Decisions: Caring for your Aging Loved One by Crain's Cleveland Business

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CARING FOR YOUR AGING LOVED ONE

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The cost of long-term care assistance Options available to pay for home-based help

ou may not even realize your loved one’s independence is forever starting to wane when you begin pitching in to tidy up the house or prepare some casseroles for the week. But eventually, those light chores and errands turn into full-fledged caregiving responsibilities. An estimated 44 million Americans ages 18 and older provide unpaid assistance and support to older people and adults with disabilities, according to the Family Caregiver Alliance, a nonprofit advocacy organization for caregivers. Many aging adults expect to rely on Medicare and Social Security benefits to pay for their long-term care needs when they age, but these programs do not cover most of those services or costs. The aging U.S. population means more seniors will require some form of long-term care assistance — such as cooking, bathing or remembering to take medicine — that can be provided at home or in an institutional setting. Americans ages 65 and older represented only 14% of the U.S. population in 2013. The senior population will nearly double — to 22% of the U.S. population — by 2040, according to the Associated Press–NORC Center for Public Affairs Research, which studies attitudes and trends about long-term care in the U.S. “This is an important issue as people age. You have to be proactive,” said Scott Michaels, owner of Solon-based Home Care Assistance, a home care provider. “We have to figure out how we’re going to care for the aging population and who’s going to provide that care.” Generally, home health care refers to skilled care, such as therapies and medicine administration. These services are covered by Medicare, Medicaid, Medigap (a Medicare supplement insurance policy) and veterans insurance for a specified period of time. “You also may qualify for MyCare Ohio, which is a combination of Medicare and Medicaid, if you qualify under the governmental care guidelines,” Michaels said. That integrated care program offers managed care plans that coordinate

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50s age range and younger. There are specified limitations, depending on the policy, including daily rate maximums. “You should purchase this earlier in life so that it’s not as cost-prohibitive,” Michaels said. U.S. DEPARTMENT OF VETERANS AFFAIRS BENEFITS (IF APPLICABLE). “The veterans administration also has an Aid & Attendance program that pays up to $1,000 a month for a single person, and $2,000 for a married couple so that they can access home care benefits,” Michaels said. LIFE INSURANCE POLICIES. Some life insurance policies may include provisions that enable the policyholder to access funds to help pay for home care. “I always recommend to my clients to review their policies carefully and see if they offer this provision,” Michaels said. A REVERSE MORTGAGE. Older homeowners may be able to tap into some of their home equity for additional cash flow if they meet certain requirements. “Talk to a reputable financial institution if you’re interested in pursuing this option,” Michaels said. FAMILY SUPPORT. Indeed, it may be difficult to corral caregiving support and resources from siblings or other close family members. However, in many cases, family members may be able to share the responsibilities of home care for their loved one. Or, mom and dad may move in with their children, Michaels said.

2 physical, behavioral and long-term care services for eligible individuals over age 18. Ohio’s Passport Medicaid Waiver Program also helps Medicaid-eligible individuals ages 60 and older obtain long-term services so they can remain in their homes. Meanwhile, non-medical home care services are defined as activities of daily living, such as meal preparation, light housework, personal care assistance, medication reminders and transportation. Medicare generally does not cover these services. Veterans insurance may cover home care services. Medicaid users also may qualify for home care coverage. “Medicare is very restrictive,” Michaels said. “There are some narrow provisions that may pay for nonskilled visits in between skilled visits, depending on the medical condition. If an individual is in a situation in which they’re expected to pass away within six months or so, they can move into hospice or palliative care and be covered by Medicare.” There are a number of options that can help pay for home care costs beyond private pay, Michaels said. Among them:

LONG-TERM CARE INSURANCE. About 75% of Americans do not have long-term care insurance from a private company to pay for the expenses of ongoing living assistance, according to the AP-NORC Center for Public Affairs Research. AARP says rates are generally lower with individuals in the early- to mid-

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Proposed policies to help subsidize the costs caregivers face in providing long-term care — including employersponsored family paid leave, tax breaks for caregivers, Social Security earnings credit for caregivers and tax breaks for long-term care insurance purchases — all have wide public support, according to the AP-NORC Center for Public Affairs Research. “I think you’re going to see more companies providing some kind of family leave benefit,” Michaels said. “They are faced with more and more employees having to unexpectedly take off time, and they don’t want to have the lost productivity.”

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LEGAL AFFAIRS

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Irrevocable vs. revocable trusts: Which option is right for you?

rusts are the legal delegate for one’s tax and wealth transfer goals. Some people set up trusts because they want to make sure their assets pass along directly to designated beneficiaries, with certain fixed distribution parameters. Other grantors want to offload their assets to their family, and thereby reduce their taxable estate while they’re still alive. Others set up trusts to protect their money from creditors. Depending on the grantors’ wishes, irrevocable and revocable trusts can help satisfy tax and estate planning goals. A key differentiation between revocable and irrevocable trusts is that revocable trusts can be changed, and irrevocable trusts cannot be altered. Knowing the difference is critical because of each trust’s legal and tax consequences. John Seich, principal at McCarthy, Lebit, Crystal & Liffman Co., a Cleveland-based law firm, says each vehicle has its benefits:

REVOCABLE TRUSTS

ASSETS REMAIN IN THE GRANTOR’S ESTATE

Revocable trusts avoid probate. At the time of the person’s death, assets pass directly to the trust’s heirs and outside of the probate process.

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Flexibility. A grantor can make changes to the trust at any time.

