Modern Family: Rise of the Multi-Generational Household

“Grampa is coming to live with us.” “Mom, I’m moving back home.” A struggling economy and an aging society is creating a new living dynamic in American — the three- (and sometimes four-) generation home.

We know that people are living longer and, while long-distance family caregiving is still common, it is also expensive. Families may use senior home care agencies to provide professional care to assist their elderly relatives with activities of daily living. Costs can skyrocket in times of crisis when a son or daughter finds themselves scrambling to make last-minute travel plans and miss work. Senior care costs such as those for nursing homes and assisted living communities continue to increase,  and many families may find it more economical to take a parent or parents into their own home.

According to the Pew Research Center, 57 million Americans, or 18.1% of the population lived in multi-generational family households in 2012. That number has doubled since 1980. Why the uptick? Many factors come into play, but The Great Recession of 2007-2009 has had a huge effect in the change in living arrangements. Many families lost their homes in the collapse of the housing bubble, forcing them to combine households. Young adults aged 25 to 34 have become a new demographic; known as the “boomerang youth’, they find themselves returning to the family home when it’s no longer economically viable to live on their own.

I’m part of the “Sandwich Generation”. I care for my children as well as an aging parent. The time and effort (and money) I spend supporting two households could be minimized if I could just combine them. I might also be able to claim my parent as a dependent if I pay more than half of their financial support. As a dependent, my parent’s exemption will be worth $4,000 in 2015.

Multigenerational living is not a new concept by any means. In fact, prior to WWII, it was the norm. But prosperity and suburban sprawl gave way to the migration of the nuclear family. According to the Pew Research Center, in 1940, about a quarter of the population lived in a multi-generational home; by 1980, just 12% did.

The trend reversal has benefits that extend beyond the financial. If the grandparent is healthy, they can provide free childcare to the working parent(s). Many find that daily contact between grandparent and grandchild to be invaluable. And, of course, senior isolation is nonexistent. However, there are drawbacks.

The only way to make it work, according to many multi generational families who live together, is to find a space that provides separation and retrofitting existing living spaces to accommodate the elderly. This means building an addition to a current home to provide an “in-law” apartment, or adding an elevator to ease access to multiple floors.

Some builders like Lennar with their NextGen homes, are creating “homes within homes” — complete with bedroom, full bath, kitchenette, living room, laundry room and separate entrance.
Be prepared to see more of these types of living situations. It looks like I may have to give it a go in the near future. And while I’ve always dreamed of living on the Kennedy compound, I have a feeling my multigenerational family home will look a lot more like the Waltons.

How Long Should We Live?

Recently and rather infamously, Ezekiel Emanuel, Chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania and brother to Chicago’s own mayor Rahm Emanuel, wrote a piece for the Atlantic entitled Why I Hope to Die at 75.

Citing the physical and mental degeneration that often accompanies old age, Dr. Emanuel asserts in his essay that he will forego not only life-sustaining interventions such as dialysis, ventilators and defibrillators after the age of 75, but also simple diagnostic and preventative measures, like colonoscopies and flu shots.

Reading his essay, one gets the distinct impression that Dr. Emanuel doesn’t buy the notion of aging well — the idea that as we increase our lifespans, diet and exercise (both mental and physical) can delay the decline and disabilities we face as we age. Instead of what he calls “American immortality,” Dr. Emanuel espouses his “75 and no more” philosophy.

It was like the shot heard ‘round the world, prompting responses and rebuttals from all over the web. As you can imagine, such a provocative essay hit people where they live (pun intended.) When one imagines a long life, it comes with the caveat of being able to continue functioning fully, without descending into frailty or senility.

What got me, however, was Dr. Emanuel’s supposition that your creativity declines as you age — his assertion that the elderly have nothing left to give to society. I disagree. Heartily. And I am not alone. Our friends at Homecare Together, a Dublin-based quality home care agency, sent me this wonderful infographic, Life Begins at 60+, which presents examples of seniors who changed direction, reinvented themselves, gave back to the community, and prospered well into later-stage life.

