Options after leaving nursing home - assisted living vs home/family vs other ?

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fsrph
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Options after leaving nursing home - assisted living vs home/family vs other ?

Post by fsrph »

A family member completed short term rehab for mobility issues in a nursing home. Have to decide where he should go next. Nursing home social services spoke to us and stated full care in nursing home is not needed. Mentioned possibility of assisted living or living with a family member. Patients mobility has improved but still needs assistance at times.

Another family member hinted that I should take over all care for my father in my home. I think they said this because I'm financially secure, in my low 60's, and could retire anytime. Other family member can't retire yet. I love my father. But, I see all that was done for him in the nursing home and it scares me very much to take on all these responsibilities by myself .... all day, everyday. The other close family member said they would help "whenever I can, for as long as I can". Not exactly a ringing endorsement that help is on the way. If you ask my father what he wants to do, his answer is to go home. Facility said that's not possible right now. Maybe in the future.

The situation is further complicated by my father doesn't want us to have POA for him. The reason isn't that he doesn't trust us, it's more that it cost too much and he doesn't need it. He won't budge. To his credit he can still take care of his financial affairs. He wants to preserve his savings as an inheritance, not spend it now.

What I'm looking for is suggestions or compromises how to handle this. Maybe full time assisted living? I have thought of proposing the following. I'll take care of my father, in my house, for 3 months. Then other family member takes him for 3 months in their house. If they can't do that, they need to set up assisted living for those 3 months. Just keep repeating this cycle. Any thoughts are appreciated.

This is actionable as if we can keep my father out of a facility his savings will not be depleted. He is private pay.

Francis
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drzzzzz
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by drzzzzz »

Have gone through this with both parents recently who both really need 24x7 care eventually. We have aides coming in to their apartment which isn't far from me and has worked out well. I have also thought about him coming to stay with us with an aide coming in to help him. You will get tired and resentful if you don't have appropriate assistance as long as you can afford it. The inheritance issue has become moot as we spend the money and my sister who likely wasnt in favor of the aide option initially because of the expense even agrees it is the best and really only option for us. Your relative is much more independent from what I read and you should consider aides coming in for shorter periods as needed during the day or night. I eventually hired the indivudals myself since I found the agencies unreliable because their staff is unreliable and they don't pay enough. I pay less than an agency rate, but the entire amount of the money goes directly to the aide. Some friends had suggestions for aides (none panned out) and I posted on nextdoor neighbor website which was helpful. Once you find one aide if you decide to not use an agency, many of them seem to know each other or can make referrals since their clients typically improve or die so they are constantly on the look-out for new clients for either themselves or co-workers.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by lthenderson »

I did this with two of my family. We found an independent living facility that also had another building on campus that was full time assisted living and attached nursing home. My family members lived in the independent living facility. They had their own apartment but had a cafeteria where somebody made their meals and a cleaning service that came in once a week to sweep and wash bed linens. Their personal clothing could be done with a washer and dryer in their apartment or they could pay extra for service. Honestly just having the meal service provided was a HUGE perk though it might not if your father is a picky eater. They also enjoyed the common rooms where they could go in the evenings and gather in groups to play cards, shoot pool, watch a movie, etc. The facility had people come in once a week to cut hair, do nails, etc. Both of my family members enjoyed their time there.

As they aged, both did stints in the nursing home rehab wing for various injuries. One died there and the other graduated and went back to the independent living apartment for a time before moving across the state to a dedicated assisted living facility. She enjoyed it there for awhile until Covid struck. She toughed it out for a year but finally had enough and went to live with a relative of mine who is retired. She misses the activities of the other facilities and the ease of having someone doing the food and cleaning but seems to be doing alright. She doesn't miss the isolation of locked facilities and force to eat meals brought to her room. She is still fairly mobile though and when the day comes that she isn't and my relatives are too old to be able to do the grunt work, I'm not sure where she will end up at this point.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

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This thread has run its course and is locked (relationship issue). See: Acceptable Topics and Subforum Guidelines
This is an investing and personal finance forum. We also maintain a subforum that allow our members to discuss consumer goods and services and recreational activities. Anything else is considered "Off Topic" and is not acceptable on this forum.
Update: See below.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

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After receiving a PM, this thread is now unlocked to continue the discussion.

Please stay focused on the financial aspects.
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ResearchMed
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by ResearchMed »

lthenderson wrote: Fri Jan 14, 2022 3:38 pm I did this with two of my family. We found an independent living facility that also had another building on campus that was full time assisted living and attached nursing home. My family members lived in the independent living facility. They had their own apartment but had a cafeteria where somebody made their meals and a cleaning service that came in once a week to sweep and wash bed linens. Their personal clothing could be done with a washer and dryer in their apartment or they could pay extra for service. Honestly just having the meal service provided was a HUGE perk though it might not if your father is a picky eater. They also enjoyed the common rooms where they could go in the evenings and gather in groups to play cards, shoot pool, watch a movie, etc. The facility had people come in once a week to cut hair, do nails, etc. Both of my family members enjoyed their time there.

As they aged, both did stints in the nursing home rehab wing for various injuries. One died there and the other graduated and went back to the independent living apartment for a time before moving across the state to a dedicated assisted living facility. She enjoyed it there for awhile until Covid struck. She toughed it out for a year but finally had enough and went to live with a relative of mine who is retired. She misses the activities of the other facilities and the ease of having someone doing the food and cleaning but seems to be doing alright. She doesn't miss the isolation of locked facilities and force to eat meals brought to her room. She is still fairly mobile though and when the day comes that she isn't and my relatives are too old to be able to do the grunt work, I'm not sure where she will end up at this point.
A facility like this that offers several levels of services (e.g., Independent Living, Asisted Living, Skilled Nursing, etc.) could work especially well if one is allowed, from the IL "wing" to pay for some of the services of the ASL, for example.

Even if only outside services/agencies (e.g., health care aides) are allowed, the IL area probably still has the onsite emergency services available, so it wouldn't be the same as leaving someone "alone at home".

I've read (including here, I think) about group homes that have several bedrooms where those who need some oversight/assistance can live in a less institutionalized setting. That might be worth exploring, too.

Asking at a local Elder Affairs type of agency would probably help one find some nearby facilities that offer the right level of services.

A place where one could "age in place" by moving to another 'wing' or just having more services in the same place might be less disruptive long term, too.

OP: Don't underestimate the drain, physically, emotionally, and possibly financiall, of trying to "do it at home".
When some sort of "imposition" becomes unending (or seemingly so) and also slowly (or not so slowly) becomes more and more of a drain, timewise and financially, it can become exceedingly difficult.

See if you can find services that can cover most of it, including with financial input from other family members. (Remind them that this means no one needs to provide 24 hour care, etc...).

It's tricky under the best of circumstances, and it's usually NOT "the best of circumstances".

As for your father's position about: "He wants to preserve his savings as an inheritance, not spend it now", you might try to help him understand that what would mean the most to all of you (hopefully all?) is that HE is well taken care of!

We had to go through this with very elderly MIL.
She did indeed use up almost all of her resources, but she had a very good quality of life for those final years.
(Also look for facilities that IF you start with "enough money", they will keep you if you run out of money, and switch you to Medicaid at the SAME level of services... perhaps a smaller room or such, but otherwise, no second class care, etc.)

Good luck!
Once you find the right facility, you will probably be amazed at how much better *all* of you feel.

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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by TimeRunner »

Keeping this on financial topic, you say your dad doesn't want to do a POA because it costs too much, but you should be able to get a POA done for a few hundred dollars. It shouldn't cost anything (maybe notary fee if required) to find and fill out health agent and advanced health directive and advanced directive for dementia.

My Mom had a fairly quick onset of dementia late in life (late 80's), and that required stepping in financially as well as arranging 24/7/365 caregiving as sleep patterns changed, etc. (IOW you can't count on your Dad sleeping a straight eight and someone may need to assist at 3am and not be sleeping when assistance is needed right then and now.) I would not attempt to provide this caregiving myself, nor task a relative, or even let a relative try...because assistance needs will only increase. We chose an at-her-home option because it's what she wanted, she can afford it, and inheritance burn-through is not an issue for her family.

