Search our Blog

Search our Blog

Friday, July 31, 2015

Be Wary of Promotions for Veterans Benefits

If you’re a military veteran, you may have been offered free help in applying for pension or disability benefits. But be aware of the possible dangers of transferring assets in order to qualify for these benefits. The Federal Trade Commission warns of “dishonest advisers” who don’t provide the whole story.

If you’re a military veteran, you may have been invited to a seminar or seen ads promoting “free” assistance in collecting pension or disability benefits. But veterans’ pensions are only available to those who meet certain requirements, including having financial needs. The Federal Trade Commission (FTC) warns veterans about “dishonest advisers who are claiming to offer free help with paperwork for pension claims...[and try to] persuade veterans over 65 to make decisions about their pensions without giving them the whole truth about the long-term consequences.”

Specifically, these brokers—often an attorney, financial planner or insurance agent—try to convince veterans (or their surviving spouses) to transfer their assets to a trust or to invest in insurance products so they can qualify for pension benefits. While this is perfectly legal, what they don’t reveal is that these transactions could mean that the veteran loses eligibility for Medicaid services or commits to inappropriate or unwise investments.

However, there are many knowledgeable and trustworthy advisers to guide you in asset preservation and transfer strategies. You just need to carefully to choose an adviser who considers all program regulations, not just U.S. Department of Veterans Affairs (VA) benefits. Consult with your Certified Senior Advisor.

Because the issue of veterans’ pensions is confusing and fraught with possibly serious mistakes, the best advice is to seek out the guidance of a professional who not only works with the Department of Veterans Affairs (VA) programs but also is knowledgeable regarding Medicaid regulations in your state. In fact, as of 2008, a federal rule requires that anyone who assists a veteran or family member with the preparation, presentation and prosecution of a claim for benefits, needs to be accredited by and through the Department of Veterans Affairs (VA) before they can legally provide assistance.

Accreditation means that the provider is trained in how to fill out paperwork and file claims, and isn’t allowed to charge you to complete and submit your forms. To check if a person is accredited, you can go to the VA Accreditation Search .

Pension Benefits for Veterans

Many veterans may be surprised to learn that a military pension is not automatic but is intended for veterans and their families with financial needs. Likewise, some may not be aware that assistance is available for veterans struggling financially or with serious health problems.

Generally, a veteran must have at least 90 days of active duty service, with at least one day during a wartime period (such as World War II, the Korean or Vietnam conflicts) to qualify for a “non-service” pension (that is, a current disability is not related to wartime service). In addition, the veteran must meet one of the following requirements (Veterans Administration):
  • Age 65 or older
  • Totally and permanently disabled
  • A patient in a nursing home receiving skilled nursing care
  • Recipient of Social Security Disability Insurance
  • Recipient of Supplemental Security Income

Next, your yearly family income must be less than the amount set by Congress to qualify for the veterans’ pension benefit. If it is, your pension benefit is the difference between your “countable” income and the annual pension limit set by Congress. The VA pays this difference in 12 equal monthly payments. Countable income generally includes income from earnings, disability and retirement payments, interest and dividend payments from annuities and net income from a farm or business. Some expenses, such as unreimbursed medical expenses, may reduce your countable income.

It is important to note that although many veterans and/or spouses could not qualify based solely on income, once they factor in the unreimbursed medical expenses from nursing home care, assisted living or home care, they become eligible to pursue the pension. Talk to your accredited adviser about which costs the VA considers “unreimbursed medical expenses.”

Another factor is net worth, which includes assets such as bank accounts, stocks, bonds, mutual funds, annuities and any property other than your residence and a reasonably sized lot. Currently, the VA does not have a net worth limit, but the agency is proposing $119,220 (Medicaid's maximum community spouse resource allowance in 2015), which would include both annual income and assets (Houston Chronicle).

Currently, Forbes estimates that if you get down to $80,000 in assets—not including your house or car—and you have high-deductible medical expenses, you may qualify for a pension. A single veteran’s base maximum monthly benefit is $1,788 (tax free).

The pension benefit is also available to surviving spouses (who have not remarried) and children under 18. Generally, the same qualification conditions apply for spouses and children as they do for veterans. A surviving spouse’s base maximum monthly benefit would be $1,149 (tax free).

Additional Benefits

Qualifying veterans and survivors who require another person’s assistance or are housebound may be eligible for additional monetary payment. The VA pays these benefits in addition to the monthly pension. To receive the aid and attendance (A&A) benefit, you must meet these requirements:

  • You require another person’s help to perform personal functions necessary in everyday living, such as bathing, feeding, dressing or using the toilet.
  • Your disability requires you to remain in bed apart from any prescribed course of convalescence or treatment.
  • You are a patient in a nursing home due to mental or physical incapacity.
  • Your eyesight is severely impaired.