Distribution control. When revocable living trusts are incorporated into an estate plan, the trust agreement generally governs the terms of the decedent’s property, rather than a will. A revocable trust can tailor distributions to each beneficiary’s situation, whereas a will distributes assets to the beneficiaries. “I have a client who had three children. Two children got immediate distributions from the trust, but the third’s trust was set up so that he got payments over a lifetime because he had substance abuse issues,” Seich said.

IRREVOCABLE TRUSTS

ASSETS MOVE OUT OF THE GRANTOR’S TAXABLE ESTATE

Tax benefits. A grantor may reduce his or her taxable estate when assets are gifted into an irrevocable trust. “We often set up irrevocable educational trusts for children,” Seich said. Some clients gift into the trust the annual exclusion limit of $14,000 per beneficiary. Many individuals also set up irrevocable life

REVOCABL

ABL C O V E R IR

insurance trusts to manage their life insurance policies while they are alive. The insured can also make annual exclusion contributions toward the irrevocable life insurance trust to pay the insurance premiums. The life insurance in this trust is not considered part of the insured’s gross estate, and therefore is not subject to federal estate taxation.

Asset protection. The trust provides financial support to beneficiaries while protecting assets from creditors, as long as the

trust meets certain asset protection guidelines. In Ohio, once 18 months passes from the time the trust is formed, future unknown creditors cannot access funds in the asset protection trust, according to the Ohio State Bar Association. These are ideal vehicles for individuals who work in a highrisk industry. “I once had a client who worked in a paint factory who set one up to protect his assets because he was worried he would get sued because of a superfund issue,” Seich said.

Transfer company out of your name. In one sophisticated estate planning technique, a business owner can sell his or her company to an intentionally defective irrevocable trust in exchange for a promissory note. The note payments are generated from the entity’s earnings for a certain length of time. The grantor still pays income taxes on the assets, but avoids capital gains taxes

since the entity was sold to the trust rather than gifted. This type of trust enables an individual to reduce the size of his or her taxable estate, and freezes the wealth of the company. The entity’s value appreciates in the trust, which ultimately will be passed along to its beneficiaries. “Don’t utilize this approach without an estate attorney who knows what they’re doing,” Seich said.

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You’ve relied on him since you wore your own tutu. Now it’s his turn.

APRIL 16 IS NATIONAL HEALTHCARE DECISIONS DAY. It’s time to ask your dad if he’s

completed a living will and healthcare power of attorney. Talk to him about his healthcare choices. Discuss how much medical intervention he wants if the worst happens. Ask about the hard stuff. Talk about compassionate options. Tell him how much knowing his answers matters to you, his granddaughter and your whole family. Then fill out the simple documents together. Visit hospicewr.org/decisions for helpful information, videos and free downloads.

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Maintaining rigorous quality standards is imperative for hospice providers By WILLIAM E. FINN

ational health care policy is focused on protecting patients, eliminating fraud and ensuring high quality care. Today’s evolving regulatory environment provides all health care providers — including hospice — with an opportunity to shine despite the many operational and financial challenges posed by the rapidly evolving climate. As organizational leaders, we all know it is crucial to maintain best practices and the highest ethical standards. This is important not only to preserve an organization’s reputation,

but to uphold the mission and to deliver on a promise of quality and customer satisfaction. Maintaining the highest standards of quality and establishing benchmarks for performance are particularly important in end-of-life care. Families place their trust in hospice at a vulnerable time. There are no second chances to get it right, so it is essential that hospice organizations hold themselves to the highest professional and ethical standards. What are appropriate benchmarks for evaluating a hospice’s performance and expertise? If a hospice encourages its employees to be certified in hospice and palliative care, one can assume the hos-

pice is focused on quality. Professional certification is considered the gold standard for assessing expertise. Although certification is voluntarily sought and earned, it is widely recognized by government entities, health care systems, insurers and patients themselves as an objective, Finn evidence-based benchmark for attaining the highest level of competence. Currently, there are 17,000 hospice and palliative care certified nurses and administrators practicing in the U.S., so Hospice of the Western Reserve was

honored recently when three of our staff members received national awards recognizing their expertise among peers. This year, the National Board for Certification of Hospice and Palliative Nurses named one of our nurses, Denise DiMare, Certified Hospice and Palliative Care Nurse of the Year, and Bob Phillips-Plona, director of residential services for our three hospice units, Certified Hospice and Palliative Care Administrator of the Year. Our vice president of quality, Mary Kay Tyler, was named as one of 68 fellows in Palliative Nursing in the U.S. The designation is reserved for those who

are deemed to “provide evidence of progressive leadership in the field of palliative nursing.” All of our physicians are board certified in hospice and palliative medicine and a large percentage of our nurses, social workers and other allied health care professionals also are certified in their specialties. We offer continuing education to the medical community, and professionals from our region’s academic and health care institutions sit on our board and advisory councils. By demonstrating an ongoing commitment to advancing expert care in serious illness, hospice organizations can and must stay true to the mission of relieving suffering, promoting comfort and improving the quality of life for the thousands of patients and families in our region. Finn is president and CEO of Hospice of the Western Reserve.

Learning, interaction keys to intellectual stimulation

he benefits of exercise in life’s golden years are often touted — a healthier heart, stronger bones, better balance, to name a few. What’s becoming increasingly clear is the importance of staying mentally active as well. “Seniors today, more than ever, realize that in order to have a good experience as they age, they need to continue to engage socially, mentally and physically,” said Cheryl Kanetsky, vice president of programs and services for the Alzheimer’s Association. A number of studies indicate that individuals who maintain strong social connections and keep mentally active may lower their risk of cognitive decline and Alzheimer’s. Experts are not certain about the reason for this association. One theory suggests it may be due to direct mechanisms through which social and mental stimulation strengthens connections between nerve cells in the brain. In many cases, there is an emotional payoff as well, according to Lee Ann O’Brien, director of community relations, special projects and planned giving at The McGregor Home. “Lifelong learning programs provide a means of stimulation and social engagement that can improve mood, prevent or reduce depression and motivate self-improvement,” she said. Not surprisingly, therefore, finding ways to intellectually stimulate seniors has become an area of intense interest among senior living facilities, Kanetsky said. This can range from informal activities, such as card games like bridge or games like Scrabble to structured lifetime learning opportunities.

