Moti Mizrahi

I'm Looking to Start a New Chapter in my Life. What Should I be Doing? 
To begin, you must determine what your needs are. This would include such things as:

• Have you just retired?
• Are you divorced or widowed?
• Do you currently own a home?
• Do you want to sell the home?
• What type of new living situation are you considering?
• Do you have children?
• Are you active?
• Do you require any medical attention?

How Can I Prepare My Safety Net From a Position of Security? 
The truth is none of us can predict our personal future or that of a loved one. Early planning provides us ways to protect our property and maintain our well-being. It's better to prepare for your future from a position of health and security than to wait for a crisis and make decisions in grief or haste. 

What Issues Should I be Most Concerned With? 
There are many. A partial list includes: 

Health 
Be aware of your overall health, your problem areas, and your future risks. Take all necessary precautions, including physical and mental workout as well as diet. Secure a good physician and hospital that you trust with your personal health. Your physician will evaluate your diet and exercise needs as well as other influences on your health. It is never too late to begin an exercise program or to give up bad habits. Working with your trusted specialists can add years of active living. 

Finance 
Do what you can to become educated on all matters concerning your finances. Some things to consider include: 

• Current assets
• Future assets
• Benefits
• Various insurance coverages.

You cannot rely on Medicare to cover all payments, despite the revisions made in the area of health care coverage. The cost of nursing homes, long term care, assisted living or private nursing care must be considered and planned for. Opportunities available through retirement plans, insurance riders, and state programs should be obtained and studied with a trusted financial advisor. 

Legal issues 
These should be attended to when you are of sound mind and in full control of your possessions. Protecting your personal property and finances is imperative so that they are available for your care when needed. When you are not competent due to ill health, you may not be able to initiate the legal documents necessary to allow a friend or family member to handle your affairs. Now is the time to explore who will have your power of attorney to execute decisions on your behalf when you are incapable of doing so. You should also consider the implications of a living will. 

Housing 
Determine what housing alternatives would be acceptable and available to you should your independence be threatened by illness, disability, or loss of income. Visit locations in your community and make your plans known to your family. Safety, security, cost of upkeep, accessibility, types of residents who share the facility, and even geographic location are important considerations. Assuming that someone else will make a decision to your liking when the time comes is unfair to that "someone", and risky to your future peace of mind. Being informed about deposits, waiting lists, nursing standards and eligibility requirements will lead to a good feeling of control over difficult decisions. 

Activities and Lifestyle 
As studies have shown, one of the secrets to longevity and health is a peace of mind found through renewed or continued interest in the world and its activities. Whatever your passions or hobbies, seek out furthering your education, get involved in artistic endeavors, correspond with a pen pal, or start a new business. 

Support Systems 
This is a general term for surrounding yourself with friends, relatives, and resource persons that will serve to inspire you, keep you vital, entertain you, and who will be available when help is needed. This is an area often neglected by seniors, especially after the passing of a spouse. Making plans for your future in later years deserves the same attention, excitement and positive outlook you gave to choosing a college, planning for children, and your career. A safety net of information about health, finances and legalities while continuing to develop personal interests and friendships will support and sustain you through times of difficult decision making. 

What are the Different Types of Living Facilities Available for Seniors? 
Facilities are organized into the following categories: 

• Independent Living
• Nursing Homes
• Continuing Care Retirement Communities
• Adult Active Communities
• Alzheimer's Care
• Assisted Living

Independent Living 
Often referred to as Retirement Communities, Congregate Living or Senior Apartments, this is a residential living setting for elderly and senior adults that may or may not provide hospitality or supportive services. Under this living arrangement, the senior adult leads an independent lifestyle that requires minimal or no extra assistance but offers the security and conveniences of community living. Independent living also includes rental assisted or market rate apartments or cottages where residents usually have complete choice in whether to participate in a facility's services or programs. 

Some independent communities offer organized social and recreational programs as a part of everyday activities (Congregate Living or Retirement Communities), while others provide housing with only a minimal amount of amenities or services (Senior Apartments). 

Cost/Payment 
Prices for units in these communities generally depend upon local market conditions. Most communities that provide services are market rate, but some subsidized senior apartments cater to seniors with limited incomes. Private Funds are most often used, although some senior apartments are subsidized and accept Section 8 vouchers. Medicare and Medicaid do not cover payment since no health care is provided. 

Care 
Since independent living communities are independent, health care is not provided as part of the fees. However, many communities will allow you to pay for a home health aide or nurse to come into your apartment to assist you with medicines and personal care. 