To be considered housebound, and eligible for an increased monthly pension amount, you must be substantially confined to your immediate premises because of permanent disability. 

Know What You’re Doing

In June 2012, the U.S. Senate Special Committee on Aging held hearings about marketing financial products and services to veterans to help them qualify for pension benefits. The committee learned that organizations may be charging substantial fees, ranging from hundreds to thousands of dollars, for products and services that may not always be in claimants’ best long-term interests. 

The problem is that some products and services, such as annuities, may not be suitable for elderly veterans who need money for care because they may not have access to all their funds within their expected lifetime without facing high withdrawal fees. Some annuities must be held for a decade or longer before they pay out a monthly income, and if the money is needed before that, high surrender fees apply.

Also, veterans need to be aware of the inherent risks of placing their assets in someone else’s name, such as a spouse or child. Potential problems arise in cases of divorce or a child spending the money. To make sure you’re protecting yourself and your heirs, consult with a qualified elder law attorney.

Moreover, these products and services may result in a temporary ineligibility for Medicaid. Medicaid has a 60-month look-back period: If you’ve moved substantial assets at less than market value during the previous five years, you may not be able to get Medicaid services when you need them. A veteran who is disabled enough to receive a VA pension will likely need nursing home care in five years, so he needs to make sure he is still eligible for Medicaid benefits. If you are going to transfer assets as a strategy to obtain veteran’s benefits, ensure your Medicaid benefits are protected.

The American Legion warns of a pension scam that offers to pay military retirees a lump-sum payout in return for their monthly retirement payments. These pension advances may pay only pennies on the dollar and can carry interest rates from 27-106 percent. Even though many of these companies have patriotic-sounding names and logos, beware of organizations that you find online and sound too good to be true.

VA Proposes to New Restrictions

To help discourage veterans from transferring assets when applying for pension benefits, the VA has proposed a 36-month look-back period on asset transfers. This would penalize transfers or gifts made in the three years before applying for benefits (Houston Chronicle). In addition to establishing a new combined net worth and income limit of $119,220, the new rules would limit the deductible amount of medical expenses.

The proposed rules have garnered criticism because asset transfer limits include gifts. Charitable veterans could face penalties for making a church donation or giving a grandchild a graduation gift. According to Forbes, “For a veteran who gave away $50,000, he would get a 28-month penalty. That is, he wouldn’t qualify for benefits for 28 months. A widow would be penalized for 44 months.”

Another problem is that a 36-month look-back period could add significant delays to an already-lengthy application process. Currently, the VA takes six to nine months to process a new application. If the VA has to start looking through three years of financial records for each applicant, veterans will likely wait even longer to begin receiving pension benefits.


“Elder Law: Department of Veterans Affairs proposes 3-year look-back for gifts,” March 17, 2015 Houston Chronicle

“Ask a Service Officer: Beware of VA pension scams,” April 1, 2014, American Legion

“VA Proposed Rule Is Attack on Veterans and Their Families,” Forbes

“Veterans Pensions,” Federal Trade Commission 

Be Wary of Promotions for Veterans Benefits  was featured in the June 2015 edition of Senior Spirit

Blog posting provided by Society of Certified Senior Advisors.

Tuesday, July 28, 2015

Women’s Unique Financial Struggles: Finding Effective Strategies

As women age, understanding and being in control of their financial landscape can be daunting, whether married or single. A trusted financial advisor can make all the difference.

The old adage that men won’t stop and ask for directions while women will quickly engage the directional advice of a stranger, is one of the most clich├ęd examples of gender differences. Yet, as indicated in the research below, those differing approaches are not surprising when our brain chemistry and divergent life circumstances are taken into account. The effects are particularly salient when examining the financial approaches of aging women. To serve this growing population, professionals in the financial industry
should review the most common circumstances women face:

• Women live, on average, five years longer than men. These extra years carry significant financial burdens as women have more “old age” in which to incur medical costs, and a longer period of retirement without work. Women are more likely to die alone than as part of a couple.

• Women are more likely to enter a nursing home and incur the significant annual expense: $87,600 for a private room and $77,380 to share a room (Genworth 2014). The population of assisted living residents is 80 percent women (Chamberlain 2013). In the unfortunate realm of financial elder abuse, women are twice as likely to be victims
(Metlife 2011).

