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Caregiver Companion Guide (2016)

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Bet Tzedek Legal Services is a non-profit, public interest law center which provides free legal services to low-income residents of Los Angeles County. Bet Tzedek means “House of Justice” in Hebrew. Bet Tzedek serves persons of all racial, religious and ethnic backgrounds.

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www.bettzedek.org

Bet Tzedek Legal Services
3250 Wilshire Boulevard, 13th Floor Los Angeles, CA 90010

Copyright ©2016 by Bet Tzedek Legal Services

Permission is hereby granted to reproduce this book or portions thereof, provided Bet Tzedek is acknowledged in writing on each page reproduced and such copies are not offered for sale in any manner.

Printed in the United States of America

Co-authors: Janet R. Morris, JD and Kim Selfon
Developmental Editor: Andy McPhee, HealthEdit Editorial Services

The authors and publisher have done everything possible to make this booklet accurate, up to date, and in accord with accepted standards at the time of publication. The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the booklet.

Important Note: The Caregiver Companion is based almost exclusively on California law. It is intended for use by California residents, although some aspects may be applicable in other states. This guide is not a substitute for the independent judgment and skills of an attorney or other professional. If you require legal or other expert advice, please consult a competent professional in your geographic area to supplement and verify the information contained in this guide.

ii

TABLE OF CONTENTS

1Caring for a Loved One at Home 2
Assessing Needs 2
Home Care 3
Hospice Care 4
Adult Day Care 4
Resources 7
2Paying for Home Care Services 10
Medicare 10
Eligibility 10
Medicare Home Health Services 11
Managed Care (Medicare Advantage Plan) 11
Medigap 11
Medicare Appeals 12
Medi-Cal 12
Medi-Cal Eligibility 13
Medi-Cal Home Care Services 14
In-Home Supportive Services 14
Hospice Care 14
Community-Based Adult Services Center 14
Medi-Cal Home and Community based Waivers 15
Multipurpose Senior Services Program (MSSP) 15
Medi-Cal Appeals 16
Medi-Cal Estate Claims 17
Long Term Care Insurance 17
Worker’s Compensation Insurance 18
Veteran’s Benefits 19
Resources 20
3Financial Strategies to Pay for Home Care 22
Grants and Loans 22
Home Equity Loan or Line of Credit 22
Reverse Mortgages 23
Exploring Public Benefits Eligibility 24
Selling a Home 24
Supplemental Security Income (SSI) 24
Cash Assistance Program for Immigrants (CAPI) 25
Veteran’s Benefits 25
Handyworker Program 25
Resources 26
4How to Find a Home Care Worker 28
Home Health Agencies 28
Home Care Organizations 28
iii Table of Contents
Choosing an Agency 28
Private Home Care Workers 29
Community Registries 29
Licensing and Certification 30
Resources 30
5Improving the Quality of Home Care 32
At Home 32
Home Modifications 32
Handy Worker Program 32
Home Safety Precautions 32
Emergency Alert Response Systems 33
File of Life Card 33
Organizing Documents 33
Caregiver Education and Training 33
Employee Assistance Programs 34
Understanding Health Care Professionals 34
Primary Care Physicians 34
Discharge Planners 35
Geriatricians 35
Geriatric Care Managers 36
Research Studies 37
Resources 38
6Health Care Decision Making 40
Directing Future Healthcare 40
Advanced Health Care Directives 40
Do Not Resuscitate Orders (DNR) 42
Physician Orders for Life-Sustaining Treatment (POLST) 43
Informal Health Care Decision Making 43
Conservatorship over the Person 43
Mental Health Conservatorship 44
Conservatorships vs. Advanced Health Care Directives 44
Resources 45
7Legal and Financial Decision Making 48
Durable Power of Attorney for Finances 48
Joint Bank Accounts 49
Representative Payee 49
Money Management 50
Estate Planning 50
Probate 50
Wills 51
Property Not Covered by a Will or Probate 52
Trusts 52
Special Needs Trusts 53
Table of Contents iv
Conservatorship over the Estate 54
How Conservatorships over the Estate Differ from Powers of Attorney for Finances 54
Resources 56
8Resolving Problems 58
Family Disputes 58
Mediation 59
Problems with Home Care Providers 59
Using the Courts 59
Resources 60
9Detecting and Reporting Elder Abuse and Neglect 62
Elder and Dependent Adult Abuse 62
Spotting Abuse and Neglect 62
Reporting Abuse and Neglect 64
Elder Abuse Mandatory Reporting 64
Using the Courts to Protect Elders 65
Elder Abuse Temporary Restraining Order 65
Conservatorships 65
Elder and Dependent Adult Civil Protection Act (EDACPA) 65
Scams Targeting the Elderly and Dependent Adults 65
Telemarketing Scams 66
Home Improvement Scams 66
Home Equity Scams 66
Estate Planning Scams 67
Identity Theft 67
Resources 68
10Supporting the Caregiver 70
Family and Friends 70
Support Groups 70
Caregiver Health 71
Laws and Policies that Help Caregivers 72
Family and Medical Leave Act 72
Paid Family Leave Program 72
Tax Deductions 73
Flexible Workplace Policies 73
Transitions to Other Placement 73
Placement Options 73
Resources 75
Appendices 77
AGlossary 78
BMSSP Sites 85
CPACE Programs 88
DCaregiver Resource Centers 89
Index 91

v Table of Contents

ABOUT THE AUTHORS

Janet Morris
Janet Morris has practiced in the area of elderlaw as an attorney with Bet Tzedek Legal Services since 1985. Through her Family Caregiver Project, Ms. Morris assists elders and their caregivers with a variety of legal problems. She has also served as a past Director of Bet Tzedek’s Nursing Home Advocacy Project. She has served on numerous statewide committees and as technical advisor to many projects concerning the legal rights of elderly and incapacitated individuals. Ms. Morris serves on the Board of Directors of the Alzheimer’s Association, California Southland Chapter, and is an executive board member of the California Coalition for Caregivers. Ms. Morris has received numerous awards, including the Caregiver of the Year Award from AARP and KCET, the Metlife National Family Caregiver Award, the Jack Skirball Community Justice Award and, most recently, the Betty and James E. Birren Senior Scholar Award.
Kim Selfon
Kim Selfon, a paralegal at Bet Tzedek Legal Services, specializes in providing assistance to caregivers and their families on legal issues. She assists families in navigating the maze of public benefits, helps them plan for long term care services and specializes in maximizing consumers’ In- Home Supportive Services hours. Through legal and legislative advocacy, community partnerships and education, she develops and promotes policies to improve the quality of life and community care options for disabled persons, older adults and caregivers. She is also a frequent lecturer to community and professional organizations.

vi

INTRODUCTION

Does this situation sound familiar to you? Your mother’s doctor just called to tell you that she fell and is now hospitalized. The doctor says, “She’ll be able to return home in a few days but she’ll need someone to help her at home with cooking, cleaning, and bathing.”

Your mother needs help at home.
What would you do next?
How would you arrange for her care?

If you’re like most people, you don’t know much about home care. You probably don’t know what types of home care services are available, how to pay for it, or how to ensure the best care possible.

This guide can get you started, providing clear and concise answers to these and other questions such as how to:

•pay for home care
•apply for public benefits
•make appropriate health care decisions for yourself and others
•protect elders in their homes
•thrive as a caregiver

The guide is based almost exclusively on California law. Check your own state’s laws if you live elsewhere. In addition, relevant laws change from year to year, so be sure you have the most recent edition of this guide. Always consult local experts to supplement and verify
the information contained in this booklet. A glossary is available at Appendix A to clarify unfamiliar terms.

vii Introduction

CHAPTER 1
CARING FOR A LOVED ONE AT HOME

CARING FOR A LOVED ONE AT HOME

We’re all caregivers at some point. We give care to our children, spouses, friends, and each other. For this book, though, a caregiver is defined as someone who cares for an elderly person or one with an illness or disability. The caregiver could be a spouse, relative, friend, or paid professional.

Caregivers provide many types of care, including:
•assistance with cooking, cleaning, or managing personal or family finances
•driving to and from physician or hospital appointments
•financial assistance to help pay for medications and home care.

Some individuals need high levels of medical care, such as receiving injections or being given food through a gastrointestinal tube. Caregivers provide all of these services and many more.

Numerous support services exist for individuals needing care in their home. This booklet outlines options to help a loved one stay at home. Let’s begin by breaking down what those needs might be and looking at the various types of care available.
Assessing Needs
Individuals with degenerative illnesses, such as multiple sclerosis and Alzheimer’s disease, may recognize that over time, their physical and emotional needs are destined to grow.
In such cases, caregivers are able to slowly increase their level of care over time. At other

times, though, acute illnesses may strike unexpectedly, as happens with stroke or heart attack. That’s when family members may need to quickly step into a caregiver role.

Acute illnesses may strike unexpectedly. That’s when family members may need to quickly step into a caregiver role.

Assessing a loved one’s needs is the first step in deciding whether home care is appropriate and, if so, what kinds of care are available.

Does the loved one need help shopping, housecleaning, or getting into a bathtub safely? Does the person feel lonely or isolated? Does he need constant supervision to prevent wandering, falling, or causing other harm?

1 Caring for a Loved One at Home 2

Caregivers should talk with their loved ones and health care professionals about
the kind of help needed.

Communication is Key
Whenever possible, the decision to care for someone at home should result from a continuing conversation between a loved one and family, friends, and health care
professionals. As the needs of the loved one change, the involvement of family, friends, and professionals may also change. Home care should allow a person to stay safely at home, remaining as independent as possible for as long as possible.

Home Care
Home care is almost always an option. Many health care services and community resources assist those who choose to be cared for at home.

A person can receive the same quality of care, and sometimes better care, at home than in a nursing home. Even if a doctor recommends nursing home placement, the patient could choose to go home if appropriate care can
be arranged.

Home care is almost always an option.

There are generally two choices for someone who needs nursing home-level care but does not wish to go to a nursing home: The person can stay in her own home with assistance from family members or paid care providers, or move in with a family member or friend willing to provide care.
Home Care Providers
The term home care refers to medical and supportive services provided in an individual’s home. Home health agencies,
home care agencies, private home care aides, and hospice care workers all provide home care services.

A loved one may need the services of skilled care providers, such as nurses (RNs or LVNs), physical therapists, occupational therapists, speech therapists, or licensed social workers. These providers can generally be found through licensed home health agencies, and their cost may be paid by Medicare, Medi- Cal, long term care insurance or by private payment with personal funds. See Chapter 3, “Financial Strategies to Pay for Home Care,” page 22.

3 1 Caring for a Loved One at Home

Hospice Care
Hospice care is designed for people who
are terminally ill. If a loved one is terminally ill, the patient’s physician can recommend hospice care services. A doctor’s prescription is needed to obtain services. Hospice care may be provided at home, in a hospital
or nursing home.

Non-medical services, such as shopping, housekeeping, cooking, transportation, and supervision, are provided by home care organizations. Those services may be paid by private payment or long-term care insurance. Keep in mind that although home care agencies are not licensed, reputable agencies belong to membership associations and are accredited by peer agencies.

Private home care aides also provide at-home, non-medical care, including housekeeping, cooking, assistance with bathing, and so forth. These individuals may be hired privately or through an agency and may be paid by private payment, Medi-Cal or long term care insurance.

Hospice workers provide comfort care, also called palliative care, to those with a
terminal illness. Comfort care consists of pain management and other services that keep the patient comfortable. Hospice care includes the services of home health aides, physicians, nurses, physical therapists, speech therapists, and professional counselors to help the patient and family. Medicare and Medi-Cal each pay for hospice care services.

Hospice care for the terminally ill may be provided at home,
in a hospital or nursing home.
Adult Day Care Centers
Adult day care centers provide care for the elderly and disabled. Many centers
provide transportation to and from the center. The loved one may go to an adult day care center every day, a few times a week, or only occasionally, so that the caregiver can have some time off. A participant who attends an adult day care center socializes with others, eats meals, and may even receive medical care.

When choosing a day care center, caregivers should make sure that the center is licensed and can accommodate the special needs of

1 Caring for a Loved One at Home 4

the loved one. The center should have safety measures in place to prevent wandering.

Many centers allow tours so caregivers can see what participants do there. Some centers allow potential participants to stay an entire day to see if they like the center. Caregivers should talk to people who use the center and listen to what they say are the center’s benefits and drawbacks. The loved one should like the center, and it should be clear that it will meet all the loved one’s needs.

There are a number of types of adult day care centers including:
•Alzheimer’s Day Care Resource Centers.
These centers specialize in programs for persons with Alzheimer’s disease or related dementias. They’re usually
equipped to handle people who wander, are incontinent or aggressive. They offer a supervised, structured environment and provide support groups. These centers are usually private pay on a sliding scale.

•Adult Day Care. These centers are mostly recreational in nature. The participants are supervised and have daily group and social activities. They may accept someone with early dementia but are generally not equipped for the problems of wandering, incontinence, or aggressive behavior. Many local multipurpose senior service centers provide social day care. This type
of day care is usually not covered by health insurance, Medicare, or Medi-Cal. Adult Day Care facilities are typically private pay on a sliding scale and are licensed by the

Department of Social Services.

•Adult Day Health Care Centers. These centers are licensed, Medi-Cal-certified health care facilities that provide medical, rehabilitative, and social services for physically and mentally impaired individuals. These comprehensive centers are staffed by medical personnel and social workers. Their services are designed to delay or prevent inappropriate nursing home placement. They generally offer hot meals, provide nutritional counseling, administer medications, offer recreational and social activities, and provide transportation to
and from the facility. Medi-Cal Community
Based Adult Services, Medi-Cal In-Home Operations Waivers and PACE programs pay for services at these centers.

•Adult Day Treatment Centers. These centers care for people with psychological or psychiatric problems. They may accept individuals with dementia. The centers provide social and recreational activities, counseling, and medication management for problem behaviors. Medicare and Medi-Cal may reimburse for these services on a limited basis.

•Senior Centers. These community centers provide activities, meals, limited health monitoring, transportation, and legal advice to seniors. Senior centers often house adult day care and respite activities and are excellent places to obtain information on
a variety of caregiving issues. There is no charge for attending a senior center.

5 1 Caring for a Loved One at Home

Case Study
Albert and Brenda: What Level of Care is Best?
Albert faced a critical issue: Should he put Brenda, his wife of 42 years, in an assisted living facility? Brenda was in the early stages of dementia and could still provide basic care for herself, though it was becoming more difficult. Brenda occasionally became aggressive, which made it hard for Albert to manage her and Albert was exhausted. His friends told him to put his wife in an assisted living facility, but Albert was adamant that he find care for Brenda at home. He just didn’t know what type of care he could or should get.

Core Issue
How to obtain additional care to keep Brenda at home.

Steps to Resolution
Albert knew that Brenda needed additional care but didn’t know how to get it. After consulting a geriatric care manager and obtaining information from the local Caregiver Resource Center, he decided to enroll Brenda in an Alzheimer’s Day Care Resource Center. He also hired a home care aide to help him at home. He was advised to try these two things before deciding to place Brenda in an assisted living facility.

Follow-Up
Brenda thrived at the Alzheimer’s Day Care Resource Center, where she went 3 days a week. Albert was able to connect with old friends and relax or shop while Brenda
was at the center. He also joined an Alzheimer’s support group where he learned about caregiving strategies and resources.

When Brenda’s condition worsened, Albert hired a home care worker to attend to Brenda’s needs while she was at home.

Key Points
•Because Albert was clear in his goals, care managers were better able to quickly focus on how best to meet those goals.
•Brenda’s medical team was apprised of the change in her routine. Her primary care physician worked with the Alzheimer’s Day Care Resource Center to monitor and adjust her medications.
•Albert was able to care for Brenda at home because some of the stress of full-time caregiving was relieved by different types of respite care including day care, a home care aide and the support group.

1Caring for a Loved One at Home 6

RESOURCES
For more information on topics in this chapter, consult the following resources.

Agencies
•City of Los Angeles Department of Aging: (213) 482-7252 or www.aging.lacity.org
•Los Angeles County Department of Aging: (213) 738-4004 or www.css.lacounty.gov
•Access Services: (800) 883-1295, cserve@asila.org, disabled transportation
•Center for Healthcare Rights (Medicare Information): (800) 434-0222 or www.calhealthadvocates.org
•Cityride, Los Angeles Department of Transportation:
(Area Codes 213, 310, 323, or 818) 808-RIDE (7433) or www.ladottransit.com
•Medi-Cal: (800) 541-5555 or www.medi-cal.ca.gov
•National Association of Professional Geriatric Care Managers: (520) 881-8008 or www.caremanager.org
Print
•And Thou Shalt Honor: The Caregiver’s Companion, Beth Witrogen McLeod, Rodale, 2002
•Hard Questions, Simple Answers: A Workbook to Take the Crisis Out of Caregiving,
Elana Peters, MA, Seven Locks Press, 2002

7 1 Caring for a Loved One at Home

CHAPTER 2
PAYING FOR HOME CARE SERVICES

PAYING FOR HOME CARE SERVICES

Home care services can cost thousands of dollars each year. Paying for these services can be difficult, especially for those on low or restricted incomes. There are many ways to pay. For instance, government programs, such as Medicare, Medi-Cal, In-Home Supportive Services (IHSS), and Veteran’s benefits, pay for some types of home care services. Some long-term care insurance policies also pay for home care. This chapter examines average costs of care and the payment options available.
Average Costs
Although residential care facilities or nursing homes can cost between $30,000 and
$100,000 a year, caring for a loved one at home typically costs a lot less.
The cost, however, is still quite expensive for most families.

The cost of home care services depends on the type of services required. For example, extensive nursing or other home health care
will cost more than most types of non-medical services, such as cooking, cleaning or adult day care. In 2016, a home care aide typically costs $11 to $15 per hour. A registered nurse from a home health agency costs $25 or more per hour.

There are several programs that pay for various home care services. Eligibility for programs may depend on the person’s medical needs, income, assets, and health insurance.
Medicare and Medi-Cal pay for some home care and other medical services.

Medicare
This section provides an explanation of Medicare, Medicare HMOs, Medicare eligibility and coverage, and Medicare appeals.