Nursing Homes 
These facilities are licensed and regulated by the State Departments of Public Health and are individually certified by the State for Medicare and Medicaid. They are available to seniors who do not require acute hospitalization but do need 24-hour skilled care. Some of what is provided includes: 

• Regular medical supervision
• Rehabilitation therapy
• Personal care
• Personal protection
• Assistance for most or all daily living activities such as bathing, dressing and toileting
• Regular medical supervision and rehabilitation therapy are mandated to be available, and nursing homes are eligible to participate in the Medicaid program. These facilities are State Licensed.

The Nursing Home's medical staff sets them apart from other types of senior housing as care is provided by registered nurses, licensed practical nurses, and nurses aides at all hours of the day. Facilities include:

• Trained medical staff
• Medically planned meals
• Professional service staff-activity director
• Social workers
• Furnished rooms with housekeeping services
• Physician and physician services (on call)
• Physical, respiratory, and speech therapists
• Medications
• Personal care items
• Laundry service

Depending on the facility, some of these services may have extra charges associated with them. 
Questions to Consider 
When selecting a nursing home, ask the following questions of the administrator or admissions coordinator:

• What levels of care do they offer?
• Do they accept Medicare or Medicaid?
• Are there any restrictions on the type of patients they admit?
• What is provided in the basic daily rate?
• What services cost extra?
• Is there a volunteer program?
• Is there an adequate staff?
• How long do nurse call lights stay on?
• Do the patients look clean and are they dressed in clean clothes?
• Are staff members kind and responsive when they talk to residents?
• Is the food good? Ask a resident how it tastes. See if it looks good and if it is served hot.
• Do the patients seem to get enough to eat? Are they offered second servings, diet permitting?
• Does the home serve snacks?
• Is the dining room clean and well furnished?
• Are patients assisted with eating when required?
• Is there an activity program?
• Is there a full-time activity director?
• Is a list of activities posted?
• Is there something for patients to do who are confined to their rooms?
• Are there many patients sitting around with nothing to do?
• Does the facility have community TV with good reception?
• Is there a volunteer program?

Cost/Payment 
Nursing Home facilities generally charge a basic daily or monthly fee. In most cases, however, residents and or their families will have purchased long-term care insurance in anticipation of the cost or seek alternative forms of financing. These facilities do accept a variety of Medicare, Medicaid, private insurance carriers, and private funds. 

Care 
There are three care programs. They are:

• Basic Care - These are services required to maintain a resident's activities of daily living. Basic Care includes personal care, supervision and safety. A nurse aide, practical nurse or a family member can provide this care.
• Skilled Care - This is the level of care which requires the regular services of a registered nurse for treatments and procedures. Skilled care also includes services provided by specially trained professionals, such as physical and respiratory therapists.
• Sub-Acute - This is comprehensive inpatient care designed for someone who has had an acute illness, injury, or chronic illness. Sub-acute care is generally more intensive than traditional nursing facility care and less than acute care, requiring frequent (daily to weekly) recurrent patient assessment and review.

Continuing Care Retirement Communities (CCRCs) 
Generally, CCRCs are communities which provide several levels of continuum of care for elderly persons. This continuum of care is sometimes referred to as the levels of care and may include the following: 

• Independent Living - Residents live independently in their daily activities in their independent living units. Some services are generally provided to these residents such as housekeeping, meals and laundry service.
• Assisted Living - Residents need some assistance with the activities of daily living such as bathing, dressing, eating or taking medications.
• Skilled Nursing Care - Residents generally require round-the-clock nursing service in a nursing facility.

CCRCs are different from other housing and care facilities for seniors because it usually provides a written agreement or long-term contract between the resident (frequently lasting the term of the resident's lifetime) and the community which offers a continuum of housing, services and health care system, commonly all on one campus or site. 
Questions to Consider 
If you are thinking about a CCRC, the following are some questions you might want answered:

• Who owns the CCRC?
• Are the owners financially stable?
• What are the CCRCs long term plans?
• Will the CCRC be around to deliver services as long as you need them?
• Who manages the CCRC?
• How long have they been managing it?
• Are they likely to continue?
• What is the turnover rate among the staff with whom you will be interacting on a daily basis?
• If the CCRC is a condominium, individual housing unit or a co-op, are there any restrictions on selling it?
• Is there a waiting list? If so, how long do they estimate it will take for you to be admitted?
• What services are you getting for your monthly fee?
• Are more services available if you need them? At what cost?
• Is transportation available? At what cost?
• How often and for what reasons can the monthly rate increase?
• Is the increase predictable and is it tied to something like the consumer price index?
• Is there a basic entry fee? How much is it and how long do you have to pay it? Is the entrance fee refundable and under what circumstances?
• How much care will you get for your monthly fee?
• What care is available and who chooses the care provider, you or the CCRC?
• What care is available at additional cost and at what cost?
• Will it cost extra to use your own doctor?
• What happens if you can no longer afford to stay in the CCRC?
• Are they certified for Medicare and Medicaid?
• How are medical emergencies handled?
• Is a hospital close by and what services does it offer?
• Will your cost rise if you need assistance with daily living or you need to move to assisted living or skilled nursing care?
• What if you are a couple and only one of you moves?
• What happens if you get Alzheimer's disease?
• Can the CCRC provide care for you on the premises?
• If not, where can you obtain the care?
• Who pays for all of this? If it's you, how much will it cost?
• Is there anything that gives the CCRC the right to ask you to leave?
• If so, what is it, and what happens to the money you paid as an entry fee?
• There are always rules for residents. Can you live happily with them?
• Can the CCRC handle your dietary needs and your tastes in food?