• Women are more likely to have insufficient savings for retirement, putting them in a position of economic insecurity (Waid 2013). Income disparity over a woman’s career will lead to a smaller retirementnest egg, and this will be further complicated if a woman chooses to reduce her workforce participation in favor of caregiving. These factors
translate into a 25-30 percent shortfall compared to men’s retirement savings (Insured Retirement Institute 2011).

How do we handle these discouraging statistics? Potential solutions require careful consideration of women’s most common tendencies. 

The Confidence Gap
Confidence is a benefit in moderation. Our best decisions are usually made with confidence. But too much can be problematic. For example, in a 2015 study from (Morgan 2015) data showed men are 25 percent more likely to lose money in the stock market than women, and men are also 1.5 times as likely as women to say that they expect to beat the market in the next year. So the confidence that men bring into their financial decisions is not paying off in long-term returns.

Women are more likely to stick with a buy-and-hold strategy as opposed to a method focused on frequent trading. In the end, studies show the buy-and-hold approach garners higher long-term returns. Yet despite their superior investment predispositions, women in retirement are still more likely to be economically insecure (Waid 2013). A number of factors are at play (wage gap, fewer years in the workforce due to caretaking of multiple generations), but is it possible for aging women to reverse the tide?

The act of becoming familiar with one’s money late in life can usher in a new attitude of peace. Unfortunately, women of all ages generally lag behind men in the crucial realm of financial confidence. A recent Prudential (2014) survey demonstrated 75 percent of women consider it very important to have enough money to sustain their lifestyle through retirement. But only 14 percent were very confident they would meet that goal. The 61 percent difference between the 75 percent who want to be financially independent
and the 14 percent who have the confidence they can be financially independent, represents a confidence gap. Ten years ago, the confidence gap was 62 percent. Despite the financial industry’s recent focus on women, the gap has only decreased by 1 percent.

Upon examination of this gap, the aspects of finance on which women gave themselves the lowest grades were the long-term activities of investing and generating an income stream in retirement. What can be done to address this gap? 

Create Confidence before Trying to Educate
Directions for Women (2015) is an organization created to address women’s dearth of financial confidence. It uses the following tagline to indicate the most helpful order of services when working with women: Empower, Educate, Engage. When asked, “What does financial empowerment look like?” founder Eleanor Blayney suggests a willingness to
talk about money with loved ones, spending in a way that honors values and responsibilities, learning from past mistakes, having the courage to speak up to get the support and answers she needs, and recognizing the choice to delegate—not abdicate—responsibility for managing financial affairs. An empowered woman will be a more effective student when she gets to the education phase because the context of her financial decisions will be clearer. 

Different Learning Preferences
While it may not be true for every woman, there are commonalities among women when it comes to the ways they learn best. One study shows women prefer to learn in a collaborative environment rather than in typical pedagogical formats (Cabrera 2001). But classroom collaboration is not the only environment where cooperation gives women an advantage. In The Soccer Mom Myth by Michelle Miller and Holly Buchanan (2007), the authors comment on research data indicating men have a fight or flight response, while women would tend and befriend.” They write: 

“We’ve seen brain differences that give women advantage in verbal skills. This combined with their innate sense of community and sharing, leads them to place greater value on relationships. Men are competitive and hierarchical. Women look for similarities and value cooperation.” In the field of finance, where rank and status are heavily valued, is it any wonder women are lacking confidence?

Another common learning characteristic among women is the desire to master a topic rather than learning it incompletely. In the meta-analysis, “Gender Differences in Scholastic Achievement” (Voyer 2014), researchers conclude: “Previous research has shown girls tend to study in order to understand the materials, whereas boys emphasize performance, which indicates a focus on the final grades. … Mastery of the subject
matter generally produces better marks than performance emphasis, so this could account in part for males’ lower marks (report card grades) than females.” This mastery strategy often leads to decision avoidance in topics that are difficult to master. In the financial
world of confusing jargon and strategies, avoidance often seems like the easiest way to deal. As a result, many women face their aging years without any sort of contingency plans for the most likely scenarios.

Knowing the learning preferences of many women, how can we maximize the value of our services to aging women?

Circles as a conversation technology. Financial advisors may want to consider referring clients to the Circles process to help them clarify and understand finances.

The Circle process stands apart from other financial events because it incorporates collaborative learning in a non-hierarchical environment. Originally created by Christina Baldwin and Ann Linnea of, Circle conversations are an ideal way to create a safe space for women to talk about money.

Directions for Women suggests some Circle conversation topics to get women talking as excerpted from Women’s Worth: Finding Your Financial ConfidenceEleanor Blayney (2010): childhood money memories and how they affect you now, your values and how they are reflected in your checkbook, setting S.M.A.R.T. financial goals, and creative ways to live on a budget. 