Medicare is a federal health insurance program for persons 65 and over and also for people with disabilities. Medicare benefits are divided into three parts:
•Part A covers hospitalization, skilled nursing home care, home health care, and hospice care.
•Part B helps pay for physician visits, rehabilitation therapy, outpatient hospital services, ambulance charges, and durable medical equipment. Medicare usually covers 80% of these charges, and the recipient is responsible for the rest. Medicare does not cover routine physical examinations or custodial care in a nursing home or assisted living facility.
•Part D covers prescription drugs. There are premiums, deductibles, and co- payments for this program, though some low-income individuals may be eligible for financial assistance.

Medicare does not cover routine physical examinations
or custodial care in a nursing home or assisted living facility.

Medicare Eligibility
Automatic eligibility for Medicare begins as soon as a person turns 65 and becomes eligible for Social Security or Railroad Retirement benefits. An individual can also

2Paying for Home Care Services 10

services. Most home health care is designed for people requiring physical rehabilitation at home. All services are limited to part-time or intermittent care, and the patient must need skilled therapy or nursing care. The patient’s doctor must review the patient’s condition every 60 days to ensure that the patient still needs skilled care.
Medicare pays for hospice and end-of-life palliative care if the patient gets a prescription from her doctor stating that she is terminally ill and she specifically elects to receive comfort care instead of curative health care. Some doctors are unaware of this benefit or wait too long to prescribe it. Caregivers should ask the doctor for a hospice care prescription if they think it will be helpful to a loved one.

enroll in Medicare at age 65 if a spouse or former spouse is eligible for Medicare. Individuals of any age may be eligible for
Medicare if they’ve received Social Security Disability benefits for two years or if they suffer from end-stage renal disease or ALS (Lou Gehrig’s disease).

Medicare Home Health Services Medicare pays for home health care for people unable to leave their homes and who require skilled care. Skilled care is health care provided by a professional, such as a doctor, nurse, therapist, social worker, or counselor. If a patient’s doctor determines that home health care is medically necessary—for instance, it’s needed to maintain or improve a patient’s health—then Medicare will pay for those

Medicare Advantage Plan (Managed Care)
Some Medicare recipients may choose to receive benefits from a Medicare Advantage Plan, or MA. An MA is a centralized plan of healthcare that requires patients to see a doctor within the MA network. MA plans usually have lower co-payments for doctor
visits and prescription drugs. Some MA plans such as SCAN Health Plan also offer home care and attendant care services, as well as case management. MA plans are required
to give at least the same health benefits as regular Medicare.

Medigap (Medicare Supplements) Medigap policies are private health insurance plans designed to supplement Medicare coverage. The policies are regulated by the

11 2 Paying for Home Care Services

or why it refused to pay for a service. The MA plan must also explain in writing how to appeal the decision. In either case, follow the appeal process closely. Maintain records of all communications.
Follow the appeal process closely.
Maintain records
of all communications.

Medicare fast appeals are designed for people whose health will be seriously injured if they don’t receive the requested medical treatment. Fast appeals may also be requested if the patient is receiving services from a skilled nursing facility, home health agency, or outpatient rehabilitation facility.

government and pay some or all Medicare co-payments and deductibles. Some Medigap policies also cover prescription drugs and
preventive care. Medigap policies may be costly.

Medicare Appeals
Patients have a right to appeal any Medicare decision, including denials of service or nonpayment of a bill. Individuals covered
in the original Medicare plan should receive a Medicare Summary Notice, explaining the reason for an unpaid bill or denial
and detailing how to appeal the decision. For individuals who belong to a Medicare
Advantage Plan, the MA plan must explain in writing why it denied or terminated a service

A fast appeal decision should be received within 72 hours. If the decision remains unfavorable, it can be appealed again to an independent review organization. Fast appeals are designed for people enrolled in either Medicare or Medicare Advantage plans. Fast appeals may also be requested for a denial of prescription drug coverage, under Medicare Part D.
Medi-Cal
Medi-Cal (known as Medicaid in other states) is a health insurance program for people with low income. Medi-Cal benefits pay almost 100 percent of most medical treatment, hospitalization, skilled nursing care, custodial nursing care, home care, and durable medical equipment.

Individuals may receive both Medicare and

2 Paying for Home Care Services 12

Medi-Cal. In that case, Medicare becomes the primary health insurance and Medi-Cal the secondary payor, covering all Medicare co- payments and deductibles. If a person receives both benefits, private Medigap insurance may not be necessary. Let’s examine Medi-Cal eligibility and the services it covers.

Medi-Cal
Community Medi-Cal is designed to help those who live in the community, either in their homes or in assisted-living or board-and- care facilities. Community Medi-Cal provides health insurance for those with low income and limited resources.

There are two types of Medi-Cal, Modified Adjusted Gross Income (MAGI) Medi-Cal and Non-MAGI, or traditional Medi-Cal. The two Medi-Cal programs offer the same benefits and services but have different eligibility rules.

MAGI Medi-Cal:
To qualify, an individual must be between the ages of 19 and 64 and have a modified adjusted gross income (MAGI) under 138% of the Federal Poverty level. in 2016, the MAGI income limit is $1,354 per month for
one person. Additionally, you must NOT have Medicare. There is no asset limit for MAGI Medi-Cal.

Traditional Medi-Cal (Non-MAGI):
To be eligible for Non-MAGI Medi-Cal, an individual must have low income and
assets. If an individual receives Medicare and Supplemental Security Income (SSI), he is

automatically enrolled in Medi-Cal. Medi- Cal limits the amount of assets a recipient can have. An individual is limited to $2,000; a couple is limited to $3,000. Be aware that
some items aren’t counted, such as the house in which the person lives, a car, and a burial plot.

Even individuals who don’t receive SSI may still be eligible for Medi-Cal if the person’s income is near the federal poverty level. In 2016, the maximum income (after income deductions) for a single Medi-Cal applicant was $1,211 per month. For a married couple who are both applying for Medi-Cal, the maximum income (after income deductions) in 2016 was $1,637 per month. Medi-Cal is also available to those with higher incomes if they pay a share of the cost of monthly medical expenses. However, they must still meet the low asset criteria.

Long Term Care Medi-Cal pays for care in a nursing home.

Long Term Care Medi-Cal (LTC Medi-
Cal) provides benefits to patients in nursing homes. LTC Medi-Cal eligibility requirements for married persons is more generous than the eligibility requirements for community Medi-Cal. For example, in 2016, the at- home spouse of a nursing home resident may retain up to $119,220 in countable assets, in addition to the home.

California law also allows the at-home spouse to retain a monthly maintenance-needs allowance of $2,981, in 2016, an amount adjusted annually by a cost-of-living increase.

13 2 Paying for Home Care Services

Medi-Cal Home Care Services
Medi-Cal pays for more home care services than Medicare. Like Medicare, Medi-Cal pays for skilled nursing care, home health aides, medical equipment, and physical, speech, and occupational therapy. However, one of the most important benefits of Medi-Cal coverage is that it pays for care that keeps people in
the community, such as In-Home Supportive Services (IHSS).

In-Home Supportive Services (IHSS) is
a part of the Medi-Cal program, and provides home care to individuals who wish to remain at home but can’t accomplish some daily activities on their own, such as bathing, dressing, toileting, or housecleaning. The program also pays for protective supervision for individuals who suffer from dementia
or mental impairments and who need to be watched 24 hours a day, to ensure their safety.

Protective supervision is designed for individuals who suffer from dementia
or mental impairments and need to be watched 24 hours a day.

Before IHSS services can be provided, a professional from the program interviews the eligible person at home and recommends a service plan. This plan grants a specific number of home care hours per month to the eligible person. That number can range anywhere from 1 hour to 283 hours a month, depending on the applicant’s needs. The eligible person then hires a home care aide. The State pays the

home care aide, based on the number of hours given. In 2016, the rate in Los Angeles County is $11.00 per hour. The home care aide may be a family member, friend, or paid provider.

Hospice Care: Medicare and Medi-Cal pay for hospice care for patients and their
families. (For more information on hospice care, see Chapter 1, Caring for a Loved One at Home, page 4.)

Community Based Adult Services Centers are licensed health care facilities that provide day care services. The services include medical, rehabilitative, and social services for physically and mentally disabled individuals. These comprehensive centers are staffed by medical personnel and social workers. The centers are designed to delay or prevent inappropriate nursing home placement and often offer basic

2 Paying for Home Care Services 14

health care services, such as blood pressure monitoring and medication management, as well as hot meals, nutritional counseling, recreational and social activities and transportation to and from the facilities.
Medi-Cal Home and Community-Based Waiver Programs help people obtain services in the community that might not otherwise be available to them under the regular Medi-Cal program. These services include shift nursing, attendant care, home modifications, emergency response systems, and case management.

Waivers are available to persons who would otherwise require long-term care in a nursing facility (including subacute facilities), an intermediate care facility, or a hospital. Waivers are designed to serve as an alternative to institutional living and a way for patients to stay in their homes with the same supportive services they would receive in an institutional setting. There is a waiting list for some waivers.

Medi-Cal Waivers use special eligibility rules for married couples.

Waiver eligibility rules for married couples are more favorable than those offered by community Medi-Cal. Waiver programs use special rules called Institutional Deeming rules. In 2016, the well spouse is allowed to own up to $119,220 in countable assets and allowed to keep up to $2,981 in monthly income. When an individual is on a Medi-Cal Waiver program, he stays in his home instead of going to a nursing home. The ill spouse on the Medi-Cal Waiver is eligible for Medi-Cal

covered services under the waiver program, full scope Medi-Cal benefits and In-Home Supportive Services.

Medi-Cal Waiver Programs:
The Multi-purpose Senior Services Program (MSSP) provides social and case management for frail, elderly clients. The program is designed for individuals age 65 or older
who qualify for a nursing home but want to remain in their home. MSSP arranges for social and health services that help the elder stay at home for as long as possible. MSSP

15 2 Paying for Home Care Services

caseworkers monitor elders for signs of abuse and deterioration in health and link them with community services.

To be eligible, the individual must:
•be 65 or older
•live within an MSSP site’s service area
•qualify for nursing home care
•be currently eligible for Medi-Cal with no share of cost.

MSSP services include adult day care, personal care assistance, and case management. MSSPs also offer respite care assistance for caregivers, transportation, meals, social visiting, counseling, and interpretive services. There are more than 40 MSSP sites in California. (See Appendix B, MSSP Sites.)

Married couples are eligible for the MSSP Institutional Deeming Waiver, which uses the Long Term Care Medi-Cal eligibility criteria. The ill spouse is eligible for MSSP services, IHSS, and Medi-Cal.

The Nursing Facility Waiver provides a monthly budget for home care services. The services may include home care aides, skilled care, case management, home modifications and help moving from a nursing home to a home setting. The monthly budget is based on the individual’s level of care.

A married couple may use the Institutional Deeming rules for this waiver.

The Program of All-Inclusive Care for the Elderly (PACE) provides comprehensive care for elderly individuals who require nursing home care but wish to stay at home. Health care services include physician visits, nursing care, home care, respite care, day care, rehabilitation, and medication management.

To be eligible, the person must:
•be 55 or older
•require full-time nursing home care
•live in a PACE program area.

Medicare and Medi-Cal pay for the program’s benefits. PACE is only available in limited areas. Married couples are eligible for a PACE Institutional Deeming waiver, which uses the Long Term Care Medi-Cal eligibility rules. (See Appendix C, PACE Programs.)

2 Paying for Home Care Services 16

Medi-Cal Appeals
Individuals who don’t agree with a Medi-
Cal decision, such as a denial or reduction of benefits, have the right to appeal. When Medi- Cal makes a negative decision, it is required to send a letter called a Notice of Action.
The Notice of Action explains appeal rights including important deadlines. After a person receives the Notice of Action, a Request for Hearing must be filed before the deadline printed on the notice. The state contact number and address are listed on the notice.

When asking for a hearing, it’s important that the person’s name, address, telephone number, and Medi-Cal number be included, and also a statement about why they want the hearing.

If Medi-Cal reduces, changes, or stops benefits, the person can stop the reduction or termination by asking for a hearing with Aid Paid Pending. One must ask for Aid Paid Pending before the effective date of the reduction or termination. After the person asks for Aid Paid Pending, benefits will continue until the problem is resolved or a judge issues a decision.

At the hearing, individuals may speak for themselves or be represented by a lawyer, friend, or another person. Free legal assistance may be obtained by contacting a local legal aid organization. The toll-free number for Public Inquiry and Response, included on the Notice of Action letter, may also be used to find free legal assistance. Local senior centers can also assist in presenting a case.

Medi-Cal Estate Claims
Medi-Cal does not consider a person’s home as a resource when it determines eligibility. That means if the individual resides in or intends to return home in the future, Medi- Cal can’t put a lien or make a claim against the home. However, after the person’s death, Medi-Cal will file a claim against the estate to collect monies paid by Medi-Cal.

Medi-Cal can’t make a claim against an estate if there is a living spouse, minor child, or disabled child. Furthermore, Medi-Cal may give up an estate claim if the person’s heirs show that collection of the claim would cause a substantial hardship to them. Medi-Cal may also give up an estate claim, or share of one, to
caregivers who provided care to a loved one for two or more years. The caregiver must show their care kept or delayed the loved one from going to a nursing home or medical facility.

There are only a few ways to avoid a Medi-Cal estate claim against a home. The law pertaining to Medi-Cal estate claims is complicated and changes frequently. People concerned about such claims should seek the assistance of a knowledgeable elder-law attorney.
Long Term Care Insurance
Long Term Care (LTC) insurance policies are designed to pay for home care, nursing home care, or care in an assisted living facility. Like any insurance policy, the covered individual pays a monthly premium. Levels of coverage vary from plan to plan. Some plans cover home care services in addition to nursing home costs; others do not. LTC insurance

17 2 Paying for Home Care Services

policies can be expensive and must be purchased before any illness occurs.

When considering purchasing such a policy, one should check to ensure that the policy covers home care and that its benefits
are adjusted to cover rising inflation. In addition, they should seek information from California’s Department of Insurance and

the California Partnership for Long Term Care on how to choose the best policy. Some employers offer LTC insurance policies
to their employees, dependents, and even parents. Check with the employee assistance program about these policies.
Worker’s Compensation
The Worker’s Compensation Insurance

Case Study
Jim and Sue: Avoiding Nursing Home Placement
Sue is exhausted because she cares for her husband Jim 24 hours a day. Jim and Sue had just celebrated their 40th wedding anniversary when he was diagnosed with Parkinson’s disease. Since then, his health has quickly deteriorated. Jim now needs help feeding himself, toileting, and performing most of his daily activities. Sue wants to care for Jim at home.

Jim and Sue are in their mid-70s. They worked hard all their lives and have saved $70,000 for their retirement. They receive $2200 a month from Social Security. Jim’s medical expenses are high, and the couple spends over half their monthly income, about $1500 per month, on his medical expenses and home care. They are quickly spending their retirement savings.

Core Issues
How to help Jim stay at home without spending all the couple’s retirement savings and find Sue extra help at home so she can stay healthy and continue to care for Jim.

Steps to Resolution
Sue called Bet Tzedek Legal Services for help. Jim applied for In-Home Supportive Services (IHSS), a Medi-Cal program that pays for home care services. However, he was denied because the couple had saved too much money. Sue wanted to find a program that would help Jim receive the care he needed at home, instead of in a nursing home. Sue knew that she could place Jim in a nursing home and that Long-Term Care Medi-Cal would pay for his care, but she adamantly refused. She wanted to keep him at home.

A Bet Tzedek counselor suggested that Jim apply for the MSSP Institutional Deeming Waiver. This program would provide a case manager to assist Sue in ordering medical supplies,

2 Paying for Home Care Services 18

program provides medical insurance and disability benefits for people who are injured on the job. If a claim is approved, Worker’s Compensation will pay some home health care, as long as it’s prescribed by a physician.
Veteran’s Benefits
Benefits are available for veterans who served in the military for 90 days or more, including

one day during a time of war. Under the Aid and Attendance and Housebound programs, veterans or their spouses who need home care may receive a stipend to pay for personal care services at home or in a nursing home. The veteran or spouse must provide a doctor’s letter certifying the need for care and must also meet certain low-income and asset criteria. Contact the Department of Veterans Affairs to apply.

provide emotional support, and arrange for a visiting nurse to monitor Jim’s condition. Based on the couple’s income and savings, they were eligible for the MSSP program without any monthly cost to them. (The MSSP institutional deeming waiver uses the same eligibility requirements as Long-Term Care Medi-Cal which allows the well spouse to keep $2,931 per month in income and $117,240 in assets.) After Jim was enrolled in the MSSP program, he would be automatically eligible for Community Medi-Cal and In-Home Supportive Services.

Follow-Up
Jim applied for the MSSP Institutional Deeming Waiver. Bet Tzedek helped him and Sue complete the lengthy application. In 6 weeks, Jim was approved for the program.

Jennifer, the MSSP case manager, now visits Jim and Sue every month to check on Jim’s condition to see if he or Sue needs anything. The IHSS program gives Jim 120 hours of home care services a month.

Now Sue is able to take breaks from caregiving to go to her support group, visit friends, and take care of her own needs.

Key Points
•Medi-Cal pays for home care benefits.
•Alternatives to nursing homes exist. Medi-Cal has programs that offer elderly and disabled persons supportive services so that they can stay at home and receive the care they need. These programs include the Medi-Cal Waiver programs, IHSS, and the MSSP program.
•Be persistent in finding help. If one person says no, look for someone who says yes!

19 2 Paying for Home Care Services

RESOURCES
For more information on topics in this chapter, consult the following resources.

