Is it time to get help?

Consider talking to older people about getting assistance when these questions arise:

• Are they having trouble getting out of bed, going to the bathroom, getting dressed or eating?
• Do they appear unkempt?
• Can they get around and do necessary errands? Do they have someone to drive them or do the shopping for them?
• Can they obtain food and cook it? Or is the only food in the refrigerator old and moldy?
• Can they move about in their home?
• Are newspapers, bills and unwashed dishes piling up?

Guidelines to discussion

• Be forthright and honest. Express your concern about things you’ve noticed. Ask what is going on.
• Be polite but persistent. A person with dementia can be persuasive during a five-minute phone call. Take time to check out the situation.
• Don't be surprised if the older person resists the idea of accepting help, especially if he or she always has been independent.
• Include other family members in the discussion.
• Remain polite and tactful, saying, "I care about you.”
• Include the older person in the discussion. Don't talk as if he or she’s not there.

Senior Services Glossary

Adult Day Care
Some older adults need assistance with daily activities and care but do not need full-time placement in a nursing home and want to remain in a family living situation. Adult day care gives older people a place to go during the day for care and supervision, activities and social contact with others. This program is especially helpful for working caregivers or when family members need time off from the responsibilities of caregiving. Fees vary but are much less expensive than providing in-home care for the equivalent amount of time. In some cases, fees may be arranged through sliding scale fees, subsidies, or Medicaid. 

In-Home Respite programs may be staffed by volunteers or paid staff and are intended to give the caregiver a break for a few hours. Typically the fees are modest and the programs are designed for participants with relatively mild impairment and are not equipped or staffed to meet the needs of those with complex or unstable medical conditions. Out-of-Home Respite is offered by some nursing homes for short stays on a cost-per-day basis, at a maximum of thirty days. It is important to ask if they will accept insurance coverage for these days as most do not. 

Alzheimer’s Disease / Dementia / Memory Impairment
The normal aging process can bring about many changes, including occasional forgetfulness. However, memory loss that significantly disrupts everyday functioning and decision making is not a normal part of aging. Many different diseases, medication reactions or interactions, depression, nutritional deficiencies, and alcohol use can cause memory problems. It is important to assess possible causes of memory loss with a complete medical evaluation as some causes are treatable.

Alzheimer’s disease is the most common cause of severe memory loss in older adults. The onset of the disease is usually gradual. The disease attacks the brain, resulting in memory loss and impairment in behavior, reasoning and thinking. 

Care Management
When care for an older adult becomes necessary, family members may be unaware of the services existing in the community, or may be attempting to coordinate and monitor care from a distance. Care managers are usually social workers or nurses who are familiar with resources and have experience working with older adults. Care managers can evaluate the needs of the older adult, and can recommend, implement and monitor services to meet those needs. When choosing a care manager it is important to consider professional training, experience in working with older adults and knowledge of local resources and government programs. 

Caregiver Resources
Almost every entry in this book represents a resource a caregiver might need in doing the very demanding and vital work of caring for a loved one. Additionally, many churches have support and outreach programs that can be invaluable resources for caregivers. There is also a wide array of information available on the web. A good place to start is www.haywoodconnections.org 

Community Alternatives Program for Disabled Adults (CAP/DA)
The CAP provides in-home care for Medicaid recipients who would otherwise need to be in a nursing facility. The program can provide personal care, nursing services, meals, adult day care, medical supplies, and other services. The program is administered through Haywood County Social Services and may have a waiting list. To be placed on the list you will need to provide the client’s monthly income, Social Security number, physician’s name and phone number, and basic contact information.

Counseling / Mental Health
Many older adults can benefit from counseling sessions for depression, anxiety, grief, interpersonal difficulties, and other mental health concerns. Treatment options include counseling / therapy sessions, education, support groups and/or medication. Medicare, Medicaid, and other insurance may pay for some services.

Home Care
There are several levels of home care available. Errand services handle tasks such as grocery shopping, picking up prescriptions, etc. and may also do some home tasks such as plant and pet care, waiting for repairmen, etc. Homemakers or companions can provide meal preparation, light housekeeping and laundry, in addition to assisting with errands. Home health aids or certified nursing assistants (CNA’s), in addition to the services provided by homemakers, assist with personal care needs such as bathing, dressing, walking, and toileting. Skilled nursing and other skilled services such as physical therapy, occupational therapy, speech therapy, and medical social services are offered by many home health agencies. Medicare provides a home health benefit following certain illnesses and injuries. It does not always require prior hospitalization. Medicare pays for home health benefits only under the following circumstances: 1) the patient needs intermittent skilled nursing or therapies; 2) the patient is homebound; 3) the care is ordered by and under the direction of a physician; 4) the agency providing the care is certified for Medicare visits. Hours of home health services are usually quite limited and services are usually provided on a short term. Supplemental (Medigap) insurance may have some home care coverage but tends to follow Medicare’s lead when authorizing home care.