 

Of course, not all of us will enjoy such a run, but it won’t happen without trying. I may not take drastic measures to prolong my life after 75, but I hope by the time I get there, with the help of an exceptional senior caregiver ( or perhaps a robot companion), an aged quality life full of vim, vigor, and creativity will be the rule and not the exception.

"Do not go gentle into that good night... Rage, rage against the dying of the light" — Dylan Thomas

Nursing Homes, Assisted Living Out of Middle Class Reach

It's all excitement around here as we await the release of the movie, The Hunger Games: Mockingjay - Part 1, in which our heroine, Katniss Everdeen (Jennifer Lawrence), leads the have-nots of Panem’s districts in a rebellion against the haves of The Capitol.

Dystopian views of a future society, in books and in movies, often feature a missing element of the population — the middle class. In these communities, only the very rich and very poor have access to services, the former is afforded private (superior) services, the latter, inferior, government-provided resources. Like it or not, America is beginning to look a lot like those futuristic civilizations where you are either very rich (and in the ruling minority) or very poor (the rest of us.)

The Harvard Joint Center for Housing Studies’ recent report, Housing America's Older Adults—Meeting the Needs of An Aging Population, shows that affordable elder housing will be one of the single biggest challenges we face in the near future.

Housing is the largest expense in many household budgets. Even though the majority of seniors prefer to age in place, many older Americans find that the high cost of housing expenses make it necessary to cut spending in other areas such as groceries and healthcare. In fact, over 37 percent of Americans aged 80 or older put more than 30 percent of their income toward housing expenses. And those are the property owners — the lucky ones.

In Joel Kotkin’s book The New Class Conflict, the author points out a “doomed” middle class.  In the wake of the housing bust, U.S. homeownership, which peaked in 2002 at nearly 70 percent, has since dropped to 65 percent in 2013, the lowest in almost two decades, according to the U.S. Census.

How does that affect senior housing? Even if you have the financial wherewithal to age in place, the Department of Health and Human Services estimates that 37 percent of those aged 65 and over will receive care in some sort of institutional setting at some point, with an average stay of one year.

Nursing home and assisted living costs are always increasing. The recent (Nov. 2014) Caregiverlist® Index reported the average annual cost for an Illinois nursing home is $72,631.35. Of course, quality of care usually decreases at lower cost points. The national average for assisted living base rates was $3,550 per month in 2012.
    
The typical homeowner aged 65 and over has enough wealth to cover nursing home costs for 42 months and enough non-housing wealth to last 15 months. The median older renter will not be able to afford even one month in a nursing home or in assisted living.

As a society, we will be facing these challenges together to make sure that the aging population, whether they be the Jeffersonian ideal “small landholders” or increasingly-numbered  “lower middle-class” have access to the similar quality housing and services in order to age with security and dignity.    

INFOGRAPHIC: Housing America
 

Hospice is End-of-Life Care with Comfort and Dignity

For senior caregivers, the word “hospice” is a double-edged sword. Hospice is end-of-life care, so the inevitable is on the horizon. The care recipient is terminal and the focus of care shifts from extending the quantity of life to preserving the quality of life left.

November is National Hospice Month and a great opportunity to thank those who make the care recipient’s final months, weeks, and days comfortable and as pain-free as possible. As hospice care turns 40 this year, Caregiverlist invites you to learn more about this special breed of caregiving.

The National Hospice and Palliative Care Organization (NHPCO) defines hospice care as a specialized kind of care for those facing an end-of-life illness, their families and their caregivers that:

  • addresses the physical, emotional, social, and spiritual need of patients
  • provides care in the patient’s home or in a home-like setting
  • concentrates on making patients free of pain and as comfortable as they can be so they and their families can make the most of the time that remains
  • includes family members an essential part caring for the patient
  • stresses quality of life over length of time left

Hospice centers on caring, not curing. That care is delivered holistically by an interdisciplinary team that consists of physicians, nurses, in-home caregivers, therapists, counselors, and social workers. Their combined goal is to provide compassionate and comprehensive care that includes patient pain management and family support so the care recipient can die pain-free and with dignity.