Agencies
•California Department of Insurance: 300 South Spring Street, South Tower, Los Angeles 90013; (800) 927-HELP (4357); www.insurance.ca.gov
•California Partnership for Long-Term Care (CPTLC): California Department of Health Services, Mail Stop 4100, P.O. Box 997413, Sacramento 95899-7413, (916) 552-8990, www.dhcs.ca.gov/services/ltc/Pages/CPLTC.aspx
•Department of Veterans Affairs: (800) 827-1000; www.va.gov
•Elder Law Attorney Referrals: California Advocates for Nursing Home Reform (CANHR), (800) 474-1116, www.canhr.org; National Academy of Elder Law Attorneys, (703) 942-5711, www.naela.org
•Health Consumer Alliance: (800) 896-3203, wwww.aging.ca.gov/hicap
•Health Insurance Counseling Program (HICAP): (800) 434-0222, www.aging.ca.gov/hicap
•In Home Supportive Services (IHSS): (888) 944-4477, www.dpss.lacounty.gov/dpss/ihss
•Medi-Cal Waiver Program: In Home Operations, Department of Health Services, P.O. Box 997419, MS 4502, Sacramento 95899-7419; Los Angeles (213) 897-6774; Sacramento (916) 552-9105 or www.dhcs.ca.gov/services/Pages/Medi-CalWaivers.aspx
•Medicare: (800) 633-4227, www.medicare.gov
•National PACE Association: (703) 535-1565, www.npaonline.org
•SCAN Health Plan: (877) 452-5898, www.scanhealthplan.com

Online
•Medicare booklet on home health care benefits: www.medicare.gov/Publications/Pubs/pdf/11357.pdf
•California Partnership for Long-Term Care Comprehensive Brochure “Before You Buy” www.rureadyca.org

2Paying for Home Care Services 20

CHAPTER 3
FINANCIAL STRATEGIES TO PAY FOR HOME CARE

FINANCIAL STRATEGIES TO PAY FOR HOME CARE

Sometimes Medicare, Medi-Cal, Long Term Care insurance, Workers’ Compensation, and Veteran’s benefits aren’t enough to pay for all of a loved one’s home care. Additional funds may still be needed. Here are a few tools and ideas for finding and raising money to pay for home care and home modifications.
Reducing Your Expenses
Some families choose to pay for home care privately, using retirement savings or working two jobs. To save money and reduce a loved one’s expenses, families may enroll in their utility company’s reduced rates programs
for seniors or disabled persons. Local senior centers and Area Agency on Aging (AAAs) have information on programs such as food banks, free medications, home delivered meals, and handyman services.
Grants and Loans
Some community and caregiver organizations provide funding to help pay for home care services. Sometimes these agencies offer one- time grants to help pay for daycare, home care, or respite care.

The Jewish Free Loan Association assists persons of all faiths by offering interest-free loans for medical and home care expenses. The local AAA office will have information on other special programs to help pay for day care and home care in your town.
Home Equity Loan or Line of Credit When someone purchases a home, he or she usually takes out a mortgage to help finance the purchase. The difference between the

amount the person owes and the amount the home is worth (its value on the market) is called the equity.

After equity has built up in a home, lenders may offer additional loans against the home that allows the owners to draw a lump sum of money based on the equity. The lump sum is then paid back in monthly installments. These kinds of loans are called home equity loans.

Borrowing against equity can prove useful for homeowners who want to make home improvements or pay costly medical bills. On the other hand, home equity loans can be more expensive than they’re worth.
Home equity loans have fees similar to first- mortgage fees, in which the amount borrowed is based on equity and monthly income.
Lenders offer varying interest rates for home equity loans, so shopping around makes sense to find the best deal.

Borrowing against equity can prove useful for homeowners
who want to make home improvements or pay for costly home care.

Home equity lines of credit are also loans, but usually instead of one lump payment, the borrower is able to take out smaller amounts over time. Home equity lines of credit are treated like a separate account and allow the borrower to either write checks or use a credit card to access the loan. They are also paid back in monthly installments.

3Financial Strategies to Pay for Home Care 22

If a person receives SSI or Medi-Cal, consult with a legal aid agency before signing paperwork for a home equity loan as the loan may affect benefits.

When considering a loan on real property, the borrower must be sure he or she can afford the payments. If the borrower does not make payments, the home may be subject to foreclosure. The borrower should understand all the loan documents before signing them
and may want to consult with a lawyer before signing the documents.
Reverse Mortgages
A reverse mortgage uses equity from the home to pay the borrower a lump sum or monthly amount. In a reverse mortgage, the borrower must be age 62 or older and have paid off or almost paid off his or her home mortgage.

The loan needn’t be paid back as long as the borrower lives in the home. If the home is sold, the borrower then pays back the loan with proceeds from the sale. If the borrower dies while living in the home, the estate repays the loan.

Money received from a lender can usually be used for any purpose. Reverse mortgages are more expensive than other types of loans because the initial fees are higher and the loan interest builds up over time. Individuals interested in obtaining a reverse mortgage should make sure to shop around and to borrow only from trustworthy sources.

Reverse mortgages are more expensive than other types of loans because the initial fees are higher and the loan interest
builds up over time.

If a person receives Supplemental Security Income (SSI) or Medi-Cal, income from a reverse mortgage may affect benefits. Consult an attorney or a legal aid agency before signing any paperwork for a reverse mortgage.

23 3 Financial Strategies to Pay for Home Care

clear. Selling a home or downsizing to a smaller house or condominium may make sense so that the money left over can be used to pay for home care expenses or assisted- living or retirement communities. Some people consider selling their homes if they intend to move in with their children.

Exploring Public Benefits Eligibility
Even if a loved one doesn’t qualify for Medi- Cal, individuals may want to consult an elder law attorney for advice about how
to best spend down money and assets to qualify for Medi-Cal benefits. Individuals may be disqualified from receiving Medi- Cal benefits for awhile if they give money as gifts or give away assets to meet the asset qualifications under Medi-Cal. The relevant
law is complicated; no one should give money or property as gifts without first consulting an elder law attorney.
Selling a Home
Many older adults have paid off their mortgages and own their homes free and

Selling a home may be an appropriate way to convert an asset into cash, and have enough money to pay for home care. Anyone considering whether to sell a home should consult an elder law attorney. Selling a home may have tax consequences and will affect Medi-Cal, Supplemental Security Income (SSI), and other government benefits.
Supplemental Security Income (SSI) Supplemental Security Income (SSI) is a federal Social Security program that gives additional income to seniors and disabled people who
live below the poverty line. In 2016, if a single individual’s countable income is less than $889 per month, or a married couple’s countable income is less than $1,496 a month, in most cases SSI will provide a supplement to bring the total income up to these respective amounts.

The rates change every year. There are also resource (asset) limits in this program. A single individual can have no more than
$2,000 in assets and a couple can have no more than $3,000 in assets. A house, car, and burial insurance policies are not counted toward resource limits.

People who are accepted for SSI benefits are automatically eligible for and enrolled in

3 Financial Strategies to Pay for Home Care 24

Medi-Cal. An application may be obtained at a local Social Security office or by calling (800) 772-1213.
CAPI
The Cash Assistance Program for Immigrants (CAPI) is a state program that provides
cash assistance to aged, blind, or disabled immigrants who have legal resident status. Qualified immigrants are eligible if they meet income and resource requirements.

CAPI is designed for immigrants who were or would be on SSI except for the federal citizenship requirement. Homebound applicants can receive information and an application by calling the Department of Public Social Services (DPSS) Central HELP Line at (877) 481-1044.
Veteran’s Benefits
The Department of Veterans Affairs offers several programs to help veterans pay for living expenses or home care and provide housing access for disabled vets. The Home Improvement and Structural Alterations (HISA) grants offer money to construct housing or adapt current housing to meet the needs of disabled veterans. Grants are limited to veterans who need the improvements
or alterations to gain access to their homes or critical areas within their homes such as

bathrooms. Grant amounts depend on the veteran’s disability and whether or not the disability is due to a service-connected injury.

The VA also offers home care benefits through the Aid and Attendance program and pension benefits to veterans who served on active duty for at least 90 days including one day during wartime. Veterans must have been other than dishonorably discharged, disabled or aged 65 or older, and be low income. Contact the VA at (800) 827-1000 for more information on these benefits.
Handyworker Program
The Handyworker Program provides free minor repairs to the homes of persons over 62 years old or disabled individuals who can’t afford to make repairs on their own. The service is fully funded by the City of Los Angeles Department of Housing. Individuals must own and live in their own homes within
the City of Los Angeles or within limited parts of Los Angeles County.

The repairs may include painting, installation of wheelchair ramps, debris removal, installation of windows and door locks, and other repairs as approved. Check with your city or Area Agency on Aging to see if they have a similar program.

25 3 Financial Strategies to Pay for Home Care

RESOURCES
For more information on topics in this chapter, consult the following resources.

Agencies
•AARP’s Reverse Mortgage program: (800) 209-8085
•Cancer Care: (800) 813-4673, www.cancercare.org
•Elder Law Attorney Referrals: California Advocates for Nursing Home Reform (CANHR), (800) 474-1116, www.canhr.org; National Academy of Elder Law Attorneys, (703) 942-5711, www.naela.org
•Handyworker program, City of Los Angeles: (213) 808-8803 or (866) 557-7368 (toll-free, Spanish)
•Jewish Free Loan Association: (323) 761-8830, www.jfla.org
•Meals on Wheels Association of America: (888) 998-6325, www.mowaa.org
•USC Family Caregiver Support Center: (855) 872-6060 or fcscgero.org

Online
•AARP’s Reverse Mortgage Website: www.aarp.org
•Area Agency on Aging: www.n4a.org
•National Center for Home Equity Conversion: www.reverse.org
•Federal Trade Commission: www.ftc.gov for information about reverse mortgages

3Financial Strategies to Pay for Home Care 26

CHAPTER 4
HOWTO FIND A HOME CARE WORKER

HOW TO FIND A HOME CARE WORKER

When a decision has been made to keep a loved one at home, finding a home care
worker can be a challenge. Some people use an agency to hire a home care worker. Others find the worker themselves.
Hiring through Agencies
There are two kinds of home health care agencies: home health agencies and home care organizations. They vary significantly in the kinds of services they supply. Both types of agencies act as the employer of the home care worker and pay taxes, insurance, and workers’ compensation for their employees.
Home Health Agencies
Home health agencies provide skilled medical providers, including nurses (RNs and LVNs), occupational therapists, physical therapists, and other medical personnel. Skilled medical care includes administering oral medications, injecting medications, and changing bandages or catheters, among many other skills. Because the providers are highly skilled, the agency must be licensed by California’s Department of Health Services. Payments for services provided by home health agencies may be covered by Medicare, Medi-Cal, or LTC insurance.
Home Care Organizations
In contrast, home care organizations (HCOs) provide non-medical service providers. Their services may include assistance with shopping, housekeeping, cooking, self-administered medications, transportation, ambulation, bathing, personal hygiene, and supervision.

Home care organizations are licensed by

California’s Community Care Licensing Home Care Services Bureau. They recruit, train, and supervise workers and are responsible for the quality of the care their employees provide.
Home care organizations place an affiliated home care aide in the home for an hourly fee. These organizations should complete
a criminal screening for each worker. The workers are bonded. The term bonding refers to a kind of insurance policy that compensates for theft or loss caused by the worker. The hourly rates range from $15.00 to $20.00
per hour (sometimes more), depending on the skill of the worker and the services required. Services provided by a home care organization are usually paid for privately or covered by Long Term Care insurance. Affiliated home care aides must pass a criminal background check and register on the Department of Social Services Home Care Aide Registry.
Choosing an Agency
When choosing a home health agency or

4How to Find a Home Care Worker 28

home care organization, caregivers and patients may call their local Area Agency on Aging (AAA). For people with developmental disabilities, Regional Centers can be called for referrals. In addition, the family physician, a discharge planner, friends and relatives may provide referrals to respected agencies.
Independent Home Care Aides Instead of hiring a worker through an agency, independent home care aides can be hired privately. Independent home care aides advertise their services through community registries, newspapers, senior centers, and AAAs, and are independent from government or corporate oversight.

Individuals who hire independent home care aides become the employer and therefore must follow all state and federal labor laws, tax laws, and insurance laws such as workers’ compensation. Some homeowner’s insurance policies cover independent home care aides
in case of injury. People who hire independent home care aides should consult an accountant about withholding taxes for the home
care worker.

Independent home care aides may register on the Department of Social Services Home Care Aide registry. If they do register,
they must pass
a criminal background check.
Community Registries
A community registry can be used to locate independent home care aides. A community

registry is a list of independent home care aides looking for employment. For-profit and non-profit agencies might also offer
registry listings. Community registries are not licensed and may or may not have conducted background checks or trained their workers.

29 4 How to Find a Home Care Worker

Caregivers should remember to ask the registry if its workers are required to complete criminal background checks or health care training. If
a caregiver or patient decides to hire a care worker through a registry, they become the employer and must follow all state and federal labor laws, tax laws, and insurance laws.
Contact the local AAA for lists of registries.

Labor Rules
Caregivers who hire independent home care aides or affiliated home care aides through an agency must follow the minimum wage and overtime rules of the Federal Fair Labor Standards Act (FLSA). Please refer to the United States Department of Labor booklet “Paying Minimum Wage and Overtime
to Home Care Workers” for detailed information about these rules. www.dol.gov/ whd/homecare/homecare_guide.pdf
RESOURCES

Licensing and Certification Before hiring any agency or individual, caregivers should thoroughly check the
agency’s or individual’s credentials. For home health agencies or a certified home health aide, the Department of Health Services can determine whether the agency’s or individual’s license or certification is current and if there are any complaints on file.

If the agency or individual doesn’t need a license, potential employers can still research credentials, such as educational degrees
or certificates, and check peer and client references and membership in health or home care associations. The local Better Business Bureau can help determine whether there have been complaints against an agency or registry.

For more information on topics in this chapter, consult the following resources.

Agencies
•Department of Health Services, Licensing and Certification Division: (916) 445-4171, www.dhs.ca.gov
•Los Angeles area senior services: www.la4seniors.com (available in six languages)
•City of Los Angeles Department of Aging: (213) 482-7252, www.aging.lacity.org
•Eldercare Locator: (800) 677-1116, www.eldercare.gov
•Department of Social Services Home Care Services Bureau: (877) 424-5778
•Better Business Bureau: www.bbb.org

On Line
•Department of Labor, “Paying Minimum Wage and Overtime to Home Care Workers” www.dol.gov/whd/homecare/homecare_guide.pdf

4How to Find a Home Care Worker 30

CHAPTER 5
IMPROVING THE QUALITY OF HOME CARE

IMPROVING THE QUALITY OF HOME CARE

This chapter examines what caregivers and patients need to know to improve the quality of home care, including steps to take at home, understanding the various members of the health care team, what community resources are available, and determining whether a home care agency or independent home care aides make the most sense.
At Home
Modifying a home to make it safe, making sure important information is readily at hand, managing money, getting the right training, and knowing how to obtain needed services— these are all essential tasks for ensuring a high quality of home care.

Home Modifications
Home modifications can make a loved one’s home safe and free from obstacles. Here are some tips for making sure a home is safe.
•Check the home for slippery floor surfaces, clutter, and other safety hazards.
•Make sure the home is equipped with the necessary number of smoke detectors and that they’re located in the proper locations for that particular home.
•Install a sufficient number of fire extinguishers, and make sure that they’re handy.
•Install night lights and grab bars in the bathrooms.

Handy Worker Program
The Handy Worker program offers free home assessment and home modifications to low- income seniors and disabled individuals living in the City of Los Angeles. The program is offered to homeowners and tenants. The Handy Worker program will assess a home and then modify it to make it safer. They will install grab bars, shower hoses, locks, smoke alarms, nightlights, and other hardware.

Home Safety Precautions
Home safety precautions are critical for persons who wander. Sometimes persons with dementia may get lost or wander into unsafe environments. Individuals who have dementia should be enrolled in the
Alzheimer’s Association Safe Return Program, a nationwide identification system designed to assist in the safe return of people who become lost when wandering.

Home safety precautions are critical
for persons who wander.

To keep home exits secure, deadbolt or slide- bolt locks should be installed on exterior doors, to limit access to potentially dangerous areas. Alarms that ring when the door opens should be installed on exterior doors.

Let neighbors know when a loved one is at risk for wandering.

5Improving the Quality of Home Care 32

Information and Referral Services California’s Caregiver Resource Centers, Area Agency on Aging (AAAs), senior centers, and community mental health centers all offer toll- free numbers to obtain referrals to community resources.

Emergency Alert Response Systems
An emergency alert response system, such as Lifeline, can be critical in an emergency. These alert systems offer individuals and caregivers a fast, easy way to call for help. Lifeline, for instance, offers a pendant with a button that, when pressed, alerts Lifeline responders, who can then call an ambulance.

File of Life Card
The File of Life Card lists important medical information about a loved one for quick reference in case of emergency. The card, kept in a red plastic sleeve labeled File of Life,
lists the patient’s name, emergency medical contact, insurance policy, Social Security number, health problems, medications and their dosages, allergies, recent surgery, religion, and advance directive.

The card is kept in a sleeve which attaches to the front of the refrigerator. (A wallet card is also available.) Emergency medical personnel have been trained to look for this form. The card’s visibility and readability ensure that they can find pertinent health information quickly when responding to a call, especially if the patient is confused, frightened, or unable to offer assistance or a clear history.

The File of Life card, shown here, can save valuable seconds in an emergency. The local AAA has information on how to obtain a File of Life card. Or visit www.folife.org

Organizing Documents
Collecting and organizing important health care and financial documents can ensure that a loved one or caregiver can find critical information when needed. Keep a folder with the names and contact information for a loved one’s doctors, attorney, financial
advisor, and nearby family and friends, as well as personal information, such as the Social Security number, driver’s license number, and insurance information.
Caregiver Education and Training Education and training of the caregiver is essential to keep a loved one healthy and also to prevent injuries. Caregivers should consult with their loved one’s doctors, nurses, and therapists for instruction on medical care pertinent to his condition. Caregiver support groups also provide training and support. See Chapter 10, Supporting the Caregiver.

33 5 Improving the Quality of Home Care

Employee Assistance Programs Employee assistance programs (EAPs) are offered by some workplaces to assist their employees who are caregivers or patients. Types of assistance vary widely and may include counseling for personal issues. Some retirement programs offer assistance for retirees who need at-home
care. The human resources department can determine whether a patient or caregiver qualifies for EAP benefits.

Understanding Health Care Professionals
To obtain the highest quality of care, caregivers and patients should understand the role each professional plays in the health care system.

Primary Care Physicians
Primary care physicians play an important role in caregiving. They’re responsible for monitoring their patients’ health and making sure they’re receiving the proper amount and level of care. It is important that caregivers and patients communicate with their doctor as often as necessary, especially to report changes in a loved one’s condition. The doctor may be a physician specializing in internal medicine, geriatrics, cardiology, or family practice, and should be someone with experience handling the loved one’s disability or illness.

