff and their patients and/or their health care agents under advance directives.  The conclusion of the study is frightening.  “Despite patients’ wishes, the indiscriminate use of technology and the lack of communication between patients and health care providers have been shown to result in unnecessary pain and suffering for patients.”  In addition, the study notes that the medical costs of prolonging a dying patient’s life via artificial ventilation and intensive care often range between $11,000 and $36,000.  Another study entitled Support demonstrated that 46% of dying patients received mechanical ventilation in the last three days of their lives.  Many of those individuals never wanted to be on a ventilator—yet they were forced by their physician’s decisions to live on in a state of hopeless suffering.

What can you do to prevent “wrongful resuscitation” from happening to you or someone that you love? 

• Create a written advance directive such as a Health Care Power of Attorney, Living Will, and/or a Do Not Resuscitate Order (DNR) in appropriate circumstances;
• Insist that your advance directives are placed in all of your medical records and that your physician is well aware of the existence of such documents;
• Have “the talk” with your family and doctor to make sure that everyone is very aware of your feelings regarding life-sustaining treatment in the event there is no hope of recovery. This will allow you to get all of your family members “on the same page”; and
• Choose an “advocate” as your Health Care Power of Attorney and/or surrogate decision maker.  That advocate is someone who can look a medical professional in the eye and insist that your wishes be carried out.  I recommend that you look through your family and friends and choose someone who can insist that your desire regarding life-prolonging treatment be respected by the medical profession. 

It’s important to know that there is substantial legal authority for health care directives to be followed.  In fact, it is now considered to be a “sentinel incident” when a hospital performs a wrongful resuscitation.  The Center for Medicare and Medicaid Services (CMS) has emphasized that patients have the right to make decisions regarding their long-term health care, and that those decisions should be respected by physicians and hospitals.

In Illinois you can find the statutory Health Care Power of Attorney at http://www.idph.state.il.us/public/books/PwrOf.PDF .  If you are not in Illinois, just go to Google and type in your state’s name and the words, “health care power of attorney.”

Connie Schreiner and Rick Law

Celebrating New Year’s Day after a kayak run on the Fox River, I was just about knocked to the floor when I overheard someone say, “I’ve seen some wonderful deaths.”  When I recovered from hearing this statement and recognized the sparkling eyes of the nurse who said it, I asked if I could meet with her at another time to learn about “wonderful deaths.”

Several weeks later I met up with Connie Schreiner, the effervescent and popular Director of Health Services at Provena Fox Knoll, an assisted and independent living community located along the Fox River just north of downtown Aurora, IL. 

Connie and I talked about assisted living and what a wonderful living arrangement it is for residents who no longer feel safe living at home alone or need assistance with medication management or help with routine tasks that, with age or illness, have become more difficult to manage.  Connie and I both liked the idea of being provided three meals a day as well—we considered residency ourselves!

“It is very difficult for a resident to leave the comfort and familiarity of his or her home and make a new home somewhere else.  Therefore, we make every effort to ensure that they can live the rest of their lives at Provena Fox Knoll,” said Connie.  “When our independent living residents can no longer live independently, they can transition to assisted living.  When illness causes a resident’s health to decline, or a resident is diagnosed with a terminal illness, the opportunity exists to contract with palliative or hospice care.  It is not uncommon for a resident to tell us that they don’t want to go to the hospital again.”  One resident said to Connie, “You know, I’m 95 years old and don’t want to see the inside of a hospital again.  If my time comes to be with the Lord, then let it be.”

As Director of Health Services, Connie provides residents and family members with the basics of hospice care, specifically:

• That it is important for the resident and the family be comfortable and in agreement with the decision to elect hospice care.
• That the resident’s primary physician must agree and write an order for hospice care. 
• That certain criteria must be met to qualify for hospice.

Connie then recommends they contact Provena Home Care-Hospice for an assessment and the details of care. 

