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Basic Long-Term Care Options

Medicaid and Long Term Care Planning are often focused on preserving money, at least for the families who speak with me. However, the overall process has to be about more than just assets and income. Unfortunately, many professionals push those aside and focus only on the money without sufficient emphasis on the care needed. That is one reason we put together a team that includes a geriatric care manager who provides an evaluation and a flexible care plan for all of our Care Assistance Planning clients, and, to the extent our clients allow, we involve the family as well. After all, the decision on a parent’s long-term care plan often involves the family just as much as the parent who will need care.

The Long-Term Care Options

The different options available relate often to what is referred to as the Activities of Daily Living (ADLs) as well as the Instrumental Activities of Daily Living (IADLs). These are medical/health care evaluations more officially done by a medical professional when needed, but a quick evaluation by a geriatric care manager can help guide the big discussion of where is best for long-term care needs. Here is a list of the most universally accepted ADLs and IADLs according to



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The ADLs and IADLs often come over time and are rarely piled on all at once, absent a catastrophic health event, such as a stroke. In most cases, especially when it is memory or other gradually increasing cognitive impairments, it is the IADLs that require help first.

It is also extremely common for there to be a progression of care needs and a scaling of frequency or duration of help. Unless there is that catastrophic event, many seniors start out with just needing a little bit of help, which then progresses to a little more. And then a little more. Unfortunately, there is rarely a scaling back of assistance needed when it comes to long-term care. While each situation is different and there are many customized personal care plans and services available, there are four main living options to provide the care needed:

Option 1—Companion Care

Companion care is when someone comes into the home to help you continue to live more or less independently but provides assistance only with those activities where help is needed. Companion care can run the gamut from preparing meals, house cleaning, shopping, and errands, all the way to assistance with washing and dressing. Companion care can also range from full-time to providing a supplement to help already coming from the family.

Some of the most common care arrangements start with one or more of the kids “dropping by” to help mom or dad every now and then, mainly with IADL issues, and at least initially, it’s more about making sure tasks are completed by the senior properly and not necessarily doing these tasks for their loved one. In general, the more independence in tasks the family can preserve and promote for the senior, the slower the decline and need for more intense help.

It then turns into mandatory scheduled visits on a weekly or more frequent basis. By the time the need for assistance grows to several times a week, and maybe multiple children have to assist and trade off as events in their own lives pop up, the discussion emerges about hiring someone to make sure the ball isn’t dropped along the way. That’s when the hiring process begins to bring someone into the home for specific tasks and look for certain things.

One important consideration is Medicare will often not pay for this type of care since it is custodial care and not rehabilitative in nature. Medicare is basically health insurance for seniors, and health insurance only pays for care that will get you better and on to being self-sufficient. Custodial care is essentially needed when you are not going to become self-sufficient but still need care. There are some specialized types of long-term care insurance policies that pay when custodial home care is needed for certain periods of time and are generally affordable, but they would be looked at as just a drop in the bucket when more extensive care is needed.

In a lot of cases, this is the first stage of care that may be replaced by a more structured living environment if the illness progresses. However, in some other cases, it is only a temporary measure to assist someone who is convalescing until they regain strength and mobility.

Option 2—Move in with Family

While this is often a first reaction on the part of a family wanting to help as well as provide some cost savings, there are a lot of unanticipated difficulties. On the part of the person needing help, there are often strong emotional difficulties with having a lot of reliance on family members that they themselves used to take care of. Suddenly, the children who had been dressed, fed, and bathed by a parent are now the ones doing the dressing, feeding, and bathing, and that can be a tough thing for people to emotionally deal with. On the part of the children, there is often a huge disruption in their own lives and routines for work, school, activities for their kids, and other socializations that had been set for some time.

The two key words for the family at this stage are also the most important need for the senior needing care at this point: structure and routine. Where there was a lot of chaos around some activities but not others before, now there is order in just about everything. Laundry may have been done on an “as needed” basis, but suddenly there are specific laundry days. While soccer games and practices were on certain days, dinner times may have been flexible depending on last-minute activities of people in the family, but now dinner is always at the same time every night. Trips to the grocery store were simply done when they ran out of items, but now it is done regularly at the same time on the same days. All of this is because the care needs of the senior become a high priority, and so the rest of these previously flexible activities have to now structure themselves around those care needs. While this loss of some flexibility may be a little off-putting at first, routines change to incorporate caring for the older generation.