Primary care physicians are responsible for monitoring
their patients’ health and making sure
they’re receiving the proper amount and level of care.

Patients admitted to a hospital and who wish to return home should clearly express those wishes to the primary care physician. The
doctor and his staff may not be familiar with all types of in-home care, community services, and public benefits available for home care patients. This booklet may be used to help educate the physician about available home care options and to help him complete a home care plan.

If the doctor believes a patient lacks the support needed to stay at home, a decision may be made to discharge the patient to a nursing home. If the doctor decides not to allow a patient to return home, the patient still has the right to return home against the doctor’s advice. In such cases, patients are

5 Improving the Quality of Home Care 34

Discussions with the hospital discharge planner generally start as soon as a patient enters a hospital. Doing so ensures that discharge planning is completed by the time the loved one is discharged. The loved one should be involved in the discharge process as much as possible.

Discharge planners will be able to answer questions about the various types of services available and their quality and cost. The patient or caregiver should tell the discharge planner whether they wish to return home or go to a nursing home, so that proper arrangements can be made.

required to sign an Against Medical Advice form. This form acknowledges that the patient has decided to be discharged even though she has been told that doing so may cause mental or physical harm.

Discharge Planners
A discharge planner is a professional employed by a hospital to aid in the transition phase from hospital care to other types of medical care. The discharge planner can arrange admittance to a nursing home and can set up in-home care services, rehabilitative care, or outpatient services.

Geriatricians
Geriatricians are doctors who specialize in the medical needs of older adults, just as pediatricians specialize in the medical needs of children. Geriatricians are experts in dealing with multiple medical problems and chronic illnesses. They focus on gaining optimal quality of life and functional ability for their patients.

Geriatricians typically use a holistic approach that addresses the physical, psychological, and social needs of the patient and family.
They work closely with other health care professionals and organizations, as well as the patient and family, and treat the family as key members of the health care team.

Geriatricians also scrutinize the often large number of medications that older adults take, to ensure that the medications are appropriate and are not causing serious side

35 5 Improving the Quality of Home Care

Specialists may prescribe medications to treat certain disorders but may not be fully aware of medications prescribed by other specialists.

The geriatrician will also assess the patient for pain and mood disorders, such as depression and chronic pain, which are common among older adults. The geriatrician may perform a full geriatric assessment on new patients. A geriatric assessment is a comprehensive evaluation performed by a multidisciplinary team. The assessment team may consist of specialist physicians, social workers, physical therapists, occupational therapists, dieticians, psychologists, pharmacists, and geriatric nurse practitioners.

effects. Older adults are often treated by a variety of specialists, such as cardiologists, endocrinologists, gastroenterologists, and others. These specialists may prescribe medications to treat certain disorders but may not be fully aware of medications prescribed by other specialists.

A geriatrician can evaluate all medications and determine, as a whole, how they interact. Many times, medications can be adjusted with significant improvements in the patient’s well-being.

The team creates a care plan designed to optimize an older person’s ability to enjoy good health, improve overall quality of life, reduce the need for hospitalization or
institutionalization, and enable the individual to live independently for as long as possible. The care plan identifies problems and makes specific recommendations for improving the loved one’s condition.

Patients or caregivers can request a geriatric assessment from the primary care physician or geriatrician. In addition, many larger hospitals, university health centers, and VA medical centers have geriatric assessment units.

Geriatric Care Managers
Care managers typically have a background in counseling, social work, or a related health care field. A care manager assesses the loved

5 Improving the Quality of Home Care 36

one’s needs and works with the caregiver to create, implement, and monitor a care plan designed to meet those needs. Care managers may provide conflict resolution for family caregivers and intervene in a crisis.

Care managers can be hired privately. They generally charge anywhere from $30 to $150 per hour. A person on Medi-Cal may ask for a care manager through the Multi-Purpose Senior Services Program (MSSP) or PACE program.

Free and low-cost care management may be found through hospitals, senior centers, mental health programs, home health
agencies, and social service agencies, such as Jewish Family Services, Catholic Charities, and Adult Protective Services. In addition, some Medicare HMOs offer care management services. Care management may be especially helpful when family members live far from the patient needing care.

Individuals who have both Medicare and Medi-Cal may be eligible for the Cal MediConnect program. The program
provides a care manager to help coordinate the individual’s Medical care. The Cal MediConnect program also may provide additional Long Term Supportive Services to help keep someone in their home.

Care managers should be independent and objective. Before hiring a care manager, caregivers should ensure that they fully understand the care manager’s fees including whether there is a charge for phone calls.

Find out whether the care manager seems knowledgeable about the loved one’s particular condition and physical and emotional needs.

Care managers should be independent and objective.

Research Studies
Research studies are essential to improving knowledge and understanding about medical conditions such as Alzheimer’s disease
and other dementias. People volunteer to participate in research studies for many different reasons including the opportunity to gain early access to new treatments, to access expert medical care for the condition studied and to help others by contributing to medical research. Before agreeing to participate in
a study it is important that a person fully understand the potential benefits and risks. Research studies are often conducted at universities and medical schools, but there are also private companies that conduct research. To find out about local research studies, visit The U.S. National Institutes of Health website at www.clinicaltrials.gov.

37 5 Improving the Quality of Home Care

RESOURCES
For more information on topics in this chapter, consult the following resources.

Agencies
•AAA Information Services Hotline: (800) 510-2020
•Alzheimer’s Association Safe Return Program: (888) 572-8566 or www.alz.org/safereturn
•American Geriatrics Society (AGS) Physician Referral Service: aids in locating physicians experienced in caring for older adults; participating physicians are members of AGS
and are board-certified in internal medicine or family practice; (800) 563-4916, www.americangeriatrics.org
•Cal MediConnect: (844) 580-7272 or www.calduals.org
•Eldercare Locator: (800) 677-1116 or www.eldercare.gov
•Handy Worker Program: (866) 557-7368
•National Association for Home Care: www.nahc.org
•National Academy of Certified Care Managers: (520) 884-7925 or www.naccm.net
•Senior Care Network Resource Center: (800) 664-4664
•Southern California 211 line: Dial 211 in Southern California for referrals to community resources including health care services, emergency housing and free meals
Print
•The Portable Caregiver: 8 Essential Guidebooks for Elder Care, Mary Trabert and Deborah Morris, www.portablecaregiver.com/products.asp
•Eldercare at Home: A Step-by-Step Resource for Caring for an Older Person at Home,
AGS Foundation for Health and Aging, www.healthinaging.org
•Smoke Detectors Save Lives:
http://www.fire.ca.gov/about/downloads/smokedetectorssavelives.pdf
•The Eldercare Handbook, Stella Mora Henry, R.N., Collins. 2006
Online
•WebMD Physician Directory: http://doctor.webmd.com/physician_finder
Other
•Lifeline: (800) 380-3111, www.lifelinesys.com

5Improving the Quality of Home Care 38

CHAPTER 6
HEALTH CARE DECISION MAKING

HEALTH CARE DECISION MAKING

Every adult has the right to make decisions about his or her own health care. That includes the right to authorize or refuse medical treatment. Problems may arise, however, when someone becomes suddenly incapacitated due to a stroke, accident, dementia, or another condition. A person is considered incapacitated
if she lacks the mental functioning to understand her condition, to understand the options for treatment and their consequences, and to make an informed decision about medical care.

No one knows when or if they’ll become incapacitated, so it’s important for people to plan for it—just in case—by making sure that their wishes are known and will be followed in case they’re unable to speak for themselves. This chapter explains how to do just that.
Directing Future Health Care
In California, there are four legal ways for people to express their wishes about future medical care:
1.A Power of Attorney for Health Care allows an individual to appoint an agent to make health care decisions on his behalf if he becomes incapacitated.
2.A Health Care Instruction allows an individual to list specific instructions about his future health care, such as whether he wants life support, a feeding tube, or other medical treatments.
3.A Do Not Resuscitate order allows an individual to specify that he does not wish to receive emergency resuscitative measures, such as cardiopulmonary resuscitation (CPR).

4.Physician Orders for Life-Sustaining Treatment (POLST) allows an individual to state end of life medical treatment preferences.

The first two forms are collectively called advanced health care directives, because they allow individuals to express their wishes at present for the level of health care they want in the future. The third allows the individual to refuse medical care. Let’s take a look at these methods.

Advanced health care directives allow individuals to express their wishes at present for the level of health care they want in the future.
Advanced Health Care Directives In California, any adult of sound mind can create a California Power of Attorney for Health Care and a Health Care Instruction. These documents are generally combined into one, easy-to-follow form called an Advanced Health Care Directive.

The combined document allows individuals to appoint a trusted relative or friend to act as agent and speak on their behalf if they become incapacitated. In such cases, the agent
is allowed to make all health care decisions. As the legal representative, the agent is the only person other than the patient who can legally authorize medical treatment. An agent can also refuse medical treatment, including life support, nutrition, and hydration. Some forms also allow individuals to express wishes about organ donation and funeral arrangements.

6Health Care Decision Making 40

Appointing an Agent
In the Power of Attorney for Health Care form, an individual can appoint an agent to make health care decisions for her. The agent may be a family member, friend, or another person. Individuals should make sure to select someone they feel comfortable with, someone they can trust to listen to their wishes and exercise them appropriately. An agent should be someone the patient can talk to in-depth about her wishes for future health care, especially about whether she wants to accept or refuse certain life-sustaining measures.

The agent cannot be an individual’s health care provider or an owner or employee of a residential care facility. One or two alternate agents may be selected, in case the primary agent is unable or unwilling to act.

Giving Your Agent Specific Health Care Instructions
Although an agent is authorized to accept or refuse medical treatment on an individual’s behalf, some decisions agents face can be extremely difficult. The optional Health Care Instruction section of the Advanced Health Care Directive allows individuals to document

specific instructions about life-support measures, end-of-life care, or any other type of treatment. In that section, individuals can instruct their agents and medical providers to allow life-support treatments, such as being placed on a ventilator or being given artificial nutrition and hydration through a feeding tube. They can also specify that they don’t want those types of treatments, or even that they want one but not the other.

In addition to written instructions, individuals should talk about their desires with their agent and their doctor. Discussing health
care decisions now, while the individual is able to explain his wishes, can give the agent a greater sense of comfort about making difficult decisions later.

Health Care Instruction Only
A Health Care Instruction allows individuals

41 6 Health Care Decision Making

to make their wishes known directly to their physician if they don’t have an agent or if their agent dies before them. Health Care Instructions describe what type of health care the individual wants including whether to withhold or withdraw care. A physician or hospital is obligated to following the individual’s wishes as written in the Health Care Instruction form.

Completing the Forms
In California, an advance directive must be signed, dated and witnessed. The individual signing the document must be legally competent to understand the document.
Two witnesses or a notary must witness the signing. The witnesses cannot be a family member, the appointed agent, a health
care provider, or an owner or employee of a residential care facility. If the individual
lives in the nursing home, the long term care ombudsman must be one of the witnesses.

After a person has completed an advanced health care directive, copies of the forms should be distributed to family members, the agent, doctors, and hospital. Under California law, a copy is just as valid as the original. The documents may also be registered with the California Secretary of State by calling
(916) 653-3984.

Under California law,
a copy of an advanced directive or DNR order is just as valid
as the original.

Individuals who have an Advanced Health Care Directive should prepare a wallet card that lists the telephone number of the agent and keep the card with them at all times.
Do Not Resuscitate (DNR) Orders A DNR order instructs health care providers to withhold CPR or other lifesaving measures if the individual’s heart or breathing stops.
The individual or his agent can sign a DNR order in a hospital or nursing home.

For persons who live at home and who do not wish to be resuscitated, an Emergency Do Not Resuscitate (EDNR) form is required. This form indicates that the individual doesn’t want paramedics or other emergency medical services (EMS) personnel to revive him if his heart or breathing stops. Individuals who sign an EDNR
form should wear a special Medic Alert bracelet.

Under California law an EDNR order must also be signed by the treating physician. The form is available from the California Medical Association and does not need to be witnessed or notarized. A family member or in-home care provider must show the approved EDNR or the Medic Alert bracelet to EMS personnel when they arrive.
Physician Orders for
Life-Sustaining Treatment (POLST) POLST is a form designed to assist physicians and other health care providers honor patients’ end-of-life decisions. It must be completed by the patient, or patient’s surrogate, and their physician. The form should be used when a person is terminally ill to supplement, but not

6 Health Care Decision Making 42

to replace, an advance health care directive. To learn more about the California POLST call (916) 489-2222 or visit www.capolst.org.
When the Forms Take Effect Under California law, an Advanced Health Care Directive takes effect when a person becomes incapacitated. The primary care
physician decides when an individual has lost the capacity to make health care decisions, unless the person’s document states otherwise. Individuals who want their agent to assume immediate authority for making all health care decisions should write on the form that the Advanced Health Care Directive be effective immediately, rather than when the person loses capacity. The DNR, EDNR, and POLST forms are binding as soon as they’re completed.

The California Advanced Health Care Directive, EDNR and POLST forms have no expiration date. They can be revoked at any time as long as the individual retains the mental capacity to make those decisions. Signing a new form usually revokes a prior document.

Informal Health Care Decision Making
According to California law, if there is no legally appointed agent, the nearest relative of an incapacitated person may make health care decisions for that person. Under the law, however, the relative has no formal authority to make those decisions. As a result, health care providers are often reluctant to accept
the health care decisions of the nearest relative unless the appropriate treatment is obvious or the entire family agrees with the decision.

Patients in a hospital can verbally appoint a surrogate to make decisions for them but only for medical decisions during the hospital stay.

A family member or friend can ask, or petition, a court to be allowed to make particular health care decisions for the patient or to act as the patient’s conservator.
Conservatorship Over the Person If a person lacks capacity to make health care decisions and is unlikely to regain capacity
in the near future, a family member, friend, or professional conservator may petition a court for conservatorship over the person. Conservatorship is a process in which a judge appoints a person (the conservator) to make all legal, financial, or health care decisions for another person (the conservatee).

A conservatorship over the person allows the conservator to manage a person’s personal care, such as where the person lives, and health care decisions including whether to provide or withdraw life-sustaining measures. This type of conservatorship is necessary when individuals can no longer understand their illness or treatment choices. Anyone may petition a court for a conservatorship. A doctor must determine that the conservatee lacks the capacity to
make informed decisions about her medical condition and personal care.

A petition for conservatorship over the person generally must explain why a loved one lacks capacity, the reasons for a conservatorship, and the areas the conservatorship covers.
A family member or friend desiring a

43 6 Health Care Decision Making

conservatorship should consult an attorney. Some courts may have self-help clinics to assist people without an attorney. For more information on self-help resources, go to www.courts.ca.gov/selfhelp.htm.

A conservatorship of the estate, on the other hand, allows a conservator to manage all financial and legal matters for a person.
Depending on the person’s needs, a court may appoint a conservator of the person, estate, or both.
Limited Conservatorships
A limited conservatorship is a court order where a judge gives a responsible person certain rights to care for an adult with a developmental disability such as cerebral palsy, Down’s syndrome, or autism. The limited conservator is given only the powers needed to protect the conservatee and otherwise is responsible for assisting the limited conservatee to develop maximum self-reliance and independence. To learn
more about limited conservatorships read Bet Tzedek’s Limited Conservatorship Guide.
Mental Health Conservatorships If a loved one has a mental illness (e.g. schizophrenia) and needs a conservatorship to get appropriate mental health treatment, a different conservatorship process must be
followed. The Mental Health Conservatorship (known as an LPS Conservatorship in California) allows for mental health treatment in a locked, mental health treatment facility.
This type of conservatorship is for adults who cannot provide for themselves, as a

result of mental disorder, and who will not voluntarily agree to treatment. The
appointment of a conservator must be started by a local government agency (the Public Guardian), filed in the mental health court, and is governed by the laws in the Welfare and Institutions Code. It is a much harder conservatorship to obtain than a Probate Conservatorship. The conservator also makes decisions about medical treatment, personal care and finances when necessary.
An LPS Conservatorship lasts for one year and must be renewed by the court after a hearing. Caregivers with questions about how to help loved ones with mental illnesses should contact the National Association of
the Mentally Ill (NAMI) at (800) 950-6264 or visit www.nami.org or see Bet Tzedek’s LPS Conservatorship Guide.

Conservatorships vs. Advanced Health Care Directives
Individuals who complete powers of attorney for health care can select their own agent, decide who will make decisions for them, and tell the agent what types of decisions to make, such as whether to provide artificial life- support. In short, the patient is in control.

For individuals who have never completed powers of attorney for health care and then become incapacitated, a conservatorship may be necessary. In a conservatorship, the judge appoints a conservator and decides what types of decisions the conservator can make. The conservator may possess less knowledge about the patient’s personal values and desires than they would if the patient had discussed

6Health Care Decision Making 44

his wishes in advance and completed an Advanced Health Care Directive.
Conservatorships are costly and take more

than two months to complete, although an emergency temporary conservatorship can be completed within days.

RESOURCES
For more information on topics in this chapter, consult the following resources.

Agencies
•Bet Tzedek Legal Services: (323) 939-0506, www.bettzedek.org
•California Courts Self-Help: www.courts.ca.gov/selfhelp
•California Medical Association: (800) 786-4262, www.cmanet.org
•Do Not Resuscitate Form: (800) 882-1262, http://emsa.ca.gov/pubs/pdf/dnrform.pdf
•Medic Alert bracelet: (888) 633-4298, www.medicalert.org
•National Academy of Elder Law Attorneys (NAELA): 1604 North Country Club Road, Tucson, AZ 85716, (520) 881-4005, www.naela.org
•Office of the Public Guardian of Los Angeles County: (213) 974-0515; http://www.la4seniors.com/public_guardian.htm
•Professional Fiduciary Association of California: (866) 886-7322, www.pfac-pro.org
Print
•Your Way: a helpful guide for discussing and choosing future health care,
Healthcare and Elder Law Programs Corporation (HELP) of Torrance, CA,
(310) 533-1996, www.help4srs.org
•California Probate Code Section 4600 and following
•California Welfare and Institutions Code Section 5000 and following
Online
•Limited Conservatorship Guide, Bet Tzedek
www.bettzedek.org/wp-content/uploads/2011/04/BetTzedek2014LtdConservGuide.pdf
•LPS Conservatorship Guide, Bet Tzedek
http://www.bettzedek.org/wp-content/uploads/2011/04/BetTzedek2014LPSConservBroch.pdf

45 6 Health Care Decision Making

CHAPTER 7
LEGAL AND FINANCIAL DECISION MAKING

LEGAL AND FINANCIAL DECISION MAKING

Estate planning often seems daunting and complicated. But good planning can prevent problems and confusion later. This chapter outlines key financial and legal tools available when planning for what’s expected to
happen and, maybe more important, what’s unexpected, including sudden illnesses, accidents, or mental incapacity.