Take advantage of local resources in your Community if available. There's probably at least one person out there with local knowledge who can be a sounding board. Good luck!
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by TN_Boy »

fsrph wrote: Fri Jan 14, 2022 2:34 pm A family member completed short term rehab for mobility issues in a nursing home. Have to decide where he should go next. Nursing home social services spoke to us and stated full care in nursing home is not needed. Mentioned possibility of assisted living or living with a family member. Patients mobility has improved but still needs assistance at times.

Another family member hinted that I should take over all care for my father in my home. I think they said this because I'm financially secure, in my low 60's, and could retire anytime. Other family member can't retire yet. I love my father. But, I see all that was done for him in the nursing home and it scares me very much to take on all these responsibilities by myself .... all day, everyday. The other close family member said they would help "whenever I can, for as long as I can". Not exactly a ringing endorsement that help is on the way. If you ask my father what he wants to do, his answer is to go home. Facility said that's not possible right now. Maybe in the future.

The situation is further complicated by my father doesn't want us to have POA for him. The reason isn't that he doesn't trust us, it's more that it cost too much and he doesn't need it. He won't budge. To his credit he can still take care of his financial affairs. He wants to preserve his savings as an inheritance, not spend it now.

What I'm looking for is suggestions or compromises how to handle this. Maybe full time assisted living? I have thought of proposing the following. I'll take care of my father, in my house, for 3 months. Then other family member takes him for 3 months in their house. If they can't do that, they need to set up assisted living for those 3 months. Just keep repeating this cycle. Any thoughts are appreciated.

This is actionable as if we can keep my father out of a facility his savings will not be depleted. He is private pay.

Francis
As TimeRunner says, getting a POA is not expensive. Doing that paperwork now (does he have a will, etc?) while he is still fully functional will be a big help later. Put another way, not doing a POA is making his children's life harder down the road. The family should try and gently make that clear.

Your care options depend upon the financial resources available. Assisted living is probably 4k to 8k a month depending on the facility and where you live. If you haven't researched local facilities, now would be a great time to start. In home care from an agency is probably $20 to $25 an hour, and usually they require a minimum stay of 3 or 4 hours. You can do the math on cost depending on how much help is needed.

If there is enough money for any other option, I'd recommend against you taking on the caretaking, even in 3 month chunks. If he's living with you, that means you can't leave the house for more than a few hours at a time ... maybe less, depending on exactly what help he needs. Ever. His care needs, of course, will almost surely increase. Don't do this to yourself unless you must. Find a good nearby facility and visit him a lot.

Note that once he starts paying for a bunch of health care -- aides, assisted living, etc, he can probably start taking huge medical deductions and zero out his federal taxes. That helps a bit on the cost side.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by quantAndHold »

He definitely needs a POA, for both medical and business affairs. He should have had those years ago. If he doesn’t trust any of you enough to do that, then how is he going to trust you to take care of him? It sounds like he might be in a bit of denial about his present condition.

Anyway, taking care of someone like that is exhausting under the best of circumstances. Where is he at financially? Can he afford an assisted living facility?

Another option is to have him live with you, then have in-home care for some number of hours, anywhere from a few hours a few times per week, to 24 hours. If he had 24 hour care, he could, indeed, go home to his own home.

Once our olds get to this stage, they are rarely able to get well and go home and take care of themselves for any extended period of time. So I would be working hard to convince him to move to a senior facility. Since nobody is anxious to jump in and take care of him, having him situated somewhere where he could get care as needed is probably the best option for everyone.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by BarbBrooklyn »

https://www.amazon.com/55-Essential-Leg ... 1610352580

Hey, EVERYONE over the age of 55 needs POA for financial and medical decision making.

Slip, fall.head trauma, TBI?


No documents in place, the state or whatever is making decisions for you.

His choice.

"Dad, you can make your directives known now. Or you can leave it to the state to step in, take your assets and direct your care as THEY see fit". Have had this happen to a close friend recently.

You appoint someone to direct your life for you in case of incapacity, or you think that some anonymous entity is gonna make better decisions for you.

This is the definition of "penny wise, pound foolish".

Medical advice which will get removed-- [medical advice removed by admin LadyGeek]
Last edited by BarbBrooklyn on Sat Jan 15, 2022 7:54 am, edited 1 time in total.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by Nutmeg »

Most states have adopted the Uniform Power of Attorney Act, including a standard form POA, that can be obtained free online. Does your father have a hidden reason for not signing a POA?

Does the nursing home have a social worker that can provide you with information about care and assistance after rehab?
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by celia »

For health care decisions, you don't have to spend much money. Just fill in the blanks in the Five Wishes form to indicate your preferences. This form is valid in most states and you can look yours up here. We originally learned about it from our primary care doctors who had stacks of these they were giving out. This form will only be used if you are unable to speak for yourself. If you don't fill out something, you will get what you get.

To save money on a POA form for financial decisions, his state probably has a standard form found online or at stationery stores. And most brokerages want you to fill out their own Agent Authorization (or similar title) form. I'm not saying these will meet his needs, but they are better than nothing if he someday is still alive, but can't manage his assets.

I think both of these also need to be notarized or witnessed.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by ddbtoth »

Finished taking care of my mother in June. Lots of ups and downs. Don’t rely on trading dad around every 3 months. You’ll end up doing it full time. I was lucky, my mom refused to move out of her house, and I was able to push in help to keep her there till she dies. I also realized she couldn’t come live with me- be very Frank with yourself, it is incredibly hard taking care of a parent. Mobility issues and Covid lockdown coincided with her move to a wheelchair full time. She couldn’t get out after awhile due to physical pain, and few people, other than family, dared to brave the Covid [abbreviated profanity removed by moderator oldcomputerguy] (which, as fate would happen, killed her through a totally different route) and visit. Get access (owner) to all checking accounts, you don’t have to use them, but they are yours (no probate when he dies- you can manage the estate) and medical POA- when my mother was unresponsive in the hospital with organ failure, I was able to get hospice involved, and made the end of life decisions. We were initially very fortunate to get a a live in helper and as the need increased, I should have pushed in more help, but I was desperately trying to conserve her money so that it would last another 8 years. I actually only needed three, but that’s on me.
Have a very frank conversation about end of life expectations and desires. Don’t want to endlessly second guess yourself about the morphine and Atavan drip. Be aware of your needs and ability, then be ready to change. Or not, but be honest about you. Know where all the papers are- wills, accounts, safety deposit boxes, and know a good estate attorney.
Find the good things to do with your dad, and enjoy him. You’ll be amazed at how fast he disappears, the cognitive decline and physical degradation will affect him and you. Be wary of family with lots of advice about how you can do better with your dad. Watch out for your guilt, and don,t take on other’s.
Pray a lot.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by arcticpineapplecorp. »

fsrph wrote: Fri Jan 14, 2022 2:34 pm If you ask my father what he wants to do, his answer is to go home. Facility said that's not possible right now. Maybe in the future.
So his only options are assisted living or live with another? if he wants to go home, is that only not possible because he was implying going home by himself? What if he had a family member to assist him in his home? Then clearly he could "go home", right?

Or is his home not equipped for him to return home? Are modifications, accomodations (bathroom, stair lift, etc) needed before he can return home?

Would he need to sell his home if he couldn't return or he couldn't afford to make such modifications (or didn't want to pay to do so)? Would selling the house give him more money to work with (because getting medical help or assisted living can be expensive).
fsrph wrote: Fri Jan 14, 2022 2:34 pm He wants to preserve his savings as an inheritance, not spend it now.
unfortunately, he might have to spend his savings. assisted living or in home help can be expensive.
fsrph wrote: Fri Jan 14, 2022 2:34 pm What I'm looking for is suggestions or compromises how to handle this. Maybe full time assisted living? I have thought of proposing the following. I'll take care of my father, in my house, for 3 months. Then other family member takes him for 3 months in their house. If they can't do that, they need to set up assisted living for those 3 months. Just keep repeating this cycle. Any thoughts are appreciated.

This is actionable as if we can keep my father out of a facility his savings will not be depleted. He is private pay.
I'm not sure assisted living works that way (3 months on, 3 months off, etc). Usually, you're paying a lump sum and then a monthly amount (higher than normal rent) because ammenities, food, etc. can be included AND you are usually buying in to a continuing care community. So if you enter with assisted living, but then need nursing care, you are guaranteeing yourself a spot (which may not be possible if you're trying to enter skilled care by itself, sometimes there are wait lists for that).