Use Unorthodox Teaching Methods. Women are open to learning about finance and would love to master it, but many of the educational resources available are presented in the seemingly secret language of learning about their own finances. With a background
in psychology and art, Luna Jaffe became an unlikely author for financial matters, but her Wild Money lends an artistic, creative feel to improving your financial position. The book’s exercises address both emotional and practical financial work. Paired with questions that require real introspection, the financial teachings Jaffe offers fit into the larger context of how money fits in our lives.

Another imaginative method of educating women on financial matters is to suggest women study certain books in a group where they can talk about their discoveries. A conversation starter is the story of Geneen Roth. In her book, Lost and Found, she tells the story of losing everything—she had selected Bernie Madoff as her only advisor—while gaining a profound sense of appreciation for all she still had. Roth’s humble self-awareness provides realizations that apply to many women. Roth addresses the best method of financial transformation: “Without deeply understanding the roots of our discomfort…we will revert to the same behaviors over and over again…” 

Different Approaches to Advice
To effectively help aging women navigate their financial journeys, it is important to adjust the way we provide recommendations to maximize their financial success. Going back to our ancestral roots, consider the hunter/gatherer comparison of our male and female ancestors. Women surveyed the land to gather the best food, while men focused in on a kill. Due in part to brain chemistry and a woman’s superior paths of connectivity
between the analytical right and intuitive left lobes, many women still prefer to gather many pieces of data before they feel comfortable making a decision. 

Relevant data that is gathered may include the emotional state of those around her. The benefit of this trait was measured in a study of the effectiveness of group decision-making. One key finding was the importance of emotion reading for groups to be successful (Engel 2014). The women in these groups demonstrated greater “Theory of Mind” abilities, allowing them to consider and keep track of other group members’ feelings, knowledge, and beliefs. This advantage trumped the influence of group characteristics that might seem more important: the group’s collective intelligence, the presence of an extroverted leader, and the factor of motivation towards the group’s success. The presence of women in a group led to the group’s success because of their increased ability to balance the dynamic of information, emotion, and the overall wellness of the group.

Contextualize Your Recommendations.
How do we assimilate this data gathering tendency into our recommendations? When helping a woman make decisions with financial implications, advisors should help her assess the emotions she may feel as a result of a particular course of action. Even in the case of unavoidable unpleasantries, acknowledging the potential downsides helps her grasp the big picture and feel more comfortable moving forward. 

A common characteristic of women is the tendency to equate money with security. Many financial advisors have observed their female client’s reluctance to engage during investment portfolio review meetings. An advisor might interpret her lack of interest as evidence that she doesn’t understand the graphs. In fact, for many women, their lack of interest stems from their perceived irrelevance of those graphs. Comparison of investment performance against a benchmark does not answer the one question that often keeps women up at night: “Is my portfolio on track to provide enough money at the end of my life so I don’t need to live on the street?” 

In the financial industry, this fear of being destitute at the end of life is known as “bag lady syndrome.” It permeates the world of women regardless of their income levels. In fact, 57 percent of women say the thought of running out of money in retirement is what keeps them up at night (Allianz 2013). The only other fear that ranked higher was the possibility of losing a spouse. Since these two fears are interrelated, bag lady syndrome is a natural outcropping of life expectancy statistics.

Focus on Reinvention, not Retirement.
In the coming years, fewer boomer women will be able to retire in the traditional sense of the word. But that doesn’t mean they can’t enjoy this phase of life. There are ways of working that will still fit into an aging woman’s life style, and may even inspire her in new
ways. Focus on those possibilities and help her get creative about her contributions to this world. Women possess a tremendous ability to adapt to new situations, so they should be encouraged to continue working in some way in order to delay the years of retirement portfolio draw-down. When the Social Security program was designed in the 1930s, life expectancy was only fifty-eight for men and sixty-two for women. But the retirement age was set at sixty-five. This program was not designed to cover decades of retirement
years as we have now come to expect. Now is the time to begin reinventing ourselves to create a new era for the golden years.

Highlight Alternative Housing Options
With a growing number of older homeowners unable to afford to maintain their residences on their own, change is on the horizon. The fact is the boomer generation will need to embrace some new housing models, such as the Golden Girls strategy of living with
friends, or the multi-generational housing that is coming into vogue among all age groups. As with everything else that boomers have done, they will lead the way to a new way of looking at aging. 

