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Thursday, November 20, 2014

Supporting an Older Relative: A Surprising Tax Benefit

Many people may not be aware of a powerful tax benefit that exists within
their families. Those who financially support an older relative may be able to
claim them as dependents.

Our society is changing. Over the past ten years, older parents have begun moving
in with their adult children at increasing rates. In 2000, 4.1 percent or 2.3 million
aging parents were living with family. By 2007, the number had jumped to 6.5 percent or 3.6 million. Today, multigenerational households are burgeoning (AsYouAge 2013), and many who support these aging Americans are missing an important tax benefit.

It is called the Personal Exemption. The value varies from year to year. In 2013 the personal exemption was worth $3,900, and in 2014 it increases to $3,950. In many instances, those who support older adults financially are able to claim them as dependents or seniors can claim themselves. Taking advantage of this powerful tax benefit requires knowledge of the support received by the older adult and how much seniors support themselves. In this article, individuals will discover who can claim a senior as a dependent and under what circumstances.

For older adults who claim themselves as dependents, the value can be more than the personal exemption. In addition to claiming the personal exemption, those age sixty-five and older can claim an added $1,200, and an additional $1,200 if they are blind.
Blindness is the only physical impairment that allows the additional personal exemption amount. For married couples, this is a double real benefit. For example, Reg and Chickie are both over age sixty-five and Chickie is blind. Their personal exemption
for 2014 would be:

Only taxpayers who claim their own personal exemption—meaning they are not claimed as a dependent by someone else—can get the additional age and blindness exemptions.

But if you cared for an older parent, your parent may qualify as your dependent, resulting in additional tax benefits for you.

The first thing that often comes to mind when considering dependents is the parent/child relationship. Normally, parents claim their children as dependents until they become adults. It also works the other way around. If you cared for an older parent, your parent
may qualify as your dependent, resulting in additional tax benefits for you. Once you determine that both of you meet IRS criteria, you can claim your parent as a dependent on your tax return and claim their Personal Exemption on your tax return.

The First Test is the Income Limitation
A parent must first meet income requirements set by the Internal Revenue Service to be claimed as a dependent. To qualify as a dependent, the parent must not have earned or received more (income) than the personal exemption amount for the tax year. Again,
this amount is determined by the IRS and may change from year to year. The current exemption amounts can be found in IRS Publication 501. For 2014, the personal
exemption amount is $3,950. Generally, Social Security is not counted as income, but there are exceptions. If a parent has other income from interest or dividends, a portion of the Social Security may also be taxable. 

Example 1: My mother, Minnie. Minnie only has Social Security income and draws $18,000. Because this amount is under the threshold for taxing , Minnie does not need to file a tax return. Her taxable income is below the personal exemption amount of $3,950 for 2014, and she could be claimed on someone else’s tax return.

Example 2: My aunt, Millie. Aunt Millie came to live with me in January 2014 and I am her total support. Her health prohibited her from living alone However, she did not want to sell her home, always wishing and hoping she could return to it one day. She rented her home for $350 a month but the insurance, repairs, and yard maintenance exceed the income. Because her gross income is $4,200 ($350 x 12 months), I cannot claim Aunt Millie as a dependent. 

Her $4,200 of gross income from the rental of her former home exceeds the personal exemption amount of $3,950 for 2014.

Example 3: Gale and her grandchildren. Gale has custody of her two grandchildren, Julie and Brian. The assets of their deceased parents were placed in a simple trust where Julie and Brian are the beneficiaries. The terms of the simple trust dictate that all income
made by the trust assets is distributed to the beneficiaries.But if the income distributed by the trust exceeds $3,950 for Julie and/or Brian, Gale cannot claim them as dependents.

If Gale adopted Julie and Brian, the income would not be a factor and she could claim them as “qualifying children,” unless their income from the trust supported them greater than 50 percent.

The Second Test is the Support Requirement
Adult children must have provided more than half of their parent’s’ support during the tax year in order to claim them as dependents. When determining the monetary value of the amount of support they provide, they need to consider several factors. 

First, calculate the fair market value of the room the parents occupy. That is, how much rent could be charged for the space? 

Next, consider the cost of food provided. Do not forget to include utilities, medical bills, and general living expenses, as well as the cost of transportation for the parents. This includes transportation to doctor appointments, attendance at church or synagogue, as
well as for recreation. If structural improvements were made to a home to accommodate a disabled relative, such as a wheel-chair ramp or modifications to bathroom facilities among others, the costs may qualify as medical expenses, to the extent they do not improve the value of the home. Compare the value of support you provide with any income, including Social Security, that your parent receives to determine whether you meet the support requirement. The amount of support provided must exceed the parents’ income by at least one dollar and therefore be greater than 50 percent.

Relatives Who Do Not Have to Live with You All Year
The residency test. In most instances, the person claimed as a dependent must live in your home all year. A person related to you in any of the following ways does not have to live with you all year as a member of your household to meet this test.
  • A child, stepchild, foster child, or a descendant of any of them. A grandchild would be an example.
  • A brother, sister, half brother, half sister, stepbrother, or stepsister.
  • A father, mother, grandparent, or other direct ancestor, but not a foster parent.
  • A stepfather or stepmother.
  • A son or daughter of your brother or sister.
  • A son or daughter of your half brother or half sister.
  • A brother or sister of your father or mother.
  • Your son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law, or sister-in-law.
It should be noted that none of these relationships that are established by marriage are ended by death or divorce.