BRAIN GAIN Krystal Culler, director of the Center 4 Brain Health at Menorah Park, said memory- and brain-related programs

are among the newest offerings at retirement communities. “People are so engaged in wanting to know the things that they can do to be proactive about their brain health and wellness,” said Culler, adding that they not only want the educational resources but often they are “actively taking the next step and making modifications to their daily routines, adjusting their lifestyle, getting engaged with new activities or revisiting old hobbies they used to do.” Some of the most popular programs at Menorah Park, for example, involve memory enhancement topics, which include general tips for improving focus and more specific techniques such as how color can be used as a memory

boosting tool. Other in-demand classes include detailed brain health seminars and light-hearted brain teasers. Foreign languages are another fastgrowing area of brain enhancement, Culler said. New research indicates studying a new language can boost brain activity and may ward off the symptoms of dementia and Alzheimer’s disease. Meanwhile, several McGregor residents exercised their creativity by submitting floral designs from an art course to the Shaker Lakes Garden Club’s Perennial Centennial Flower Show last year. “Quite a few of them were recognized,” she said. “They got a lot of enjoyment out of engaging with other

people with similar interests in the area while also achieving a reward.”

STIMULATION THROUGH INTERACTION Many older adults participate in lifelong learning programs for the social aspects as much as for the learning experience, according to Ohio Living Breckenridge Village executive director David Schell. “There was a time when older adults wanted to have activities brought to them,” Schell said. “Now, however, they want to be engaged in activities that are more social.” Activities like ranger-led outdoor hikes, educational field trips and travel

provide opportunities to make new friends while engaging in stimulating discussions. Closer to home, Schell said, many retirees opt for activities that are also “socially accountable” – not only of interest to their needs, but opportunities to give back. Among its most popular programs is one in which residents are paired with nearby third-grade pen pals. In another example, residents are active through the Leadership Lake County program, where they help develop programming for young participants. Through a “living lab” partnership with Case Western Reserve University engineering students, residents are helping test some of tomorrow’s independent living technologies.

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WELLNESS

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Home modifications help seniors age in place safely

or some seniors, aging comfortably means staying put. Many homes, however, are not well-suited to accommodate the physical challenges that come with age, and renovating living spaces to be safer and easier to navigate can be a daunting and sometimes expensive proposition. The good news is, “it doesn’t all have to happen at once,” said Nancy Smoot, program director at senior products company Integrant. “The majority of these things can happen in bite-size pieces over time.” Still, experts say whether you are retrofitting a home for yourself or for a loved one, the best time to start is now. Falls, after all, are the leading cause of fatal injuries for older Americans, according to the National Council on Aging. Even a non-fatal fall can threaten

a senior’s safety and independence and may generate enormous economic and personal costs. Individuals and couples worried about the cost of installing safety features might have options. Many long-term care insurance policies cover modifications necessary to help a person remain in the home, according to Kathy Hirko of KAZ Co., an insurance brokerage. In addition, seniors who have not recently reviewed their Medicare supplement plan and shopped around the coverage and cost could be surprised at what they find. Hirko said some people may have the potential to save hundreds of dollars in premiums each month by doing some careful shopping. “A $300-per-month savings adds up to $3,600 in a year,” she said. “Now, I have the money to put those bars up in

the shower or install a ramp up to my front door.”

START SIMPLE Seniors and their caretakers can ease into modifying the home with small — yet meaningful — changes, said certified aging-in-place specialist Cindy Griebeler, owner of Stay At Home Modifications in North Ridgeville. Loose throw rugs and area carpets with curled edges, for example, are a major tripping hazard for seniors. Griebeler said to remove throw rugs altogether and secure the edges of area rugs to the floor with double-sided tape. Consider replacing door knobs with door levers. Levers are easier for seniors to open than a traditional round door knob. Also, clear walking paths. Often, Griebeler said, she and her team

To ensure that grab bars are installed properly, it’s important to use a qualified installer.

need to remove excess furniture like coffee tables or end tables to create 36inch walkways, which is ideal. Finally, Smoot said, ensure living spaces, especially walkways, are well lit, and if a senior is not able to get up and move around safely on his or her own, locate frequently used items within reach.

TARGET THE BATHROOM Bathrooms can be one of the most dangerous areas of the home for two reasons. First, surfaces tend to be wet and slippery. Second, people are often alone in the bathroom; a fall victim might not be discovered quickly. Grab bars are a must for anyone having difficulty with mobility or balance, according to Mike Foti, president of Cleveland-based Innovate Building Solutions and another certified aging-in-place specialist. Grab bars can be installed in showers and baths to aid in entering and exiting and next to toilets to assist in getting up and down. While handy homeowners may be able to properly install grab bars themselves, Foti suggested most people use a qualified installer because placement and stability are critical. Plus, water seeping behind improperly installed grab

bars can rot out a bathtub or shower. A zero-threshold shower base — no ledge to step over — is another important bathroom feature for seniors, Foti said. Swapping out a one-piece shower/tub or a conventional stand-alone shower with a ledge for a “curbless” version is a larger financial commitment, but greatly increases accessibility, he said, and makes daily showering a much safer activity, particularly for seniors who have mobility issues or live alone.