Some Medicare-certified agencies also provide services of nurses or home health aids which can be paid for by the patient. These services are called private duty services. Many home health care agencies that are not Medicare-certified also provide nursing and home health aid services paid for by the patient. Agencies differ in the minimum number of hours they will provide service, with a two-to-four-hour visit common.

Medicare pays for up to 60 hour/month of home care under the Personal Care Services (PCS) program. For those at risk of nursing home placement, CAP/DA can provide more extensive services.

All agencies that provide “hands-on” care must be licensed by the North Carolina Division of Facility Services. Requirements must be met in the areas of staff qualifications, patient care, patient records, and agency administration. Some agencies voluntarily meet additional standards of special accrediting organizations. When contacting an agency for in-home services, obtain as much information as possible before contracting for services. Be sure the agency is licensed by the state and is Medicare-certified if the services are to be covered under Medicare. 

Hospice
Hospice services provide care for people who have life-limiting illnesses and who have chosen to request palliative (comfort) care rather than aggression treatment for their illness. Hospice services are covered by Medicare and most private insurance companies but are typically available even to those unable to pay for services. Hospice care involves a team of professionals, including doctors, nurses, home-health aids, social workers and volunteers who work with the patient and family to ease the process of dying. Hospice care can be provided in the home or the hospice facility or, in some cases, in long-term care facilities. 

Housing Options
Assistance for seniors comes in many forms, dependant on the level of care the person needs. The various choices:

• Apartment complexes for seniors. These eliminate the need for lawn and building maintenance, but the older person is responsible for cooking, housekeeping and laundry. There are waiting lists for most senior housing.
• Home-care services. These include aides who help with bathing and homemakers who shop and clean house. Meals can be arranged through Meals on Wheels.
• Congregate housing. Seniors have their own rooms with small kitchenette and bath facilities and they gather for meals and activities.
• Assisted-living centers. Seniors have their own room or apartment, with meals provided in dining areas. Activities and some personal care are provided. Assisted-living centers can be quite luxurious - and quite pricey. There is staff on premises.
• Nursing homes. For individuals who need the most care, nursing homes provide 24-hour service, including bathing, rehabilitation and hand-feeding when necessary.

There are apartment complexes in Haywood County for those with low to moderate income. Many have age or disability requirements with a certain number of units reserved for seniors. 

In “subsidized” housing, rent is generally based on percentage of income, usually 30% after allowing for certain deductions. A government subsidy pays for the rest of the rental cost. In “affordable” housing, rents for a given size unit may be the same for all residents, or there may be two levels of rent depending on income. These rents are typically lower than market-rate because the developer receives a tax credit: as a result these apartments are sometimes called tax-credit properties. 

Eligibility for senior subsidized and affordable housing is based on income. The applicant’s income must be below a set limit in order to qualify. These income levels change yearly bases on the median income in the area. In most cases, the cutoff is 50% of the area median income, which HUD considers “Very Low Income.” In affordable housing, there is often a minimum income level as well as a maximum.

The demand for low-income housing exceeds the supply. Most have waiting lists, making it a good idea to investigate the options and get on waiting lists ahead of time.

Legal Services and Advance Directives
Advance directives are documents such as living wills and healthcare powers of attorney that specify your wishes related to healthcare in the event you are unable to speak for yourself. 

A “power of attorney” is a legal document giving someone else, called your “agent” or “attorney-in-fact”, the power to act on your behalf in certain circumstances. A specific power of attorney is for one special purpose, often a single transaction such as buying a house. A general power of attorney gives the person the power to act for you in a variety of transactions, which are usually listed in the document. A durable general power of attorney is one that stays in effect even if you become incompetent. This is a very important document to have in place BEFORE it is needed so someone you trust can manage you affairs. It is important to remember that a power of attorney gives the “power to” do things that you would choose to do yourself, not “power over” you to do things against your will. As long as you are competent, you can overrule your agent’s decisions and you can revoke the power of attorney.

Guardianship is a legal proceeding by which a person can be declared incompetent to manage their own affairs. A representative is then appointed to make decisions on the person’s behalf. A guardian, unlike a person who holds a power of attorney, can overrule a person’s decision if necessary to care for the person’s needs. For instance, if someone with dementia has a legal guardian, the legal guardian can make decisions about placement in a nursing home, even if the person with dementia disagrees. Sometimes there are two guardians – a guardian of the person who makes decisions about care and a guardian of the estate who makes decisions about money.