The number of patients and families utilizing hospice has steadily increased over the last few years. In 2013, an estimated 1.5 to 1.6 million patients received hospice services. The median length of hospice service in 2013 was 18.5 days.

Who pays?
The Medicare hospice benefit, established 1982 by the U.S. Congress, is the predominate source of payment for hospice care. As of today, 42 states also offer Medicaid coverage for hospice. Private insurance and VA benefits cover this end-of-life care as well.

Few caregivers, especially family caregivers, are prepared to handle the events and changes that happen at the end of life. To that end, the Hospice Foundation of America has published a guide called The Caregiver’s Guide to the Dying Process. The booklet is designed to help the caregiver

  • address the needs of the dying by providing descriptions of the physical, emotional and spiritual changes occurring near the end of life
  • help to understand and recognize what is happening physically and emotionally to the terminally ill care recipient
  • suggestions for what you, as the caregiver, can do to ease distress and make
  • the dying person as comfortable as possible
  • information to help you, as the caregiver, communicate effectively with the hospice team
  • insight on how you might feel as the caregiver for someone who is dying ideas of how to care for yourself

My personal experience with hospice occurred with my good friend (and senior) Louie. Louie knew he was dying. At the time, he was in the hospital and asked to go home, where he could spend his last days surrounded by his family in the home he’d shared with his late wife and look upon the garden he’d tended for the last 45 years. Hospice brought a hospital bed into the greatroom, where he could look out onto the backyard and his garden. They eased his pain with generous doses of morphine so he showed no signs of physical duress as family and friends came to hold his hand and say goodbye. All the while, members of the hospice team were in and out, making sure everyone involved had all they needed to make Louie’s passage as warm and peaceful as possible. They made it possible for Louie to die at home, as he wished, listening to his favorite big-band music as they attended to his comfort. It was a beautiful and natural way to die and I will forever be grateful to them all for their inestimable services.

Join the NHPCO hospice community on Facebook and help ensure all Americans get access to quality end-of-life care.

White House Plans Conference on Aging in 2015

Americans are living longer than ever. One hundred years ago, in 1914, a man’s life expectancy was 52 years, a woman’s almost 57. If you are 65 years old in 2014, the Centers for Disease Control and Prevention estimates that as a man, you will live to about 83 and if you are a woman, your life expectancy is about 80 ½  years old.

In order to address the needs and concerns of an aging population, the White House is gearing up for its sixth White House Conference on Aging (WHCoA), to be held in 2015. The first conference was held in 1961, with subsequent conferences held each decade since.

Next year marks the 50th anniversary of Medicare, Medicaid, and the Older Americans Act. It’s also the 80th anniversary of Social Security. The 2015 White House Conference on Aging is an opportunity to look at these programs and see what public policies need to be implemented to understand the issues facing older Americans, their families and their caregivers.

WHCoA in 2015 will address four main issues: retirement security, healthy aging, long-term services and supports, and elder justice.

Financial security for retirees has changed in the last few decades, with fewer employers providing pensions. The future of Social Security is always in question and the need to protect that benefit is crucial to U.S. citizens retiring with dignity. Many older Americans have seen their retirement savings fall with the economy. The question of when to retire is being replaced with IF to retire. The conference will address “improving wages and benefits for all American workers—especially older workers—and ensuring opportunities for older Americans who choose to remain in the workforce, can provide additional avenues for income security in retirement.”

Healthy aging is made possible with better life choices including healthy eating, exercise, health screenings and supportive communities.

Senior care costs continue to escalate and it’s a fact that as we live longer, many of us will need assistance with the activities of daily living, whether it be through home care, assisted living, or nursing homes. Less than three percent of Americans currently have a long-term care insurance policy. WHCoA will explore new options to help Americans in preparing for their long-term care needs as they age.

The elderly are one of the most vulnerable segments of our society. Scam artists are just waiting to bilk people out of their savings. Physical and emotional neglect and abuse cut across economic, racial and ethnic lines, affecting seniors regardless of where they live.