EXTEND ACCESSIBILITY If mobility issues reach the point where the homeowner needs a wheelchair or a walker, more complicated modifications will likely be needed. It’s not a simple project, but widening doorways could be the thing that makes a home accessible for wheelchairs, Foti said. Other projects can include installing stair lifts and wheelchair ramps or adding pull-out shelves in cabinets and closets. “It’s important to remember that these upgrades are an investment in safety, giving you peace of mind when caring for a loved one or when making plans for living comfortably in the future,” he said.

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EXPRESS YOUR LEGACY CREATIVELY Outdoor tributes, handmade items convey lasting impression

ECO-FRIENDLY END-OF-LIFE

ndividuals who make philanthropic gifts leave a personal stamp on their most valued causes. A donor’s interest perpetuates through cash donations, endowment funds and estate gifts. Donors who bequeath stock, appreciated assets, real estate or certain personal investments to their favorite organizations ensure the vitality of a particular mission. For those seeking a more experiential way to be remembered, there are several charitable and creative opportunities to make sure their legacy lives on. “Many nonprofits have naming opportunities that come along with making a philanthropic gift,” said Laura Frye, planned giving officer at the Hospice of the Western Reserve. “They could have a dedicated building, room, atrium or even garden.” The Hershey Play Garden at Ames Family Hospice House in Westlake, for example, was funded through both foundational and individual support. The 5,000-square-foot space includes a playground, koi pond and chalk garden, offering a reprieve for children and their families who are visiting loved ones in hospice. Other outdoor tributes such as engraved benches and tribute trees along the Vista Walk at David Simpson Hospice House offer personalized support to strollers seeking sanctuary among views of Lake Erie and the gardens.

The Hershey Play Garden at Ames Family Hospice House is an interactive garden that offers a safe, playful environment for children.

Art projects also convey a loved one’s wishes and serve as a comforting keepsake for family members and a cherished heirloom for future generations. “Some people create scrapbooks, recordings or videos that become a comforting keepsake for their families,” said Bonnie Robbins, foundation relations manager at Hospice of the Western Reserve. “At (Hospice) on East 185th, we have many examples of beautiful quilts that were made to commemorate important moments in a person’s life. Expressing feelings through art is healing. People can be sure any message they need to relate is told to their loved one, and

that fulfills them.” People also find comfort in writing out their hopes, dreams and life lessons through an ethical will (which is not a legal document). “An ethical will is essentially a legacy letter to your family,” Frye said.

For those who want to carry forward their ecologically minded principles in the after-life, green burials afford an end-of-life recognition to conservation and sustainability. A small but increasingly interested segment of the aging population is inquiring about green funeral planning, said J. Mark Busch, funeral director at Busch Funeral and Crematory Services, which operates seven funeral homes throughout Northeast Ohio. “We did green funerals for about four to six families last year,” he said. “People who do pre-planning are thinking about their disposition.” Busch said his operation was at the forefront of the movement in Ohio, having been certified by the Green Burial Council shortly after that advocacy organization was founded in 2005. Green burials, or natural burials, are free from formaldehyde, metal or concrete grave liners and burial vaults. Caskets, coffins or other containers are made with biodegradable materials. The body is not embalmed. “Only certain cemeteries in Ohio allow green burials because they require different rules and regulations,” he said. Five cemeteries in Ohio are Green Burial Council-approved providers. More than 300 have come online throughout the U.S. since 2006. Busch said his operation handles most of their green funerals at Foxfield Preserve (above), a nonprofit cemetery located in Stark County. “Green burials are a topic I’ve been asked a lot of questions about,” Busch said. “People are interested in a resting place that preserves nature and promotes conservation.”

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Senior living communities embrace resident-centered model, expand amenities and services

hen it comes to deciding on a retirement living community, today’s seniors want options — and lots of them. In response, independent living and assisted living facilities have ramped up the range of amenities offered to residents, from services that help with daily tasks like housekeeping and medicine reminders to an increased array of recreational options like cultural events, fitness classes and educational opportunities. “Seniors are looking for lots of choices so that they can get support when they need it or want it but also have the autonomy to choose some things and not others,” said Allison Salopeck, president and CEO of the Jennings Center for Older Adults. “It used to be that choices at a senior living community were nice, but not essential. … I do not think we will ever go back to the more cookie cutter set of (senior living) offerings and people will be satisfied with that.” Salopeck said this is especially

true for baby boomers, the newest generation of seniors, who put a high value on the “a la carte” variety of services that can be accessed when wanted and as their needs change with age. Many who opt to settle in a continuing care retirement community, like the Jennings Center, do so to maintain their independence as long as possible. Meal services, housekeeping, help with bathing and dressing and transportation to doctors’ appointments and grocery stores are just a few of the features that keep older adults living independently. Others include ancillary services like physical therapy and podiatry. Beyond these personal care options, however, today’s seniors also want residences that offer socialization, variety in entertainment and food, and the ability to remain connected through technology. “Seniors are really looking for communities that offer areas where they can gather together and opportunities to engage with each other,” said Sheryl Sereda, vice president and chief

advancement officer at Eliza Jennings. “They want to see large spaces for socialization, community dinners and dancing. They are a more active senior group looking for more fun activities.” Entertainment ranges from visiting musicians and performers to day trips that might include local farmers markets or wineries, forays into nature or an outing to a casino or museum. Easily accessible — even onsite — walking trails and natural features like ponds or golf courses are another draw. In common areas, seniors meet for board games, poker or bridge, movies or special interest groups like scrapbooking or gardening clubs. And, boomers, especially, often are technologically savvy, according to Danbury Senior Living director Andy Harpster, and are looking for communities with high-speed internet and wireless networks that can help them maintain virtual connections to family and friends. They also understand the importance of staying active and opt for settings where they can maintain or improve their level of