For example, Frank and Marie were the caregivers and supporters of Marie’s father, John. Marie died in 2013 but Frank continues to support and care for her father. Although John was Marie’s father, the relationship between Frank and John did not end with her death. If qualified, Frank can continue to claim John as a personal exemption on his tax return for 2014. 

What about temporary absences? A person is considered to live with you as a member of your household during periods of time when they are temporarily absent due to special circumstances such as: 

  • Illness
  • Education
  • Business
  • Vacation
  • Military service

If the person is placed in a nursing home or care facility for an indefinite period of time to receive constant medical care, the absence may be considered temporary.

Death or Birth
A person who died during the year, but lived with you as a member of your household until death, will meet this test. A person doesn't need to be alive the entire year to be claimed as a full-year dependent. If a dependent died during the year and you otherwise
qualify to claim the personal exemption for the dependent, you can still claim the exemption.

Example: My mother, Minnie, died on January 15, 2014. She met the tests to be my qualifying relative. The other tests to claim an exemption for a dependent were also met, and I am able to claim the personal exemption for her on my tax return. The personal exemption is not prorated, but the full $3,950 is allowed although she did not live all year. 

Head of Household
A taxpayer using the Head of Household filing status is entitled to use the head of household tax rates, which feature wider tax brackets. Also, the taxpayer is entitled to a larger standard deduction ($9,100 for tax year 2014) than taxpayers using Single or Married Filing Separately ($6,200 for tax year 2014). Head of Household is a filing status for individual United States taxpayers. To use the head of household filing status, a taxpayer must:
  • be unmarried or considered unmarried as of the last day of the tax year;
  • have paid more than half the cost of keeping up a home for the tax year (either one’s own home or the home of a qualifying parent);
  • in most cases have a qualifying person who lived with the head of household in the home for more than half of the tax year except if the qualifying person is a dependent parent.

Deducting Medical Expenses
If you paid for your parent’s medical care, the expenses may be deductible. They can be claimed as itemized deductions on Schedule A. Itemized deductions are beneficial when they exceed the amount of the standard allowable deduction. Total medical expenses,
including the cost of prescription drugs, equipment, hospital care, and doctor’s visits, must exceed 10 percent of adjusted gross income to be claimed. The IRS understands the heavy burden that medical expenses sometimes create, and has made an exception
for this deduction.

You can deduct your parent’s medical expenses even if they do not meet the income requirement to be claimed as your dependent, as long as you provide more that half of their support. 

Example: My mother, Minnie. Minnie makes too much money for me to claim her as a dependent. But if I support her greater than 50 percent, I can claim her medical expenses I paid on my Schedule A, Itemized Deductions on my tax return.

People sixty-five and older have an exclusion of 7.5 percent of income from the amount they can claim as medical. Taxpayers under age sixty-five have a 10 percent of income exclusion. This provision of the Affordable Health Care Act is in effect until 2017 when
all taxpayers fall under the 10 percent exclusion. However, if I claim Minnie’s medical expenses on my tax return, Schedule A, Medical, I am still subject to the 10 percent of adjusted gross income exclusion unless I, too, am sixty-five or older.

Dependent Care Credit. The child and dependent care credit is a non-refundable tax credit. It can be claimed by taxpayers who pay for the care of a qualifying individual and meet certain other requirements. If parents are physically or mentally unable to care for
themselves, they are qualifying individuals.

In order to qualify for the credit, you must meet certain requirements. You need to have earned income and work-related expenses to qualify. This means that the care must have been provided while you were either working or looking for work. In addition, you must be able to properly identify the care provider. This includes giving the provider’s name, address, and identifying number (either Social Security number or employer identification number to the IRS on your tax return). If you are married but file a separate return, you may not claim this credit.

The cost of home care, which enables the taxpayer to work elsewhere, can be applied towards a medical expense deduction or the Dependent Care Credit, but not to both. Usually, it is advantageous to apply these expenses up to the maximum amount ($3,000) toward a dependent care credit and the remainder as medical expense deductions. However, this may not always be the case. It is advisable to seek a tax professional to
determine which is more advantageous.

In 2013, twenty-eight states have some version of the Federal Child and Dependent Care Credit. These states allow tax filers to deduct a percentage of their federal tax credit from their state tax returns. If the dependent care tax credit in your state is 50 percent of the federal amount and your federal credit is $1,050, you can also deduct $525 for your state taxes. Many states apply a range of percentages based on the income of the person claiming the older adult as a dependent. Some states limit the credit for higher-income taxpayers, allowing only 35 percent of their federal credit. Your state’s website will be a good source of information about this potential credit.

Claiming a Dependency Exemption under a Multiple Support Agreement
Multiple Support Agreements are a little-known boon to taxpayers with older dependents. Many seniors who may qualify as dependents go unclaimed on federal income tax returns each and every year. Although there are no statistics on unclaimed individuals (neither the IRS or the U. S. Census Bureau have these numbers), many who financially support seniors may fail to claim their personal exemptions because they do not know about the Multiple Support Agreeement. 