You should check with your local office of aging to discuss options.

Some states have waiver/home and community based services, though these may be through the medicaid dept, so he'd have to spend down his resources to qualify (and there are income requirements, and medical requirements--need to be skilled care eligible, doesn't sound relevant right now).

assuming he owns no long term care insurance that covers in home help?
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by TN_Boy »

arcticpineapplecorp. wrote: Fri Jan 14, 2022 10:55 pm
fsrph wrote: Fri Jan 14, 2022 2:34 pm If you ask my father what he wants to do, his answer is to go home. Facility said that's not possible right now. Maybe in the future.
So his only options are assisted living or live with another? if he wants to go home, is that only not possible because he was implying going home by himself? What if he had a family member to assist him in his home? Then clearly he could "go home", right?

Or is his home not equipped for him to return home? Are modifications, accomodations (bathroom, stair lift, etc) needed before he can return home?

Would he need to sell his home if he couldn't return or he couldn't afford to make such modifications (or didn't want to pay to do so)? Would selling the house give him more money to work with (because getting medical help or assisted living can be expensive).
fsrph wrote: Fri Jan 14, 2022 2:34 pm He wants to preserve his savings as an inheritance, not spend it now.
unfortunately, he might have to spend his savings. assisted living or in home help can be expensive.
fsrph wrote: Fri Jan 14, 2022 2:34 pm What I'm looking for is suggestions or compromises how to handle this. Maybe full time assisted living? I have thought of proposing the following. I'll take care of my father, in my house, for 3 months. Then other family member takes him for 3 months in their house. If they can't do that, they need to set up assisted living for those 3 months. Just keep repeating this cycle. Any thoughts are appreciated.

This is actionable as if we can keep my father out of a facility his savings will not be depleted. He is private pay.
I'm not sure assisted living works that way (3 months on, 3 months off, etc). Usually, you're paying a lump sum and then a monthly amount (higher than normal rent) because ammenities, food, etc. can be included AND you are usually buying in to a continuing care community. So if you enter with assisted living, but then need nursing care, you are guaranteeing yourself a spot (which may not be possible if you're trying to enter skilled care by itself, sometimes there are wait lists for that).

You should check with your local office of aging to discuss options.

Some states have waiver/home and community based services, though these may be through the medicaid dept, so he'd have to spend down his resources to qualify (and there are income requirements, and medical requirements--need to be skilled care eligible, doesn't sound relevant right now).

assuming he owns no long term care insurance that covers in home help?
Couple of things ....

1) I should have noted this before. As arcticpineapplecorp suggests, no facility is going to allow a "3 months in, 3 months out" schedule. Moving a resident in is paperwork intensive. And, the resident has a room. With furniture and possessions .... they won't let the room sit there empty unless you pay for it. So family alternating with a care facility every 3 months is almost certainly a non-starter.

2) "AND you are usually buying in to a continuing care community." I disagree with usually. In fact, I believe most people in care facilities are not in a continuing care community. Furthermore, most continuing care communities want the resident to be fairly healthy *at the time they move in*. Continuing Care communities are also quite expensive. In my area good ones cost 100s of thousands to move in, and have multi-year waiting lists. So this is not an option if OP's area is anything like mine.

3) The question: What if he had a family member to assist him in his home? Then clearly he could "go home", right?. Depends on the level of help needed. Suppose he needs help everytime he goes to the toilet? Can he do any food preparation? Can he eat without much help? There are definitely situations where somebody might be able to manage at home with aides and family stopping by a lot. But .... it completely depends upon the help needed and the willingness and ability of family to be there. A lot. Also, if you do the math, it doesn't take all that many hours of home health care at $20 to $25 an hour to be more expensive than an assisted living facility.

It's great to save dad's money for an inheritance. But that might be a terrible tradeoff for the people giving the care. For that matter, if the OP winds up taking him in, OP should be reimbursed in some way for that burden. The family member suggesting that OP take that task on should be told that is what is going to happen.

Really, you have to understand the numbers. How long could dad's savings plus SS pay for assisted living? Is the house paid for? If it was sold now, how much money can you get for it? Once you have a full grasp of the financials, it will be clear what options are available. It is likely that dad will have to be slowly and gently led to understand the options and the impact of various options on other people.

I'll repeat a comment I've made in other threads on LTC; just because someone is old doesn't mean they get to dictate what everybody else does. A parent insisting that children spend all their time taking care of them when other options are possible is being selfish.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by galawdawg »

fsrph wrote: Fri Jan 14, 2022 2:34 pm The situation is further complicated by my father doesn't want us to have POA for him. The reason isn't that he doesn't trust us, it's more that it cost too much and he doesn't need it. He won't budge. To his credit he can still take care of his financial affairs. He wants to preserve his savings as an inheritance, not spend it now.

This is actionable as if we can keep my father out of a facility his savings will not be depleted. He is private pay.

Francis
I agree with the recommendations that having POA, durable power of attorney for healthcare, advance directives and such are important.

Your post implies that your father is mentally competent. Is that correct? The response below assumes your father is not incompetent and would not be found to be incompetent in a guardianship proceeding.1

You indicate that your father does not wish to have a POA in place because he does not wish to spend the money to have one prepared. In that case, if he is willing to have a POA (and hopefully other related documents) prepared, your only option from a financial standpoint is to pay for them and/or have them prepared yourself.

You should recognize that a competent adult gets to make their own decisions, however unwise, and that a POA does not confer upon the agent the authority to take action contrary to the wishes of the principal. Therefore, if your father is competent and says he does not wish to move into assisted living, that is the decision. If your father wishes to stay in his home, that is the decision. If your father is willing to move into assisted living or have home health care but does not wish to use his savings/investments to pay for such services, then even with a POA, you don't get to spend his money on assisted living, home health care, etc. Therefore, from a financial standpoint, if he unwilling to spend his funds on assisted living (or home health care or other options), then the only options I see are for him to either not receive those services or for you and/or other family members to pay for them yourselves.

Sorry for the dose of reality, but if he is a competent adult, where and how he lives and where and how he spends his money are his decisions to make, however unwise those decisions may be. While the nursing home may opine that his going home, as he has decided he wishes to do, "isn't possible right now," they do not get to make that decision. Your father does, even if contrary to the best medical advice. While none of us want to see any harm or adverse consequences befall any senior, particularly our loved ones, a person does not lose their freedom of choice, their ability to live their life as they choose, and their right to spend their money as they see fit as a result of old age, infirm condition, or unwise decision-making.

Elder issues can be complex but anything beyond the financial aspects of your question involve medical and relationship issues, both of which are off-topic on this forum. I would recommend consultation with an elder law attorney about the legal aspects of your father's circumstances (including issues of mental capacity) as well as with qualified professionals in the geriatric/eldercare field who can help you and your family understand how to navigate these challenging times.

Best wishes.




1Issues of mental capacity and competence of an elder person are well-beyond the scope of this forum. The assistance of that person's medical providers and a qualified attorney is absolutely necessary to address such matters.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by jmw »

I've been through this already as the child of an elderly parent.

Most of the time, the cost of housing dad at the assisted living center will be a lot cheaper than providing the equivalent care at home with hired help. The assisted living center has economies of scale that cannot come close to being duplicated at home other than having adult children provide labor for free or by providing substandard care and supervision. The free labor from you will drain you quickly both physically and emotionally. You will end up hating your father at times. Free labor is a terrible option I highly do not recommend. Do not volunteer yourself. I don't even recommend trying it for a few weeks. Just don't do it. Aging in home is ideal, but it's not the economical option. If he wants to live at home/family, he needs to open his wallet very wide. Otherwise go to the assisted living place.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by BarbBrooklyn »

Please remember that this is not just about what Dad wants.

You get to say if you want your life highjacked by fulltime caregiving.

If dad is deemed competent but Social Services says he can't go home alone, that doesn't equate to you moving in or taking Dad home with you.

Don't ask him "what do you want?" Give him two clear choices--go home with aides X # of hours a week or Assisted Living.