Excellence in Caring

ABOVE: Residents stretch and improve muscle strength during chair-yoga at Jennings Center for Older Adults. RIGHT: Eliza Jennings’ Renaissance Retirement Campus includes an on-site golf course.

fitness — whether it’s joining a chairbased yoga or dance-fitness Zumba class or going it alone in onsite fitness centers and swimming pools. “Some of the popular wellness offerings include things like reiki and tai chi,” Salopeck said. Safety is another important consideration. Some communities have secure entrances, Sereda said, and many are monitored. Most offer alert systems so if residents have emergencies in their own apartments or rooms, they can summon help, she said. It all comes down to a desire on the part of seniors to live as safely and comfortably as they can, which means independent and assisted living facilities are expected to provide more than a place to reside. They must deliver a lifestyle that often surpasses

the homes and neighborhoods they are leaving behind, Harpster said. “We hear a lot of the time after people move in, ‘I wish I had done this two years ago,’” he said. “Once they are in the community and surrounded by the people and activities and conveniences, they know they made the right decision.”

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HEALTH

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Choose a Medicare plan that meets interim and long-term needs

edicare coverage comes in an alphabet of offerings, and understanding what those plans will cover can spell out significant advantages in savings and health care coverage. “Each individual should think about how they consume health care today, and how they anticipate they will consume health care in the future, when they are deciding which Medicare plan is most appropriate,” said Mike Novelli, vice president of AultCare Corp., a Canton-based insurance company. “Medicare doesn’t pay for everything.” Medicare is the federal health insurance program for individuals age 65 and older. Medicare Part A (hospital insurance) covers inpatient hospital stays, skilled nursing care, hospice care and some home health care. Medicare Part B (medical insurance) pays for preventive and doctors’ visits, outpatient services and medical supplies. Medicare Part C (Medicare Advantage Plan) includes both Part A and B benefits and, depending on the plan, prescription drug coverage. Private companies contract with Medicare to provide Medicare Advantage Plans, which include Health Maintenance Organizations (HMO); Preferred Provider Organizations (PPO); private fee-for-service plans; special needs plans; and Medicare Medical Savings Account Plans, according to the U.S. Centers for Medicare & Medicaid Services. Lastly, Medicare Part D plans add prescription drug coverage to the original Medicare plans (Parts A and B). Novelli offers the following factors to consider when determining which plan is most suitable to fit your needs:

DETERMINE AFFORDABILITY “How much can you afford? This is No. 1 on your list,” Novelli said. Monthly premiums in 2017 under Medicare Part A range from $0 to $413 based on your or your spouse’s work history. The Part A premium is free if you have worked 40 quarters, or 10 years, in your lifetime. Part A deductibles in 2017 are $1,316. The standard monthly premium in 2017 for Part B insurance is $134. The annual deductible is $183, with a 20% coinsurance after the deductible is met. Part C and Part D monthly premiums vary according to the plan. A Medicare supplement insurance policy — also called Medigap — subsidizes some of the health care costs that original Medicare doesn’t cover. “Let’s say you have a $15,000 outpatient knee surgery. Without a supplement, you’re responsible for the first $183 deductible, plus 20% of the $14,817,” Novelli said.

VERIFY PROVIDER NETWORK Some plans insure a larger bandwidth of providers than others. Individuals who are insured by Medicare and a medical supplement can visit any provider that accepts Medicare. “This is important because if you live in Akron and your doctors are in Cleveland, but you buy a plan that doesn’t cover your Cleveland providers, you’re more restricted,” Novelli said. “This is also a key consideration, especially for snowbirds who may split their time between Ohio and Florida.” Indeed, gender, age, tobacco use, payment method and medical claims are among other factors that affect supplemental insurance premiums, according to the Ohio Department of Insurance’s “Guide to Medicare Supplement Insurance,” which lists different insurance companies and their plan costs. “An important question to ask when you’re buying a Medicare supplement is what the plan will cost when you turn 66, 67 or 70,” Novelli said. “A broker or agent should be able to tell you what kind of rate increases they’ve had over the years.”

AVOID THE DRUG INSURANCE HEADACHE

THE UNAPPETIZING DONUT HOLE The uncertainties surrounding the Affordable Care Act have created a cliffhanger for many Americans, who wonder whether the Trump administration will sufficiently replace what it repeals. Among them is Medicare’s Coverage Gap, or the so-called “donut hole.” It works like this: You pay the full cost of your brand-name prescriptions until you reach your plan’s deductible. Then you and Part D share the cost of the prescriptions until the total drug costs reach $3,700. At this point, you enter the coverage gap stage, and pay 40% of the cost for brand-name drugs and 51% for generic drugs costs until you reach your annual out-of-pocket

spending limit (which is $4,950 in 2017). By 2020, the coverage gap is to be “eliminated” by decreasing to 25% the patient’s financial responsibility under the Affordable Care Act. Prior to passage of the Affordable Care Act, seniors were responsible for 100% of their drug costs once they reached the coverage gap. “The big question is: Will the Trump administration eliminate the donut hole? Prescription drugs and the donut hole are a big deal for seniors because their drug costs are so expensive,” said Mike Novelli, vice president of AultCare, a Canton-based insurance company.

