Gertie Brooks, a columnist for my local paper, the Tri-City Times, has written an interesting column on the origin of ‘Taps’. I have no idea if the history is accurate, but Gertie seems a trustworthy source and the story, while astounding, explains much. ‘Taps’ apparently originates from the civil war and a story worthy of ancient tragedy:

It all began in 1862 during the Civil war when Union Army Captain Robert Ellicombe was with his men near Harrison’s Landing in Virginia. The Confederate Army was on the other side of the narrow strip of land. During the night, Captain Ellicombe heard the moan of a soldier who lay mortally wounded on the field. Not knowing if it was a Union or Confederate soldier, the Captain decided to risk his life and bring the stricken man back for medical attention. Crawling on his stomach through the gunfire, the Captain reached the stricken soldier and began pulling him toward his encampment.

For the rest of the story click here.

For a variety of reasons–a relative’s health problems, the recent passing of a client–I find myself all the more appreciative of life in general. It is one blessing of working with the elderly generally that I am often reminded of life’s preciousness, and working with veterans in particular helps me to know the extent of the sacrifices our veterans have made. To all of our veterans and their families, thank you.

UPDATE: The History Channel offers a very different story on the origin of ‘Taps’ that can be found here.

The reality is that families faced with the chronic illness or disability of a loved-one often have few options but a traditional long-term care facility. Aside from the financial devastation that this usually entails, there is the fact that a traditional nursing home is a difficult place to be in. It is good therefore to see nursing home alternatives emerging, such as described in this story about a new nursing home developing near Grand Rapids, Michigan:

Differing from a traditional “hospital-style” nursing home, the so-called green house concept features smaller facilities designed to create a home-like setting with private rooms, baths and other amenities. Residents still receive the daily assistance and medical care they need, though their activities are not regimented nor predicated on their medical needs.

While the article is silent on the cost of care at this facility, it is not unreasonable to assume that it will be more expensive than traditional nursing home care. If it were otherwise, the article would be trumpeting both higher quality care and lower costs. The fact is that this sort of care remains out of reach for most seniors whose savings would be quickly depleted by the cost of this higher level of assistance. Perhaps the best chance most seniors will have at this sort of care is begin planning early in order to maximize assets.

The same technology that allows coffee and internet afficiandos to stay in one cafe for hours on end is now helping seniors to retain their independence and cope with serious health issues. A new Wi-Fi device is capable of alerting your physician in case of heart attack. Thoughtful implementation of new technologies offers a great deal of promise for those seeking to remain independent for as long as possible. Similar technologies offer the promise of helping seniors remain independent as long as possible. Advances in home design and remodeling are likewise helpful to seniors who wish to age in place.

Years of experience in management of long-term care crises is enough to convince anyone of the importance of planning. Working in the area of elder law generally and nursing home crisis situations in particular leads me to emphasize the importance of developing a plan for health care, finances and family to last through the retirement years. This type of planning is increasingly known as “life care planning.”

Life care planning is a comprehensive retirement, estate, and lifestyle plan. It encompasses all facets of estate planning, asset protection, health care, and retirement. The objectives of this planning can be as varied as the individual family, but in general the goal is to maximize resources, preserve independence, and avoid crises. Having assisted many families though nursing home crises, I am convinced that problems resulting from caregiver burnout, insufficient or inadequate health care, probate court fees, and financial waste can be greatly reduced or even eliminated with proper planning.

In order to be effective, a life care plan should be comprehensive. With respect to health care and the activities of daily living for example, an assessment of anticipated needs and possible solutions can be completed by a geriatric care manager. Geriatric care managers specialize in guiding seniors through everything from housing solutions to home health care to adaptive technologies for the home that can preserve independence and reduce the risks of accidents. The assistance of a geriatric care manager can ultimately save resources by getting the right care at the right time.