Do you know what his financial means are? While we had initial sticker shock at the cost of my mom's care, my SIL who managed mom's money, quicly pointed out that there were huge cost savings with mom no longer at home--and of course eventually we sold the house to fund her care.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by carolinaman »

If you do decide on assisted living, choose a facility that has multiple levels of care. That way, if/when your father needs a higher level of care, he can get it in the same facility. We put my mother in an assisted living facility. She had a fall and they said she could no longer stay there. We had to find a SNF immediately and paid for 24 hour care for mother until we found one.

It is unclear of your dad's long term prognosis, but if he wants to go home, that might work with your assistance and some in home aides. Is your father able to be by himself overnight?

These are always tough situations and decisions. Make sure whatever is decided can work for you. You should not have to be your father's dedicated servant.

Best wishes.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by Jack FFR1846 »

We've dealt with this for DW's aunt and are intensively looking again for both my mom and her dad.

As mentioned, some facilities have:
1: Independent living. Figure $4k for a 1 bedroom near me (outside Boston)
2: Assisted living. This can be a designated assisted living facility or at an independent, they've paired with a service provider that can be paid a-la-cart. For full assisted living near me, about $7k a month for 1 bedroom.
3: Full nursing home care. Near me, $16k per month.

Some facilities have buy in, but not all. One near me is $140k. But they also have an option that the monthly rent is higher with no buy in. They also have some "give back" to beneficiaries if the patient passes. You have to really go and get info on the facility. The ones we're considering (4 of them) 2 have a $4k buy in, the other 2 have none.

Some facilities have a 30 day notice to leave. If a patient is still a snow bird, this could potentially work. My mom is talking about this, renting furniture and then going for the winter to Florida near my sister. Ask. Places all differ.

Do NOT underestimate how much full time care takes out of you. If you think a 16 hour day is too much, then in home may not work without help. Depending on the care needed, 8 hour, full time care givers may have to rotate, so you need at least 3 people and probably 4 to cover 7 days a week. If you plan to do this with relatives, be aware of the commitment.

Unless the patient has a solid 2 comma portfolio, expect that they are going to spend ALL of their money on their own care. And I get that family seems to always feel that that's not fair and that the money should go to family like the patient wants. I say no. The money is to pay for care. I don't want to pay for your relatives and I shouldn't have to. There are law firms that advertise taking out a trust so that inheritance isn't taken by the nursing home. But guess what? If the patient doesn't have private pay money for 3-5 years, good luck finding a place. You might sit back and say "they'll get free care at a medicaid place. Good luck with that and the 35 year wait.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by JoeRetire »

fsrph wrote: Fri Jan 14, 2022 2:34 pmI have thought of proposing the following. I'll take care of my father, in my house, for 3 months. Then other family member takes him for 3 months in their house. If they can't do that, they need to set up assisted living for those 3 months. Just keep repeating this cycle. Any thoughts are appreciated.
You know your family. But in many families I know, this would fail. You would end up permanently taking care of your father.

Frankly, in many families, hiring in-home care is the best option, augmented with help by the family. In some situations, long term care insurance can help pay for it.
This is actionable as if we can keep my father out of a facility his savings will not be depleted. He is private pay.
Ultimately, it comes down to what dad wants (assuming he is still mentally capable), and what family is willing to do. Avoiding depletion of his assets at the cost of his family doing all the work is not a choice dad can make on his own.

Sounds like you need to gather everyone for a long discussion. Good luck.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by arcticpineapplecorp. »

TN_Boy wrote: Fri Jan 14, 2022 11:44 pm Couple of things ....

1) I should have noted this before. As arcticpineapplecorp suggests, no facility is going to allow a "3 months in, 3 months out" schedule. Moving a resident in is paperwork intensive. And, the resident has a room. With furniture and possessions .... they won't let the room sit there empty unless you pay for it. So family alternating with a care facility every 3 months is almost certainly a non-starter.

2) "AND you are usually buying in to a continuing care community." I disagree with usually. In fact, I believe most people in care facilities are not in a continuing care community. Furthermore, most continuing care communities want the resident to be fairly healthy *at the time they move in*. Continuing Care communities are also quite expensive. In my area good ones cost 100s of thousands to move in, and have multi-year waiting lists. So this is not an option if OP's area is anything like mine.

3) The question: What if he had a family member to assist him in his home? Then clearly he could "go home", right?. Depends on the level of help needed. Suppose he needs help everytime he goes to the toilet? Can he do any food preparation? Can he eat without much help? There are definitely situations where somebody might be able to manage at home with aides and family stopping by a lot. But .... it completely depends upon the help needed and the willingness and ability of family to be there. A lot. Also, if you do the math, it doesn't take all that many hours of home health care at $20 to $25 an hour to be more expensive than an assisted living facility.

It's great to save dad's money for an inheritance. But that might be a terrible tradeoff for the people giving the care. For that matter, if the OP winds up taking him in, OP should be reimbursed in some way for that burden. The family member suggesting that OP take that task on should be told that is what is going to happen.

Really, you have to understand the numbers. How long could dad's savings plus SS pay for assisted living? Is the house paid for? If it was sold now, how much money can you get for it? Once you have a full grasp of the financials, it will be clear what options are available. It is likely that dad will have to be slowly and gently led to understand the options and the impact of various options on other people.

I'll repeat a comment I've made in other threads on LTC; just because someone is old doesn't mean they get to dictate what everybody else does. A parent insisting that children spend all their time taking care of them when other options are possible is being selfish.
good points.

in regards to the last point (being selfish) just a reminder to the OP to have your father prepay for his funeral expenses (irrevocable burial) if you think he might run down resources on expensive care and/or need nursing care in the future and/or medicaid (an irrevocable burial is excluded from countable resources for medicaid).

no need to have to pay for a parent's funeral expenses when the parent had the resources to do so while they were alive, but didn't.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by BarbBrooklyn »

To put it succinctly, your dad gets to decide how to spend his money.

YOU get to decide how to spend your llife.

Some folks like to have the whole "inheritance" thing to use as a tool. Especially unfair to you if this "inheritance" is split with family member who isn't doing the caregiving.

Consider looking into what in-home care costs and working out rent, food and caregiving costs (in your home) on paper if you think you might do this.

Do not entertain "he cared for you as a baby". Rubbish. Babies grow up and are not cared for by folks in their 60s.

You work 8 hours a day. He hires aides for the other 8, eventually 16. And he hires full time care (or goes to respite at AL or NH) so you get two weekends a month and one month's paid vacation.

This can be written up as a "caregiver contract" with or without a lawyer. The cost of care will make his eyes water.

One reason to have any agreement looked over by a lawyer familiar with Medicaid is that there is a 5 year look back on financial transactions. Do not fall for transferring the house out of his name, or a promise that you'll get it later. Tread carefully and familiarize yourself with HIS finances and Medicaid regs.

Good luck.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by A2_MI »

Note that once he starts paying for a bunch of health care -- aides, assisted living, etc, he can probably start taking huge medical deductions and zero out his federal taxes. That helps a bit on the cost side.
I’ve read some fairly clear articles on what is required to deduct assisted living facility expenses as medical expenses, and some not so clear articles on ability to deduct independent living facilities. Has anyone seen a successful outcome where an aging relative was able to deduct independent living costs if they don’t quite need the assisted living level of care but medical issues make it impossible to live on their own anymore? OP’s relative may find it more palatable to be somewhere where the staff isn’t going to try to help with showering or getting dressed, for example. And, as mentioned, lowering the tax bill can allow the dollars to stretch out to cover a much longer period of care.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by InMyDreams »

Even in a nearby assisted living facility, you will probably be giving a lot of support.

If your father wants to insure a legacy for his heirs, he could do some planning with an elder law attorney.

One question I would be asking (and you may have already) - are there any prospects for him progressing to full independence?

Did he serve in any branch of the Armed Forces during a period of conflict, even if he did not see action? He may be eligible for Veteran Aid and Attendance (even if he didn't serve a full 20+ years). It does have a financial cap, and like Medicaid, has a look back period.

Besides the time/emotion commitment to bringing him into your home, is your home really suitable for his physical abilities? What about his future abilities? Would your home still give you the space that you need (for yourself!) if he were living there?
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by fsrph »

Wanted to check in, I'm the OP. I wanted to thank everyone for their thoughtful and informative responses. I can assure you I read every one. I learned a lot. I'll reply to specific questions when I have more time. Thank You Everyone!