LIFETIME COST PROJECTIONS FOR MEDICARE PARTS B, D, SUPPLEMENTAL INSURANCE PREMIUMS AND OUT-OF-POCKET EXPENSES Premiums

Out-Of-Pocket

Total Costs (Present Value)

Total Costs (Future Value)

65-Year-Old Couple

$288,400

$89,012

$377,412

$567,903

55-Year-Old Couple

$368,474

$97,433

$465,907

$943,760

45-Year-Old Couple

$484,103

$108,172

$592,275

$1,614,712 SOURCE: HealthView Services

Medicare Part D tacks on drug coverage to Medicare. Insurance companies provide these plans and categorize drugs into five tiers: two tiers of generics, two tiers of brand names and one specialty. “It’s very important that seniors make sure they know what tier their medication is considered, and whether

Part D covers their drug, and what the co-pay is,” Novelli said. “Medicare.gov allows you to enter in your drugs and ZIP code, so you can determine what your plan and costs will be.” Pre-emptively adding prescription drug coverage upfront is a defensive move that could save individuals

money down the road, even if they don’t currently take medication. Otherwise, Medicare assigns a lateenrollment penalty for those who go more than 63 days without a Medicare drug plan or other credible drug coverage. The individual incurs a penalty for each

month he or she doesn’t have coverage. “I had a gentleman come in who was 70 and hadn’t taken prescription drugs his whole life,” Novelli said. “Then he needed a certain medication. He found out he had to pay a penalty on top of his $30 premium.”

KEY CONSIDERATIONS

Ask yourself these questions to help guide your decision in choosing the best health care plan: n Do you want an original Medicare or a Medicare Advantage Plan? n Do you want prescription drug coverage? n Do you want supplemental insurance coverage to help pay for deductibles, copays, coinsurances and other costs that Medicare does not cover? n How much can you afford to spend on your plan? SOURCE: Medicare and AultCare

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Palliative care improves quality of life for patients with advanced conditions

ri-Ann Kotecki spent most of her days caring for her father while making frequent visits to see her mother in a nursing home, all while juggling three jobs and pursuing an undergraduate degree. She’s had to face both of her parents being on life support, and has been

shouldered with the responsibilities of making decisions on her father’s behalf as his power of attorney. “Hospice (of the Western Reserve) stepped in when my father went on life support for the second time,” Kotecki said. “Then he bounced back, and entered their palliative care program.”

Now, at age 23, Kotecki has pressed pause on her college studies — she’s a senior health sciences major at Cleveland State University — to provide full-time care for her father, who moved in with her. “I only have so much time with him. I can always finish college later,”

she said. “Having the support from Hospice’s palliative care program is such a relief because they offer 24/7 support if I need it. I’ve called them at midnight, and they send a nurse right away. They not only help my family, but they are a huge help to me.” Palliative care services alleviate

’S

PrimeTime Health Plan is an HMO-POS plan with a Medicare contract. Enrollment in PrimeTime Health Plan depends on contract renewal. For more information, please contact PrimeTime Health Plan at 1-800-577-5084, TTY users can call 1-800-617-7446, Monday-Friday 8:00 a.m. to 8:00 p.m. (October 1-February 14, we are available 7 days a week from 8:00 a.m. to 8:00 p.m.), or visit www.primetimehealthplan.com. A sales person will be present with information and applications. For accommodation of persons with special needs at sales meetings, call 1-800-577-5084. TTY users may call 1-800-617-7446. Medicare evaluates plans based on a 5-Star Rating system. Star Ratings are calculated each year and may change from one year to the next. Our plan does not discriminate based on race, color, national origin, sex, age, or disability in its health programs or activities. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-577-5084 (TTY 1-800-617-7446). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-577-5084 (TTY 1-800-617-7446). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-577-5084 (TTY 1-800-617-7446).

some of the caregiver’s commitments, and provide support for individuals who are dealing with a combination of chronic and advanced conditions, such as cancer, dementia, chronic obstructive pulmonary disease, advanced renal failure and congestive heart failure. The Hospice of Western Reserve’s palliative care program offers both social and medical services to help individuals manage their condition, whether from home or a senior living facility. “Most of our patients are a year to three years away from receiving hospice services, although we have a handful of individuals who’ve been receiving palliative care support Kotecki for four to five years,” said Joan Hanson, director of Western Reserve Navigator, the Hospice of Western Reserve’s nonhospice palliative care program. “Our focus is on improving the quality of life for patients and their families through emotional, physical and spiritual support.” The organization uses a team-based care approach, with trained volunteers, social workers and advanced practice nurses working together with patients and their families. Families either can consult the patient’s physician to determine whether he is a candidate for palliative care, or contact a palliative care provider directly. The Western Reserve Navigator coordinates the initial patient visit with an advanced nurse and social worker, who both assess the patient’s unique needs. “An advanced nurse may be able to help the patient manage their symptoms, guide them on how to take their medications or how to use a certain type of therapy,” she said. “The social worker becomes the main patient and family contact if the medical issues are under control. We want to make sure we are caring for the individual with a holistic approach.” Volunteers assist with respite care. They may help patients balance a checkbook, prepare meals or fill out paperwork. On-call nurses are available around the clock to answer questions or for in-home visits. “Our patients often are on the brink of the next acute episode,” Hanson said. “If they don’t call, they may end up in the emergency room with a prolonged stay. We can help manage the symptoms in home and prevent a hospital stay.” The Western Reserve Navigator works closely with the Western Reserve Area Agency on Aging, a Northeast Ohio nonprofit that connects older adults and individuals with disabilities to community-based resources. Palliative care programs also facilitate the power of attorney declaration process with patients and their loved ones. “It’s so important to decide who will be your powers of attorney early on because you want the POA to relay your wishes,” Hanson said. “You don’t want to place the burden on a loved one to make a decision for you.”