Even if you do not provide more than half the support of another person, you may still qualify for a dependency exemption ($3,950 in 2014) if you have a multiple support agreement. This agreement applies if you contribute more than 10 percent of the person’s support and, together with others, contribute more than 50 percent of the person’s support. Then each of the other supporters who contribute more than 10 percent
must agree among themselves who will claim the exemption (it cannot be prorated among the supporters). Only one person can claim the exemption.

Example: You and your three sisters support your mother. You contribute 40 percent and the other sisters each contribute 15 percent, and your mother contributes 15 percent toward her own support. 

Since you and your sisters contribute more than half of your mother’s support (40 + 15 + 15 + 15 = 85 percent), a multiple support agreement can be used for one of you to claim your mother as a dependent and receive her personal exemption. 

Any one of you may claim your mother as a dependent, but only one of you each year, and this can be done on alternating years. IRS Form 2120 Multiple Support Agreement must be signed by all who contribute greater than 10 percent to the parent’s support. Contributing more than 10 percent is a requirement to claim the dependent.

A worksheet for determining support in order to claim an older adult as a dependent and receive a personal exemption can be found at Once completed, the worksheet will determine who can claim the older adult. It should be
retained, with documentation to support the schedule, with the tax records of the individual making the claim. Taxpayers in the top tax brackets will experience the phase-out, a provision of the tax code that reduces itemized deductions and personal exemptions, sometimes to zero, simply because of the amount of their income.

A knowledgeable and trustworthy tax professional can be the most valuable asset in determining who can and should claim an older adult as a dependent. Financial advisors should be aware of these tax benefits and refer their clients to tax professionals
for assistance. •CSA

Beanna Whitlock is an Enrolled Agent in private practice as Whitlock Tax Service, LLC, in Reno, Nevada. She is an adjunct professor at Auburn University, and is a faculty member at the National Center for Professional Education. She has been honored by Accounting Today as one of the 100 Most Influential in Accounting for an unprecedented seven years. Contact her at Beanna@, or see

Supporting an Older Relative: A Surprising Tax Benefit was recently published in the Summer 2014 edition of the CSA Journal.

Blog posting provided by Society of Certified Senior Advisors

Monday, November 17, 2014

Home and Community Based Services: A Broader View

Navigating the myriad of resources available to older adults in need of special services can be daunting. This article covers them in detail.

Those who are new to the aging industry often find themselves confused by the world they have entered. Even experienced service providers have difficulty understanding how to weed through the labyrinth of the “continuum of care.” As a professional advisor, you know your clients wish to remain active, healthy, and independent but are unsure how to find resources to assist them with that goal. 

To make things more complicated, older adults have different needs based upon their stage of life. You may be working with older seniors (not boomers) who deal with issues such as: Should I still be living in my current home? If not, where should I be living? Am I safe in my environment? Should I be driving? How do I get to the doctor? Will I have enough money to survive through my final years? These same questions and others may be initiated from the family member or caregiver.

Boomers may be in a different phase of life, but still be unsure where to go to get help. They may be unemployed when it is difficult to find a job and are not old enough to qualify for Medicare.  Sometimes they find themselves members of the “sandwich generation” who are still supporting children while taking care of their older parents. Perhaps they are looking for a way of reinventing themselves by finding opportunities that allow them to apply their skills and talents in a new  environment. How do they deal with these challenges in meaningful ways? 

With the growing numbers of older adults, it is important for advisors to be aware of the resources available in their communities to help these individuals. These services are defined by the public sector as Home and Community-Based Services (HCBS). However, it is important that service providers understand there are many public and private resources available for their clients. To better serve older adults, providers should consider realigning their existing paradigms of what services are available and developing a broader knowledge of home and community-based services.

The Common Perception of Home and Services

HCBS allow people of all ages who have limitations to remain independent in the least restricted settings possible, and to be connected with their communities. Both of these defined goals are critical to an older person’s quality of life. They need to be independent and they need to feel connected to the community in order to have balance and meaning. 

Some people identify HCBS as publicly supported services serving the low-income, older adult population. Although there may be some services under publicly supported HCBS that are paid for with private-funding, the majority of publicly-funded services are paid for through publicly funded sources. These services are available to all older adults, but typically are provided based on the greatest need. 

The National Association of States United for Aging and Disabilities (NASUAD) defines HCBS as “services or other supports to help people with disabilities of all ages to live in the community.” Each state has a mix of public programs and funding sources. The Medicaid program pays for many of these public services in all states. There are also other federal, state, and local dollars that fund home and community-based services, including the Social Services Block Grant (SSBG), Older Americans Act (OAA), Education and Rehabilitation funds, and State General Funds (NASUAD Clearinghouse). 

In 1965, Congress passed three important pieces of legislation that, over time, would shape and define the nation’s approach to its growing older population: Medicare, Medicaid and the Older Americans Act (OAA) (Niles-Yokum and Wagner 2011).

Over the last forty-eight years, the OAA has been largely responsible for the development of the public aging network and services. These services are administered and overseen by fifty-six State Units on Aging and 629 Area Agencies on Aging (AAAs) across the nation. The Congressional authors viewed the role of AAAs to include identifying the priority service needs of the age sixty-plus population in their communities, developing plans of action to address those needs, and serving as visible advocates with and on behalf of older Americans. 

