Shedding New Light On Hospice Care

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Woman and caregiverEarlier this year, Kathy’s 86-year-old mother was hospitalized in Colorado after a fall. As she rushed to her side, Kathy asked for a consultation with a palliative care nurse.

“I wanted someone to make sure my mother was on the right medications,” Kathy said.

For all her expertise — Kathy Brandt advises end-of-life organizations across the country — she was taken aback when the nurse suggested hospice care for her mother, who has advanced chronic obstructive pulmonary disease, kidney disease and a rapid, irregular heartbeat.

“I was amazed — really?” Kathy said, struggling with shock.

It’s a common reaction. Although hospices now serve more than 1.4 million people a year, this specialized type of care, meant for people with six months or less to live, continues to evoke resistance, fear and misunderstanding.

“The biggest misperception about hospice is that it’s ‘brink-of-death care,’” says Patricia Mehnert, a longtime hospice nurse and interim chief executive officer of TRU Community Care, the first hospice in Colorado.

In fact, hospice care often makes a considerable difference for those with months to live. “When someone is further out from death, we can really focus on enhancing their quality of life,” says Rachel Behrendt, senior vice president of Hospice of the Valley, which serves the Phoenix metropolitan area.

New research confirms that hospice patients report better pain control, more satisfaction with their care and fewer deaths in the hospital or intensive care units than other people with a similar short life expectancy.

What should seniors and their families, the largest users of hospice care, expect? It’s fairly well understood that patients forgo curative therapies in favor of comfort care when they enter hospice. Here are additional features:

Four Levels Of Care

Hospice providers are required to offer routine care in patients’ homes (this includes seniors who reside in assisted living or nursing homes); continuous care at home for people with out-of-control symptoms such as pain or breathing problems; inpatient respite for families that need a break from caring for a loved one; and general inpatient care for medical crises that cannot be handled in any other setting.

With continuous care, a nurse must be on-site in the home for at least eight hours a day, helping to bring symptoms under control. Usually, this will happen in one to three days. Respite care has a maximum limit of five days.

Some hospices have their own general inpatient facilities and “it’s a common misconception that patients are sent to inpatient hospice to die,” says Jean Cohn, clinical manager at Montgomery Hospice’s inpatient facility, Casey House. “In fact, we’re frequently fine-tuning patients’ regimens in inpatient hospice and sending them back home.”

Intermittent Care At Home

Routine care at home is by far the most common service, accounting for about 94 percent of hospice care, according to the latest report from the National Hospice and Palliative Care Organization.

While services vary depending on a patient’s needs, home care typically involves at least one weekly visit from a nurse and a couple of visits from aides for up to 90 minutes. Also, a volunteer may visit, if a patient and family so choose, and social workers and chaplains are available to address practical and spiritual concerns.

Hospices will provide all medications needed to address the underlying illness that is expected to cause the patient’s death, as well as medical equipment such as hospital beds, commodes, wheelchairs, walkers and oxygen. Typically, there is no charge for such gear, although a copay of up to $5 per prescription is allowed.

What families and patients often do not realize: Hospice staff will not be in the home every day, around the clock. “Many people think that hospice will be there all the time, but it does not work that way,” Brandt says. “The family is still the front line for providing day-to-day care.”

In assisted living, patients or their families may have to hire nursing assistants or companions to provide supplemental care, since hands-on help is limited. In nursing homes, aides may visit less often, since more hands-on help is available on-site.

Self-Referrals Are Allowed

Anyone can ask for a consultation with a hospice. “We get many self-referrals, as well as referrals from family and friends,” says Behrendt of Hospice of the Valley. Usually, a nurse will visit and do a preliminary assessment to determine if a person would qualify for hospice services.

To be admitted, two physicians — the patient’s primary care physician and the hospice physician — need to certify that the person’s life expectancy is six months or less, based on the anticipated trajectory of the patient’s underlying illness. And re-certification will be required at regular intervals.

A Person Can Choose Their Physician

A person has a right to keep their primary care physician or they can choose to have a hospice physician be in charge of their medical care.

At JourneyCare, the largest hospice in Illinois, “we prefer that the patient retains their primary care physician because that physician knows them best,” says Dr. Mark Grzeskowiak, vice president of medical services.

These arrangements require close collaboration. For instance, if a nurse observes that a patient with heart failure is experiencing increased shortness of breath, JourneyCare staff will get in touch with that patient’s primary care physician. The physician is responsible for altering the treatment plan; the hospice is responsible for implementing that plan and giving clear instructions to the patient and family.