All adults have the right to manage their own finances and make decisions about how to spend their money. Problems may arise, however, when someone becomes incapacitated due to a stroke, an accident, dementia, or another condition. A person is considered incapacitated if he is unable to manage his own personal care, property, or finances and lacks the ability to understand his actions when making a decision.

Planning for financial well-being in case loved ones become unable to care for themselves should begin sooner rather than later. Let’s look at the various options to consider, including Durable Power of Attorney for Finances, joint bank accounts, representative payee, wills, and trusts.

Durable Power of Attorney for Finances
A person of sound mind may complete a Durable Power of Attorney for Finances. This document allows an individual, the principal, to appoint a trusted relative or friend to be an agent. The agent can manage finances
immediately or at some future time. A durable power of attorney for finances is generally used to pay bills, manage bank accounts,

or handle other legal and financial matters.

With a durable power of attorney for finances, all property remains under the principal’s ownership. However, the agent may act on the principal’s behalf. The document may be used for a particular purpose, such as paying bills only, or for general financial management.
The agent may have access to bank accounts, stocks, retirement accounts, and even the deed to the home.

With a durable power of attorney for finances, all property remains under the principal’s ownership.

7Legal and Financial Decision Making 48

Persons considering durable power of attorney for finances should choose an agent who is trustworthy, capable, and knows them well enough to be able to make decisions according to their wishes. The agent has a fiduciary duty and, as such, is responsible
for using the utmost care in handling the money for the principal and must act in that person’s best interest. Note that there is no court oversight to ensure that the agent acts responsibly or to prevent an abuse of power.

A durable power of attorney for finances may take effect immediately or go into effect only if the principal becomes incapacitated.
Individuals who want a durable power
of attorney for finances to take effect only if they become incapacitated should create what’s called a springing power of attorney for finances.

A durable power of attorney for finances may be revoked at any time. The principal may revoke it by completing a revocation of power of attorney form. This form must be notarized. The completed revocation form should be given to the prior agent as well as the principal’s financial institutions. If the individual has
real property, he may choose to record the revocation with the local county recorder’s office. A power of attorney for finances is automatically terminated upon death.

Although an attorney isn’t needed to complete a power of attorney for finances document, individuals may wish to consult an attorney to ensure that the form is valid and meets all of their needs.

Joint Bank Accounts
People who add a friend or family member as a joint account holder to a bank account should be aware that they’re giving an
ownership interest to the joint account holder. Joint account holders have full ownership rights in the account and can use the money for themselves. Also, any liabilities or judgments of the joint account holder could be taken from the account.

Individuals who don’t want to give an ownership interest in a bank account but do want to give a family member access to the account could fill out a power of attorney card at the bank. This card grants the family member access to the account and requires them to use the money for meeting the main account holder’s needs.
Representative Payee
A Representative Payee is a person authorized to manage Social Security and Supplemental Security Income (SSI) payments. Having a representative payee can be especially helpful for people who struggle with paying their bills or are not spending their income wisely because of incapacity.

A family member, an agent, or a healthcare

49 7 Legal and Financial Decision Making

provider can ask to be a representative payee directly at the Social Security office. A
physician must verify the person’s incapacity, and then Social Security will issue the payment to the representative payee. The representative payee must use the money
for the recipient’s care.

Like Social Security, the Department of Veterans Affairs (VA) allows representative payees to receive payments for an incapacitated veteran.

Social Security and the VA allow representative payees for incapacitated adults
to receive payments.
Money Management
Money management programs are important for elders and dependent adults who need help managing bills and being protected from financial abuse. Money management programs offer representative payee and bill- paying services. There are also free money management programs for low-income elders and dependent adults.

Senior center professionals, social workers from Adult Protective Services (APS), as well as AARP’s money management program can help locate money managers. In addition, a money manager can be hired at an hourly rate. Contact the American Association of Daily Money Managers for help in finding one.

Caregivers and patients should make sure to check the person’s credentials through

the local Better Business Bureau and to ask for, and then contact, their references. Thoroughly review and discuss their fees before agreeing to any services.
Estate Planning
The law provides a system for distributing an estate when someone dies. The term estate means all personal property, real estate, money, stocks, and any other property owned by a person at the time of death. If a deceased person didn’t leave a will or trust, the estate passes through something called “intestate succession.”

In the intestate (pronounced in-TES-tayt) succession process, a court distributes the estate to the deceased person’s next of kin in accordance with that state’s inheritance laws. In California, the estate would go first to a surviving spouse or registered domestic partner, and then to any surviving children or other next of kin. If there are no living
relatives and no will or trust, the estate would go to the State of California.
Probate
Probate is a court process in which a person’s will is reviewed for its validity, creditors are paid, and the balance of assets are distributed to heirs. Although probate is often talked about as a lengthy and burdensome process, it does serve to protect the interests of the deceased individual.

This process ensures the will is actually carried out according to the wishes of the deceased. If a person dies without a will, a probate process ensures that the estate

7 Legal and Financial Decision Making 50

is distributed to the next of kin according to state law. In California, an estate worth less than $150,000 can be settled quickly and with little paperwork.

In California, an estate worth less than $150,000 can be settled quickly and with little paperwork.
Wills
A will is a legally binding document that tells others how to distribute an estate when a person dies. A will may also name a person, called an executor, to oversee the distribution of property and follow other directions in the will. Instructions for burial may also be included in a will.

Even for persons with few assets, a will can be crucial. For example, wills can relay a deceased person’s desire to give certain items of personal property, often with sentimental value, to chosen family members.

Naming an executor allows the person to settle the estate more quickly, because the executor will have legal authority to take control of all property and accounts.

Writing a Will
In California, there are three basic types of wills:
•handwritten will (also called a holographic will)
•statutory will
•individual attorney-drafted will.

A handwritten will is a will that has been written entirely by hand, dated and signed by the person making the will, called the testator, but not signed by witnesses.

Individuals with few assets may consider a California Statutory Will. A California Statutory Will is a simple form that allows individuals to make specific gifts of their
house, cars, and money, and then designate one or more persons to receive the balance of the estate.

51 7 Legal and Financial Decision Making

whom to include in a will, should contact an attorney to help them create the will that fulfills their wishes exactly as they want.

People with large estates or who wish to exclude certain family members from inheritance, should consider creating an
attorney-drafted will. An attorney can help draft a will that will stand up in court should someone want to dispute or contest the will. In addition, an attorney can write a will that can do things a statutory will can’t, such as create a trust or appoint more than one executor.
People who feel pressure from anyone about

Wills are legal documents and must be executed properly. Otherwise, a California court may refuse to accept the will as valid. California law requires that a typewritten or printed will be signed by the person making the will and by two witnesses. The witnesses should not be people who would benefit from the will. A handwritten (or holographic) will doesn’t need witnesses, but it must be signed and dated. A will may be changed by adding an amendment or codicil. A will may also be revoked by writing a new will.

Wills are legal documents and must be executed properly.
Property Not Covered by a Will or Probate
Some forms of property ownership are not distributed by a will. Joint tenancies, life insurance proceeds, and accounts with payable on death beneficiaries are all
examples of property distributed outside of the probate process. Some kinds of trusts also skip the probate process.

Trusts
A trust is a legal entity that holds property. The trustee manages the trust property for a beneficiary. The trustee has a duty to the
trust and beneficiaries to make good business decisions and protect the trust assets for the beneficiaries. A trust may be created while a person is still living or through a will.

7 Legal and Financial Decision Making 52

The trust document states how the trust should be managed and how or when income and principal from the trust should be given to the beneficiary. There can be more than one trustee and more than one beneficiary.

There are four basic types of trusts:
•revocable living trust
•irrevocable living trust
•testamentary trust
•special needs trust.
A revocable living trust is a legal document created by an individual (the grantor) to hold and manage property for the beneficiary. This trust can be revoked or changed at any time as long as the grantor still has the mental capacity to do so.

Assets placed in the trust are owned by the trust and managed by the trustee. The
trustee may be the grantor, a family member, or an organization such as a bank. The grantor may name a successor trustee to manage the trust should the original trustee become incapacitated.

A living trust also avoids probate. Trust assets are distributed to the beneficiaries, according to the terms of the trust. Distribution of assets through a trust is less costly and less time consuming than probate.

Assets placed in the trust are owned by the trust
and managed by the trustee.

An irrevocable living trust is similar to a revocable trust except that after it has been created, an irrevocable trust can’t be changed or revoked by the grantor. Irrevocable
living trusts are often used for people with substantial assets because those assets aren’t taxed as extensively when the grantor dies. This type of trust also avoids probate.

A testamentary trust is a trust created through a will. It is often used when the grantor doesn’t want the hassle of managing a trust while still living but wants to create a trust for minor children or just to have more control over the distribution of assets. For example, the trust document could specify that the beneficiary receive income only for certain purposes such as an education.

Special Needs Trusts
A person who receives government benefits such as SSI, can have very limited assets by law. A special needs trust (SNT) holds assets for the beneficiary so they still qualify for benefits. The SNT is designed to pay for things that Medi-Cal or SSI can’t pay for, such as entertainment, travel, education, and
certain medical expenses. In a SNT, the trustee has complete control over the distribution of trust income, and the beneficiary has
no control.

Because of the complicated nature of all trusts, individuals wishing to create one should consult an attorney with specialized knowledge of trusts. Note that trusts MAY NOT protect assets from Medi-Cal recovery claims.

53 7 Legal and Financial Decision Making

Individuals wishing to develop a special needs trust
should consult an attorney
to avoid losing government benefits.
Conservatorship over the Estate When no planning has been carried out and a person lacks the capacity to make financial and legal decisions, a conservatorship may be necessary. Conservatorship is a probate court process in which a judge appoints a person, the conservator, to make decisions for the incapacitated person, called the conservatee. Depending on a person’s needs, a court may appoint a conservator of the person, the estate, or both.

A conservatorship is necessary when a person can no longer handle personal or financial affairs due to mental or physical incapacity. A family member, friend, private professional, or public guardian may act as a conservator. A physician must determine that the conservatee lacks the capacity to make informed decisions.

A petition for conservatorship must explain why a loved one lacks capacity, the reasons for needing a conservatorship, and the areas

that the conservatorship should cover. The conservator has a fiduciary duty to the conservatee and must act responsibly and in the conservatee’s best interest.

A court oversees a conservatorship of the estate to ensure that the conservator acts properly. The court will generally require the conservator of the estate to be bonded. Any family member or friend desiring a conservatorship should consult an attorney. Some courts may have self-help clinics to assist people without an attorney.

How Conservatorships over the Estate Differ from Powers of Attorney for Finances
In powers of attorney for finances,
an individual chooses her agent, decides who will make decisions for her, and tells the agent what types of decisions to make. She’s in control.

In a conservatorship, the judge chooses the conservator and decides what types of
decisions the conservator can make. Ultimately, the conservator is in control and is required to act in the best interest of the conservatee.

7 Legal and Financial Decision Making 54

Case Study
Esther and Frank: The Importance of Legal Planning

Esther and Frank have been married for five years. It is the second marriage for both. Frank is hospitalized from a recent stroke and can’t talk or write. He has bank accounts and stock accounts in his own name. His pension check is direct deposited to one of his bank accounts. Frank is coming home and needs additional care.

Core Issues
How Esther can gain access to Frank’s income and assets so that she can pay for Frank’s bills and care.

Steps to Resolution
Esther sought help at her local senior center, which referred her to an elder law attorney. The elder law attorney interviewed Esther about her and Frank’s income, property, previous estate planning, and care needs now and in the future. Because Frank didn’t have a power of attorney, trust, or advance directive, the attorney advised Esther to petition the court for conservatorship.

Follow-Up
The court made Esther the conservator over Frank’s person and estate because Frank was totally incapacitated and could not make decisions or provide care for himself. Using the conservatorship, Esther could access Frank’s bank account, so she could pay for his care, and to make medical decisions for him.
The elder law attorney also did an estate plan for Esther and put her bank accounts and property in a trust. He also created a will and powers of attorney for health care and finances. Esther appointed her daughter as successor trustee and agent. This way, her daughter would not have access to her assets now, but could immediately take over should Esther become incapacitated.

Key Points
•Because Frank never completed a trust, advance directive or power of attorney while he was well, Esther was forced to go to court to take over Frank’s finances.
•Esther took the opportunity to do some estate planning for herself and appointed her daughter as her agent in case of her own incapacity.

55 7 Legal and Financial Decision Making

RESOURCES
For more information on topics in this chapter, consult the following resources.

Agencies
•American Association of Daily Money Managers: (814) 357-9191, www.aadmm.com
•American Association of Retired Persons (AARP): Provides legal advice on wills and other estate planning documents, (888) 687-2277, www.aarp.org
•Bet Tzedek Legal Services: (323) 939-0506, www.bettzedek.org
•California Advocates for Nursing Home Reform Lawyer Referral Service: (800) 474-1116, www.canhr.org
•Los Angeles County Superior Court: information on transferring small estates
(less than $150,000) without probate, www.lacourt.org/division/probate/PR0077.aspx
•National Academy of Elder Law Attorneys (NAELA): (703) 942-5711, www.naela.org
•Office of the Public Guardian of Los Angeles County: (213) 974-0515, www.la4seniors.com/public_guardian.htm
•Professional Fiduciary Association of California: (866) 886-7322, www.pfac-pro.org

Print
•State Bar of California: Offers consumer pamphlets, including ones on wills, trusts, and estate planning, (888) 875-LAWS (5297) or the Senior Information Hotline
at (888) 460-7364, www.calbar.ca.gov
•California Probate Code Sections
■Trusts: PC§15000 and following
■Wills: PC§6100 and following
■Powers of Attorney: PC§4000 and following
■Conservatorship: PC§1800 and following
■Small Estates: PC§13100

7Legal and Financial Decision Making 56

CHAPTER 8
RESOLVING PROBLEMS

RESOLVING PROBLEMS

Caregiving situations may be fraught with emotions, and disputes are bound to arise. This chapter looks at some of the more common issues that may arise while caring for a loved one, including family problems and problems with home care providers.
Family Disputes
Despite a family’s best intentions, caring for a loved one can be an emotional task. Families should try to unite to provide the best possible care for their loved one.

Families should try to unite to provide the best possible care
for their loved ones.

One way to avoid problems is to call a family conference to discuss caregiving duties and roles. Sometimes developing clear-cut family roles can help everyone know what they should do for the loved one. Having a specific role can provide order and structure to what outwardly seems chaotic. No one should accept a caregiving role unwillingly. Individuals who accept the role of caregiver should feel free to request significant help from family members inside and outside the household.

Family conferences may also prove helpful in sorting out the expectations of each family member. Family conferences are also a good way to make long term plans for a loved one, share information and feelings, and plan emergency or vacation backup for the primary caregiver.

Family meetings can be awkward, especially for people who haven’t talked easily or openly

about family matters. Talking about feelings or the need for help is difficult for many people. Caregivers who think a family conference might be difficult should consider inviting a neutral third party to facilitate the family conference.
This person could be a social worker, therapist, clergy, care manager or a friend.

Family conferences may prove helpful
in sorting out the expectations of each family member.

Community senior centers and Caregiver Resource Centers offer a wide array of services, including care managers, to help families resolve problems involving a loved one’s care.

8Resolving Problems 58

If possible, all members of the family should be invited to family conferences. Family members who can’t attend a family conference should be updated through e-mail or phone calls. Sometimes it takes time for family members to accept the deteriorating health of a loved one. Having a family conference can go a long way toward avoiding disputes and getting help for the primary caregiver.
Mediation
When families can’t reach agreement through family conferences, they may turn to outside help. Sometimes problems arise when family members disagree about basic decisions concerning a loved one’s care.

For instance, a family disagrees about where Mom should live or how her finances should be used for her care. Mediation, a type of informal problem resolution, may prove helpful in such situations.

Mediation involves the family meeting with a trained mediator. The meetings are confidential and are designed to resolve differences rather than place blame on one side or another. Mediation is unlike going to court and is relatively inexpensive. This form of problem solving is ideal for most
family caregiving issues because it encourages positive and collective decision making and
is designed to help keep the family working together, without hard feelings.

Contact the local bar association to find a mediator. Also, many city attorney offices offer free mediation services. Caregivers

should make sure to ask whether they have expertise in caregiving disputes.

Problems with Home Care Providers
Families entering into a home care service agreement should review the service provider’s contract and grievance policy. If problems arise with a care worker, it’s important that the employer provides a reliable grievance policy that will help them handle concerns quickly and responsibly.

If a problem arises, notify the employer and begin following the grievance policy. Persons who hire a independent home care aide may be required to fulfill certain contractual and legal obligations, such as providing notice for termination of the employee and paying worker’s compensation insurance.

If the issue is one of abuse or neglect, remove the person immediately and notify Adult Protective Services. (See Chapter 9, page 62, for more information on Detecting Elder Abuse and Neglect.)
Using the Courts
If problems with a hired worker can’t be resolved, or, in extreme cases, a family can’t resolve a dispute, a lawsuit may be the best option. If the amount of money or damages in question is under $10,000, individuals can file a claim in a small claims court and represent themselves.

However, legal representation may be needed in the following instances:
•to enforce a contract

59 8 Resolving Problems

•if a care agency employee has injured a loved one or caregiver
•if someone else is suing the caregiver or family
•if financial or physical elder abuse occurs.

The attorney will guide the individuals involved through litigation, a lengthy court process in which judges and juries make decisions under state law. Litigation can be expensive and time consuming. A case resolved

RESOURCES

in the court system is binding and enforceable.