Each AAA has evolved in the context of a unique social, economic, and political environment. Further, AAAs are flexible and take advantage of emerging opportunities and “climates for success” to mount new initiatives or expand services that support the health and independence of those sixty and older, especially the most frail and vulnerable, and their caregivers. Consequently, no two AAAs are alike. Yet, the OAA provides the umbrella uniting them in a common mission with a common set of roles and responsibilities (National Association of Area Agencies on Aging 2011). Existing programs and services provided through the aging network have been categorized as follows (Niles-Yokum and Wagner 2011):
  • Home-based and community-based long-term care
  • Elder rights protection 
  • Health, prevention, and wellness 
  • Special projects
AAAs either provide these services directly or contract with providers to provide the services identified in Figure 1. AAAs often serve as the pass-through for Older Americans Act funds, contracting with local service providers to provide the actual services for older adults. Many of these services are provided through the network of senior centers across the country. The National Institute of Senior Centers states there are over eleven thousand senior centers nationally. These entities are either nonprofits or run through local governments, providing services that include meal programs, transportation to and from the centers, case management and assistance programs, as well as social and fitness activities.

The Broader Picture of HCBS

It is clear that the publicly provided HCBS are an important resource to assist older adults. However, a relatively small proportion of the older population receives services directly funded by the Older Americans Act (O’Shaughnessy 2011). Most older adults receive care from family, friends, public and/or private agencies. These existing networks provide services for older individuals in most communities around the country. Service providers, working in what is called the “continuum of care,” meet many people’s needs (Tenenbaum 2010).

In addition to publicly funded home and community-based services, many are paid for with private monies and service fees. Demand for services in the private sector have grown annually an average of 5.1 percent from 2009-2014 resulting in an industry revenue total of $14 billion (IBISWorld 2014). This trend supports the growth of the private service sector including services such as adult day care, non-medical home care or homemaker services, social activities, group support and companionship services. The U.S. Bureau of Labor Statistics states jobs for home-care workers (home-health aides and personal-care aides) are projected to increase 70 percent—1.3 million from 2010-2020, much faster than average. In fact, these are two of the projected fastest growing occupations in the United States (currently at 1.9 million nationally). 

Privately-funded services are typically found in senior resource directories under varying categories, but some can list up to fifty categories of senior resources. For example:
  • Living Arrangements: adult day care, assisted living facilities, nursing homes, hospice care, independent living, continuing care retirement communities, active adult living, housing referral service, moving and relocation services.
  • Estate Services: elder law, estate planners, financial planners, funeral services, reverse mortgages, insurance providers.
  • Health, Prevention and Wellness: hospitals, physicians, non-medical home care, medical home health, geriatric care management, companion services, health clubs, fitness programs, chiropractors, personal trainers, nutritionists, dietitians, physiotherapists, occupational therapists.
  • Medical Supplies: assistive devices, health products, foods & supplements, medical equipment.
  • Home Maintenance and Delivery: home maintenance, home modification, house cleaning, grocery delivery, meal delivery.
  • Transportation: medical and non-medical transport services.
  • Employment: jobs for seniors, civic organizations, training organizations.
  • Volunteering: senior volunteering programs, community volunteering organizations.
  • Education: aging advocacy, education for seniors, lifelong learning programs.
  • Information and Resource Referrals: resource centers, care managers, and others.
Why Understanding the Broader Picture is Important: Silos of HCBS Services

Though many services may be available, piecemeal development of HCBS over a long period of time largely explains why the services do not always work in coordination with each other. Additionally, programming and funding have emerged from an array of congressional appropriations, state programs, nonprofit grants, private enterprise, and community initiatives. The service providers’ inspirations and intentions, background, mission, and purpose are equallyvaried. Neither funding nor providers are developed for comprehensive care on an at-home basis (Tenenbaum 2010).

Public funding for home and community-based care comes from different departments, agencies, and levels of government, sometimes described as “silos” because operationally they are self-contained and vertical. Funding and services from non-profits and foundations are organized around missions, goals, and funding priorities. Private-pay providers organize their services around a skill set or resources they can manage well. This is fair because all of these provider organizations are meeting their purposes, charters, and goals to provide a program or service. However, none are mandated to consider or provide the whole continuum to match client needs, which is the optimal situation for a service consumer (Tenenbaum 2010). As a result, people are often unaware of available resources to help them address their needs.

Resources to Find HCBS

As an advisor to older adults, connecting your clients with resources to help them remain independent can be confusing. Questions you may need to ask yourself include: What specific services does my client need to remain independent? Does my client qualify for publicly-supported programs and services? If so, is there a waiting list for these services? How accessible are existing aging resources for my client? How affordable are privately-developed services for my client? You may not feel comfortable addressing these issues with your clients. If so, consider referring them to a geriatric care manager or a local AAA. Many AAAs have Aging and Disability Resource Centers (ADRC), which can help them find existing services.

Aging and Disability Resource Centers

Information and referral resources are available from multiple public and private organizations. As a result of the 2006 amendment called “Choices for Independence,” Aging and Disability Resource Centers (ADRCs) are growing across the nation. Tied to Area Agencies on Aging, ADRCs look to better coordinate services and assist consumers across the age spectrum to access them.