Concerns About Medications

“There’s a misconception that a person is going to be medicated to a highly sedated state in hospice,” says Dr. Christopher Kerr, chief executive officer and chief medical officer for Hospice Buffalo Inc. in upstate New York. “The reality of our primary goal is to increase quality wakefulness. Managing these medications is an art and we’re highly experienced.”

Family caregivers are on the front line since they are responsible for administering pain medications such as morphine. “Absolutely, there’s a great deal of fear and anxiety around all the issues associated with giving medications,” says Cohn of Montgomery Hospice. “We try to reassure caregivers that the doses we start with are very small, monitor how the patient reacts, and go deliberately slow.”

Because most hospice stays are short — the median length is only 17 days — and because the diversion of painkillers from people’s homes is a risk, doctors have begun writing prescriptions for a week or two at a time, says Judi Lund Person, vice president of regulatory and compliance for the National Hospice and Palliative Care Organization. If concerns exist, hospices can have a lockbox for medications sent to the home.

Discharges Are Possible

Estimating when someone is going to die is an art, not a science, and each year hundreds of thousands of hospice patients live longer than doctors anticipate.

If physicians can document continued decline in these patients — for instance, worsening pain or a noticeable advance in their underlying illness — they might be able to re-certify them for ongoing hospice care. But if the patient is considered stable, they will be discharged, various experts say.

In 2015, nearly 17 percent of hospice patients were so-called live discharges, according to a report from the Medicare Payment Advisory Commission. Two days before a discharge, hospices are required to give the patient or family members a Notice of Medicare Non-Coverage. Expedited appeals of discharge decisions can be lodged with a Medicare quality improvement organization.

There are no regulatory requirements governing what hospices should do to facilitate live discharges. Some hospices will spend weeks helping patients make arrangements to receive medications, medical equipment and ongoing care from other sources. Others offer minimal assistance.

At The Very End

Almost 1 in 8 hospice patients do not get visits from professional staff during their last two days of life, according to a study published in JAMA Internal Medicine last year. And this can leave families without needed support.

Some hospices have responded by creating programs specifically for people who have a very short time left to live. “We’ve put together a special team for people who are expected to live 10 days or less because that requires a different kind of management,” says Ann Mitchell, chief executive officer of Montgomery Hospice. “Instead of a nurse for every 15 patients, a nurse on this team will have five to six patients and a social worker is available seven days a week.”

“One-third of our patients are here for less than seven days and often we receive them in a crisis,” says Kerr of Hospice Buffalo. “We’ve had to re-purpose our services to address the urgency and complexity of these patients’ needs and that means we have to be ever more present.” Across the board, Hospice Buffalo requires that patients be seen within 24 hours of an expected death.

Long-Term Care At Home Without Breaking The Bank

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The vast majority of older adults choose to receive long-term care at home and not in nursing homes. But many people forget to make plans for this very important expense.

Nor do they see long-term care insurance as a viable option — because it is expensive and often seen as protection against the cost of only nursing home care.

That should change, some experts contend. If the long-term care insurance industry focused more on helping people cover home-based services, they argue, policies would be more affordable, and potentially appealing.

Long-term care, for most people, is a home care problem. It makes sense to insure people for the likelihood of where care is going to be needed first — which is at home.

Genworth, one of the nation’s leading long-term care insurers, acknowledged that this position is supported by industry claims data.

“Primarily, we are seeing people utilizing home care and a smaller percentage using nursing home care,” said Beth Ludden, Genworth’s senior vice president for long-term care insurance products.

“People think, ‘While I might start out needing care at home, eventually I’ll need to be in a facility,’” Ludden continued. “But that’s not something we see in our data. For the most part, people are able to stay at home for the whole time.”

Currently, more than 6 million older Americans are thought to have a “high need” for long-term care, according to a report from the U.S. Department of Health and Human Services. That’s defined as requiring daily assistance with two activities (eating, bathing, toileting, dressing, continence or transferring from a bed to a chair) that lasts at least 90 days or a need for substantial assistance due to severe cognitive impairment.

About 52 percent of adults reaching age 65 today will need these services — 26 percent for two years or less; 12 percent for two to four years; and 14 percent for more than five years, the HHS report projected.

Yet fewer than 10 percent of older adults have purchased long-term care insurance, which has somewhat declined in popularity as premiums skyrocketed and insurers exited the market over the past decade. Whether the industry can fix its major problem — affordability — remains to be seen.