Litigation is a lengthy court process in which judges and juries
make decisions under state law.

County bar associations offer lawyer referral services. Legal aid organizations provide
free legal services for persons of low income. Consult the local legal aid organization in the phone book or contact the local bar association for more guidance.

For more information on topics in this chapter, consult the following resources.

Agencies
•Bet Tzedek Legal Services: 3250 Wilshire Boulevard, 13th Floor, Los Angeles, CA 90010,
(323) 939-0506; www.bettzedek.org
•California Advocates for Nursing Home Reform (CANHR) Lawyer Referral Service: (800) 474-1116; www.canhr.org
•California Courts Self-Help Centers: www.courts.ca.gov/selfhelp.htm
•Los Angeles County Bar Association Civic Mediation Project: free mediation services; 1055 West 7th Street, 27th Floor, Los Angeles, CA 90017; (213) 896-6533, www.lacba.org/give- back/civic-mediation-project
•Los Angeles County Bar Attorney Referral and Information Service: (213) 243-1525, www.smartlaw.org
•National Academy of Elder Law Attorneys (NAELA): (703) 942-5711; www.naela.org
•Office of the City Attorney Dispute Resolution Program: 200 N. Spring Street, 14th Floor, Los Angeles, CA 90012, (213) 485-8324; www.empowerla.org/cityattorney-dispute-resolution- program
•USC Family Caregiver Support Center: (855) 872-6060; www.fcscgero.org
•State Bar of California: list of certified lawyer referral services; (866) 442-2529, www.calbar.ca.gov/Public/LawyerReferralServicesLRS.aspx

8Resolving Problems 60

CHAPTER 9 DETECTING
AND REPORTING
ELDER ABUSE AND NEGLECT

DETECTING AND REPORTING ELDER ABUSE AND NEGLECT

Elder and dependent adult abuse is a growing problem. It is critical that caregivers, their loved ones, and their family members learn how to detect elder and dependent adult abuse, so that problems can be quickly identified and reported and then handled appropriately.

This chapter discusses physical and emotional abuse, as well as various types of financial abuse that rob seniors and dependent adults of money and other possessions.
Elder and Dependent Adult Abuse Under California law, elder and dependent adult abuse is a crime and can lead to both criminal and civil penalties. Elders and dependent
adults receive added protection under the law because of the unique vulnerability of the two populations. The law provides for increased civil and criminal penalties if the victim is an elder or dependent adult.

An elder is someone aged 65 or older. A dependent adult is any person aged 18 to 64 whose physical or mental limitations restrict their ability to protect their rights or to perform regular daily activities.

Spotting Abuse and Neglect
The term elder and dependent adult abuse covers:
•physical abuse
•emotional abuse
•neglect
•self-neglect
•financial exploitation.

Physical abuse includes physical and sexual assault, unreasonable physical restraint, prolonged deprivation of food and water (unrelated to end-of-life health care decisions) and the use of unauthorized or inappropriate medication to subdue or alter a person’s emotional state.

Emotional abuse includes verbal abuse, infliction of emotional distress, isolation, confinement, or refusal of emotional support.

Neglect includes failure to help an elder or dependent adult with hygiene, to provide shelter and clothing, medical care or food and water, and to protect the elder or dependent adult from safety hazards.

Self-neglect includes the inability to care for oneself. The signs are lack of food, vermin infestation, lack of hygiene and general self disregard. Self-neglect may be a warning sign that the elder needs more help in the home or has a cognitive impairment.

Warning signs of physical abuse and neglect may include:
•unkempt or dirty physical appearance
•matted hair
•unexplained injuries like sores or bruises
•burn marks
•malnutrition
•marks on the body in the shape of an object.

9Detecting and Reporting Elder Abuse and Neglect 62

a particular caregiver or family member. The elder or dependent adult should be allowed to speak freely and have as much independence as possible.

Be wary of situations in which elders or dependent adults are kept isolated from family and friends.

While the indicators above don’t necessarily mean that the elder or dependent adult has been abused, any of the signs should be fully investigated. If the explanations of the
caregiver, family member, or service provider aren’t adequate and there is a suspicion that the loved one is being abused or neglected,
it should be reported immediately to Adult Protective Services.

Signs of emotional abuse include the person’s acting:
•withdrawn
•confused
•depressed
•angry
•frightened
•secretive.
Another clear warning sign of any type of abuse is isolation. Be wary of situations in which elders or dependent adults are kept isolated from family and friends, particularly if they aren’t allowed out of the presence of

Financial abuse includes any type of theft or embezzlement of money or property from the elder or dependent adult. Types of financial abuse can range from the theft of
small amounts of cash to tricking the elder or dependent adult into transferring property to another person. Signs of financial abuse are similar to signs of emotional abuse and include the abused adult’s acting withdrawn, confused, forgetful, angry, depressed, or isolated.

Other signs of financial abuse include:
•unusual bank account activity
•checks signed by the elder or dependent adult who later can’t remember having signed them
•purchases that the person doesn’t want or need

63 9 Detecting and Reporting Elder Abuse and Neglect

•lack of clean clothes or adequate food
•new friend who consumes much of the person’s attention and offers to manage money and assets.

Reporting Abuse and Neglect Individuals who think a loved one is in immediate danger should call 911. After the loved one is safe, other options for help
should be considered. If abuse is suspected but the loved one isn’t in immediate danger, the abuse should be reported to Adult Protective Services, local law enforcement, or the State Attorney General.

Adult Protective Services (APS), part of the California Department of Social Services, was formed to help protect elders and dependent adults from abuse in private homes, hotels, hospitals, and health clinics.

Every county in California has an APS office responsible for investigating allegations of abuse and arranging for appropriate services for the elder or dependent adult. Services include: investigating elder abuse reports, arranging for temporary shelter, providing counseling and referral services and consulting with other professionals.

Individuals who suspect that a loved one, neighbor, or friend is being abused, should report the abuse to APS. Individuals reporting

abuse are protected from criminal and civil liability, and the reporter’s name is kept confidential. It is also possible to report anonymously.

Every county in California has an APS office responsible for investigating allegations of
abuse and arranging for appropriate services
for the elder or dependent adult.

The Department of Aging, Long Term Care Ombudsman is responsible for investigating abuse that occurs in a long-term care facility, such as a nursing home, assisted living facility, board-and-care home, or similar residential facility for elders or dependent adults.
Ombudsman services are free and confidential.

The California Attorney General’s office has a task force designed to combat and prevent elder abuse. The task force specializes in dealing with financial abuse and abuse in nursing homes and other facilities.

Elder Abuse Mandatory Reporting State law requires that certain individuals report suspected abuse to the appropriate
agency. Mandatory reporters include doctors, nurses, social workers, and other health care professionals, clergy (with some exceptions), employees of health care facilities, bank employees, and anyone who assumes the care or custody of an elder or dependent adult.

Using the Courts to Protect Elders
Sometimes an elder or dependent adult needs

9 Detecting and Reporting Elder Abuse and Neglect 64

the added protection of a court, usually in the form of a temporary restraining order or conservatorship. In addition, California law provides that an abused elder or dependent
adult can sue the abuser for civil damages. Let’s examine each of these protective resources.

Elder Abuse Temporary Restraining Orders Temporary Restraining Orders (TROs) are court orders that temporarily require an abusive person to stay away from the elder or dependent adult, or else face arrest. An elder or dependent adult can ask a judge for an Elder Abuse TRO for physical abuse, neglect, abandonment, isolation, kidnapping, refusal of services, or the infliction of emotional pain. The elder or dependent adult can ask for a TRO, as can the person’s conservator
or court-appointed guardian. After a hearing, the judge can be asked to make the TRO permanent. If it becomes permanent, it will stay in effect for three years.

Although a TRO is a legal protection that police and sheriff’s officers must enforce, it isn’t a guarantee the abuser will stay away.
In some instances, the TRO may anger the abuser and escalate the situation. Applying for a TRO should be considered very carefully.

To file a TRO, go to a courthouse in your county and fill out forms EA-100 and EA-
120. The court clerk will make copies and provide instructions on how to file the completed forms, obtain a hearing and get a restraining order. For more information, visit the California Court’s website at www.courts. ca.gov/selfhelp-elder.htm.

Conservatorships
Conservatorships offer another way to receive court protection. A court will appoint a conservator for a person who cannot care for himself and needs protection from an abusive situation. Once a conservatorship is in place, the conservator is responsible for protecting the loved one from abuse, including physical, emotional, and financial abuse.

Elder Abuse and Dependent Adult Civil Protection Act
The Elder and Dependent Adult Civil Protection Act (EDACPA) is a California state law that allows elders, dependent adults, their agents, and their conservators to sue abusers for damages. Abusers can be sued for
physical and emotional abuse or neglect or for financial abuse. The law provides for damages plus reasonable attorney’s fees and costs.
The law also provides for pain and suffering damages even after the elder’s or dependent adult’s death. This helps prevent abusers from escaping liability. Consult an experienced attorney to file an elder abuse case. County bar associations have attorney referral services.
Scams Targeting the Elderly Financial abusers can be family members, caregivers, or complete strangers. There are several prevalent schemes, including international fraud rings or businesses that target elders and dependent adults for financial fraud and theft of property or
money, including telemarketing scams, home improvement scams, home equity fraud (predatory lending), estate-planning scams, and identity theft.

65 9 Detecting and Reporting Elder Abuse and Neglect

Never send money
to someone who requests it over the phone.

Then talk to trusted family members and friends about the telemarketer’s offer. Call the local Better Business Bureau or state licensing agency to verify the telemarketing company. Call the Attorney General’s Charity Registry to verify a charitable organization. Get on the National Do Not Call registry by contacting the Federal Trade Commission.

Telemarketing scams involve someone who claims to be an employee of a company
or charity and who calls to offer a chance of winning a prize or to solicit funds for a worthy cause. Some scams involve the telemarketer wanting to sell something right away at a discount, explaining that money must be sent that same day. Other
telemarketing scams involve offering loans at extremely low interest rates.

To protect against telemarketing fraud, individuals should never send money to someone who requests it over the phone. It is likely a scam if someone asks you to send money by Moneygram, Western Union, or reloadable debit cards. Take down the name and address of the company or charity and ask someone to send written materials about the offer or request.

Home improvement scams involve people offering to do work on an individual’s home, and then charging extremely high prices, doing shoddy work, or not finishing the
job at all. Often these scammers claim to be contractors with leftover materials from another job and say that fixing the person’s roof would be very cheap.

To avoid these scams, always obtain at least two other bids from reputable contractors and contact references before hiring someone to work on your home. Check to make sure the contractor is licensed and no complaints are filed. In addition, be sure to get everything in writing regarding exactly what the contractor will do and how much it will cost.

Home equity scams involve someone trying to trick individuals into borrowing more money than they can afford to repay and then taking their homes when they default on the loan.
To avoid these scams, homeowners should be wary of any lender who offers a loan based on their home’s equity instead of their

9 Detecting and Reporting Elder Abuse and Neglect 66

income, because they may not be able to make the monthly payments. Be wary as well of lenders who change terms at the last minute, pressuring homeowners to sign right away, repeatedly trying to refinance the loan, adding credit insurance to the loan, or not explaining all of the loan terms.

Individuals who think they’ve been a victim of home equity fraud should contact a legal aid organization, such as Bet Tzedek Legal Services, or the Federal Trade Commission.

Estate planning scams involve people posing as estate planning experts who offer to create a revocable living trust for a low fee. These salespeople often aren’t lawyers and aren’t authorized to create trusts or practice as an estate planner. Many estate-planning scammers try to sell annuities, using a
person’s savings, to become eligible for Medi- Cal. These “trust-mill scams” should be reported to the local District Attorney’s office or the California Department of Insurance.

Identity theft is a growing problem throughout the United States and can have drastic effects on finances and credit rating. Identity thieves steal bank account numbers, Social Security numbers, credit card numbers, and other personal information to obtain access to an individual’s cash and credit.

Identity thieves steal bank account, Social Security,
and credit card numbers to obtain access to
an individual’s cash and credit.

To avoid identity theft, individuals should always shred or tear up mail and other papers containing personal information before throwing them in the trash. People should never give out personal information to unsolicited callers, even if they claim to be from the person’s bank or credit card company. Reputable companies don’t call their customers asking for such information.

Individuals who think they’ve been a victim of identity theft should immediately contact the credit agencies and ask them to put a fraud alert on the credit report. If unauthorized activity is noted on a bank account or credit card, those companies should be notified immediately to put a fraud alert on those accounts. A complaint may also be filed with the Federal Trade Commission, which uses an Identity Theft Affidavit to notify all businesses where the defrauded individual has an account. Individuals may request a free credit report by calling the Annual Credit Report Request Service at (877) 322-8228.

Credit Agencies
Here’s a handy list of agencies that provide fraud alerts and credit reports. You might wish to clip this box and keep it in a handy place.

Agency Fraud Alerts Credit Reports
Equifax (800) 525-6285 (800) 685-1111
Experian (888) 397-3742 (888) 397-3742
Trans Union (800) 680-7289 (800) 916-8800

67 9 Detecting and Reporting Elder Abuse and Neglect

RESOURCES
For more information on topics in this chapter, consult the following resources.

Agencies
•Adult Protective Services: Los Angeles County Community and Senior Services, (877) 477-3646 (Hotline); http://css.lacounty.gov/programs/adult-protective-services-aps
•Attorney General’s Charity Registry: (916) 445-2021, www.oag.ca.gov/charities
•Bet Tzedek Legal Services: 3250 Wilshire Boulevard, 13th Floor, Los Angeles, (323) 939-0506; www.bettzedek.org
•California Attorney General’s Office: (800) 952-5225; for telemarketing and mail fraud
•California Courts: www.courts.ca.gov/selfhelp.htm; for help filing a TRO
•California Department of Consumer Affairs: (800) 952-5210; for license checks and consumer complaints
•California Department of Insurance: (800) 927-HELP (4357), www.insurance.ca.gov
•Contractors State Licensing Board: (800) 321-CSLB (2752), www.cslb.ca.gov
•Federal Trade Commission: (877) 438-4338 for identity theft and list of new scams or (877) 382-4357 for consumer information and complaints; www.ftc.gov
•Long-Term Care Ombudsman Program Crisis Line: (800) 231-4024 to report abuse at a facility
•National Do Not Call registry: (888) 382-1222, www.ftc.gov
•National Fraud Information Center: (202) 835-3323 (ext.815), www.fraud.org
•State Attorney’s Task Force on Elder Abuse: (800) 952-5225 to report suspected abuse or financial scams; or (800) 722-0432 to report Medi-Cal provider fraud or elder abuse in long-term facility
•State Bar of California: (866) 44-CA-LAW (22-529) for referral to a local certified attorney referral service
•Wise and Healthy Aging Fraud Support Group, (310) 394-9871 ext. 373

Print
•A Citizen’s Guide to Preventing and Reporting Elder Abuse: (800) 952-5225 or www.ag.ca.gov/bmfea/pdf/citizens_guide.pdf
•Elder Abuse and Dependent Adult Civil Protection Act (EDACPA), Welfare and Institutions Code sections 15600 et seq

9Detecting and Reporting Elder Abuse and Neglect 68

CHAPTER 10
SUPPORTING THE CAREGIVER

SUPPORTING THE CAREGIVER
Caring for a loved one can be rewarding for both the caregiver and elder or dependent adult. However, caregiving can also be physically and emotionally exhausting as well. Caregivers may feel anger, resentment, depression, exhaustion, and isolation. The keys to successful caregiving include staying healthy, maintaining autonomy and privacy, and having support from family and friends.

This chapter discusses how to obtain support for caregivers, how caregivers can remain healthy, and how to make a transition from home to an assisted living facility
or nursing home.

Family and Friends
Caregivers and the people they care for need the support of family and friends. One of the first steps any caregiver should take is to arrange a meeting with all family members and friends willing and able to participate in caregiving. The caregiver and loved one should take inventory of the kinds of help required and which friends and family members can best provide it.

That help may include sharing caregiving duties or providing financial support, equipment, or certain skills. Caregivers must avoid isolating themselves and the loved one they care for. Support from family and friends can drastically reduce the level of physical, emotional, and financial stress on the caregiver and their loved one. Some people may want to seek the advice and support
of their clergy or congregation.

Some people may want to seek the advice and support
of their clergy or congregation.
Support Groups
In support groups, caregivers can learn more about caregiving, share strategies, resources, and learn how to deal with stress. Support groups are offered through a variety of agencies and organizations devoted to caregiving for seniors and dependent adults. Support groups are conducted in many languages and are also available on the internet.

California has many Caregiver Resource Centers that serve countywide areas.
These centers focus on individuals with

10Supporting the Caregiver 70

brain impairments, such as Alzheimer’s disease, stroke, Parkinson’s disease, and brain injuries resulting from an accident.
Alzheimer’s Greater Los Angeles, Leeza’s Care Connection, USC Family Caregiver Support Center, hospitals, adult day care centers, Department of Veterans Affairs, and senior centers also offer support groups.
Caregiver Health
Caregiving is often associated with health problems, including stress and depression. Although caring for a loved one doesn’t cause health problems itself, caregivers often feel

stressed and neglect their own health to take care of a loved one. That can lead to frequent illness, lack of sleep, anxiety, isolation, high levels of stress, depression, alcoholism, or drug abuse.

Caregivers who have learned coping and management skills tend to feel less stressed. In addition, those who have family and friends who visit and help out tend to feel less anxiety, isolation, and depression.

Caregivers who have learned coping and management skills tend to feel less stressed.

Caregiver Tips for Reducing Stress

If you’re a caregiver, here are five steps you can take to help reduce the stress of caring for a loved one.
•Ask for support, and when offered, accept it. Talking to family and friends about caregiving is important. Take time to socialize and talk about other things.
•Set aside time to relax, have fun, and get away from caregiving. Remember that wanting time for yourself or time away from the caregiving situation doesn’t mean that you’re a poor caregiver. Time away from caregiving helps you stay healthy and happy. It also allows your loved one time to have a break too.
•Take care of yourself physically. Adequate sleep, exercise, and healthful eating are all essential for maintaining

energy, warding off illnesses, and reducing stress.
•Learn as much as possible about your loved one’s illness. Knowing about the illness helps you manage your loved one’s care better because you’ll be more aware of what happens during the illness and why.
•Use respite care as often as possible to take a break from caregiving duties. Adult day care provides an opportunity for a loved one to visit with peers. Your loved one can attend an adult day care center for activities during the day. Or have friends and family visit with your loved one while you take a break outside of the home. Respite care services can also be used for a few days to allow time for the caregiver to visit other family or take a short vacation.