Geriatric care managers can work in tandem with elder law attorneys to maximize financial resources to provide the best quality of care and preserve an independent retirement as much as possible within the legal system. Increasing financial pressure on state and federal programs like Medicare, Medicaid, and the Veteran’s Administration has resulted in a steady increase of regulation. Asset transfers today are potentially subject to a five year period of scrutiny by the state. An elder law attorney can help seniors retain the enjoyment of their assets while at the same time freeing them from the scrutiny of the five year look-back period. Furthermore, proper planning can enhance the availability of government assistance with health care and other costs. Asset protection planning provides the means for handling your estate according to your needs and desires and frees you, as much as possible within the law, from the constraints and costs that the government seeks to impose.

Traditional estate planning can help to clarify goals for family wealth and allocate responsibilities for care-giving and surrogate decision-making. Establishing power of attorney for finances and health care can help to avoid probate court fees and preserve independent decision-making. Moreover, a customized estate plan can help avoid the problems that sometimes result when one adult child bears a greater share of care-giving responsibility and seeks reimbursement from the family estate. Clear planning avoids these controversies and keeps families united.

The goal of a life care plan is to achieve the best possible results for all parties involved. For seniors, it is matter of making their wishes for independence, health care, surrogate decision-making, and estate division known. It means keeping them involved, active, and independent in everyday life. For care-givers, a life-care plan provides fairness, options, and clarification. Few sources of stress are more acute than the care of an aging parent. Developing a plan and maintaining the best resources for revising the plan when necessary can reduce this stress as much as possible. And for medical care providers, a life-care plan provides the opportunity to focus on delivering the best care available under the circumstances with a clear understanding of the insurance, cost, and financing of care.

Optimal results are seldom achieved in a crisis. Stephen Covey, author of The Seven Habits of Highly Effective People, advocates attending to those things that are important before they become urgent because urgency generates error and stress. This is not the way to handle what is most important in life. Misunderstandings and missed opportunities are only the beginning of what can result from a failure to plan. By contrast, realistic planning with experienced professionals-elder law attorneys, geriatric care managers, and financial planners-helps seniors retain independence, receive the best quality of care, and have their wishes respected.

The Michigan Department of Community Health announced today that Detroit nursing homes would receive $1.7 million for improvements. See this Free Press article for coverage. I have never visited a nursing home that did not have a dedicated, but heavily-burdened staff. And obviously there is no end to the needs of the nursing home residents. I can imagine that in Detroit in particular, there would be certain areas that would feel an acute scarcity. I am glad that the patients and staff of these facilities will be receiving some help.

One very important matter for retiring seniors is the decision of when to begin receiving social security benefits. This helpful calculator from AARP can help in the decision-making process. But be forewarned: there is a lot of information on the internet suggesting that you should delay receiving benefits as long possible. And this is not without some merit as your benefits will be higher and theoretically provide better cashflow through your retirement the longer you wait to begin receiving benefits. However, in many cases the modest monthly gain for waiting is not offset by the years of foregone benefits. Consider it this way: If you retire at 65 with a household income of about $50,000.00, you can immediately begin receiving about $1,750.00 per month. If you choose to wait until age 67 to begin receiving social security, your monthly benefit will be about $1,988.00 per month. Think you should wait for the extra $238.00 per month? Well, in order to receive that additional $238.00 per month, you will not receive $42,000.00 in benefits ($1750.00 x 24 months = $42,000.00). The additional $238.00 per month will take you a little more than 176 months to make up the difference between the total of what you would have received with the earlier election and waiting to have the higher monthly payout.

Several reforms to Michigan’s Blue Cross Health Insurance are currently pending in the Michigan Legislature. Proponents hope that these reforms will help reduce the costs of health care in Michigan, while advocates for the health insurance industry voice concerns about declining revenues and increased costs. The issues are complicated, but it seems fair to say that health care is only getting more expensive as the system continues to absorb the shock of a growing retiree population. The system is further strained here in Michigan by increased demands for individual coverage, a demographic that provides financial difficulties for insurers because of the disproportionate number of high-risk cases. Employment based coverage provides greater opportunity for insurance companies to manage risk because the varied population is more likely to include healthy individuals who opt for coverage because it is paid for at least in part by the employer. The key is of course sustaining the highest quality of care for the greatest number of people. As noted in Crain’s Detroit Business:

“Throughout the process one point has become clear, that more and more people are finding themselves in need of individual coverage, but the system does little to help them. As the bills go back to the House, we are hopeful that there will be meaningful solutions on this important issue,” Blue Cross said.