From a consumer’s perspective, if the goal is covering several years of home-based care, not nursing home care, a person can purchase a less expensive policy without all the bells and whistles that drive up costs.

A 55-year-old couple buying a policy of this kind — say, $4,000 a month in benefits for each person, for a maximum of three years, with a 1 percent compounded annual inflation protection provision — from a major insurance company would pay $2,380.05 a year in premiums. It’s common for policyholders to pay premiums for 10 or 20 years before claiming benefits. Terms are similar in most states.

How much help in the home might this policy provide?

According to 2016 data compiled by Genworth, the average annual cost for care provided by a home health aide was $46,332, compared with $82,128 for a semiprivate room in a nursing home. That translates into $3,861 a month, for 44 hours of home care a week — the equivalent of slightly more than six hours of care, seven days a week.

That might not be enough for seniors with serious, disabling illnesses, but it can provide much-needed relief to unpaid family caregivers who could otherwise be on call nonstop.

What happens if someone ends up needing nursing home care?

People might consider what is known as a “qualified long-term care partnership policy” — a plan available in every state except Alaska, Hawaii, Illinois, Massachusetts, Mississippi, New Mexico, Vermont and Washington, D.C. 

These little-known insurance products are designed to help consumers preserve their assets if they become seriously ill, need nursing home care and seek to become eligible for Medicaid, which pays for nearly half of nursing home costs in the U.S.

To qualify for Medicaid, most states require that an individual have no more than $2,000 in assets; couples are allowed to have up to about $120,000, so that a well spouse does not become impoverished. With a partnership policy, every dollar received in long-term care benefits is exempted from Medicaid’s asset test and protected from seizure by the state.

In other words, if you get $200,000 in benefits from a partnership policy and your state has an asset limit of $2,000 for Medicaid, you can keep $200,000 in assets plus the $2,000 allowed and still meet your state’s asset test.

Partnership policies do not guarantee Medicaid eligibility and a person would still have to meet whatever income standards their state sets for Medicaid. (Many, but not all states, allow people to “spend down” to qualify, using their income to pay for institutional care.)

Alan, 61, of Las Vegas, purchased a partnership policy three years ago because it allows him to retain control of his financial assets, even if he needs caregiver services. Another plus: The policy permits him [if he decides to stay at home] to take a certain amount of the monthly amount and give it to someone he chooses to provide care for him, even if that person is a family member.

There is no reliable national data about how many people with partnership policies end up going on Medicaid to cover nursing home care. Nor is there good data about the number of these policies that have been sold or the benefits paid out to date.

David Guttchen, who directs the Connecticut Partnership for Long-Term Care, the first such program in the country, is skeptical about policies with benefits that will cover only a portion of expected costs. (Four states, including Connecticut, were the first to launch partnership programs and have special rules.)

“A person absolutely needs to know what the average home care and nursing home costs are for their state, to get a sense of what the exposure might be,” he said. “If you don’t buy meaningful benefits, you’re wasting your premium.”

If a person is able to cover a good amount of home care but the policy does not cover nursing home care, some protection is gained, for a while, but a person could still pay an enormous amount out-of-pocket going forward, if Medicaid is not an option.

It’s a gamble because people cannot be sure what kind of care they will need in the future, or for how long, or what the future of Medicaid will offer. Before buying any policy, consult with an elder law attorney and an independent insurance adviser.

Is Maturing Unaffordable?

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Could you pay more than $200 a day for nursing home care? Around two-thirds of Americans over age 65 will need long-term care, either through at-home health care services, assisted living or a nursing facility.

Yet more than 90 percent of those surveyed in the Genworth Financial “2014 Annual Cost of Care” report haven’t talked about critical long-term care issues with their spouse, partner or adult children.

Genworth Financial asked survey participants how long-term care issues impact relationships, jobs, stress and anxiety for those in the circle of care — care recipient, primary caregiver, secondary caregiver and families involved.

Having a plan before there is a need is crucial.

Discussions about long term care issues often lead to patients experiencing less depression, less pain and less anxiety. Care recipients should talk to their loved ones about what their options are for care, how it will be financed and what family members might be involved in care giving. Genworth offers help starting the conversation.