Francis
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by fsrph »

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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by fsrph »

quantAndHold wrote: Fri Jan 14, 2022 8:16 pm If he doesn’t trust any of you enough to do that, then how is he going to trust you to take care of him? It sounds like he might be in a bit of denial about his present condition.

Anyway, taking care of someone like that is exhausting under the best of circumstances. Where is he at financially? Can he afford an assisted living facility?
First, if it's relevant my father is in his early 90's. It's not that he doesn't trust us, he doesn't think he needs one. His financial accounts all have POD designations so that's good enough for him. I know POD is not equivalent to POA but that's his view. I think he could afford assisted living but he views his assets as being reserved for inheritance. He'd rather not spend it on himself. I wish I could break him of thinking like this.

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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by fsrph »

galawdawg wrote: Sat Jan 15, 2022 4:22 am
Sorry for the dose of reality, but if he is a competent adult, where and how he lives and where and how he spends his money are his decisions to make, however unwise those decisions may be. While the nursing home may opine that his going home, as he has decided he wishes to do, "isn't possible right now," they do not get to make that decision. Your father does, even if contrary to the best medical advice. While none of us want to see any harm or adverse consequences befall any senior, particularly our loved ones, a person does not lose their freedom of choice, their ability to live their life as they choose, and their right to spend their money as they see fit as a result of old age, infirm condition, or unwise decision-making.
A few replies asked about the going home option. Want to clarify what happened. My father has mobility issues but improved quite a bit with physical therapy. He was classified as a one person assist but physical therapist told me he is right on the cusp of needing no assist. Family had meeting with social services director at nursing home. He explained options like assisted living. We asked is going home an option? Response was no Doctor would authorize that unless there was 24 hour care at home. We asked what if the family was willing to spend a lot of time helping him at home. They stated that would be considered taking him home against medical advice (AMA) and if anything happens to him, like a fall, we could be accused of elder abuse.

Francis
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by fsrph »

galawdawg wrote: Sat Jan 15, 2022 4:22 am
Your post implies that your father is mentally competent. Is that correct? The response below assumes your father is not incompetent and would not be found to be incompetent in a guardianship proceeding.1

You indicate that your father does not wish to have a POA in place because he does not wish to spend the money to have one prepared. In that case, if he is willing to have a POA (and hopefully other related documents) prepared, your only option from a financial standpoint is to pay for them and/or have them prepared yourself.

Yes, he's mentally competent. I already tried the route for the POA you suggested. A week or so ago he agreed to start the process for the POA. I contacted a lawyer and she drafted the POA. The lawyer wanted to visit my father to make sure he wanted this. Told my father this and he was very upset and did not want to meet her. Said we could have done this other ways than getting a lawyer involved.

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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by fsrph »

drzzzzz wrote: Fri Jan 14, 2022 3:08 pm Some friends had suggestions for aides (none panned out) and I posted on nextdoor neighbor website which was helpful. Once you find one aide if you decide to not use an agency, many of them seem to know each other or can make referrals since their clients typically improve or die so they are constantly on the look-out for new clients for either themselves or co-workers.
That's a good idea, hiring aides by yourself. Are these aides licensed? If so how do you verify they have the appropriate license?

Francis
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by Wannaretireearly »

I sometimes wonder, is it much cheaper abroad? Say Mexico. Is this a good reason to move to a warm/cheap location in your 70s/80s with decent healthcare and cheaper elder care (Mexico, Panama, Thailand etc).

OP: sounds like you’ll figure this out, and money is not a major issue. Best of luck to you and your family.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by BarbBrooklyn »

fsrph wrote: Sat Jan 15, 2022 11:02 pm
galawdawg wrote: Sat Jan 15, 2022 4:22 am
Sorry for the dose of reality, but if he is a competent adult, where and how he lives and where and how he spends his money are his decisions to make, however unwise those decisions may be. While the nursing home may opine that his going home, as he has decided he wishes to do, "isn't possible right now," they do not get to make that decision. Your father does, even if contrary to the best medical advice. While none of us want to see any harm or adverse consequences befall any senior, particularly our loved ones, a person does not lose their freedom of choice, their ability to live their life as they choose, and their right to spend their money as they see fit as a result of old age, infirm condition, or unwise decision-making.
A few replies asked about the going home option. Want to clarify what happened. My father has mobility issues but improved quite a bit with physical therapy. He was classified as a one person assist but physical therapist told me he is right on the cusp of needing no assist. Family had meeting with social services director at nursing home. He explained options like assisted living. We asked is going home an option? Response was no Doctor would authorize that unless there was 24 hour care at home. We asked what if the family was willing to spend a lot of time helping him at home. They stated that would be considered taking him home against medical advice (AMA) and if anything happens to him, like a fall, we could be accused of elder abuse.

Francis
In other words, the discharging doctor won't sign off unless there is round the clock supervision for your dad?

1. I would ask WHY he needs 24/7 supervision-- is it because of physical limitations or because of poor judgement, i.e., shouldn't be cooking, wouldn't leave in case of fire. Pin them down.

2. " Dad, this is out of our hands. We could be arrested if we take you home".

3. If you hire aides, will he tolerate them? Or will he fire them and place you and he at risk.

4. Spending money on care is NOT spending on himself. It's giving YOU the gift of being his kids, not his caretakers. It's paying his own way, not enslaving you by his increasing needs.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by LadyGeek »

I don't see a very important point mentioned, and it's likely why the doctors won't discharge him to go home without assistance.

Quite simply, you can't move a person by yourself. If Dad needs help getting out of bed, for example, the family member is not trained to do this in a safe manner.

Also think about situations where it's 2 AM and Dad needs to use the bathroom. Are you setup to handle this?

I had this situation with my late husband. Nursing homes are poor options, but in my case it was the only option due to other issues. When doctors determine a patient is "not safe to go home", listen to them. Please follow-through with the POA.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by BarbBrooklyn »

Wannaretireearly wrote: Sun Jan 16, 2022 3:17 am
OP: sounds like you’ll figure this out, and money is not a major issue. Best of luck to you and your family.
[ quote fixed by admin LadyGeek]

If the OP's dad is so concerned about spending a few hundred bucks on a properly executed POA, I wouldn't assume that money isn't a major issue.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by chazas »

A very nice continuing care community has been a godsend for my mom. She’s been in independent living for a decade. She has friends, she has loved hanging out with them in the dining room or playing cards. As she’s aged the younger ones in her circle have kept a bit of a watch on her. Now she’s moving to the assisted living section - she’s not thrilled, but knows she needs more help, and my sibling who lives in the area simply isn’t able to stay with her to make sure she goes to eat, takes her meds, etc. Staying with my sibling isn’t an option. My sibling, who bears the burden on the ground, didn’t feel comfortable with managing in-home help for my mom.

The facility staff has been very helpful in figuring out how to approach her diagnosis so she can claim on her LTC policy, which will make the additional cost of assisted living net out about the same. The apartments and finishes and facilities are about the same, so it’s not a huge shock to move, and she can still see her friends in independent living from time to time.

It’s not cheap but it’s well within her ability to fund, even thought she’s had friendly brokers “managing” her money over the years and as a BH I shudder about those fees. In the end it’s enough to fund a very comfortable living situation for her and that’s all that matters.

If your dad was upset about seeing a lawyer for POA/estate planning type of stuff, it’s probably time for a very loving but frank discussion.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by TN_Boy »

BarbBrooklyn wrote: Sun Jan 16, 2022 7:26 am
fsrph wrote: Sat Jan 15, 2022 11:02 pm
galawdawg wrote: Sat Jan 15, 2022 4:22 am
Sorry for the dose of reality, but if he is a competent adult, where and how he lives and where and how he spends his money are his decisions to make, however unwise those decisions may be. While the nursing home may opine that his going home, as he has decided he wishes to do, "isn't possible right now," they do not get to make that decision. Your father does, even if contrary to the best medical advice. While none of us want to see any harm or adverse consequences befall any senior, particularly our loved ones, a person does not lose their freedom of choice, their ability to live their life as they choose, and their right to spend their money as they see fit as a result of old age, infirm condition, or unwise decision-making.
A few replies asked about the going home option. Want to clarify what happened. My father has mobility issues but improved quite a bit with physical therapy. He was classified as a one person assist but physical therapist told me he is right on the cusp of needing no assist. Family had meeting with social services director at nursing home. He explained options like assisted living. We asked is going home an option? Response was no Doctor would authorize that unless there was 24 hour care at home. We asked what if the family was willing to spend a lot of time helping him at home. They stated that would be considered taking him home against medical advice (AMA) and if anything happens to him, like a fall, we could be accused of elder abuse.