Criteria for Selecting Financial Advisors 
Many women will be most secure when they have taken charge of their finances and chosen to delegate them to a trusted advisor. But even the process of selecting an advisor is different for women. One study showed 70 percent of widows fire their financial advisors within one year of their husband’s death (Spectrem 2011), suggesting that what was good for the gander may not suffice for the goose.

Women tend to prefer qualitative means when selecting a financial advisor, as 61 percent cite a feeling of trust and respect as the top factor. More affluent women consider it imperative that an advisor take a long-term view of their needs (Insured Retirement Institute 2011). This tendency to focus on qualitative aspects of the hiring decision can cause a woman to lose sight of the more quantitative attributes of candidates. To provide
the best blend of both types of considerations, the Certified Financial Planning (CFP ) Board has created a list of ten interview questions to help consumers make the best selection possible To help a woman in the middle of a selection decision, the advisor should offer to be her sounding board and provide a safe place to ask questions.

In conclusion, women are more than capable of making successful financial decisions, but are often deterred by circumstantial, personal, or economic factors.  In the aging population especially, advisors to women can choose to play an edifying role that helps
to change a woman’s thinking about and behavior toward money. These factors may be just as important as the balance in her accounts when it comes to changing
her financial course. •CSA

Candice McGarvey, CFP® is a client advisor with Lumina Financial Consultants in Richmond, Virginia. By working with women to increase their financial wellness and strengthen their financial position, she guides clients through financial transitions. Her services range from full-scale wealth management to financial coaching. She can be
contacted at, or visit

Women’s Unique Financial Struggles: Finding Effective Strategies was published in the Spring 2015 edition of the CSA Journal. 

Blog posting provided by Society of Certified Senior Advisors

Friday, July 24, 2015

Meet Our CSA Spotlight, Richard Russo

After a 25-year career in manufacturing and sales, I decided to sell the company that I owned and operated to one of my competitors. Windham Weavers manufactured and imported home furnishing products from Asia, which we then sold to large retailers in the USA. At 50 years old, traveling three or four months a year became less glamourous and more stressful. A changing retail environment coupled with increasing competition and import restrictions made me realize that selling the business was the right decision for me and my family. I worked with the new owners for two years while the business was integrated into the new conglomerate. Then it was time to close that door and start a new chapter in my life. 

After much thought and inner contemplation, I decided that I needed a total career change and was looking for an opportunity that allowed me to give back to the community. I did my research and found a company called CarePatrol, based in Gilbert, Arizona. CarePatrol, founded in 1994, is a Senior Placement Service helping seniors and their families find assisted living, dementia living, nursing homes and in-home care based on their specific care requirements. The service is free to families because CarePatrol is compensated by our referral network, similar to a real estate transaction. Sensing a great need for such services, I purchased franchises in Westchester County, New York, and Fairfield County, Connecticut in January 2011. Being a national franchise, CarePatrol offers extensive training and support. I earned my Certified Senior Advisor designation in the spring of 2011. I chose to partner with CarePatrol because of their commitment to personal service. We meet and accompany our clients on community tours that satisfy their needs based on location, services and budget. Ultimately, we help our clients find a comfortable “safe solution.” 

CarePatrol and the Society of Certified Advisors (CSA) have a long standing, mutually beneficial relationship. All franchisees are required to acquire the CSA designation with good reason. I find that being a CSA has given me much needed knowledge in many different areas that affect seniors today. I’ve learned to communicate with seniors regarding their health, social and financial issues in a sensitive and non-confrontational manner. I have a much better perspective of the aging process and the everyday struggles that seniors face. CSA courses and ongoing support has given me the confidence to properly refer my senior clients to the appropriate professionals who can help them with their specific needs. 

I love working with seniors and families in this capacity. It is personally rewarding for me to be able to help find safe solutions and ease the stress of these transitions. I am a son, husband and father with family members dealing with similar life-changing situations. I treat everyone” like family,” which means that I look at the senior as if they are my “aunt or uncle” and their children, whom I frequently work with, as “my cousins.” These are “my families” and not “my clients.” After helping a family get their loved one settled there is no greater reward than a kiss on the cheek saying “thank you, you are a gift from Heaven.” I wish everyone that experience. 

We specialize in Westchester County, New York, and Fairfield County, Connecticut. 203-244-9562 or 914-357-8084

Richard was featured as the CSA Spotlight in the June 2015 Senior Spirit Newsletter

Blog posting provided by Society of Certified Senior Advisors

Thursday, July 23, 2015

Advanced Care Planning: An Ongoing Process

Planning in advance for how we want to be cared for as we age should be an ongoing process, and continued until the need for care arises. Health care decisions should be an individuals' right.