CCRCs offer a variety of residential services, including the following:

• A maintained apartment, townhouse, or other unit
• Cleaning and laundry service
• Meals in common dining areas (number of meals per day may vary)
• Grounds maintenance
• Security
• Social, recreational, and cultural programs
• Health care services
• Care is covered for contracted services
• Personal care and help with daily activities
• Nursing care
• Rehabilitative care
• Respite & hospice care
• Alzheimer's & special care clean, furnished rooms

Cost/Payment. 
The agreements or contracts used by CCRCs differ, but are generally based on the health care provided. The three most common types of health care coverage in the CCRC agreement are listed below.

• Extensive agreements - These include housing, residential services and amenities, and unlimited, specific health related services with little or no substantial increase in periodic (monthly) payments
• Modified agreements - These include housing, residential services and amenities, and a specific number of long term nursing care days with no substantial increase in periodic (monthly) payments. After you have used your allocation of nursing care, you are then charged the daily rate for each additional day
• Fee-for-service agreements - These include housing, residential services and amenities for the fees stated in your agreement. You also pay for any health related services as you use them, at the current rate, either daily or monthly.

The three general types of payment or fee arrangements are:

• Entry fee and monthly fee
  The entry fee is a one-time, up-front fee that is combined with monthly fees to cover the living unit, services and care items covered in your resident agreement. CCRCs may charge an entrance fee that depends on the individual CCRC. The entrance fees charged can be minimal to several hundred thousand dollars. This is the most common type of fee arrangement offered. The entry fee may or may not be refundable. If it is refundable, it will be under certain conditions as specified in the mandatory disclosure statement
• Monthly-fee-only or rental
  There is no lump sum entry fee. The cost of your living unit, services and care are covered in your monthly fee payment. Sometimes, however, there is a small up-front fee or deposit charged
• Ownership or equity (condominium, cooperative or membership).
  These types of CCRC agreements involve the actual purchase of real estate and/or a membership. The purchase of the real estate can be an expensive undertaking, especially if a large down payment is required. Additionally, there can be a mortgage associated with the transaction. The service and health care package is generally separate from the real estate transaction and is covered through monthly fees or assessments.

Services 
Monthly fees generally cover the following:

• Meals (numbers may vary)
• Scheduled transportation
• Housekeeping services
• Unit maintenance
• Laundry
• Health monitoring services
• Some utilities
• Organized social activities
• Emergency call monitoring
• Security

Active Adult Communities 
The terms "Active Adult", "Senior" or Resort Communities, refer to rental communities where you must be 55 years or older and sometimes 62 years or older to live. These options are designed specifically to attract "age qualified" retired persons and those nearing retirement age who wish to get a start on owning a place where they will eventually retire and who desire the maintenance-free lifestyle. They offer an independent lifestyle in addition to social and recreational activities with older adults. 

Services 
These communities may offer facilities and amenities such as:

• Golf
• Tennis
• Views
• Walking and biking trails
• A swimming pool
• Exercise rooms and a variety of clubs and interest groups.
• Many are gated communities that offer a high level of security and some have health care facilities on site
• Classes such as art, dancing, woodworking, ceramics, chorus, yoga, etc.
• Many will have a clubhouse or country club with dining facilities, and depending on location, a marina and beach.
• Residents may live in individual single-family homes, condominiums, town houses or suites in high rise towers.

Alzheimer's Care 
At some point, the needs of the Alzheimer's patient may be too great to continue home care or prior care in an Assisted Living Facility. Transferring to an Alzheimer Care Facility presents the patient with a treatment center whose focus is geared toward supervision. These facilities are part of a new trend to provide specialized care for those with Alzheimer's. Some of what differentiates these facilities from Nursing Homes or Assisted Living Facilities are elements like design features within the facility that assist with the problems associated with this disease such as: color-coded hallways, visual cues, and secure wandering paths for additional security. 