The ADRC program, a collaborative effort of the Administration for Community Living (ACL), formerly Administration on Aging or AoA, the Centers for Medicare and Medicaid Services (CMS), and now the Veterans Health Administration (VHA), supports state efforts to streamline access to long-term services and support (LTSS) options for older adults and those with disabilities. ADRCs simplify access to LTSS, and are a key component to long-term care systems reform (ACL 2013). ADRCs are known to be “No Wrong Door (NWD)” or “Single Entry Point (SEP)“and are designed to serve as highly visible and trusted places available in every community across the country where people of all ages, incomes, and disabilities go to get information and one-on-one counseling on the full range of LTSS options. Nationally, ADRC programs have taken important steps towards meeting AoA (now ACL) and CMS’s vision by:
  • Creating a person-centered, community-based environment that promotes independence and dignity for all.
  • Providing easy access to information and one-on-one counseling to assist consumers in exploring a full range of long-term support options.
  • Providing resources and services that support the needs of family caregivers.
As a CSA, you should locate one of the 629 national Area Agencies on Aging in your region to ensure you are connecting your clients with available aging resources and services through the ADRC program. In addition, you should educate those connected with AAAs and ADRCs about your services. 

The HCBS resource chart lists home and community-based resources that will help you connect your clients and their family members with solutions. •CSA

Erika T. Walker, MBA, MSeD, CSA, is owner and CEO of SAGE WAVE Consulting, LLC, in Gainesville, Georgia. She conducts strategic planning with businesses and
communities across the country, helping them to prepare for the growing aging population. With over twenty-five years of experience, she has served as Director of the SAGE Institute and Director of Geriatrics at Greenville Hospital System. She may be contacted at 678-971-4778,, or at

Home and Community Based Services: A Broader View was recently published in the Summer 2014 edition of the CSA Journal.

Blog posting provided by Society of Certified Senior Advisors

Wednesday, November 12, 2014

Hospice Care in America:What You May Not Know

The concept of hospice is often misunderstood and many people really don't know what it is. This article dispels the myths with concrete facts and figures.

Hospice is not a place—it’s a program of care that focuses on comfort and quality of life for those who need it. Since its humble beginnings in 1974, hospice care in America has grown into an integral part of the health care fabric of the nation through the work of more than 5,300 hospice agencies. During its brief history, hospice care is now considered the model for quality, compassionate care for individuals facing a life-limiting illness with a focus on caring, not curing. “Hospice makes sure that people receive comfort, love and respect during one of life’s most significant experiences—the journey of life’s end,” says J. Donald Schumacher, PsyD., president and CEO of the National Hospice and Palliative Care Organization (NHPCO). Hospice is able to achieve this by providing expert medical care, pain management, and emotional/spiritual support expressly tailored to the patient’s needs and wishes. At the same time, support is provided to the patient’s loved ones as well, including a minimum of one year of bereavement support.

This focus on caring, not curing, is provided primarily through family members with the integrated skills of an interdisciplinary team of professionals. Teams consisting of the patient’s personal physician, hospice physician/medical director, nurses, home health aides, social workers, clergy/spiritual counselors, bereavement counselors, trained volunteers, and various therapists (physical, occupational) if needed, are available via phone or home visits as scheduled or needed. Some hospices even provide 24/7 one-on-one care at special palliative care units in hospitals or stand-alone facilities. Most notable is the fact that all of these professionals provide their skills at the home of the patient, where the vast majority of patients prefer to be. An important part of hospice service is the focus on the wishes and needs of the patient and the family. Once those are determined, the hospice team then sets up a customized care plan to accommodate those wishes and needs, with the appropriate interdisciplinary team members, and schedules the hospice visits to fulfill the care plan.

The National Hospice and Palliative Care Organization (NHPCO) is the largest membership organization representing hospices in the U.S. with 3,400 organizations throughout all fifty states, the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands. The following information from the “2012 NHPCO Facts and Figures: Hospice Care in America” is provided as a brief snapshot of the current hospice environment, which should be of interest to all Certified Senior Advisors.


An estimated 1.65 million patients received hospice care in 2011 representing a 17.9 percent increase since 2007. Of this 1.65 million, 1.06 million or approximately 44.6 percent of all deaths in the U.S. were under hospice care. 

Of all the hospice deaths, 66.4 percent received care in the place the patient called home including private residences (41.5 percent), nursing homes (17.2 percent),  and residential facilities (7.3 percent). Hospice inpatient facilities accounted for 26.1 percent, while acute care hospitals accounted for only 7.4 percent. In addition to providing home hospice care, approximately 20 percent of hospice agencies also operated a dedicated inpatient unit or facility. Most of these facilities are either freestanding or located on a hospital campus. Short-term inpatient care can be made available when pain or symptoms become too difficult to manage at home, or the caregiver needs respite.

There are several different types of hospice agencies. The majority are independent, freestanding agencies (57.5 percent). Hospital systems account for 20.3 percent, home health agencies (16.8 percent) with nursing homes accounting for the remaining 5.2 percent. Of these agencies, 32 percent of the active Medicare hospice providers are nonprofit, while 63 percent are for-profit, and the remaining 5 percent are owned and operated by federal, state, or local government agencies. 

Hospices range in size from very small all-volunteer agencies that care for fewer than fifty patients per year to large, national chains that care for thousands of patients each day. One measure of agency size is total admissions over the course of the year. In 2012, 77.4 percent of all hospices had fewer than five hundred total admissions; 17.7 percent had between 501-1,500 admissions and 4.9 percent had over 1,500 admissions per year.