Advanced care planning should be an ongoing process in everyone’s life. It’s therefore important to gain a perspective on how America needs to change its thinking about caring for our oldest citizens. The questions we ponder and the answers and solutions we seek will be different for each of us and it is a difficult challenge. In 1843, Soren Kierkegaard, a Danish philosopher and theologian, discussed the difficulty of the challenge when he said, “Life can only be understood backward but it must be lived forward.”

One of the most striking themes of aging is how many decisions there are to be made. Who will take care of us? How much of our lives must we and can we give over to caring for another? How much should be done to prolong life? Finally, how do we rethink and revise our health care and payment system that largely fails to provide care for those nearing the end of life? One that is compassionate, coordinated, affordable, and the best quality possible?

Advanced care planning has been defined as a process of coming to understand, reflect on, discuss and plan for health care decisions using a health care power of attorney and advanced directive. The development of an individual’s right to make their own health care decisions concerning life sustaining treatment is illustrated in the historic case of Karen Ann Quinlan.

In 1975, Karen Ann Quinlan, age twenty-one, collapsed, stopped breathing, and slipped into a coma. She had just arrived home from a party where friends reported that she took prescription drugs and drank alcohol. Doctors were able to save her life, but she suffered severe brain damage and fell into a persistent vegetative state. She required a ventilator and a feeding tube to survive.

Karen’s father, Joseph Quinlan, was appointed her guardian. After several months, he asked doctors to remove both the ventilator and the feeding tube but they refused. He filed a law suit in New Jersey Superior Court, In Re Quinlan. The court denied the father’s request, but the New Jersey Supreme Court, in a landmark legal decision, ruled in favor of the guardian on the basis of a “constitutional right of privacy.” It argued “that this unwritten right…is broad enough to encompass a patient’s decision to decline medical treatment it is broad enough to encompass a woman’s decision to terminate a pregnancy under certain circumstances,” citing Roe v. Wade, the U.S. Supreme Court’s decision that all state and federal laws against abortion violate a “constitutional right to privacy.”

In 1976, supported by the Quinlan decision, California passed the Natural Death Act, which became the first state to legalize advanced directives, allowing a person the ability to control life-ending decisions. By 1986, forty-one states had enacted some form of the advanced directive. Today, every state has an advanced directive, although legal requirements vary from state to state. The Five Wishes is the only advanced care document accepted in every state. 

Although Quinlan was removed from mechanical ventilation in 1976, she lived on in a persistent vegetative state for almost a decade until her death from pneumonia in 1985.

Federal Legislation on Advanced Directives

The Federal government, through congressional legislation, passed the Omnibus Budget Reconciliation Act of 1990, which contained The Patient Self-Determination Act (PSDA). The act applied to all states that accepted Medicaid and Medicare reimbursements. It required each participant to develop a written policy concerning advanced directives to be provided to all patents at admission, along with a consultation to discuss the nature of an advanced directive with each patient.

In 2006, Congress directed the Department of Health and Human Services to conduct a study of the PSDA to determine how well it was working. The study concluded that it did not increase the percentage of patients with an advanced directive; that hospital staff was either unwilling or unable to provide useful education to the admitting patient; and that patients were generally too distracted by the urgency of being in the hospital setting to concentrate on the document.  Further, the PSDA experience was consistent with the failure of patients to understand and execute the advanced directive. The conclusion was that even when patients had an advance directive, it did not accurately reflect the patient’s health-care wants or needs. 

The Winds of Change 

The developing definition of advance care planning is a broader, less legally focused concept. It encompasses not only the health-care power of attorney and advanced directive, but also the need to have an ongoing discussion among family members and care providers about the effect of serious illness. It recognizes the financial concerns of a long illness. It opens the possibility of considering the patients spiritual questions and fears. A nationally recognized model of the new thinking has been developed by the Gundersen Lutheran Medical Foundation.

The Gundersen Lutheran Medical Foundation in LaCross, Wisconsin, is one of the leaders in developing the model for assessing and planning advance care strategies. Its program, “Respecting Choices,” has been nationally recognized as a successful and forward-thinking advanced care plan system. The program is an advanced care planning process of communication that helps individuals understand their choices for future health care, reflect on personal goals, values, religious, or cultural beliefs, and talk to physicians, healthcare agents, and other loved ones as needed. 

The process of communication needs to be individualized, based on a person’s state of health, and revisited at appropriate times. The stages of planning have three distinct and focused steps.

Step One. This step is appropriate for all adults, but should be initiated as a component of routine health care for those between the ages of fifty-five and sixty-five. The goal is to motivate individuals to learn about advanced care planning, select a healthcare decision maker, and complete an advanced directive that identities the basic goals for life-sustaining treatment in the event of a severe neurologic illness from which the individual is unlikely to recover.