Average costs:

The survey reveals the average cost of various services nationwide:

  • Homemaker services (hands-off non-medical care like cooking and running errands): $18/hr.
  • Home health aides (hands-on non-medical care like bathing and dressing): $19/hr.
  • Adult daycare (social, non-medical, community-based setting for some part of the day): $65/daily
  • Assisted living facility (single occupancy, 1 bedroom, hands-on medical care): $3,450/monthly
  • Nursing facility (semi-private room, 24-hr care): $207/daily
  • Nursing facility (private room, 24-hour care) $230/daily

Nursing facility care has increased more than $16,000 a year since Genworth’s 2008 survey. The cost of a private room in a nursing home has risen 4.45 percent annually, nationwide, since 2008, with this year’s median cost at $83,950 per year.

Assisted living facility costs vary dramatically by state. In Arizona, the average annual cost is $37,800, in Texas, $40,035 and in New York, 47,400.

However, home care rates have remained relatively flat over the past five years. One reason may be because homemaker and home health aides are considered unskilled labor and the organizations that provide these services do not have the expense of maintaining a stand-alone health care facility.

Find out the costs of care where you live.

How will you pay for long-term care?

Medicare is an option for those over age 65 or disabled. Home health services may be covered under certain medically necessary conditions. For care in a nursing facility, however, only 100 days are covered per benefit period after a three-day hospital stay (observation vs. admitted), 20 days are covered at 100 percent and days 21 to 100 require a co-pay.

Medicaid generally covers those with low incomes and limited resources and may cover some home services as well as facility care, but Medicaid limits the amount of assets you may own and the monthly income you receive before you are eligible for coverage. Eligibility varies by state and there are restrictions for transferring assets out of your name to receive benefits.

Self-insurance means you or a family member pay out-of-pocket for care services.

Long-term care insurance will pay for a wide variety of home and facility care up to the policy limitations. Many states participate in the Long Term Care Insurance Partnership Program, which allows patients to access Medicaid if they reach their LTC policy limits, while still retaining more assets than normally allowed under Medicaid. Generally, those who own a long-term care insurance policy that meet the partnership requirements may participate in their state’s partnership program.

Fear of Alzheimer’s

The Alzheimer’s Association reports that the cost of care related to Alzheimer’s, including health care, long-term care and hospice, will soar to a projected $1.2 trillion per year by 2050, depleting the financial reserves of many families, along with the nation’s Medicare funds.

In a study conducted by Age Wave on behalf of Genworth, 61 percent of respondents ranked having Alzheimer’s disease as their single greatest fear later in life.

The Alzheimer’s Association estimates that approximately 5.2 million Americans of all ages have Alzheimer’s disease. This includes an estimated 5 million people age 65 and older and approximately 200,000 people under age 65 who have younger-onset Alzheimer’s.

One in nine people age 65 and older and about one-third of people age 85 and older have Alzheimer’s disease. Yet 49 percent of survey participants had not considered the possibility of needing long-term care.

Other interesting statistics

Care recipients:

  • 34 percent are mothers receiving care from adult children.
  • 12 percent are fathers receiving care from adult children.
  • 9 percent are spouses receiving care from a spouse.

Who pays?

  • $14,000 paid by care recipient (excluding cost of facility).
  • $8,000 paid by family members (excluding cost of facility).

Eighty-eight of survey participants said household income was reduced 34 percent due to a long-term care event.

How they paid for care:

  • Dipped into savings/retirement funds.
  • Borrowed, took a reverse mortgage or sold home.
  • Reduced savings, vacation and family expenses.

How A Life Insurance Policy Can Fund Your LTC


The costs of long-term care are increasing every year, but most families do not understand what they will be confronting when it is their time to start paying for care. Too many people wait until they are in the midst of a crisis situation before they start trying to figure out how the world of long-term care works.

Most people want to remain financially independent and in control of their care decisions for as long as possible. People do not want to go onto Medicaid, yet consumers lack awareness and are unprepared for how they are going to cover the costs of Home Care, Assisted Living, Skilled Nursing Care, or Hospice. It is a subject typically ignored until a loved one is in immediate need of care.

There are ways to help people find solutions to their long-term care needs and problems. The best way to get help is to seek as much information as possible from an accredited independent advisor who is aware of all options in the market. A person can expect to be informed so they can make decisions about how to plan and fund their long-term care.

One solution analyzed is the growing use of life insurance policies as a tool to fund long-term care. Did you know that a life insurance policy can be acquired and the funds used tax-free to pay for assisted living, home care and all other forms of long-term care? Instead of allowing a policy to lapse or be surrendered, the owner has the legal right to convert the policy into a long-term care benefit plan. The only problem is — despite the fact that millions of people own life insurance, too few people understand their rights as the owner. Life insurance policies are assets. Think of them just like a house. The owner of a house wouldn’t just move out without selling their property. Why should the owner of a policy “move out” without first finding out the real value of their policy?