Length of Service

Length of service (stay) is the total number of days that a hospice patient receives care in a hospice setting. It is influenced by a number of factors including disease course, access to care, but most notably timing of the referral to a hospice program. Even though hospice services are available to patients with life-threatening illnesses that a physician determines have a life expectancy of six months or less, the average length of service in 2012 was only 71.8 days, with over 35 percent of all hospice patients dying within the first seven days of hospice access and an additional 27 percent dying between eight and twenty-nine days. On the other side, 11.5 percent of all hospice patients continued hospice access past one hundred and eighty days via recertification from a physician.

How Are Hospice Services Paid For?

The Medicare hospice benefit, enacted by Congress in 1982, is the predominant source of payment for hospice care in America (84 percent). Other payment sources for hospice benefits are managed care/private insurance (7.7 percent), Medicaid hospice benefit (5.2 percent), uncompensated/charity care (1.3 percent), self-pay (1.1 percent) and other payment sources (0.7 percent). 

Hospice Benefit Eligibility Requirements

The criteria most often utilized for admission into a hospice program is if the patient has been certified as being terminally ill by a physician and having a prognosis of six months or less if the disease runs its normal course. In order to qualify for the Medicare hospice benefit, the patient must be entitled to Medicare Part A.

Services Provided to Patients and Families

Among its major responsibilities, the interdisciplinary hospice team:

• Manages the patient’s pain and symptoms.

• Assists the patient and the family with the emotional, psychological, and spiritual aspects of dying.

• Provides needed drugs, medical supplies, and equipment.

• Instructs the family on how to care for the patient.

• Delivers special services, such as speech and physical therapy when needed.

• Provides bereavement care and counseling to surviving family and friends.

Since hospice services were introduced in the U.S., families constantly express their gratitude for the services and support that hospice provides them. They praise hospice for allowing patients to be in control of their own end-of-life journey in an environment of their own choosing, and that is conducive to bringing both the patient and family together and offering closure. Others appreciate the personal assistance and support of the interdisciplinary team members and their willingness to be at the patient’s and family’s side during the final stages of life.

Characteristics of the Hospice Patient

In 2011, 83.3 percent of all hospice patients were sixty years of age or older with more than one-third being over eighty-five. Females accounted for 56.4 percent of all hospice patients with 43.6 percent being male. White/Caucasian patients accounted for 82.8 percent of hospice patients, Black/African American, 8.5 percent; Multiracial/Other, 6.1 percent; Asian/Hawaiian/Pacific Islander, 2.4 percent; and American Indian/Alaskan Native, 0.2 percent.

When hospice care in the U.S. was first established, cancer patients made up the largest percentage of hospice admissions. In 2011, cancer represented only 37.7 percent of the primary diagnoses. The top four non-cancer primary diagnoses were: debility unspecified, 13.9 percent; dementia, 12.5 percent; heart disease, 11.4 percent; and lung disease, 8.5 percent. HIV/AIDS accounted for only 0.2 percent of all primary diagnoses.

Bereavement Support

For a minimum of one year following a patient’s death, grieving family members can access bereavement education and support through their hospice provider. In 2011, for each patient death, an average of two family members received bereavement support from their hospice provider, including follow-up phone calls, visits, and mailings. In addition, most hospice providers offer some level of bereavement services to communities that accounts for about 14.3 percent of those served by hospice bereavement programs.

Volunteer Commitment

The U.S. hospice movement was founded by the labor of volunteers and there is continued commitment to volunteer service no matter the size of the hospice provider. The NHPCO estimates that in 2011, 450,000 hospice volunteers provided twenty-one million hours of service by spending time with patients/families, providing clerical and other service support, and helping with fundraising efforts and/or board of director duties. Note that Medicare conditions of participation require volunteers to provide at least 5 percent of total patient care hours. With society placing increased emphasis on the importance of compassionate, end-of-life care for its citizens, CSAs and other professionals who work with older adults and their families can assist their clients by offering them hospice resources as a vital part of their end-of-life planning. •CSA

Douglas Wagemann has been involved with hospices nationally and internationally for thirty years. He is a certified funeral service practitioner and a certified cemetery funeral executive. He is currently on the board of directors of the National Hospice Foundation and the Foundation for Hospices of Sub-Sahara Africa. He can be contacted at

Hospice Care in America:What You May Not Know was recently published in the Summer 2014 edition of the CSA Journal.

Blog posting provided by Society of Certified Senior Advisors

Monday, November 10, 2014

Senior Living Decisions: Motivating Factors and Fear of Change

When circumstances make it clear that it’s time for some older adults to make changes in their living situations, the decision can be difficult if not traumatic. Helping them through the process requires trust and understanding of the person’s needs and fears.

"I'm just starting to look into different senior living services and options.”

This is typically the first thing someone says when inquiring about senior living services. As many senior advisors know, whether they are working with seniors or their adult children, there is typically a motivating factor that is prompting the inquiry. This is also true for someone simply inquiring about in-home care or independent living, but the motivating factors usually increase in severity or complexity as the level of services needed increases. It is human nature to resist change until there is a reason, so it is natural that most people take a reactive approach when researching senior living services and options. They do so only when the situation is no longer safe, or when there has been an incident that requires a higher level of support.