Questions to Consider

• Inquire about the facilities specialties - This should include information about dementia training (both past and on-going) for employees, specialized activities and a calm environment.
• Inspection Report - Request to see the most recent facility inspection report. This document is public information, must be posted in a visible area, and highlights the kind of care provided.
• Staff - Inquire about the size of the staff and what their availability is throughout the days, evenings, nights and weekends. This will help determine how much individual attention your family member will receive.
• Determining your individual needs - Inquire about whether the facility offers a cognitive assessment as part of the screening. Such an assessment helps assure the family and the facility that the residence is capable of meeting the individualized needs of the resident.
• Security - This pertains to the facility's ability to safeguard potential wandering of their patients.
• Long Term Care - Learn about the staff's ability to care for your loved one as the disease progresses. Not all facilities provide care throughout the progression of the disease.
• Learn about your families involvement - Identify the facility's plans for maintaining and involving family in the care, support, and problem-solving of the patient

Care/Facility 
Similar to Assisted Living communities, most provide assistance with dressing, grooming, bathing, and other daily activities. Assistance with medications differs according to state regulations. Meals, laundry and housekeeping are usually provided within private and semi-private rooms in a residential type setting. 

Assisted Living Facility (ALFs) 
Assisted Living Facilities are privately owned facilities which provide room, board and limited personal services (such as help with bathing and dressing) as well as access to available community services. ALFs can range in size from a few residents to a facility housing as many as several hundred older adults. ALFs also vary considerably in monthly rent, types of services offered, and physical amenities. Some ALFs accept certain low-income adults who are certified eligible for state-supported assistance as determined by the Department of Children and Families. ALFs usually are appropriate for persons in the early to middle stages of Alzheimer's disease. 

Services 
ALFs will generally provide a range of services that promote resident quality of life and independence, including:

• Personal care services (help with eating, bathing, dressing, toileting, etc.)
• Various health care services
• Social services
• Supervision of persons with cognitive disabilities
• Social and religious activities
• Exercise and educational activities
• Arrangements for transportation
• Laundry and linen service
• 24-hour supervision
• Three meals a day plus snacks in a group dining room
• Housekeeping and maintenance.

Questions to consider 
If you decide that assisted living is the right solution, consider the following when evaluating the assisted living choices in your area:

• Is the management experienced?
• Do they have genuine concern and respect for the residents?
• Are the residents and families happy and satisfied?
• Is staff friendly and caring?
• What is the staff to resident ratio?
• Is the community clean and comfortable?
• Is this a place children would like to visit?
• Are meals appealing and well balanced?
• What health and wellness services are available?
• Is the location convenient to friends and family?
• What activities are planned for residents?
• Will the prospective residents like these activities?
• Will the prospective resident enjoy the daily life as compared to the other options?
• Do services and quality of living meet your standards?
• Is the value comparable to cost?
• What are the residency criteria?
• Considering all...will assisted living improve the quality of life for a resident?

Cost/Payment 
While costs vary across the nation, assisted living generally costs less than home health services or nursing home care. The following factors should be considered:

• Types of services
• Size of accommodation
• Location of community, etc.

Most assisted living residences charge monthly rates and do not usually have an entrance fee. Many also have daily rates for short-term stays (respite care). 

What should I Know Before Choosing a Senior Housing Facility? 
Perform a thorough review of the services, operations and finances of the establishment, including a review of their audited financial statements. 

Consult an attorney and/or a financial advisor to determine if the establishment is appropriate for your lifestyle and financial situation. 

Spend as much time as you can visiting the establishment and try to participate fully in its activities. 

Compare Establishments. Do as much research as possible. Make sure that whatever place you choose, your choice is right for you. 

Interview residents and staff. Objectively evaluate the services and amenities based on your lifestyle and your condition. 

Share the details with someone you know and trust. They might be able to be more objective than you and assist in your evaluation. 

What Should I Know About Private Insurance Policies? 
Some insurance companies offer private insurance policies specifically for long-term nursing home care. These policies vary widely in coverage and cost, and it is important to understand precisely what kind of policy you are purchasing. 

Make sure the policy being considered does not duplicate skilled nursing facility coverage provided by any coordinated care plan such as Medicare or Medicaid or other coverage already received. Check for any prerequisites required before the company will pay benefits. For example, ask if the company requires that a patient have prior hospitalization before any benefits are paid out. Some diseases such as arthritis-related problems and Alzheimer's do not require hospitalization before the need for nursing care arises. 

If possible, seek an insurance policy that pays benefits immediately upon entry into a nursing care facility. Many insurance policies, which are purchased prior to the need for nursing care, require a waiting period after entry into a nursing care facility before payments are made. It is highly unlikely that nursing care insurance can be purchased after a person has entered a nursing care facility. 

Another private insurance policy, Medigap supplemental insurance, is designed to close the gap between medical costs and amounts paid by Medicare. However, both Medicare and Medigap are primarily designed for short term, acute care and, consequently, are unlikely to meet the long-term needs of nursing care residents