In the midst of growing demand and dwindling resources, it is now all too clear that the long-term care funding crisis has arrived. The problem for America is the most basic of economic principles – supply and demand. The “demand” of seniors that need (or will need) long-term care is growing at a much faster rate than the “supply” of resources (dollars) to pay for their care. This demographic-economic reality has forced the government to reduce benefit levels and raise barriers to entry for the three primary entitlement programs: Social Security, Medicare and Medicaid. The harsh reality is that more of the responsibility to fund retirement and long-term care is being pushed back on the individual (and their family).

Owners of life insurance have been in the dark for years that a policy can be used to pay for senior care. Millions of seniors needlessly abandon life insurance policies in the final years of their lives because they either can no longer afford the premium payments, and/or they are looking at eventually qualifying for Medicaid.

But a little known fact is that it is the legal right of every life insurance policy owner to convert their policy into a long-term care benefit plan to pay for senior care. The Supreme Court ruled over 100 years ago that life insurance is personal property and the owner has the same property ownership rights with a policy as they do a home or any other asset. A homeowner would not abandon their home for nothing in return and the owner of a life insurance policy does not need to either. A policy owner has numerous guaranteed rights for the use of their policy including converting the policy into a long-term care benefit plan.

We have reached the point that we can no longer ignore the realities of an ever growing population that will require long-term care, and the diminishing resources to pay for it. People able to sustain themselves with private pay dollars will benefit from access to higher-end senior living environments and care providers, greater choice, more control, and less financial impact on loved ones. Those unable to pay for long term care at some level on their own through the use of savings and assets (such as a long-term care insurance policy or a life insurance policy conversion), or with the assistance of family, will be forced to rely on the government.

New approaches to fund long-term care are here today and converting life insurance is an option available to all owners of policies. Due to legislative action taken up by national groups like NCOIL and introduced as laws in states across the country, as well as national media attention from news outlets such as The New York Times and The Wall Street Journal fewer and fewer policies will be lapsed or surrendered. Seniors and their families are beginning to learn that life insurance policies they have been abandoning for decades could instead be converted into a benefit to pay for senior care and delay their need to go onto Medicaid.


The cost of home care, assisted living and nursing home care has risen in Scottsdale, Arizona according to local planning professional..

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The cost of home care, assisted living and nursing home care in Scottsdale, Arizona has increased over the previous year according to an analysis conducted by Ernie Bobel, a long-term care insurance professional.

 Nationally the average hourly rate for a home health aide is $21, a 4.7 percent increase from the previous year, according to the yearly study conducted by the American Association for Long-Term Care Insurance. The average monthly rate for assisted living communities increased 2 percent to $3,100 and a private room in a skilled nursing facility now averages $220, up $10 from the previous year.

Costs for home care in Scottsdale, Arizona will range from $18 per-hour to $22 depending on the level of care needed explains Bobel.   Most people who require home care pay for several hours of care daily.

Costs for nursing home care in Scottsdale can range from $5400 per month to $7400.   All costs for care locally are rising and people need to prepare today so that a future need for care won’t wipe out a lifetime’s worth of savings.

The national average for one year in a private nursing home is $80,300 according to the Association study. Local skilled nursing home costs will vary but one thing is certain, they never decrease.

People tend to think they will never need long term care. Unfortunately when they do need it they are not prepared. With long term care insurance you can take control and be prepared. It helps you retain your independence, preserve your quality of life, stay at home as long as possible, protect your assets and savings and avoid burdening friends and family.

As life expectancies increase, there is a greater chance that people will require long term care.  According to an AARP study, only half of people say they “feel very or fairly prepared if they suddenly required long term care for an indefinite period of time.” 

If you are among the half that do not feel prepared, knowledgeable long-term care insurance agent, Ernie Bobel offers free, no obligation information that can help you plan and reach a decision regarding your future. 

To learn about ways to reduce the cost for long-term care insurance or to obtain a no obligation quote, contact Ernie Bobel at EHB Insurance Group by calling 602.617.4770 / 877.441.4714. Or visit the EHB Insurance Group website.

Bobel is a member of the American Association for Long-Term Care Insurance the national organization for leading insurance and financial professionals committed to educating consumers on the importance of planning.