Blue Cross officials have said the individual market needs new rules to accommodate a growing number of people expected to join it over the next five years. The Blues argued for the high-risk insurance pool, which would require assessments from competing insurers after two years.

The push and pull of the legislative process is a reasonable mechanism for working out these controversial and complex topics. There is no easy solution to the pressure that health care costs place on the economy as a whole or the individual retiree’s monthly budget. The key is to remain informed and involved in the process.

When one spouse requires long-term care in Michigan, the Department of Human Services will do an assessment of the couple’s total resources. Without any planning or asset positioning, the spouse at home will be permitted to keep 1/2 of the couple’s assets as of the date the spouse needing long-term care entered either the hospital or long-term care, with a maximum of $104,400.00 and a minimum of $20,880.00 (in 2008). For example, a marital estate valued at $100,000.00 in non-exempt assets will be limited to $50,000.00 that the at-home spouse can keep. The remainder will have to spent on long-term care or converted to exempt assets before Medicaid will provide assistance with the cost of long-term care.

One simple estate planning technique to overcome this problem is to place the marital home in a revocable living trust before any health problems arise. Instead of being excluded from the total value of the estate, under Michigan law, the equity value of the home held in a living trust will be counted as an asset. So a couple with $100,000.00 in the bank and a home in a trust worth $150,000.00 will be treated as though they have $250,000.00 in assets when the asset declaration is completed. This couple will therefore be entitled to keep the full $104,400.00.

There are several cautions to using this technique. First of all, the home must be returned to the name of a natural person (not the trust) before applying for Medicaid. Failure to do so promptly can have horrific consequences. Second, relying on this technique can leave the home exposed to estate recovery. A more comprehensive asset protection plan is necessary well in advance of disability to be certain to avoid estate recovery. Third, this technique will not help with a home valued at more than $500,000.00. A variety of different asset protection techniques can be utilized in those circumstances. But for a married couple hoping to secure assets through retirement, placing a home in a revocable living trust can be quite helpful.

A recent article in The Economist explained how some senior citizens used Facebook to fight back when their investments in Asset Backed Commercial Paper ended up in bankruptcy court. Sometimes the innovations wrought by the internet can be a little startling, even if pleasantly so. The idea that a broad spectrum of investors, including many elderly, might form a coalition on Facebook and force a corporation to hear (and heed) their complaints is an astonishing example of how much has changed. Not only has the internet brought people together in wonderful new ways, but the phenomenon has spread to all parts of society, including the elderly:

Following the example of their children and grandchildren, some small investors formed a group on Facebook, a social-networking site, to trade information, provide mutual support and plot strategy. Brian Hunter, the group administrator, says the site turned out to be an “amazing tool”. People who would never have met in real life, from pig farmers and retired loggers to MBA students and pastors, created a formidable interest group.

I find the internet a fascinating world of possibility. There is no limit to the connections that can be formed or the information that can be harnessed. Although written several years ago (and updated more than once) I would recommend The World is Flat to anyone hoping to see the breadth of what has changed through the influence of the internet.

Sue Schiebel has written an excellent article on Medicaid Planning. While her article concerns MassHealth, which is the Massachusetts Medicaid program, the rules and ideas explained are the same in Michigan. She writes:

A lot of middle-aged people don’t realize Medicare, the federal health insurance program, pays for a very limited amount of skilled nursing home care. As we live longer, that means more of us will have to spend our own money for long-term care or must rely on MassHealth, the state health insurance for low income people. Many people wind up doing both — first using up many of their own assets to “spend down” to Medicaid limits so they are financially eligible for state help.

Medicaid qualification is a complex area of the law. To highlight just one counter-intuitive aspect, consider that donations to a church or charity are treated as gifts under the law. One making such a gift is technically creating a period of ineligibility for Medicaid. Strictly speaking, one could then have no means to pay for a nursing home after all other assets have been spent down. An elder law attorney helps families cope with these bizarre rules and avoid such unfortunate results.