Francis
In other words, the discharging doctor won't sign off unless there is round the clock supervision for your dad?

1. I would ask WHY he needs 24/7 supervision-- is it because of physical limitations or because of poor judgement, i.e., shouldn't be cooking, wouldn't leave in case of fire. Pin them down.

2. " Dad, this is out of our hands. We could be arrested if we take you home".

3. If you hire aides, will he tolerate them? Or will he fire them and place you and he at risk.

4. Spending money on care is NOT spending on himself. It's giving YOU the gift of being his kids, not his caretakers. It's paying his own way, not enslaving you by his increasing needs.
Well, if he needs a one-person assist, that is *probably* why he needs round the clock supervision. The need for an assist implies:

1) can't go to bathroom by himself
2) can't bathe himself
3) can't ..... get up without help. At all.

Regardless of what the doctors say (and pinning them down is appropriate), somebody who cannot get out of a chair or bed and walk to the bathroom by themselves needs help 24x7. They just do.

OP says he is mentally competent, but even a person of sound mind could easily wakeup, or let their mind wander, and try to get up ... then promptly fall. If you've been walking for 90 years, it's easy to forget for a instant that's not a option. I would.

I'll also add to the comment another person made, even when someone is "only" a one-person assist, it's scary helping such a person. I had an elderly relative at that level. She weighed 100 lb. I'm a reasonably fit 170+. I was nervous even helping her stand up when visiting because she was frail ... you can't just grab someone like that if they start to fall. You might dislocate a shoulder. You have to be right beside them and very quick. It's not unusual for someone needing an assist to fall *even with somebody there*.

The bit about elder abuse if a fall seems a bit over the top. A person in the OP's dads situation might fall with an aide sitting in a chair six feet away. The aide looks away for 15 seconds and dad tries to get up .... it happens. Think about a toddler learning to walk. They try and get up to walk all the time. And fall, even with mom or dad nearby. Fortunately, they have a very short way to fall. Not so for frail adults.

The need for an assist puts the question back on the OP -- are you comfortable helping dad to/from a toilet, helping him bath and dress, etc? 24 hours a day?

I should however, point out the bad news about care facilities. A resident in assisted living is not always going to get immediate help. There isn't enough staff. There will be times, especially at night and on weekends where he is going to want help with the bathroom, for example, and he won't get it immediately. Which is partly why the bit about needing 24x7 supervision is actually incompatible with standard assisted living. Or skilled nursing for that matter. Does the current facility have an aide sitting in his room 24 hours a day?

A further note is that once a person declines to needing a two-person assist -- perhaps they are very heavy, or so frail they can give no help at all moving around -- some facilities short of skilled nursing may not keep them. The problem is the staff load -- you might tie up two staff for 15 minutes or more.

It's a problem.

Another wrinkle, at the skilled nursing facility he is probably getting PT 3 or 4 times a week, maybe daily. What PT will he get at home? Will he keep it up?
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by TN_Boy »

galawdawg wrote: Sat Jan 15, 2022 4:22 am
fsrph wrote: Fri Jan 14, 2022 2:34 pm The situation is further complicated by my father doesn't want us to have POA for him. The reason isn't that he doesn't trust us, it's more that it cost too much and he doesn't need it. He won't budge. To his credit he can still take care of his financial affairs. He wants to preserve his savings as an inheritance, not spend it now.

This is actionable as if we can keep my father out of a facility his savings will not be depleted. He is private pay.

Francis
I agree with the recommendations that having POA, durable power of attorney for healthcare, advance directives and such are important.

Your post implies that your father is mentally competent. Is that correct? The response below assumes your father is not incompetent and would not be found to be incompetent in a guardianship proceeding.1

You indicate that your father does not wish to have a POA in place because he does not wish to spend the money to have one prepared. In that case, if he is willing to have a POA (and hopefully other related documents) prepared, your only option from a financial standpoint is to pay for them and/or have them prepared yourself.

You should recognize that a competent adult gets to make their own decisions, however unwise, and that a POA does not confer upon the agent the authority to take action contrary to the wishes of the principal. Therefore, if your father is competent and says he does not wish to move into assisted living, that is the decision. If your father wishes to stay in his home, that is the decision. If your father is willing to move into assisted living or have home health care but does not wish to use his savings/investments to pay for such services, then even with a POA, you don't get to spend his money on assisted living, home health care, etc. Therefore, from a financial standpoint, if he unwilling to spend his funds on assisted living (or home health care or other options), then the only options I see are for him to either not receive those services or for you and/or other family members to pay for them yourselves.

Sorry for the dose of reality, but if he is a competent adult, where and how he lives and where and how he spends his money are his decisions to make, however unwise those decisions may be. While the nursing home may opine that his going home, as he has decided he wishes to do, "isn't possible right now," they do not get to make that decision. Your father does, even if contrary to the best medical advice. While none of us want to see any harm or adverse consequences befall any senior, particularly our loved ones, a person does not lose their freedom of choice, their ability to live their life as they choose, and their right to spend their money as they see fit as a result of old age, infirm condition, or unwise decision-making.

Elder issues can be complex but anything beyond the financial aspects of your question involve medical and relationship issues, both of which are off-topic on this forum. I would recommend consultation with an elder law attorney about the legal aspects of your father's circumstances (including issues of mental capacity) as well as with qualified professionals in the geriatric/eldercare field who can help you and your family understand how to navigate these challenging times.

Best wishes.




1Issues of mental capacity and competence of an elder person are well-beyond the scope of this forum. The assistance of that person's medical providers and a qualified attorney is absolutely necessary to address such matters.
I agree with the spirit of this post. I particularly agree when a person is for example, just barely able to deal with living alone, but continues to do do despite the fact it would be "safer" to move to assisted living. Or they won't move from the country house to a place in town, etc. A greater risk is a reasonable decision in many situations. As long as they can, in fact, mostly take care of things.

However, regardless of how competent someone apparently is, if they literally cannot go to the bathroom by themselves (as later posts by the OP make clear) then in fact, no, the person doesn't get to call the shots because they cannot implement that plan. And it's other people that will have to keep fixing things. Sometimes the family has to unite and say, "No, that is not going to happen."
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by TN_Boy »

Wannaretireearly wrote: Sun Jan 16, 2022 3:17 am I sometimes wonder, is it much cheaper abroad? Say Mexico. Is this a good reason to move to a warm/cheap location in your 70s/80s with decent healthcare and cheaper elder care (Mexico, Panama, Thailand etc).

OP: sounds like you’ll figure this out, and money is not a major issue. Best of luck to you and your family.
The problem with someone moving overseas for cheaper elder care facilities (and, they are cheaper in many places) is that it makes it pretty close to impossible for family to monitor the care unless they move also. Someone actually in a care facility needs outside help from friends or family.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by InMyDreams »

fsrph wrote: Sat Jan 15, 2022 10:30 pm I think he could afford assisted living but he views his assets as being reserved for inheritance. He'd rather not spend it on himself. I wish I could break him of thinking like this.

Francis
i was actually thinking about this yesterday after your last post.

IMO, the best "inheritance" to give to your children is being able to sustain yourself. Sure, you need some assistance from the next generation, but not a 24x7 effort that is more than a worker would give in a job.

A friend's husband was reaching his end-of-life days, and she wasn't able to give that kind of effort, nor were her children stepping up. I asked her if she had saved money for a rainy day? and pointed out that it was raining cats and dogs and it was time to spend it.

Caregiver stress is real. Does your father realize what he is asking of his children to take him into their home? What does he want to do?