Long-Term Care
Families provide the majority of care to older relatives, either in the older adult’s home or in the home of the family caregiver. However, sometimes the physical, emotional and social demands on the caregiver become more than the family can handle. Families may reach the decision that care in the home is no longer possible, and may find their loved ones safety and health are at risk if they remain in the home

Finding a facility that meets the needs of the older adult can be an overwhelming task for family members because the placement decision often comes in a time of crisis. It pays to visit several facilities before making a decision to avoid having to make another move later. When applying to a facility, it may be helpful to have a form FL-2 in hand. The form is filled out by the patient’s doctor and spells out the level of care needed. Ask plenty of questions and be sure the facility provides the level of care and staff training that the patient needs. Visit the facilities more than once if possible, at different times of day and different days of the week.

Several levels of care are provided in long-term care facilities:
Skilled Nursing Care is appropriate when the patient needs ongoing nursing intervention following illness or for chronic conditions, or short-term intensive physical, occupational, or speech rehabilitation therapy. The patient’s care is under the direction of a physician. 
Intermediate Care is appropriate for persons who may need nursing intervention, but not on a continuous basis. Rehabilitation programs, activities, and personal care assistance are available. The care is provided under the direction of a physician.
Adult Care Homes / Assisted Living / Rest Homes provide custodial care for persons who do not need medical intervention but cannot live alone unsupervised. Room and board, activities, administration of medications, medical transportation, assistance with personal hygiene, and 24-hour supervision are provided. Whether a nursing facility, adult care home (also called rest home or assisted living), family care home, or DDA home (group home for developmentally disabled adults), in North Carolina this level of care is licensed as “adult care”. 

Long-term care can be very costly. It is a common misconception that Medicare will cover most of the cost of long-term care. Medicare pays for less than 2% of nursing home care, limited to short-term skilled care after the resident meets strict criteria including prior hospitalization. Medicaid is a federal/state program that does cover the cost of intermediate and skilled care. To be eligible, the nursing home resident must meet the age and disability criteria as well as meeting income and resource limits

The Ombudsman program provides information related to long-term care issues and investigates complaints involving suspected abuse, neglect, and exploitation of  individuals who reside in nursing homes and assisted living facilities. This is one of the programs administered in our area by the Southwestern Commission Area Agency on Aging.                                        

Medical Supplies, Equipment, and Assistive Devices
There are many types of assistive products and equipment that make it easier for those with physical or cognitive impairments to manage in their home. Medicare Part B helps to pay for some durable medical equipment such as wheelchairs, oxygen equipment, etc. The equipment must be medically necessary, ordered by a physician, and supplied by a Medicare-approved provider. Medicare will usually pay 80% of a monthly rental cost.

Some assistive equipment is available at no charge through a community loan closet maintained by the No Boundaries agency.

Personal Emergency Response Systems
Personal emergency response systems can be lifesavers for persons who live alone, or are frequently home alone. Most systems consist of a button that can be worn as a pendant around the neck or on a wristband. Pressing the button sends a signal via a toll-free number to a national monitoring center. The monitor then contacts the subscriber and/or their designated responders (family members, neighbors, 911) and maintains contact until help arrives. 

Subscribers pay an installation/equipment fee and a monthly fee for the monitoring. Costs are typically $30 to $40 per month and the services are usually not covered by Medicare or other insurance. 

Senior Centers
Senior centers offer independent older adults the opportunity to be together and take part in programs and activities related to health, fitness, recreation, and education. Senior centers are not care facilities: those who need care and supervision during the day should investigate the Adult Day Care program. Noon congregate meals sponsored by Meals on Wheels are available at the senior centers; the cost is by donation and participants must sign up ahead of time.

Meals on Wheels is a program that delivers a hot noon meal to the home Monday through Friday. Costs vary with the service being subsidized by funds through the Older Americans Act and Social Services Block Grant. 

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Haywood Community Connections
Welcome ... we’ve been waiting for you! We provide
information related to issues involving seniors in Haywood County.

The Haywood Community Partnership is supported by the Robert Wood Johnson Foundation®, www.rwjf.org through its Community Partnerships for Older Adults (CPFOA), www.cpfoa.org national initiative. Community Partnerships for Older Adults is a national program funded by the Robert Wood Johnson Foundation to help communities develop leadership, innovative solutions, and options to meet the needs of older adults over the long term