It is usually clear to the advisor, family members, and even older adults themselves that a change in support is needed to continue living a safe and quality life. So why is it that despite a clear need, there is often a high level of resistance to make changes in support services or in the living situation?

There are several common objections among those faced with these types of decisions:

“I don’t want to lose my independence.”

“I have to sell my house before I can do anything.”

“I am still managing just fine in my home by myself.”

Even if these objections are true, the concern that prompted the inquiry still exists. But often the reality is that these are just excuses. There may be some level of validity, but most of the time there are deeper underlying fears that keep a person from making necessary decisions.

This is where the tug of war begins. A crisis or a concern causes people to feel that a change is needed, yet underlying fears pull them away from making the change, causing uncertainty as to which direction to go.

So how can you help someone through the ambivalence that comes with looking into senior living services and options? The key is to understand that this is not simply a transactional decision. It’s not just deciding to bring in additional services to their current home, or choosing a certain home or apartment in a senior living community. Rather, it’s an emotional decision where your main intent should be to help provide solutions instead of simply starting services. The higher the level of trust and education you are able to build with clients, the higher the likelihood they will make the necessary changes they need.

Here are some simple steps to build client relationships and to more effectively help someone through the overwhelming decision process about senior living options.

Learn the Motivating Factor
It is common for people to be guarded and private when initially inquiring about senior living services. This is often caused by having had an experience with an advisor who took a pushy approach. Clients also may not know where to begin their search or what to ask. An important question for the senior advisor to ask is, “What is happening or has happened to cause you to inquire about senior living services?” Knowing what is motivating the inquiry will help direct the conversation, and showing genuine care in addressing the concern will help establish initial levels of trust.

Understand the Day-to-Day
Gather information about what the day-to-day situation is like for the older adult. Often the crisis or emergency is only the tip of the iceberg, and most likely just a symptom of the current situation. Understanding the day-to-day challenges and contributing factors is important because often, when these are resolved, the urgency to make a change decreases. People are then more inclined to continue in the situation that caused the emergency in the first place. They are less likely to open up and be honest about the challenges when the immediate need goes away. A good question to ask is, “What is not working in your current situation?” As mentioned, this is a decision process. This step may take some time and include numerous phone calls, visits, and meetings with the older adult and/or family members. The very nature of building trust takes time, but as the level of trust increases, the layers will begin to peel away and the client’s level of education will increase as well.

Get to the Bottom of It
Advisors should try to find out what is really causing the ambivalence. It isn’t uncommon for people to be unable to fully recognize the true underlying fears and concerns that are preventing them from making the necessary changes to their living situations. The resistance may be because this is a topic that most people avoid until they are forced to look into it. Encourage clients to make a list of what is pushing them to make a change and what is keeping them from making the change. The simple act of writing out thoughts often helps people to identify what is creating their ambivalence.

Recognize the Fears
A senior advisor must understand the underlying fears. Fear is one of the main emotions people struggle with when faced with bringing additional services into one’s current home or moving from living in a single-occupancy home to a community environment, including:
  • fear of losing independence;
  • fear of losing control of day-to-day decisions;
  • fear of change; 
  • fear of the unknown; 
  • fear of running out of money; 
  • fear of not being the one to care for a spouse; 
  • fear of admitting they need help;
  • and fear of losing their identity.
It is critical to understand what the person’s individual fears are. A simple question that can open up this conversation is, “What do you feel you would lose if you made a change in your current situation?” Once the concerns are stated, follow up with questions that help you better understand them. For example, “What does independence mean to you?” Or, “What would help you feel like you were maintaining your independence?”

Readdress the Motivating Factor
The final step is to readdress the motivating factors for the initial inquiry. If the fears and concerns are not addressed, the importance of motivating factors often gets downplayed, and the fears win the tug of war. Yet, if advisors have a clear understanding of their clients’ fears along with a high level of trust, they are more equipped to help them stay focused on the motivation for change and the steps needed to address the concerns. A few simple questions to ask when helping someone struggling with ambivalence might be: “What do you feel you would gain by making this change?” And “What do you feel you would gain by waiting to make this change?”

People by nature tend to have a hard time with change due to the uncertainty of something new and not knowing what to expect. The greater the change, the more difficult the decisions required to make that change can be. It is often said that the decision to utilize senior care services or to move to a senior living community can be one of the most difficult decisions a person will ever make. The harder the decision, the higher the level of ambivalence. Hopefully, by incorporating this simple approach to addressing a person’s ambivalence, advisors will be able to increase the level of trust with their clients and more effectively help them through this difficult decision process. •CSA

Catherine L. Owens is an expert in the senior living industry, and specializes in relationship-based sales techniques. Her book, Be Your Own Hero: Senior Living Decisions Simplified, is a guide for those who are going through the process of making life-changing living decisions. To learn more, visit her website at

Senior Living Decisions: Motivating Factors and Fear of Change was recently published in the Summer 2014 edition of the CSA Journal.