Step Two. This step should be initiated for individuals with chronic, progressive illnesses who are experiencing a decline in functional status, are suffering from multiple chronic illnesses, are experiencing more frequent hospitalization, and are at risk of complications that would leave them unable to make health care decisions. The goal is to understand and plan for the progression of their illness, to understand potential complications, and to understand the specific life-sustaining treatments that may be required as the illness progresses.

Step Three. The last step is intended for the frail or others whose death is expected within twelve months. Many are in long-term care facilities, are at risk of complications, and at risk of losing their decision-making capacity. Specific life sustaining treatment decisions concerning CPR, hospitalization, artificial nutrition and hydration, and comfort care options must be made. A physician’s order for life-sustaining treatment (POLST) is the most effective way to accomplish this goal in states recognizing it as a legally binding document.

The faces of our changing health care have many expressions. At the same time that individuals are learning to develop more advanced care plans, the health community is challenging its current way of thinking about end-of-life issues. A concern about the present care model for end of life medical treatment, and the possible new way of thinking is being driven by Atul Gawande’s book, Being Mortal: Medicine and What Matters in the End, and a 2014 report issued by the Institute of Medicine, “Dying in America: Improving Quality and Honoring Individual Preference Near the end of Life.”

In his book, Gawande discusses his perception of the problem when he states: 

“You don’t have to spend much time with the elderly or those with terminal illness to see how often medicine fails the people it is supposed to help. Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology and strangers. Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people, and denied them the basic comforts they most need.”

The American Bar Association, Commission on Law and Aging, studied both Gawande’s book and the Institute’s report, and determined that not only were the concepts presented important to the end-of-life quality of care and the process of aging, but also represented human right issues. The Commission developed and adopted a five-element resolution that will be presented into the legislative process to promote a high quality system of care for persons with advanced illness. The resolution contains five elements. 

Element 1. Finance and payment mechanisms that support access to person-centered care coordination and care management across all care settings, providers, medical conditions, and time.

Element 2. Advance care planning through counseling, disclosure, and meaningful discussion of prognosis, goals of care, personal values, and treatment preferences, including planning caregiver’s needs.

Element 3. Access to palliative care, community based supportive services, and caregiver support to enable persons with advanced illness to remain in the home and community in accord with their preferences and needs.

Element 4. Expanded research to improve care delivery and payment practices that will benefit individuals and families facing advanced illness.

Element 5. A strong health-care workforce educated and equipped with the clinical and social skills to serve people with advanced illness and their families and caregivers.

As professionals, we all need to understand the context of advanced care planning, and encourage our clients, family, and friends to continually assess their health. When a chronic illness takes the stage, encourage them to express their wants, needs, and desires through the end of life.

As a nation, we need to begin to move from the care model described by Gawande to one consistent with the five elements. 

We need to honestly assess the baby boomer wave that began to build in 2014. Ten thousand people in the United States turn sixty-five every day, and it is estimated this will go on for the next seventeen years. This infant wave is already causing financial issues for government and health services, a quality of life issue for the health system, and a dilemma for thousands of household trying to support loved ones. •CSA

John Parr is a partner in the law firm of Parr Bylerly in Olympia, Washington. His focus is on estate planning, elder law, probate, and the “what if” questions of aging. He is a Fellow of the American Bar Foundation, and a member of The Washington Bar Foundation and American Bar Association. He can be contacted at Visit his
Advanced Care Planning: An Ongoing Process was published in the Spring 2015 edition of the CSA Journal. 

Blog posting provided by Society of Certified Senior Advisors

Monday, July 20, 2015

Home of the Future for Older Adults

With a housing crisis looming for seniors, local governments and the building industry are becoming aware of the shortage for accessible housing and are starting to build homes with features that appeal to people of all ages.

There’s a housing crisis looming for seniors. With baby boomers entering their retirement years at a rapid rate, most housing is not keeping up with their needs. Most older adults say they want to stay in their homes as they age, but most homes are not designed for older bodies that have a hard time with stairs, slippery shower surfaces or hard-to-turn door knobs.

But local governments and the building industry are becoming aware of the shortage for accessible housing and are starting to build homes with features that appeal to people of all ages.

What Boomers Want in Homes

In surveys of retirees and those about to retiree, the vast majority want to stay in their homes, even if that means living someplace where the weather might not be as nice as Florida. A Merrill Lynch survey (as reported March 6, 2015, by Next Avenue) also found that only half of those surveyed were interested in downsizing, and some even wanted to upsize their homes.
Those 65 and up said they prefer living with people of diverse ages and generations, rather than segregating themselves with other seniors. And, whether older adults do decide to move or stay where they are, the main reason is to be close to family.