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SUPPORT FOR CAREGIVERS

in the home or in an assisted living or skilled nursing facility. Typically private pay, respite stays offer the benefit of 24/7 care, a nursing team, meals and medication management. Another perk is Medicare Part D can often be used to provide potential therapy for a loved one during a stay. “A lot of caregivers don’t take full advantage of respite care,” Connelly says, indicating HCR ManorCare’s Arden Courts memory care communities offer respite stays and 30-day trial stays. “A 30-day trial lets you see how the resident adapts to the community, and also lets us adapt to the resident. It’s a chance for the caregiver to adapt to someone being in a new environment.” Other forms of respite care are adult day programs and senior companion programs, in which volunteers spend a few hours a day doing mindstimulating activities with homebound senior citizens.

Where to turn for help when the task of caregiving becomes overwhelming

oday, about 40 million family caregivers provide to their loved ones more than $450 billion in unpaid care annually, according to the American Association of Retired Persons (AARP). And the burden is expected to rise as the number of elderly in the United States increases.

CAREGIVING CHALLENGES The challenges of caring for elderly family members can be mental, physical and emotional. Indeed, the National Alliance for Caregiving reports the following: n 11% of family caregivers say providing care has harmed their own physical health; n 24% say caregiving has harmed their work performance and shortened time spent at work; n 70% have made a job change due to caregiving responsibilities. So where do you turn for help when caregiving becomes overwhelming? Liz Pencak, director of marketing and clinical liaison for The Village at Marymount in Garfield Heights, says first and foremost, make sure the decision to provide care for a loved one is for the right reasons. “Make sure you are taking into consideration your loved one and their needs, and you’re not doing it because it makes you feel better,” Pencak says.

CARE FOR THE CAREGIVER Pencak says caregivers first have to care for themselves. “If you have a job, you have vacation and sick time. You have to be able to utilize that time to keep some balance in your life,” Pencak says. She adds that in her own research, about 35% said they had difficulty finding time for themselves, and another 29% said they found it difficult to manage the emotional and physical stress of caregiving and balancing work and family responsibilities. Ken Connelly, divisional director of marketing/sales development for Toledo-based HCR ManorCare, says there is a lot of guilt and fear that goes along with taking a break from caregiving. “What we’ve seen in the past is people are waiting too long until there’s a crisis — then it becomes even more of a crisis,” Connelly says. “The caregiver burden is very impactful. Caregivers wind up in the hospital and have no choice but for their loved one to go to a community or facility. Caregivers have to take care of themselves and utilize the resources available to them.” There are options available, but caregivers have to be proactive in finding them.

AGING NETWORK Did you know Ohio has the sixth largest elderly population in the nation?

Christine Foley, director of the Home Care Program at the Benjamin Rose Institute on Aging in Cleveland, said a lot of people aren’t aware of the Older Americans Act of 1965, which created a national aging network with a dynamic group of home- and community-based services, including Meals on Wheels, in-home services, transportation, legal services, elder abuse prevention and caregiver support. Foley said the Benjamin Rose Institute’s caregiver support program is geared toward individuals who fall through the cracks and don’t have insurance for personal care coverage, which provides everything from preparing meals and light housekeeping to personal care. “Personal care aides take over caretaking responsibilities while the caregiver takes a break,” says Foley. There are a variety of options available to caregivers. Support groups can be a wealth of information and provide a necessary outlet for caregivers. Pencak says sometimes just knowing you are not alone is enough. Memory Cafes are similar to support groups, but are held in a public place

THE FUTURE Foley says one of the biggest takeaways from this is to encourage younger individuals who are now caregivers to start thinking about their future needs. “While caring for older adults, start thinking about your needs when you get older,” Foley says. “There are a lot of little niche communities and services out there people don’t know about.”

Caregivers need to make sure they prioritize their physical health and emotional well-being, so that they can care for their loved ones.

and are more relaxing. Senior centers can provide healthy senior adults with options to participate in activities, field trips and educational

“Let us be the caregivers so you can be a son / daughter / husband / wife.”

programming. Many provide free transportation to their centers, as well as to medical appointments. Respite care services can be provided

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Communication device improvements help users retain independence in home setting

ugmentative and alternative communication devices have come a long way from the 20-pound onerous apparatus that was used some 40 years ago to help individuals relay their wishes. These impractical devices only offered about eight to 10 picture-card choices for non-speaking users that featured basic expressions, such as, “I am in pain,” or, “I need to use the bathroom.” “A hand would move slowly around the device to get to the right picture that the individual was pointing at. If your thought or need wasn’t represented on the device, you were out of luck,” said Michelle Foye, director of speech language and learning services at the Cleveland Hearing & Speech Center. Communication devices have since transitioned from the mechanical phase, to electric light boards and then to computerassisted technological equipment. Until about 10 years ago, speechgenerating devices served a singular purpose — to help users speak. “We’re moving from specialized devices to general technologies such as the iPad or other mobile devices,” said Melanie Fried-Oken, a member of the

PIVOTAL TECHNOLOGIES THAT WILL TRANSFORM U.S. HEALTH INDUSTRY Look for artificial intelligence to replace human intelligence and virtual technologies that will change the user’s experience in the physical world. Robots will augment or assist humans in their daily living activities, and remote patient monitoring will help individuals maintain independence and remain within their homes longer. Advances in technology will impact physicians’ roles in patient health care. According to PwC’s 2015 Health Research Institute’s workforce survey of clinicians, about 55% of participants believe that physicians in 10 years will spend less time conducting in-person care. About 85% of those clinicians surveyed believe physicians will focus more time on analyzing data and wearable technologies. SOURCE: PwC Health Research Institute’s “Top Health Industry Issues of 2017”

Augmentative and alternative communication devices have evolved from cumbersome equipment to user-friendly, portable technologies.