Americans are encouraged to participate in the discussions. The White House is being more inclusive than ever before, bringing the conference online at www.WhiteHouseConferenceOnAging.gov, which will provide regular updates on Conference events and activities. You can get involved by signing up for weekly emails, or sharing your thoughts on elder issues or stories celebrating the contributions of older Americans.

Best (and Worst) Places to Grow Old

How do you envision growing old? I dream of living in a lake (or oceanside) house, growing my own food, within walking distance of a town with a vibrant cultural community, with family or friends nearby who I can count on if I’m in trouble. I am near transportation that allows me quick travel to a world-class city like New York, Chicago, Paris, London, Tokyo (or a myriad of others around the world—and if we’re dreaming, I also have a flat there) and access to an airport for occasional national and international travel.

For that dream to come true, I will need a few things. First, I will need an enabling environment. That means the place in which I live should have socioeconomic and political policies and programs in place to help me age with safety and dignity, and give me access to the best resources I need to age well.

I’d like to surround myself with vital members of the community, the educated (and, dare I say, employed.)

I will need some money, of course. The society in which I live should provide a little bit of a financial net. Some call it a pension, in the U.S. we call it Social Security.

Finally, you have nothing if you don’t have your health. The ideal spot to grow old will give me access to a clean environment and good medical care. Life expectancy should be high and I should live those years in good health and feel that my life has meaning.

How does one find such a spot?

HelpAge International's Global AgeWatch Index brings together data on health, income security, employment and education, social connections, safety and transportation into one number and ranks countries from 1 to 96 (with 1 ranking highest). The index represents nine out of ten people over 60 years old, all across the world.

Norway tops the list of overall global rankings. It earns first place in both income security and capability (employment and education). It comes in at number 4 in the enabling environment domain (social connections, safety, civic freedom, and transportation)—Switzerland wins here, and 16th in Health Status (Japan takes the number 1 spot.)

Overall, the U.S. ranks 8th, behind (in order), the aforementioned Norway, Sweden, Switzerland, Canada, Germany, the Netherlands, and Iceland. Better in some measures than others, I was surprised to learn that we as a nation rank 25th in Health Status, just behind Malta.

The worst places to grow old, according to the index are Afghanistan (96), Mozambique (95), West Bank and Gaza (94) and Malawi (93). But all around the world, life expectancy is on the rise.

The entire index is a fascinating interactive website with more data points than I can list. In addition to rankings by geographic area, the report includes emerging pension policies to help create basic regular income for the poorest of populations. Peru, Mexico, and Tanzania are among the countries highlighted for their new non-contributory “social pensions” as safety nets.

In a statement released by Help Age International, Professor Sir Richard Jolly, advisor to the Index as well as architect of the UNDP Human Development Index said, “People do not stop developing when they reach sixty or seventy or eighty. Our older years should be as much a time to expand our horizons as our earlier years.”

If you want to make a difference and make your aging voice heard, join Help Age International’s campaign Age Demands Action that is calling for a UN convention to protect older people's rights by law.

Alzheimer's Caregivers Cannot Sue, Rules California Court

Seniors who suffer Alzheimer’s can be a challenge to their professional caregivers, especially those who are able to age at home, outside of an institutional setting like a nursing home. Especially in later stages, Alzheimer’s patients and those with other dementia’s can be aggressive, angry, and violent. That can be a very difficult environment, especially for the in-home professional caregiver.

But if a senior caregiver suffers an injury at the hands of their Alzheimer’s client, they cannot sue the patient nor their family or estate for damages, according to a ruling by the California Supreme Court. Monday’s ruling came as a result of a case of a home health aide who was cut with a knife by her elderly client.

Prior to hiring her as to aid his ailing wife, a Los Angeles man informed the agency and the home health aide that his wife was prone to violent outbursts, including biting and scratching. Because of this prior knowledge, the court ruled 5-2 that it would not be appropriate to allow workers to sue their employers. 