Hospice provides lavish support for both the ill person and his or her loved ones.  Hospice care includes nurses, nurse aides, social workers, and pastoral care—all who work alongside the family and the Provena Fox Knoll staff in support of the resident.  In addition to frequent visits, a hospice nurse is always on call to ensure needed care and comforts are afforded the resident—not only managing physical well-being through medication, but also caring for emotional and spiritual needs. “We currently have a resident on hospice, and her best medicine is a visit from pet therapy.  Provena Fox Knoll is blessed to have three women who visit with their dogs.  It is truly heartwarming to see the excitement on our residents’ faces when these dogs visit,” Schreiner remarked.

Provena Fox Knoll is licensed by the Illinois Department of Public Health (IDPH), as are all assisted living communities.  Schreiner explained that IDPH limits the scope of nursing care that she and her staff can provide.  However, hospice nurses are authorized to provide care that is beyond the scope of their assisted living licensure.  Additionally, most of the hospice costs are covered by Medicare.  

Connie remarked, “The three essential elements to provide a wonderful death are the collaborative efforts of the family, the assisted living staff, and the hospice personnel—which then allows our residents to stay in their home environment with friends and familiar caregivers and peacefully live out the end of their lives.  I have been part of several end-of-life decisions with our residents.  I am richer for it and tremendously grateful to have shared with the resident and his or her family, some wonderful deaths.”

More information on Provena Fox Knoll can be accessed at www.provena.org/foxknoll and Provena Home Care at www.provena.org/homecare.

Page Williams with her horse

When I started practicing elder law, the only people I saw as clients were of my parents’ generation.  But now my own boomer generation is also coming through the doors.  Some are afflicted with early onset Alzheimer’s or Parkinson’s, and they are surprised that they now need long term care.  In 1921 Charlie Chaplin and Mary Pickford dreamed that the movie industry folks would always “take care of our own” and started The Motion Picture & Television Fund, which in turn funded the Motion Picture & Television Country House & Hospital (commonly referred to as Motion Picture Home)—a home that is now closing due to bankruptcy.

My friend and fellow boomer Page Williams recently sent me an e-mail which expressed her anxiety about her own long term care prospects. She is a board member of a union representing theatrical, stage, movie, and TV show workers who are not actors, producers, or writers.  But what’s really bothering her is that “Like millions of boomers, I chose not to marry or have children.  But I don’t think that we unmarried boomers fully realize that there’s a lot more to worry about now than just long term care for our geriatric parents.”  As an entertainment worker, the closing of the Motion Picture Home has her scared. “I always used to joke with my friend Terry as we were riding along on our horses that some day we would be old and gray and sitting around the MP Home having a drink and remembering these days.  Now I wonder what’s going to happen to us.” 

Like other boomers, Page sees promises of retirement era benefits vanishing long before the boomers themselves even arrive at the gates.  Members of her union have paid into the Motion Picture & Television Fund for years with the expectation that if they needed it, that senior home would be there for them.  In great contrast to ordinary nursing homes, the Motion Picture Home has benefited from high profile pre-Oscar fundraising events generating up to $15 million in contributions per year.  Nonetheless, the hospital board says they just can’t carry the alleged $10 million per year nursing home deficit any longer.  They, like other facilities around the country, are receiving insufficient reimbursement from Medicare and Medicaid, the primary sources of governmental health care funding for North American seniors.  Jim Lott, executive director of the Hospital Association of Southern California, complained that Medicare provides reimbursement for only about 87 cents of each dollar that the hospital spends on care. Medicaid reimbursement is even worse, with the state only delivering about 78 cents for each dollar cost of care. 

All over the country, hospitals and nursing homes are closing due to inadequate and long-delayed reimbursement dollars owed to them by both the state and federal governments.  The closing of Motion Picture Home is one more warning that both seniors and boomers must work together to insist that our government provide health care reforms that ensure quality end-of-life care.  As we listen to government claims that they are going to provide universal coverage, it would be nice to see examples of our government actually providing excellent care.  Unfortunately, those examples do not exist. 

What this means for our readers is that it’s time to get serious about your own long term care security, especially if you’re a boomer. Do not delay investigating—and investing in—long term care insurance. There are some new “hybrid insurance products” that will pay out with either a life insurance death benefit or a long term care health policy. Call your trusted financial advisor today.