There are many benefits for the family even in this loss of structure because more time is being spent together as a family. Children and grandchildren end up seeing their senior relatives in a whole new light. Everyone learns new things about each other, skills and knowledge are traded, and the entire family grows closer. There is no doubt that this arrangement has a lot of benefits, not the least of which is that the family is together during a time of difficulty and they can gain much emotional support from each other. And the cost savings compared to some of the other options is also a great benefit to the family.

In some cases, moving in with the family has also been combined with the companion care option so that while family members are providing a lot of the needed care, there is someone else coming in to help with some of the activities that the parent would prefer to delegate to a non-family member, or, in some cases, cannot be done by a family member. In my own grandmother’s case, she had moved in with my aunt when it was better that she not live alone anymore, but it reached a point when neither my aunt nor either of her two young sons could lift her from bed to a chair or from a chair to a walker without great difficulty.

Option 3—Assisted Living

Assisted living arrangements can range from simply living independently in a more communal environment where prepared meals and dining facilities are available along with organized activities all the way to needing some help with everything just short of skilled nursing care. In many cases, assisted living facilities provide the whole range of assistance as needed so there is no need for someone needing more help to move out of the assisted living facility until it is time for more skilled medical care and assistance than the facility can provide.

Assisted living is often less expensive than nursing care, but it is still more expensive than independent living and certainly more expensive than moving in with family. However, there is definitely more that can be done for veterans, spouses of veterans, and widows/widowers of veterans when it comes to assisted living care, specifically when it comes to the Veterans Pension Benefit. For more information on this important resource, check out the course at

This is often logically the next step up from care at home or companion care, but it is important to see the differences. Some seniors start out immediately going into assisted living and bypassing companion care or moving in with relatives for a variety of reasons. First, they may want to keep as much independence as possible from their loved ones because they don’t want to be a burden, or they want the next generations to keep thinking of them as self-sufficient role models. It’s more about wanting to be seen a certain way, and it is something to be respected. Second, it could simply be that they have the financial resources to afford it, and they want life for their progeny to continue unabated. So they may be entering a progressive assisted living environment and community before there is an actual need to be there, starting out on the independent side of things until more comprehensive care is needed.

Option 4—Nursing and Skilled Long-Term Care

This is often called nursing home care, but the fact is that it really is more accurate to call it “skilled care” because it can be administered in a facility or at home. This is also by far the most expensive type of care short of being in a hospital environment. This is why many professionals focus solely on the cost perspective of things rather than looking holistically at the needs of the client and their families. In the end, that is what they are being hired for. For more information on the costs of long-term care, especially at the skilled nursing level, please check out the free webinar at

Many people needing this level of care would also prefer to stay at home while still receiving advanced care, and it can often be more cost-effective to do so. (When it comes to Care Assistance Planning and having Medicaid or other programs help pay for some of the care at home, the government is equally willing to have the lower costs of in-home but skilled care since it is cheaper for the government. However, there are different stipulations and rules surrounding qualification.) In other cases, a facility that provides skilled care may be exactly what is needed, so staying at home may not medically be the best option for you or the family.

In any event, this is the level of care that often frustrates families the most because, unless they are medical professionals, the care of their loved one is taken largely out of their hands. This also may be exacerbated by the fact that the senior may have been living with family for an extended period of time, and the family will miss the closeness they had experienced over those years. Again, dealing with the loss of control is difficult for the individual needing care just as much as the family, and this is one of the reasons we enlist a geriatric care manager for all of our Care Assistance Planning cases to help counsel families on these issues.

While most people come to us to help with the financial aspects of Care Assistance Planning, we have to start with what kind of care is required and preferred by our clients in order to achieve the best possible outcome. After all, saving money is and should be secondary to getting comfortable, competent, and appropriate care, but it would be naïve to think that money is not going to be an issue.

For more information on paying for long-term care, check out the free webinar at

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