American Speech-Language-Hearing Association. “The challenge is screen technologies don’t work for everyone, especially those with cognitive or motor impairments. The great thing is, there’s a large population buy-in. Almost everyone has a mobile device.”

Today’s portable technologies enable users to communicate face to face and long distance, with more independence. “It’s so much easier for individuals who’ve had a stroke or another brain injury to be connected with people in front of them and the outside world because of access to these different technologies,” Foye said.

Tablet-sized eye-gaze devices use infrared eye tracking and eye-control technology that calibrate with the user’s eyeballs. When used with a speech-generating device, the equipment can easily interpret and relay the user’s thoughts with voice output. The technology is a far departure from staring at a communication board and using one’s eyes to spell out her feelings letter by letter.

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“It was obviously fatiguing, and required a lot of guesswork with their communication partner,” said Jessica Blakeman, a speech language pathologist at the Cleveland Hearing & Speech Center. “The devices have changed to adapt to individuals’ motor skills, which, especially with the elderly, change as they get older. Now, communication partners don’t need to predict what their loved one is thinking.” New technologies are helping individuals with declining or limited speech abilities to retain more autonomy, safely, at home. Alarms can be programmed into devices to remind an individual with dementia to put wet laundry into the dryer, or to take medication, Blakeman said. Even improvements in voice output volumes are a game-changer. “Now, you don’t need to be in the same room all the time with a loved one because their voice output can call out to you,” she said. “It gives the user and their loved one’s peace of mind.” Meanwhile, funding for communication devices has become more accessible. Medicare, Medicaid and private insurers generally cover these technologies — which typically fall in the $1,000 to $20,000 range. “There was a time when you’d have to go through trial periods and rental periods, which delayed the ability to get a device,” Blakeman said. “Now, people are getting devices a lot more quickly.”

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TRENDS IN HOME HEALTH CARE A growing industry is helping seniors age in place

or some, there’s no place like home. And home health care offers aging seniors the chance to live out their lives where they’ve been comfortable for decades. Home health companies provide a range of skilled nursing, health care and personal care services to patients in their homes. And, according to the National Association for Home Care & Hospice, a variety of forces will begin to push care away from nursing homes and drive it toward home and community-based care.

the family to provide support. His employees also go into facilities and nursing homes and provide bedside care. He says nursing homes often have one nurse for every 15 beds. “When a family member can’t be there, we provide companionship and help at the bedside,” Cefaratti says. “It’s often done in the evening hours and through the night. It’s a protection layer through the night.”

agency provide — registered nurse, physical therapist, speech therapist, occupational therapist, nutritionist, social worker, home health aide? n How much experience does someone have? How long has the agency been in business? n Does the agency conduct background checks on all staff? n Do the same staff members provide service, or do they rotate? n Is the agency certified to be paid by Medicare or Medicaid? n Are costs and payment expectations in writing? n Do staff members receive ongoing training?

n How often do staff communicate with family members and how?

TECHNOLOGY Home care combined with technology is helping more seniors age in place. Telehealth, activity

monitors, digital consults with doctors and nurses, and online social networks, combined with in-home health care professionals are helping seniors stay in their homes longer. A five-year study in 2016 from St. Jude Medical (now Abbott) found that patients with cardiac devices who used remote monitoring had significantly fewer hospitalizations and lower overall health care costs than patients who did not use the technology. “We’re trying to remain young so we can keep our clients young,” Cefaratti says. “We strive for updated websites, introducing technology to them and providing all the latest and greatest the world has to offer.”

AGING IN PLACE

THE ‘SILVER TSUNAMI’ In 2016, home health care spending totaled $78 billion as the first of the 78 million baby boomers turned 65 last year, according to a MarketResearch.com report. The “silver tsunami” is coming as the remaining boomers reach their golden years over the next two decades. At the same time, fewer younger family members are taking on caregiving responsibilities for older relatives because of the burden it places on their families. According to the U.S. Centers for Disease Control and Prevention, more than 10 million people need long-term care.

Angel Church, private duty coordinator with FamilyTree Home Care Services in Aurora, says the biggest trend she’s seen in home health care is an increase in the education agencies are providing to families specific to a loved one’s diagnosis. “They are not getting that kind of education in the doctor’s office, but there is a big focus on keeping individuals coming out of rehabilitation from going back into the hospital,” Church says. “A lot of our care is, ‘What do we need to do to keep you out of the hospital?’ Your home health care nurse also provides patient teaching and education.” The ultimate goal, Church says, is to keep an individual out of the hospital. “They will do better where they should be living,” Church says, whether that is the home, independent living or assisted living. “The objective is to prevent decline and going back to the hospital.”

AN AGING MARKET Carmen Cefaratti, CEO of Guardian Angels Family Care, says his private pay company has seen incredible growth over the five years it’s been in business. The company provides services ranging from laundry and errands to 24/7 care and end-of-life work. “The market is aging,” he says. “The need for and want for maintaining home residence is out there.” A lot of families, he says, are hesitant to put loved ones in nursing homes because of the stigma. Home health care companies can provide supplemental care, working with

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Call 440.942.4342 to schedule your visit today! WHAT TO ASK When interviewing home health care providers, seek out referrals from friends, neighbors, co-workers or medical professionals. And check references. There are a number of questions to ask: n Is the agency licensed by the state? n What services does it provide, and are they available 24/7? n What kind of staffing does the

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