71 10 Supporting the Caregiver

family member being cared for must have a serious medical condition, and the employee must have worked at the agency or company for at least one year.

The Family and Medical Leave Act requires employers to grant
up to 12 weeks of unpaid leave to an employee who has to care for a new child or an ill immediate family member.

After the 12 weeks are over, the employee is guaranteed to return to his old job or to a different job at the same level and pay scale.

Laws and Policies that Help Caregivers
Caregivers are often working full-time jobs when the need for caregiving arises. Federal and state laws, and now workplace policies, help caregivers navigate work and caregiving issues. Here’s a look at some of those laws and policies.

Family and Medical Leave Act
The Family and Medical Leave Act (FMLA) is a federal law requiring employers to grant up to 12 weeks of unpaid leave to an employee who has to care for a new child or an ill immediate family member (spouse, parent,
or child). The FMLA applies to all public agencies (federal, state, and local) and private companies with at least 50 employees. The

Paid Family Leave Program
California’s Paid Family Leave Program pays workers up to 6 weeks of partial pay a year when taking time off from work to care
for a new child or ill family member. Most people receive just over half (55%) of their usual pay, up to a maximum $1129 per week, while on leave.

The program is part of the State Disability Insurance (SDI) program, and the benefits are paid entirely by employees through payroll deductions. The program pays benefits to the caregiver while she takes family leave to care for an ill spouse, registered domestic partner, child, or parent. It also pays benefits for leave due to a newborn child or new adoptive or foster child.

Tax Deductions
Caregivers who pay for loved one’s bills and expenses may be eligible for tax deductions

10 Supporting the Caregiver 72

for caregiving. These bills can include nursing home costs, doctor visits, caregiver expenses and transportation. Consult a tax professional for advice on these issues.

Flexible Workplace Policies
Flexible workplace policies are becoming more popular among employers and employees. Flexible time allows workers to modify typical work day hours or work from home. Some workplaces also offer on-site support groups and adult day care, leaves
of absence, and flexible spending accounts. Flexible time policies can provide much- needed support for caregivers.

When people decide to care for a loved one, they should investigate employment laws and rights that apply to caregivers, as well as their own employer’s benefits and policies.
Caregivers should make a list of important issues to discuss with their employer and try to negotiate changes in their workload or schedule, where appropriate. They should also request access to any caregiving benefits the employer provides.
Transitions to Other Placement Sometimes families decide that caregiving at home is no longer an option. The current caregiving situation may become unmanageable for the caregiver, loved one, and family. Making a decision to stop
caregiving in the home can be difficult, but it may help prevent further problems.

Common reasons to make the transition from home to an assisted living center or nursing

home include caregiver burnout, safety of the caregiver or loved one, and unavailability of a caregiver.
Making a decision
to stop caregiving in the home can be difficult, but it may help prevent further problems.
Placement Options
There are several placement options depending on the level of care the loved one needs, including senior housing, retirement communities, assisted living facilities, and skilled nursing facilities. Let’s look at them one by one:
•Independent retirement communities and senior housing may offer individual units with group meals and social activities. Non- profit groups and the Housing and Urban Development (HUD) Authority operate senior housing. Rent is calculated on a sliding scale, based on the senior’s income. Senior housing buildings also provide housing to disabled persons under age 65.
•Assisted living facilities provide independent living environments with supervision and non-medical care. These facilities may be referred to as rest homes, retirement homes, or board-and- care homes. They’re usually private pay only, with prices ranging from $7000
to $10,000 per month. The Medi-Cal Assisted Living Waiver (ALW) pays for care in participating facilities. The ALW is limited to certain counties, including Los Angeles. Call the ALW at (916) 552-9322

73 10 Supporting the Caregiver

for more information. Some long-term care insurance policies reimburse for assisted living. A limited number of facilities accept persons who receive Supplemental Security Income (SSI). See Chapter 3, Financial Strategies to Pay for Home Care, page 22, for more information on SSI.
•Skilled nursing homes provide medical and nursing care, custodial care, and 24-hour supervision for residents in a
medical setting. Skilled nursing homes have full-time nurses and doctors available to oversee care. Nursing homes in California charge between $3500 and $8000 monthly.
Medicare pays for short-term (100 days or less) nursing home stays for patients requiring skilled nursing care. Long Term Care Medi-Cal pays for long-term stays in nursing homes. Long term care insurance

may also pay for long-term nursing home stays. Nursing homes also accept private pay patients. Due to the high cost of nursing homes, many people in nursing homes receive Long Term Care Medi-Cal.

Assisted living facilities provide independent living environments with supervision and non-medical care.

Both assisted living facilities and nursing homes must be licensed by the State of California. For more information on these care facilities, order a copy of Bet Tzedek’s guides “Assisted Living Companion” and “Nursing Home Companion” by calling (323) 939-0506 or download at www.bettzedek.org/resources.

10 Supporting the Caregiver 74

RESOURCES
For more information on topics in this chapter, consult the following resources.

Agencies
•California Advocates for Nursing Home Reform: (800) 474-1116; www.canhr.org
•California Paid Family Leave Program: (877) BE-THERE (23-84373)
•California Property Tax Postponement at State Controller’s Office: (800) 952-5661, www.sco.ca.gov, then click on ‘Public Services’
•California State Franchise Tax Board: (800) 852-5711
•Employment Development Department, for information on state disability insurance: (800) 480-3287
•Assisted Living Waiver: (916) 552-9322, www.dhcs.ca.gov/services/ltc/pages/alwpp.aspx
Print
•Assisted Living Companion and Nursing Home Companion, Bet Tzedek, (323) 549-5897, www.bettzedek.org
Caregiver support
•Alzheimer’s Greater Los Angeles: support groups at www.alzgla.org; (844) 435-7259 Helpline
•Caregiver Action Network: (202) 454-3970, www.caregiveraction.org
•Family Caregiver Alliance, National Center on Caregiving: online support groups at www.caregiver.org; (800) 445-8106
•Leeza’s Care Connection: (818) 847-3686; www.leezascareconnection.org
•National Alliance for Caregiving: (301) 718-8444, www.caregiving.org
•USC Family Caregiver Support Center: (855) 872-6060; www.fcscgero.org
•Veterans Affairs Caregiver Services: (800) 827-1000, www.caregiver.va.gov

75 10 Supporting the Caregiver

APPENDICES

APPENDIX A: GLOSSARY

Adult Day Care Center: a facility that provides social and recreational activities and sometimes basic medical care for the elderly and disabled

Adult Day Treatment Center:
a facility that provides social, recreational, and basic medical and psychiatric care for people with psychological or psychiatric problems

Adult Protective Services (APS): a state agency that investigates and protects elders and dependent adults from abuse
in private homes, hospitals, and health care facilities

Advanced Health Care Directive:
a legal document that allows individuals to express their wishes about their future health care

Affiliated Home Care Aides: aides employed by a Home Care Organization. These aides must pass a criminal background check and register with the Department of Social Services Home Care Aide Registry

Against Medical Advice: a form signed by a patient that acknowledges that he or she has decided to be discharged even though the person has been told that doing so may cause mental or physical harm

Aid Paid Pending: a term used to indicate that Medi-Cal benefits continue
to be paid until the person receives a state hearing

Alzheimer’s Association Safe Return Program: a nationwide identification system designed to assist in the safe return of people who are cognitively impaired and who become lost after wandering away

Alzheimer’s Day Care Resource Center: a facility that specializes in programs for persons with Alzheimer’s disease or a related dementia and are equipped to handle people who wander, are incontinent or aggressive

Area Agency on Aging (AAA):
a government agency that coordinates a wide array of services to seniors and adults with disabilities at the community level and serves as the focal point for local aging concerns

Assets: the entire property owned by a person; can include cash, stock, inventories, property rights, and insurance policies

Attorney-in-Fact: an agent who, through a power of attorney, acts on behalf of a patient and is legally allowed to make decisions for that person

Bond: a type of insurance policy that compensates the consumer for theft or loss

Caregiver Resource Center:
an organization that provides support, information, and education to individuals providing care to adults with brain impairments due to disease or injury

Glossary 78

Caregiver: an individual who cares for a disabled, ill, or elderly person. Can be family, a friend or a paid worker

Cash Assistance Program for Immigrants (CAPI): a state program that provides cash assistance to aged, blind, or disabled immigrants with legal resident status and low income

Chore Worker: an individual who provides basic housekeeping services, such as cleaning, cooking, and driving for the elderly or disabled

Codicil: an amendment added to an existing will

Community Medi-Cal: a type of Medi- Cal insurance designed to help those who live in the community, either in their own home, with family, in an assisted-living or board- and-care facility

Community Registry: a list of private home care workers looking for employment; usually maintained by home care agencies or senior centers

Conservatee: a person whom a judge has decided is unable to handle his own
affairs and for whom a conservator has been appointed

Conservator: a person appointed
by the court to manage the affairs of an individual who is not capable of managing his own affairs

Conservatorship: the process through which a judge appoints a conservator to make legal, financial, and/or health care decisions for a conservatee

Conservatorship Over the Estate: a type of conservatorship that allows a conservator to manage financial and legal matters for a conservatee

Conservatorship Over the Person: a type of conservatorship that allows a conservator to manage the conservatee’s
personal care, such as where the person lives, and health care decisions

Countable Assets: property that can be readily converted to cash, such as bank accounts, stocks, and certain investments

Curative Health Care: medical care designed to cure or alleviate disease

Dependent Adult: a person aged 18 to 64 who has a physical or mental disability that restricts the ability to protect his or her rights or to perform regular daily activities

Durable Power of Attorney for Finances: a document that allows an individual to appoint a trusted relative or friend, who can then manage the individual’s finances immediately or at some future time

79 Glossary

Elder Abuse Restraining Order: a civil protective order which an elder or dependent adult can apply for and obtain to prevent someone from physically, emotionally or financially abusing them

Elder and Dependent Adult Civil Protection Act: a California state law that allows elders, dependent adults, and their conservators to sue abusers for physical and emotional abuse, neglect or financial abuse

Emergency Do Not Resuscitate Order: a form that instructs paramedics or other emergency medical services (EMS) personnel to withhold emergency resuscitation

Emotional Abuse: a form of abuse that includes verbal abuse, infliction of
emotional distress, confinement, or refusal of emotional support

Employee Assistance Programs: programs offered by some workplaces to assist employees who are caregivers or patients; may include counseling, legal services, information and referrals

Equity: the difference between the amount a person’s house is worth and the amount the person owes for the house

Estate: all personal property, real estate, money, stocks, and any other property owned by a person at the time of death

Executor: a individual named in a will to oversee the distribution of property and follow other directions in the will

Family and Medical Leave Act (FMLA): a federal law requiring certain employers to grant up to 12 weeks of unpaid leave to an employee who needs to care for a new child or an ill family member

Fast-Track Appeals: a type of Medicare appeal designed for people whose health will be seriously injured if they don’t receive
requested medical treatment or for individuals receiving services from a skilled nursing facility, home health agency, or outpatient rehabilitation facility

Fiduciary Duty: a responsibility of an agent to use utmost care in handling money for
an incapacitated person and acting in that person’s best interest

File of Life Card: a card that lists important medical information for quick reference in an emergency. Paramedics are trained to look for this card on the refrigerator

Financial Abuse: a theft or embezzlement of money or property from an elder or dependent adult

Flexible Time: a work program that allows workers to modify typical workday hours or work locations

Geriatric Assessment:
a comprehensive evaluation performed by a multidisciplinary team used to develop a care plan for therapy and long term follow up

Geriatric Care Manager:
a professional with a specialized focus on aging and elder care. They assist older adults and their families in designing plans of care to

Glossary 80

maximize independence and well being of the older adult

Geriatrician: a doctor who specializes in the medical needs of older adults. A geriatrician is an expert in dealing with multiple medical problems and chronic illnesses

Grantor: a person who creates a trust

Handwritten Will: a legally valid will that has been written entirely by hand and dated and signed by the person making the will.
No witnesses are required. Also called a holographic will

Handyworker Program: a program that offers free home repairs to low-income seniors and disabled persons living in the City of Los Angeles

Health Maintenance Organization (HMO): a managed care health plan that requires patients to see a doctor within a contracted HMO network

Holographic Will: another name for a handwritten will

Home Care Aides: see Affiliated Home Care Aide and Independent Home Care Aide

Home Care Organization
an organization that provides home care workers at an hourly rate

Home Secure: a program that offers free home assessment and home modifications to low-income seniors and disabled persons living in the City of Los Angeles

Hospice: a program that provides comfort care for terminally ill patients in a health care facility or the patient’s home

HUD (U.S. Department of Housing and Urban Development): a federal program whose mission is to increase homeownership, support community development and increase access to affordable housing free from discrimination

Identity Theft Affidavit: a form developed by the Federal Trade Commission that can be used to report identity theft to financial institutions

Identity Theft: the theft of Social Security numbers, credit card numbers, or of other personal information to obtain access to an individual’s cash or credit

Incapacity: the lack of mental functioning to understand one’s condition and the inability to make informed decisions about one’s own personal care, property or finances

Independent Home Care Aides: aides who work independently and not through an agency

In-Home Supportive Services (IHSS): a state benefit that provides home care to individuals who live at home and need help with some daily activities, such as bathing, dressing, toileting, or housecleaning

Intestate Succession:
the distribution of an estate to a deceased person’s next of kin in accordance with state inheritance laws, used when no will exists

81 Glossary

Irrevocable Living Trust: a trust created while a person is living and has the ability to make decisions about property and money and that cannot be changed or revoked

Litigation: a court process in which judges and juries make decisions under state or federal law

Long Term Care Medi-Cal: an insurance program in California that pays for care in a nursing home

LPS (Lanterman-Petris-Short) Conservatorship: a conservatorship in mental health court allowing for the
involuntary treatment of a mentally ill adult

Mandatory Reporter: an individual required by state law to report suspected abuse; includes doctors, nurses, social workers, and other health care professionals; clergy, with some exceptions; employees of health care facilities; bank employees; and anyone who assumes the care or custody
of an elder or dependent adult

Mediation: a form of informal problem resolution

Medi-Cal: a California state insurance program that provides vital health and long- term care coverage for low-income children, their parents, elderly, and disabled Californians

Medicare: a federal government sponsored health insurance program, generally reserved for the elderly and disabled

Medicare Summary Notice:
a Medicare document used to explain the reason for benefits provided or denied and details how to appeal the decision

Medigap Policy: a private health insurance policy designed to supplement Medicare coverage

Multi-Purpose Senior Services Program (MSSP): a program that provides social and health care management for frail, elderly persons who wish to live at home instead of a nursing home

Neglect: Failure to adequately assist an elder or dependent adult with personal hygiene, or to provide food, clothing, shelter or needed medical care

Notice of Action: a letter sent by Medi-Cal informing the recipient of a change in benefits and explaining appeal rights

PACE: Program of All-Inclusive Care for the Elderly. A Medi-Cal and Medicare program which provides comprehensive care for older adults who require nursing home care but wish to stay at home

Paid Family Leave Program:
a California program that pays workers up to 6 weeks of partial pay a year when taking time off from work to care for a new child or ill family member

Palliative Care: comfort care provided to a terminally ill individual

Glossary 82

Payable on Death Beneficiary:
a bank account designation which transfers assets on death to a designated beneficiary. Does not go through the probate process

Petition: to make a request of a court of law

Physical Abuse: physical or sexual assault, unreasonable physical restraint, prolonged deprivation of food and water (unrelated to end-of-life health care decisions), or the use of unauthorized or inappropriate medication to subdue or alter a person’s emotional state

Physician Orders for Life-Sustaining Treatment (POLST): a form stating a patient’s medical treatment wishes regarding end-of-life care

Power of Attorney for Health Care and Health Care Instruction: a form in which a person appoints an agent to make health care decisions should the person become incapacitated

Principal: the person who creates a power of attorney and names an agent

Probate: a court process in which a person’s will is reviewed for its validity, creditors are paid, and the balance of assets are distributed to heirs

Property Tax Postponement: in counties that have adopted the program, this county- run program allows low-income individuals to postpone paying some or all of their property taxes until they move, sell the home, or die

Protective Supervision: an IHSS benefit to protect individuals who have mental impairments and who need to be watched 24 hours a day, to ensure their safety

Representative Payee: a person authorized to manage Social Security, Supplemental Security Income (SSI) or Veteran’s Administration checks for another individual.

Request for Hearing: a form used to appeal a Medi-Cal decision

Respite Care: temporary relief for caregivers caring for someone who is ill, injured or frail. Respite care can be provided in an adult day care center, the home, or other settings

Reverse Mortgage: a type of home loan the borrower does not have to repay
as long as she lives in the home

Revocable Living Trust: a trust created while a person is still living and has the ability to make decisions about property and money. Can be revoked or changed prior to a person’s death or incapacity

Right of Survivorship: ownership rights in joint tenancy property in which the survivor owns the entire account or property on the death of the joint owner. Does not go through probate

Self-Neglect: a person who endangers himself by failing to adequately care for himself

83 Glossary

Senior Center: a community center that provides activities, meals, limited health monitoring, transportation, and social services to seniors

Skilled Care: health care provided
by a professional, such as a doctor, nurse, therapist, social worker, or counselor

Special Needs Trust: a type of trust in which a trustee has complete control over the distribution of trust income and the beneficiary has no control. Commonly used for developmentally disabled individuals receiving SSI or Medi-Cal

State Disability Insurance:
a California state program that provides disabled persons up to one year of partial wages if unable to work due to disability

Statutory Will: in California, a simple “fill in the blanks” will used for people with relatively small estates

Supplemental Security Income (SSI): a federal Social Security program that gives additional income to seniors and disabled people who live below the poverty line

Support Group: a group of people, sometimes led by a therapist, who provide each other with moral support, information, and advice on problems relating a shared experience, such as caregiving

Testamentary Trust: a trust created through a will which must go through the probate process

Testator: an individual who creates a will

Trust: a legal entity that holds property

Trustee: an individual who manages trust property for a beneficiary and who holds a duty to the trust and beneficiary to make good business decisions and protect the trust assets

Will: a legally binding document that directs how a person’s estate will be distributed
on death

Worker’s Compensation Insurance: a program that provides medical insurance and disability benefits for people who are injured on the job

Glossary 84

APPENDIX B: MSSP SITES
This table, adapted from the California Department of Aging, shows Multipurpose Senior Services Program agencies and contact information, county-by-county. Information can also be obtained by calling the California Department of Aging at (800) 510-2020 or on-line at www.aging.ca.gov/programs/mssp.asp.