How good is the social worker at the SNF where he is - is s/he willing to work with your father on some of these ideas? And, even tho he is mentally competent, it doesn't mean that that this specifically is a rational decision, and like you, he may not see the big picture of the effort this will require.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by galawdawg »

TN_Boy wrote: Sun Jan 16, 2022 11:27 am
--Quoted post removed in part--

However, regardless of how competent someone apparently is, if they literally cannot go to the bathroom by themselves (as later posts by the OP make clear) then in fact, no, the person doesn't get to call the shots because they cannot implement that plan. And it's other people that will have to keep fixing things. Sometimes the family has to unite and say, "No, that is not going to happen."
I certainly respect your opinion but the information I posted was intended to convey a general outline of the financial/legal aspects of the situation OP is facing based upon my legal education, training and experience as an attorney. I didn't want to get this thread bogged down into a discussion on competence/mental capacity, but perhaps that may be helpful at this point. While what you opine makes sense from a layperson's standpoint, the law provides a mechanism to handle that situation and it is not a DIY approach.

Instead, the legal protections are there to safeguard the rights that each person has which cannot be infringed upon absent due process of law. That includes the right as an adult to make one's own choices about where and how to live so long as those choices do not violate a criminal statute or endanger themselves or others when caused by mental illness, substance abuse or lack of mental capacity. When the exercise of those rights may pose a risk of harm to the person making those decisions or others, the law provides remedies. For instance, we may all agree that a habitual drug addict who injects heroin is posing a substantial risk to their life, however a concerned family member doesn't get to lock them in a room or physically force them into rehab to prevent them from gaining access to narcotics. Instead, the law provides for legal mechanisms to involuntarily detain that person until they no longer pose a risk of harm to themselves but it requires certain legal processes be followed.

So until and unless a court issues a guardianship order for that senior, that senior retains their decision-making authority. Even with a POA, the senior retains their decision-making authority. With just a POA, if the senior says "I am going to live in my own house and you are not to spend my money on a home health aide/assisted living" then the family member who is has the POA is NOT authorized to spend the senior's money on those things. One who is an agent under the grant of a power of attorney cannot take actions contrary to the express instructions of the principal. It takes a guardianship order to grant another person that decision-making authority and to deprive the senior of the decision-making authority they once had.

I'm not at all suggesting that the family is required to provide care themselves or otherwise conform to the wishes/demands of their senior loved one. While the senior can say, "I'm going to live in my home", that decision doesn't obligate their family to simply acquiesce and provide health care or other medical services that they are unwilling and/or unable to provide. Certainly a family can endeavor to persuade their loved one to make wise decisions about their own care, but if that is unsuccessful and the situation becomes as you posit, competence becomes an issue (for example, lacking ability to comprehend information, understand the importance of the information, make sound decisions and understand the potential impact of their decisions). In that circumstance, the family should consult with an attorney about the elder's mental capacity, as I recommended to the OP.

Hope that helps clarify the discussion! :happy
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by JPM »

Most people with stubborn and/or demented parents reach a point where they either:
1) Don't take no for an answer, and place the parent in an assisted living or skilled nursing center and arrange payment etc more or less against the will of the parent without a guardianship or activated POA. . This option is not strictly legal, but is commonly done in our part of the midwest.
or
2) Have to await some fresh medical problem like undeniable frailty, a fracture due to a fall necessitating placement, or neuropsychological deterioration to the point where guardianship or POA activation becomes feasible and legal authority for involuntary placement is in the power of the guardian. In our part of the midwest just having a POA is not sufficient for a POA to assume control of the property or medical care of the subject; the POA has to be activated and two doctors have to examine the subject and agree that the POA assuming control is appropriate to the situation to activate the POA.

An elderly person can be technically medically competent and so not eligible for guardianship but still be stubborn and/or unrealistic and/or foolish enough to make particularly poor decisions.

Arranging for a willing POA is so important. These can be hard to find for some. A widowed friend and colleague had only two children and by the time he became demented in his 80s they were middle aged and lived many hundreds of miles away and could not (or would not?) conveniently arrange care for him. He had made no contingent arrangements with a professional trustee of any kind and ended up a ward of the county public guardian living in his million dollar + estate with god knows how much $$$$ in his accounts.

Another friend and colleague suffered a brain injury and soon recognized that he was declining cognitively. As an experienced MD, he knew that at his age this meant that he would likely become demented in a matter of months and so while still competent arranged for his own admission to a very nice skilled nursing facility and arranged for our practice accountant to assume control of his property/trusts and see to it that his bills and those of his already-demented wife were paid. Worked out well.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by ResearchMed »

JPM wrote: Sun Jan 16, 2022 12:32 pm In our part of the midwest just having a POA is not sufficient for a POA to assume control of the property or medical care of the subject; the POA has to be activated and two doctors have to examine the subject and agree that the POA assuming control is appropriate to the situation to activate the POA.
Your state doesn't have a DPOA (DURABLE Power of Attorney), or even a plain vanilla POA?

It sounds like you are describing a Springing POA, which only kicks in once the person reaches incompetency... and then verification of the "incompetency" becomes essential.
It's typically this potential difficulty (under most situations, where the person is not protesting someone else having such oversight) where the DPOA is useful... there's no need to make a determination about whether/when the person has become "incompetent".

Otherwise, either a plain POA or a DPOA should "work", the former while the person is still competent, and, importantly, the latter while the person is still competent AND when the person becomes incompetent.
Of course, if the person is competent and refuses to allow someone else to exercise the DPOA that becomes a problem. Or if the person is not competent but is proclaiming they refuse to allow someone else to exercise the DPOA... then it's probably back to the SPOA. And it might be more difficult to get this approved if the person is actively declining said oversight.

But if someone is actively protesting allowing someone else to make decisions, that's a different complication...

(There also might be a use for a POA-type of document for regular/financial decisions and a separate one for medical affairs.)

RM
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J295
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by J295 »

If I were in your shoes, I would encourage my father to move into assisted living (or home or independent living with home health care*), explaining that the units are on a month-to-month basis, and if he continues to have improvement and can become independent he can then move back home (or to independent living or whatever he chooses at that subsequent time).

Many of us know from experience how difficult these transitions can be. Framing it as potentially temporary can be a good option to handle the immediate decision.

* We have experience with assisted-living, nursing home, and home health care. Home health care has its own unique challenges, especially now with the labor shortage.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by clip651 »

JPM wrote: Sun Jan 16, 2022 12:32 pm
2) Have to await some fresh medical problem like undeniable frailty, a fracture due to a fall necessitating placement, or neuropsychological deterioration to the point where guardianship or POA activation becomes feasible and legal authority for involuntary placement is in the power of the guardian. In our part of the midwest just having a POA is not sufficient for a POA to assume control of the property or medical care of the subject; the POA has to be activated and two doctors have to examine the subject and agree that the POA assuming control is appropriate to the situation to activate the POA.

This depends on the type of the POA. I am not a lawyer, but I know they can be written indifferent ways, and may vary by state. Here is one overview:

https://www.kindredhealthcare.com/resou ... hould-know

When the elder trusts the person that is the designated POA, it can be helpful to choose the type that allows the POA to act without needing to prove any incompetence. For example, both of my parents reached a "can you just handle that for me?" stage a while before dementia or other incapacity became bad enough for a doctor to sign off on anything. Their POAs were written in a way that I could step in as needed. And it saves the hassle of needing to go through that step of getting doctors to sign off and all that. But this assumes the elder can trust the person to act appropriately whether they are incapacitated or not.

To OP, when you talk to your father, you can point out that he doesn't have to sign financial or health care POAs. But you don't have to help him, either. He can work with the social worker on his own and figure out what to do next, with you providing care not one of the options. If he wants your help (or that of another family member) then he needs to get the paperwork done to facilitate you helping. You can point this out gently, or firmly, or whatever, depending on your relationship. With my own parents, they didn't realize that setting up the paperwork properly would really enable me to help them when needed, and failing to do so would be a barrier to me being able to help them. Pointing this out helped a lot, though it still took some arm twisting to get the appointment made and the consultation and paperwork completed. While it may be possible to get these documents done without a lawyer, the lawyer can also explain the ins and outs and options to your father and help him understand the usefulness of these documents.

