LAST WEEK, I told the story of my mother’s last few years on the planet, only because it illustrates how long-term care can work, given certain circumstances.
This week, I’d like to backtrack on some of those circumstances, playing “what if.”
Meaning, what if some of those circumstances had been different?
How might the whole thing have played out then?
A few things you need to remember in order for this to make any sense: She was single, lived alone, owned her home (well, paying a mortgage) and we had a durablepower of attorney (DPOA) in place.
Let’s start there: Because we had the DPOA, I was able to get her doctor to sign-off on her being “incapacitated” and, thus, was able to transact business and begin making medical decisions on her behalf that same day.
What if we hadn’t had the DPOA?
My only choice would have been to pursue a guardianship through the courts.
True, there would have been no real question as to the outcome, but it would have been stressful, time-consuming and expensive.
And life would have become very complicated while the wheels of justice turned.
Next, you may recall that we eventually ascertained that she was not going to “rehab back” from a right-brain stroke, so would require 24/7 care forever.
Consequently, we were looking at placement in a skilled nursing facility. But what if some of the circumstances had been different?
What if there had been a reasonably well spouse in the picture?
And what if I’d had siblings (I’m an only child, to no one’s great surprise) or other family in the area?
Might we have been able to keep her at home?
Answer: Very probably.
Assuming that spouse and family could have provided the backbone of her care (which was not, for the most part, skilled medical care) and given the fact that she would have qualified for Medicaid in-home care, it probably could have worked.
Let’s back-up.
Assuming that Mom’s and her spouse’s income and assets didn’t exceed certain limits (which are more inclusive than you might think, but I’m not going to get into that level of detail right now), she would have qualified for Medicaid in-home care, which would have provided (among, potentially, some other things) a paid caregiver to come in and provide care for a certain number of hours per month, so the entire burden wouldn’t have been on spouse and family.
She could have transferred her assets (e,g, one-half interest in the house, etc.) to her well spouse.
Why would she do that? Well, remember “Medicaid estate recovery,” known colloquially as “… the state will take the house?”
Well, how that really works is that, upon the death of certain Medicaid clients at or above certain ages (again, I’m sparing you the detail, in the name of understanding the big picture), the state has the right to reclaim the amount of money it paid out for Medicaid care, from the estate; so, if she’d transferred all of her assets to her spouse, there would have been no estate, get it?
In that scenario, then, what if she had needed some skilled medical care, which she obviously would have received in a nursing home, but now she’s at home?
How would that have worked?
Well, if we (family/friends/neighbors) couldn’t have gotten her to the necessary medical appointments without a major logistical undertaking, her doctor could have ordered Home Health to come to the home and provide skilled nursing care, paid for by Medicare.
(Note: Yes, a person can be on both Medicaid and Medicare at the same time. It’s referred to as “dual-eligible,” and can provide some distinct benefits to the person.)
Now, let’s be honest: Would all of this have been easy? No.
And even given the best-intentioned assistance by local family/friends/neighbors plus a talented, Medicaid-paid caregiver, the lion’s share of her care would have fallen on her spouse.
That’s just the truth of it. All day and night includes 3:30 a.m. just as much as it does 3:30 p.m., so that’s just how it goes, but it would have been possible.
The fact is, there are hundreds of people and families all over the state who are making this kind of scenario work every day.
Might she have eventually required placement into a facility, simply because spouse plus family just couldn’t do it any longer, or the care she required just got to be too much?
Maybe, and if that came to pass, Medicaid would have paid for her nursing home care.
Again, this is “big picture” stuff, and let’s face it: Not all families, and not all spouses, are able to take on this kind of extended, very personal care. Very personal care. And there can be any number of very good reasons for that, so I’ll be the last to rush to any judgments.
The point here is simply to illustrate how some of this stuff can work.
And as you may recall, this is not what happened with my mom.
It just wasn’t possible, so the only option was skilled nursing facility care, and I’ll tell you this: I never saw her experience poor, negligent or disrespectful care.
True, I was in and out of that nursing home a lot.
And, true, I made darned sure that the Long-Term Care Ombudsman program was aware of her placement (that’s a story for another day), so they were another source of “eyes and ears” (and friendly faces) on the scene, so things went as well as they possibly could, under the existing circumstances.
I’ll close with two things:
• Remember her two small, fat dogs?
Well, she had gotten them from a rescue group, whom I contacted after the stroke.
These wonderful folks came and got those two small, fat dogs immediately and found them a loving home — together.
I was very grateful for that.
• I visited her in the facility a lot.
Sometimes, she knew who I was, so we could just be who we were.
Sometimes, she didn’t, but even then, she knew I was somebody whom she liked.
I was very grateful for that.
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Mark Harvey is director of Clallam/Jefferson Senior Information & Assistance, which operates through the Olympic Area Agency on Aging. He is also a member of the Community Advocates for Rural Elders partnership. He can be reached at 360-452-3221 (Port Angeles-Sequim), 360-385-2552 (Jefferson County) or 360-374-9496 (West End), or by emailing harvemb@dshs.wa.gov.