County Agency Phone
Alameda City of Oakland Department of Human Services (City of Oakland only)
City of Fremont Human Services Department (510) 238-3762

(510) 574-2050
Alpine Area 12 Agency on Aging (209) 532-6272
Amador Area 12 Agency on Aging (209) 532-6272
Butte California State University—Chico (530) 898-5082
Calaveras Area 12 Agency on Aging (209) 532-6272
Contra Costa Office on Aging (925) 335-8710
El Dorado Department of Human Services (530) 621-6300
Fresno Fresno-Madera Area Agency on Aging (559) 453-6494
Glenn California State University—Chico (530) 898-5082
Humboldt Humboldt Senior Resource Center (707) 443-9747
Imperial Work Training Center, Inc. (760) 352-6181
Inyo Inyo-Mono Area Agency on Aging (760) 873-6364
Kern Aging and Adult Services (661) 326-0105
Kings Kings-Tulare Area Agency on Aging (559) 730-9921
Lake Community Care Management Corp. (707) 995-7010
Lassen Golden Umbrella (530) 226-3097
Los Angeles City Jewish Family Service of Los Angeles (323) 937-5930
SCAN Independence at Home (562) 492-9878

85 MSSP Sites

APPENDIX B: MSSP SITES
(continued)

County Agency Phone
Los Angeles City/County Altamed Health Services Corp. (323) 889-7862
Los Angeles Huntington Hospital (626) 397-3110
Human Services Association (562) 806-5400
Partners in Care Foundation (818) 837-3775
Partners in Care Foundation-South (818) 370-6777
Madera Fresno-Madera Area Agency on Aging (559) 453-6494
Marin Jewish Family and Children Services (415) 491-7960
Mariposa Area 12 Agency on Aging (209) 532-6272
Mendocino Community Care Management Corp.—Ukiah (707) 468-9347
Community Care Management Corp.—Fort Bragg (707) 964-4027
Merced Human Services Agency (209) 385-3000
Modoc Golden Umbrella (530) 226-3097
Mono Inyo-Mono Area Agency on Aging (760) 873-6364
Monterey Department of Social and Employment Services (831) 755-3403
Napa Area Agency on Aging (707) 644-6612
Orange Social Services Agency (714) 825-3000
Orange CalOptima (888) 587-8088 or
(714) 246-8400
Placer UC Davis Care Management (916) 734-5432
Riverside Office on Aging (951) 697-4697
Sacramento UC Davis Care Management (916) 734-5432
San Bernardino Aging and Adult Services (909) 891-9019

MSSP Sites 86

APPENDIX B: MSSP SITES
(continued)

County Agency Phone
San Diego Aging and Independent Services (800) 339-4661 or
(800) 510-2020
San Francisco Institute on Aging (415) 750-4150
San Joaquin Department of Aging (209) 468-2202
San Mateo Department of Health Services (650) 573-3900
Santa Barbara MSSP Unit (805) 346-8385
Santa Clara Council on Aging of Silicon Valley (408) 296-8290
Santa Cruz Human Resources Agency (831) 454-4600
Shasta Golden Umbrella (530) 226-3097
Siskiyou Golden Umbrella (530) 226-3097
Solano Area Agency on Aging (707) 643-5170
Sonoma Area Agency on Aging (707) 565-5970
Stanislaus Department of Social Services (209) 558-2233
Tehama California State University—Chico (530) 898-5082
Trinity Golden Umbrella (530) 226-3097
Tulare Kings-Tulare Area Agency on Aging (559) 730-9921
Tuolumne Area 12 Agency on Aging (209) 532-6272
Ventura Area Agency on Aging (805) 477-7300
Yolo UC Davis Care Management (916) 734-5432
Yuba Health and Human Services (530) 749-6775

87 MSSP Sites

APPENDIX C: PACE PROGRAMS

Program of All-Inclusive Care for the Elderly (PACE) centers can currently be found only through these agencies. PACE Programs are limited by geographic area. Please look for a PACE program in your area.

•Redwood Coast PACE 1910 California Street Eureka, CA 95501
(707) 443-9747
www.humsenior.org
•On Lok Lifeways
1333 Bush Street
San Francisco, CA 94109 (415) 292-8888
www.onlok.org
•Center for Elders’ Independence
1955 San Pablo Avenue Oakland, CA 94612
(510) 433-1150
www.cei.elders.org
•Sutter SeniorCare 1234 U Street Sacramento, CA 95818 (916) 446-3100
http://www.checksutterfirst.org/ seniorservices
•Fresno PACE 2042 Kern Street Fresno, CA 93721 (559) 400-6420 www.fresnopace.org
•AltaMed Senior BuenaCare 5425 East Pomona Boulevard Los Angeles, CA 90022
(323) 728-0411
www.altamed.org

Brandman Centers for Senior Care
7150 Tampa Avenue
Reseda, CA 91335
(818) 774-8444
www.brandmanseniorcare.org
•InnovAge PACE
410 Parkcenter Circle
San Bernardino, CA 92408 (909) 366-4230
myinnovage.org/ProgramsandServices/ InnovAgeGreaterCalifornia-PACE.aspx
•CalOptima
505 City Parkway
Orange, CA 92868
(714) 246-8500
www.caloptima.org
•St. Paul’s PACE
111 Elm Street
San Diego, CA 92101 (619) 677-3800
www.stpaulspace.org
•San Diego PACE 3364 Beyer Boulevard San Ysidro, CA 92173 (619) 205-4585

For additional information, please go to www.calpace.org

PACE Programs 88

APPENDIX D: CAREGIVER RESOURCE CENTERS

Family Caregiver Alliance
Bay Area Caregiver Resource Center Statewide Resources Consultant 180 Montgomery Street
Suite 1100
San Francisco, CA 94104 (415) 434-3388 or
(800) 445-8106
E-mail: info@caregiver.org Website: www.caregiver.org
Counties: Alameda, Contra Costa, Marin, San Francisco, San Mateo,
and Santa Clara

Coast Caregiver Resource Center
1528 Chapala Street
Suite 302
Santa Barbara CA 93101 (805) 962-3600
(887) 488-6555
E-mail: info@coastcrc.org Website: www.coastcrc.org
Counties: San Luis Obispo, Santa Barbara, and Ventura

Del Mar Caregiver Resource Center
1537 Pacific Avenue
Suite 300
Santa Cruz, CA 95060 (831) 459-6639 or
(800) 624-8304 (regional) E-mail: hpc@hpcn.org
Website: www.delmarcaregiver.org Counties: Monterey, San Benito,
and Santa Cruz

Del Oro Caregiver Resource Center
5725D Marconi Avenue Carmichael, CA 95608
(916) 971-0893 or
(800) 635-0220 (regional) E-mail: crc@deloro.org Website: www.deloro.org
Counties: Alpine, Amador, Calaveras, Colusa, El Dorado, Nevada, Placer, Sacramento, San Joaquin, Sierra, Sutter, Yolo, and Yuba

Inland Caregiver Resource Center
1420 East Cooley Drive Suite 100
Colton, CA 92324
(909) 514-1404 or
(800) 675-6694 (CA)
E-mail: info@inlandcaregivers.org Website: www.inlandcaregivers.com Counties: Inyo, Mono, Riverside,
and San Bernardino

LA Caregiver Resource Center
3715 McClintoch Avenue Los Angeles, CA 90084 (855) 872-6060
www.fcscgero.org (800) 540-4442

89 Caregiver Resource Centers

APPENDIX D: CAREGIVER RESOURCE CENTERS
(continued)

Passages Caregiver Resource Center
25 Main Street
Room 202
Chico, CA 95259
(800) 995-0878
(530) 229-0878
Email: MCRC@csuchico.edu Website:
www.caregiverresources.org/MCRC_home Counties: Butte, Glenn, Lassen, Modoc,
Plumas, Shasta, Siskiyou, Tehama, and Trinity

Caregiver Resource Center of Orange
130 West Bastanchury Road Fullerton, CA 92835
(714) 446-5030 or
(800) 543-8312 (CA)
E-mail: ocrc@stjoe.org Website: www.caregiveroc.org County: Orange

Redwood Caregiver Resource Center 1140 Sonoma Avenue Suite 1B
Santa Rosa, CA 95401 (707) 542-0282 or
(800) 834-1636 (regional)
E-mail:rcrc@redwoodcrc.org Counties: Del Norte, Humboldt, Lake,
Mendocino, Napa, Solano, and Sonoma

Southern Caregiver Resource Center 3675 Ruffin Road
Suite 230
San Diego, CA 92123 (858) 268-4432 or
(800) 827-1008 (CA)
E-mail: scrc@caregivercenter.org Website: http://caregivercenter.org Counties: Imperial and San Diego

Valley Caregiver Resource Center
3845 North Clark Street Suite 201
Fresno, CA 93726
(559) 22-9254 or
(800) 541-8614 (regional) E-mail: info@valleycrc.org Website: www.valleycrc.org
Counties: Fresno, Ken, Kings, Madera, Mariposa, Merced, Stanislaus, Tulare and Tuolumne

Caregiver Resource Centers 90

INDEX

A–B
Adult day care centers, 4-5, 78 Adult day health care centers, 5 Adult day treatment centers, 5, 78
Adult Protective Services, 64, 78
Advanced health care directives, 40-42, 78 appointing agent for, 41
completing forms for, 42 do-it-yourself, 41
giving agent specific instructions for, 41-42 health care instruction only and, 42
vs. conservatorships, 44 when effect of, begins, 43
Against medical advice, 78 Aid Paid Pending, 78
Medi-Cal appeal and, 16
Alzheimer’s Association Safe Return Program, 78 Alzheimer’s day care resource centers, 5, 6, 78
Area Agency on Aging, 29, 78 Assisted living facilities, 74 Attorney-drafted will, 51-52
Attorney-in-fact, 78

C
CAPI, 25, 79
Caregiver, 78
discontinuing home care and, 73-74 education and training for, 33
family and friends as support source for, 70 health problems associated with, 71
law and policies that can help, 72-73 resource center for, 78, 89-90
stress-reducing tips for, 71 support groups for, 70-71 Care managers, role of, 36-37
Cash Assistance Program for Immigrants, 25, 79 Chore workers, 4, 79
Codicil, 79
Community Medi-Cal, 79
Community registry of home care workers, 29 Conservatee, 79
Conservator, candidate for, 44, 79
Conservatorship, 43-44, 79

mental health conservatorship, 44 over estate, 54, 79
over the person, 43, 79 as protective measure, 65
vs. advanced health care directives, 44 Credit reports, agencies that provide, 67

D
Dependent adult, 79 Dependent adult abuse, 62-67
conditions that constitute, 62
protecting dependent adults from, 65-67 reporting, 64
warning signs of, 62-64 Discharge planners, role of, 35
Do Not Resuscitate orders, 40, 42, 43
Durable Power of Attorney for Finances, 48-49, 79 vs. conservatorships over estate, 54

E
Elder abuse and neglect, 62-67 conditions that constitute, 62 protecting elders from, 65-67 reporting, 64
warning signs of, 62-64
Elder Abuse Temporary Restraining Orders, 65
Elder and Dependent Adult Civil Protection Act, 65, 80 Emergency alert response systems, 33
Emergency Do Not Resuscitate form, 42, 43, 80
Emotional abuse, 62
signs of, 63
Employee assistance programs, 34, 80 Estate claims, Medi-Cal and, 17 Estate planning, 50-54
Estate planning scams, elders and, 67 Executor, 80
Expenses, reducing, 22

F
Family disputes, resolving, 58-59 Family Medical Leave Act, 3, 72, 80
Fast-track Medicare appeal, 12, 80
File of Life Card, 33, 80

91 Index

INDEX

Financial abuse, 63, 80
signs of, 63-64
Financial decision making, 48-54 Financial documents, organizing, 33, 34 Fraud alerts, agencies that provide, 67
G
Geriatric care managers, role of, 36-37, 80 Geriatricians, role of, 35-36, 81
Grants for home care, 22

H
Handwritten will, 51, 81
Handyworker Program, 25, 81 Health care decision making, 40-44
informal, 43-44
Health care documents, organizing, 33, 34
Health care instruction, 40, 41, 42, 83 Health maintenance organization, 81
Medicare and, 11
Holographic will, 51, 81 Home care
assessing loved one’s needs and, 2-3 average costs of, 10
discontinuing, 73-74
financial strategies to pay for, 22-25 grants for, 22
hospice care and, 4 improving quality of, 32-37 loans for, 22
Medi-Cal and, 12-16
Medicare and, 10-12
as option, 3
providers of, 3-4, 28-30 research studies and, 37
Home care aides
how to find, 28-30
licensing and certification of, 30 tips for hiring, 29
Home care organizations, 28-29 choosing, 29
Home care providers, resolving problems with, 59 Home equity line of credit, 22-23
Home equity loan, 22

Home equity scams, elders and, 66-67 Home health agencies, 28
choosing, 29
Home improvement scams, elders and, 66 Home safety precautions, 32
Home sale, 24
Home Secure program, 32, 81
Hospice care, 4, 81
Medi-Cal and, 14
Medicare and, 11

I
Identity theft, elders and, 67, 81
Independent home care aides, 4, 29, 83 Independent retirement communities, 73
In-Home Supportive Services, Medi-Cal and, 13-14, 81 Intestate succession, 50, 81
Irrevocable living trust, 53, 82

J–K
Joint bank accounts, 49

L
Lanterman-Petris-Short Conservatorship (LPS), 44, 82 Legal decision making, 48-54
Legal planning, considerations for, 48 Legal representation, need for, 60
Lifeline as emergency alert response system, 33 Litigation, problem resolution and, 59-60, 82 Loans for home care, 22
Long term care, Medi-Cal and, 13, 82 Long term care insurance, 17
Loved one
assessing needs of, 2-3 home care as option for, 3-4
time off from work to care for, 3, 72 LPS Conservatorship, 44, 82
M
Managed care, Medicare and, 11 Mandatory reporting of elder abuse, 64, 82 Mediation of family disputes, 59, 82
Medi-Cal, 12-17, 82
appealing decision of, 16-17

Index 92

INDEX

eligibility for, 13 estate claims and, 17
home care services and, 13-16 long term care and, 13
Medicare, 10-12, 82 appealing decision of, 12 benefits provided by, 10 eligibility for, 10-11
Fast Track Appeals, 12, 80
HMOs and, 11
home health services and, 11 summary notice from, 12, 82 supplementing coverage of, 11-12
Medigap, 11-12, 82
Money management programs, 50
Multi-purpose Senior Services Program, 15, 82 county-by-county contact information for, 85-87 Institutional Deeming Waiver and, 16
Medi-Cal and, 15-16

N
Neglect, 62, 82
warning signs of, 62 Non-medical services, 4
Notice of Action, Medi-Cal appeal and, 16, 82

P–Q
PACE, 16, 82, 88
Paid Family Leave Program, 3, 72-73, 83
Palliative care, 4, 83
Physical abuse, 62, 83 warning signs of, 62
Physician Orders for Life-Sustaining Treatment, 40, 43, 83
Placement options, 73-74
POLST, 40, 43, 83
Power of Attorney for Health Care, 40, 41, 83 Power of Attorney for Finances, 48, 54 Primary care physicians, role of, 34-35 Probate, 50, 83
property not covered by, 52
Program of All-Inclusive Care for the Elderly, 16, 82 contact agencies for, 88
Property Tax Postponement Program, 83

Protection of elders by court, 65-67 Public benefits, eligibility for, 24

R
Representative payee, 49-50, 83
Request for Hearing, Medi-Cal appeal and, 16 Research studies, home care improvement and, 37 Respite care, 14, 71, 83
Reverse mortgages, 23, 83
Revocable living trust, 53, 83

S
Scams, elders as targets for, 65-67 Self-neglect, 62, 84
Senior centers, 5, 84
Senior housing, 73
Skilled care, 11, 84 Skilled nursing homes, 74 Special needs trust, 53, 84
State disability insurance, 84 Statutory will, 51, 84
Supplemental Security Income, 24-25, 84

T–U
Tax deductions, caregiver and, 73 Telemarketing scams, elders and, 66 Temporary Restraining Orders, 65 Testamentary trust, 53, 84
Trustee, 84
Trusts, 52-53
special needs, 53
types of, 53

V
Veteran’s benefits, 19, 25

W–Z
Waiver programs, Medi-Cal and, 14-15, 16
Wills, 51-52, 84
property not covered by, 52 types of, 51-52
Worker’s compensation, 18, 84
Workplace policies, 73

93 Index

NOTES

94

NOTES

95

OUR MISSION

Bet Tzedek provides free legal assistance to thousands of people who would otherwise be denied access to the legal system underpinning our democracy.

Bet Tzedek (Hebrew for “The House of Justice”) was founded in 1974 by a few individuals who sought to act upon a central tenet of Jewish law and tradition which appears in the Bible:
“Tzedek, tzedek tirdof—Justice, justice you shall pursue.” This doctrine decrees that it is the duty of all men and women to advocate the just causes of the poor and helpless.

Although Bet Tzedek remains intent on ensuring that the legal needs of the Jewish poor are met, we recognize that it is our duty to serve the entire community. For this reason, Bet Tzedek has always provided assistance to all eligible needy residents of Los Angeles County, regardless of their racial, religious or ethnic background.

Indeed, at Bet Tzedek, we believe that all of the groups in our wonderfully diverse society are strengthened when bridges are built that bring us together in a common, just cause. For the people who are Bet Tzedek—the lawyers and non-lawyers, staff members and volunteers, contributors and clients—our mission, therefore, is to pursue equal justice for all.

Attachment BetTzedek2016CaregiverCompanion.pdf

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