You can also talk to the PTs and social worker about whether there is an option to keep him and continue his PT there until he can truly take care of himself, if he is refusing placement elsewhere, refusing home health, and you are unable/unwilling to provide care.

best wishes to OP!

cj
Last edited by clip651 on Sun Jan 16, 2022 2:47 pm, edited 1 time in total.
Ret2018
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by Ret2018 »

I recently went through something similar with one of my parents. From that I lealrned that hospitals/medical professionals refer to nursing homes to CYA, or in some instances, boost admissions into a facility that is part of their health system. Rarely does it have to do with what is best for the patient--based on the patient's wishes. Institutional care was poor at best before the pandemic; it's downright dangerous now. If someone has sufficient capacity to live in assisted living, then it is likely they can remain at home with sufficient community based supports. Until someone is completely bed-ridden, a lay person can easily learn the tasks to support someone in the home.

Medicare covers a bundle of home health services (nursing, PT, OT, and bath aides) if started within 30 days of a hospitalization. If a doc certifies that the expected survival time is less than six months, Medicare covers a similar bundle of home-based services under the hospice benefit without the requirement for a prior hospital stay.

And don't forget the role technology can play. You can now get internet based cameras that are motion tripped to send an alert, and then you can talk through the camera. This is a big help if you're away from the home for a few hours. And an alarm on the bed for when you're present and you need to know the patient is moving.

As others have said, spending the assets now is the best thing that can be done for you and your siblings. Once assets are spent down, then Medicaid can fund additional home and community based services.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by JoeRetire »

fsrph wrote: Sat Jan 15, 2022 11:02 pmWe asked is going home an option? Response was no Doctor would authorize that unless there was 24 hour care at home.
So he has the option of going home, provided he pays for 24 hour care. Seems like an option that might please him.
I'm much more comfortable criticizing people behind their backs.
TN_Boy
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by TN_Boy »

galawdawg wrote: Sun Jan 16, 2022 12:31 pm
TN_Boy wrote: Sun Jan 16, 2022 11:27 am
--Quoted post removed in part--

However, regardless of how competent someone apparently is, if they literally cannot go to the bathroom by themselves (as later posts by the OP make clear) then in fact, no, the person doesn't get to call the shots because they cannot implement that plan. And it's other people that will have to keep fixing things. Sometimes the family has to unite and say, "No, that is not going to happen."
I certainly respect your opinion but the information I posted was intended to convey a general outline of the financial/legal aspects of the situation OP is facing based upon my legal education, training and experience as an attorney. I didn't want to get this thread bogged down into a discussion on competence/mental capacity, but perhaps that may be helpful at this point. While what you opine makes sense from a layperson's standpoint, the law provides a mechanism to handle that situation and it is not a DIY approach.

Instead, the legal protections are there to safeguard the rights that each person has which cannot be infringed upon absent due process of law. That includes the right as an adult to make one's own choices about where and how to live so long as those choices do not violate a criminal statute or endanger themselves or others when caused by mental illness, substance abuse or lack of mental capacity. When the exercise of those rights may pose a risk of harm to the person making those decisions or others, the law provides remedies. For instance, we may all agree that a habitual drug addict who injects heroin is posing a substantial risk to their life, however a concerned family member doesn't get to lock them in a room or physically force them into rehab to prevent them from gaining access to narcotics. Instead, the law provides for legal mechanisms to involuntarily detain that person until they no longer pose a risk of harm to themselves but it requires certain legal processes be followed.

So until and unless a court issues a guardianship order for that senior, that senior retains their decision-making authority. Even with a POA, the senior retains their decision-making authority. With just a POA, if the senior says "I am going to live in my own house and you are not to spend my money on a home health aide/assisted living" then the family member who is has the POA is NOT authorized to spend the senior's money on those things. One who is an agent under the grant of a power of attorney cannot take actions contrary to the express instructions of the principal. It takes a guardianship order to grant another person that decision-making authority and to deprive the senior of the decision-making authority they once had.

I'm not at all suggesting that the family is required to provide care themselves or otherwise conform to the wishes/demands of their senior loved one. While the senior can say, "I'm going to live in my home", that decision doesn't obligate their family to simply acquiesce and provide health care or other medical services that they are unwilling and/or unable to provide. Certainly a family can endeavor to persuade their loved one to make wise decisions about their own care, but if that is unsuccessful and the situation becomes as you posit, competence becomes an issue (for example, lacking ability to comprehend information, understand the importance of the information, make sound decisions and understand the potential impact of their decisions). In that circumstance, the family should consult with an attorney about the elder's mental capacity, as I recommended to the OP.

Hope that helps clarify the discussion! :happy
Right, thank you for explaining in more detail your comments. I think we were talking past each other a bit, which is mostly my fault.

While a layperson, as past holder of a DPOA, I do in fact understand and am aware of the legal points you make above.

The point I was making, and I don't want to derail this into a "relationship" issue post, is that the family has to work together to do the right thing. The right thing may not be want dad wants at first. Period. It thus becomes a matter of family dynamics how to proceed and the legal details are usually not critical for the typical scenario with a family that actually cares for each other. I.e. the family is not trying to railroad a competent individual into an inappropriate living situation, and will not abuse DPOAs and such.

So what, in TN_Boy's humble opinion, needs to happen in this sort of situation?

First, the family really has to understand the short and medium term prognosis. Often this is not clear-cut, but you need to get the best idea you can. Because one thing you'd like to do is avoid the housing shuffle. Relative is *maybe* okay in one situation (perhaps at home, perhaps at child's home, in assisted living, whatever), until the tiniest downturn, in which case you have to move them. A few months, or even weeks later. This is sometimes unavoidable (people can go downhill fast), but getting the best idea you can of the big picture can really really help planning. Try to avoid spending enormous time and effort creating an environment that is so fragile any change requires a move. Spoiler alert: frail patients in their 90s rarely get a lot better. Usually, it goes the other direction.

Second, as I noted before, the financial situation absolutely has to be understood. If the aging relative can't afford assisted living or home health care, what then? Family pays? Family takes in dad? You have to understand the $$ before you know the options.

Third you have to get everybody on the same page. Dad may want to go home. Family may say "Sorry, we are simply not going to take you home right now." If dad can then -- as is his legal right -- get somebody else to take him home, fine, but most people are unwilling to completely break with family. This is basically all I was saying in my post.

It's probably quite obvious that the family may have to convince dad his preference is wrong (do make sure he really is wrong ...), but I've seen -- and been in -- situations where everybody wants to be tactical and go with what appears to be the easiest solution at first (just let dad move in!) and then one is stuck putting out large fires for the rest of dad's life. Right now, while he is in a safe skilled nursing facility, is the time to do some serious planning not for just the next six weeks, but the next six months, the next three years, etc. There is no reason to hurry discharge unless you are hitting medicare reimbursement limits on rehab (which gets back to, what are the finances here) if you don't have a good plan on where he goes next.

A very common thinking trap is believing the person will bounce back to their previous level. They might. But with frail 80+ people, they likely won't.
Last edited by TN_Boy on Sun Jan 16, 2022 2:38 pm, edited 1 time in total.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by TN_Boy »

JoeRetire wrote: Sun Jan 16, 2022 2:16 pm
fsrph wrote: Sat Jan 15, 2022 11:02 pmWe asked is going home an option? Response was no Doctor would authorize that unless there was 24 hour care at home.
So he has the option of going home, provided he pays for 24 hour care. Seems like an option that might please him.
Well at, 200k+ a year for 24x7 help. If he'll accept the care takers ..... it goes back to how much money he has. Full time care at home is fantastically expensive.
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Re: Options after leaving nursing home - assisted living vs home/family vs other ?

Post by JoeRetire »

TN_Boy wrote: Sun Jan 16, 2022 2:37 pm
JoeRetire wrote: Sun Jan 16, 2022 2:16 pm
fsrph wrote: Sat Jan 15, 2022 11:02 pmWe asked is going home an option? Response was no Doctor would authorize that unless there was 24 hour care at home.
So he has the option of going home, provided he pays for 24 hour care. Seems like an option that might please him.
Well at, 200k+ a year for 24x7 help. If he'll accept the care takers ..... it goes back to how much money he has. Full time care at home is fantastically expensive.
No doubt. It's his life. It's his money. It's his choice.

I'm guessing the care would please him, but the cost would not. We all have to make tough choices at times.
I'm much more comfortable criticizing people behind their backs.
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