Blog posting provided by Society of Certified Senior Advisors

Wednesday, November 5, 2014

Meet CSA Spotlight, Anne Eidschun

The CSA Designation Is Not Just Business - It's Personal

The Education Road Map

Do you have educational and advanced professional degrees? I do. My high school diploma and good grades allowed me to officially apply to college. In college, I graduated with a teaching degree which made it possible for me to get my first job. My master’s degree gave me the right to earn $1000 more on the pay scale. When I transitioned into the insurance business, my designations (CLU, ChFC) helped me climb the corporate ladder. My financial planning degree (CFP®) gave me the credibility I needed when I joined an accounting firm as the Client Relationship Manager. I was quickly learning that each degree was my ticket to the next step.

Now don’t get me wrong. Everything I learned along the way was personally helpful and enabled me to serve students and clients well. I thought there was nothing else for me to learn. After all, I was almost an official senior and I don’t mean acquiring my AARP card!

Decades of Expectations

When you think about it – every decade has its expectations. When we are in high school we struggle with what we want to be when we grow up and we either continue with further education or get a job. If college is part of the plan, it’s all about choosing the right course of study so that we can get a job when we graduate and have our own apartment. In our 20’s, it’s about dating and perhaps making some permanent relationship decisions. Then it’s about having children and deciding if we really need a dog. As we reach our 40’s, a career change may be on the horizon because we need to make more money so that our kids can go to college. In our 50’s, we may begin seeing the doctor more often. As we round the corner to 60, we may be looking forward to retirement and our boss may be dropping subtle hints about “when” we might be thinking about moving to Florida.

In my case, I was not thinking about retirement. I loved my work and felt like I was 40. Then I was unexpectedly called upon to be a personal caregiver for a friend’s father. At the time, I was working full time for an accounting firm and for almost two years I helped out three nights a week. I had no time to pursue a degree in this responsibility. I used my instincts and learned on the job. I knew how to cook nutritious meals, was able to help with personal hygiene, could assist with dressing and medications and I provided my friend’s father with mental security just by being asleep in the next room. When he passed away at 99 ½, I still had not really related to the whole concept of “getting old.”

Career Change – Designation # 7

Then I made my final career change and became a Director of Griswold Home Care in New Castle County, Deleware – a non-medical home care company franchise that has been in business over 30 years. Almost immediately, I was looking for the designation that would give me some quick credibility in the industry since I was an unknown individual in the health and home care community. Honestly, I was not looking forward to receiving another large carton with books and study materials, but I knew that signing up for the CSA course work was the right thing to do and I was determined to successfully complete the work in six months.

I remember the first day I opened the book and reviewed the chapter titles. My first thought was that I had studied most of this material in my other course work so this should be relatively easy. That was comforting, but wrong! As is my nature, I sat down with a calendar, looked at the exam date and then working backwards, set up a detailed plan of study which would comfortably allow me to cover all chapters and leave one week for review. I also played the CDs I purchased every moment that I was in my car.

I Passed!

The morning of the exam I was really nervous. I wanted to pass this exam more than any I had ever taken. Why? Because from the first chapter, I was hooked. This was the most meaningful study material I had ever encountered and the corresponding CDs were riveting in their content and delivery. Once I passed, I found myself using all the information almost immediately and to this day, I still keep the textbook on my desk as a reference.

The course material inspired me to want to share what I had learned with those who were part of the “sandwich generation” and other seniors in the community. I set out on a mission to speak at senior centers, churches, interest clubs and libraries. My competitors were all talking about diseases. I wanted to talk about the practical and more enjoyable aspects of the senior journey. I wanted to take my textbook and have it come alive. By the end of 2014, I will present almost 50 talks to various groups and the discussions in my text book will provide the inspiration for all of my topics.

My AH HA Moment…

Six months after passing the exam, I started receiving mail from numerous insurance companies offering me Medicare prescription plans and Medigap policies. Initially, I was throwing them in the garbage. Then one day, all of a sudden, my CSA degree and my impending 65th birthday collided.

Yikes…..I was going to be 65 and now I was going to be an owner/partner in the business. I had reached the goal of having a stake in the ground to secure my future. This was actually scary since I was now all of a sudden worrying about my health. I had read about health concerns in the course material and had seen firsthand the challenges faced by seniors in my business, but now it was about me.

Then There Was Clarity – This Was About Me!

Everything I had learned in the CSA course material was certainly about providing better service and advice to my clients, but this course was about me. It was about my senior journey. It was about the challenges I would face and about the importance of understanding good senior health practices and resources. It was about what I needed to do to give me the best chance of having a successful senior journey.

So now I exercise every day. I speak to people of all ages including seniors as often as possible. My personal goal is to not only help them, but also enlarge my circle of friends and understanding.

It’s Not Just Business – It’s Personal

For me, completing the CSA coursework was unexpectedly personal – not just good information. This was my course on the senior journey. This was my playbook. I owned every word on every page. Now it was my responsibility to share myself with others. I was walking in their shoes. As a result, I am now a better advisor to my clients and their families who face the challenges of home care, a better teacher, a better listener and a better person – all because of my CSA designation.

Life is full of surprises, but the best one for me was finally finding the resource that would help me face the future decades of my life and enable me to share what I learned with other people in the community.

Anne Eidschun, CSA, CFP®, CLU, ChFC is a Partner/Owner of the Griswold Home Care office in New Castle County, Deleware. Email: Phone: 302.456.9904

Anne Eidschun was featured in the  October 2014 Senior Spirit newsletter.

Blog posting provided by Society of Certified Senior Advisors