Another survey, by Better Homes and Gardens Real Estate, about the homes that baby boomers envision for retirement, found slightly different results from the Merrill Lynch survey, possibly because it studied a younger group—ages 49-67 (as reported by Next Avenue).

Most said they would move after they retire, but not far. The vast majority plan to stay in the state where they currently live. Other findings include:
  • The most popular place to live is rural areas (small towns and farms), followed by retirement communities and urban areas.
  • More than two-thirds who plan to move are willing to update or renovate their next home to fit what they want and need.
  • The most important factor in choosing their next home is low-maintenance features.
Impending Housing Crisis

Despite what baby boomers say they want in their homes, the reality may not be so rosy. The nation is facing a lack of affordable, physically accessible and well-located homes for older adults, especially those with low incomes, according to a 2014 study by the Harvard Joint Center for Housing Studies & AARP Foundation (as reported in Next Avenue). By now, the figures have been often quoted: In 15 years, 1 in 5 Americans will be 65 or older. By 2040, the United States will have 28 million people who are 80-plus. When you combine the largest generation in U.S. history with increased longevity, it’s not hard to see housing problems cropping up.

1. The cost of renting and owning a home is high, with no signs of improvement in the near future. Low-income seniors must often choose between paying for housing or food and health care.

2. Even though Americans say they want to age in place, they’re living in the wrong places. The problem is that most older adults live in suburbs and rural towns, far from any public transit, so they must rely on cars. As we age, most of us are less inclined to drive, especially on busy streets and at night, and about 24 percent of households 80+ are carless. This means seniors become dependent on others or become isolated in their homes.

3. Most homes aren’t designed for seniors with physical challenges, and many houses and apartments lack basic accessibility features. Only 1 percent of U.S. housing units have all five of what are known as universal design features: no-step entry, single-floor living, extra-wide doorways and halls, accessible electrical controls and switches and lever-style door and faucet handles (which are easier to grab than knobs).

Creating a House for Life

Builders are beginning to construct homes that incorporate features for young families as well as aging adults(from AARP):
  • A side-door entrance with no steps offers an accessible entrance without a ramp or lift.

  • To accommodate various users (from children to people with wheelchairs), sinks and vanity cabinets are positioned at 36- and 32-inch heights. The sink cabinet's doors and threshold can be removed to provide wheelchair access. The toilet is set in a larger space for wheelchair access.

  • A barrier-free shower has grab bars and a seat for better safety.

  • A first-floor bedroom provides the option for one-level living and can also act as a home office or other space if not needed as a bedroom.

  • Hard-surface flooring provides easier mobility for anyone using a wheelchair or assistive device.

  • A peninsula countertop in the kitchen is set 30 inches high to provide both a sitting area for light meals as well as a lowered work surface where a cook or helper can sit instead of stand.

  • Storage for everyday items is at reachable heights and includes several easy-access drawers with cabinet pulls, which are easier to grip than smaller cabinet knobs.

  • A roomy garage provides enough space for easily getting into and out of a vehicle.

  • Staircases have handrails, ideally one on each side.

  • For those who can afford it, an elevator can be built into first- and second-floor closets.

One Solution in Oregon

As local governments around the country start to deal with a future crisis in housing for seniors, one region in Oregon has come up with a novel solution. In Oregon’s Rogue Valley, where more than 40 percent of the population is over 50, AARP and the local government have been working together to create a program to encourage more livable spaces for people of all ages. A voluntary home certification system can assess the "age-friendliness" and accessibility of both newly constructed and existing homes.

The Lifelong Housing Certification Project provides consumers and building industry professionals with a checklist of accessible features in a home, including rental units, based on universal design standards. Those seeking or renovating a home can decide which level (from 1 to 3) of accessibility they want by referring to the checklist. At the same time, builders, architects and other professionals have a standardized tool for building or modifying a home for lifelong livability.
“The Homes Boomers Will Retire In,” April 14, 2014, Next Avenue

“The Next Housing Crisis: Aging Americans' Homes,” Sept. 2, 2014, Next Avenue

“Retirees and Their Homes: They Want It Their Way,” March 6, 2015, Next Avenue

“How to Encourage More 'Lifelong' Housing,” AARP

“A House That Can Be a 'Home For Life,’” July 2014, AARP
Home of the Future for Older Adults was featured in the July 2015 edition of Senior Spirit.
Blog posting provided by Society of Certified Senior Advisors