California law already states that caregivers in nursing homes and other institutional facilities cannot sue Alzheimer’s patients who hurt them because those risks are inherent in their duties, especially since it’s well known that , although it’s not common for Alzheimer’s patients to become violent, discomfort and confusion can cause a violent flare-up.

The ruling is intended to help families keep their loved ones as home longer. If home healthcare workers were allowed to sue, families might decide it more financial sense to put seniors with memory issues into a nursing home.

Senior caregivers who are not warned of their client’s potential violent nature are precluded from future lawsuits, the court added. 

The best way a professional caregiver can learn how to deal with Alzheimer’s and dementia sufferers and help prevent latent violent outbursts is to partake in professional caregiver training. Caregiverlist® Basic Training, powered by Caregiver Training University provides the elemental training for every in-home caregiver. In addition, Caregiverlist® offers training videos especially for care techniques for those giving care to those with Alzheimer’s and other memory loss diseases.

Facts About Senior Care

So few of us plan for our long term care, yet the majority of us will need to avail ourselves of professional senior care at some point in our lives. By 2030, the U.S. population aged 65+ will exceed 70 million. According to the American Geriatrics Society, the vast majority of these older persons will have at least one chronic disease, and substantial numbers need assistance in performing basic and more advanced activities of daily living

There are a variety of professional senior care options to choose from, based on need and cost. Most seniors prefer to age-in-place, at home. If there is no family member to care for them, many times professional in-home care, provided by a trusted Home Care Agency is the go-to option. Residential options include Independent and Assisted Living Communities, and nursing homes. Nursing home costs vary widely based upon the state in which you live.

Our good friend, colleague, and elder law expert Ben Neiburger writes about the five key facts of long-term care.

1. Statistics
Nearly 41% of people under 65 and approximately 70% of people who live to age 65 will need some type of long-term care.
2. Medicare
Medicare covers skilled short-term medical care as well as short-term assistance with nursing home costs, but only if the circumstances meet strict requirements. However in most situations, this is simply not a viable long-term care option for most people.
3. Medicaid
Medicaid is a state-based program supplemented by Federal funds that provide health services to the poor and impoverished. Medicaid might cover your loved one, if he or she meets your state’s poverty criteria.
Many people attempt to spend down their assets to state-required levels or transfer their assets to family members to become eligible for Medicaid, but the state has the right to look back into your finances for 5 years before the date you apply for coverage, and may refuse to pay for your long-term care if you don’t handle your money “appropriately” during those 5 years.
4. Nursing Homes and other Long Term Care
Both Medicare and health insurance are intended to cover skilled, short-term medical care as you recover from an illness or injury—NOT long-term care. That means a health insurance policy rarely covers ongoing long-term care, especially if one is over 65.
5. Private Pay
Personal savings are one way to cover long-term care expenses. Keep in mind however, that in 2011, the national average annual cost of long-term care services in a semi-private nursing home room was $75,555. Since the average length of stay in a nursing home is 2.4 years, that would come to approximately $181,000 out of your savings.

We now know that, due to the longevity of our nation’s population, most of us will indeed need long-term care. Seniors once relied upon family members for elder care, and while there are many, many family caregivers (43.5 million of adult family caregivers care for someone 50+ years of age), many seniors will need to look to professional caregivers for their senior care needs.

Ways to pay for care that don’t include Medicare, Medicaid, or private pay includes long-term care insurance and reverse mortgages. Be vigilant in your research, however. Some long-term care insurance pays only for nursing homes and not for in-home senior care.
A reverse mortgage has its own pitfalls, making it an option of last resort.

U.S. veterans may be eligible for Veteran’s Aid & Attendance Benefit. For this benefit, you’ll need to apply and be persistent and patient. Those wheels tend to grind slowly.

Caregiverlist® understands the process involved in finding the right senior care can be arduous. Estate planning can assist you in determining your best options in how to pay for professional senior care for you or your senior family member.  

Ben Neiburger is an active member of the National Academy of Elder Law Attorneys (NAELA) and a member of the Executive Committee and Board of Directors for the Illinois Institute of Continuing Legal Education and through frequent speaking engagements and ongoing course work both locally and nationally, is in continuous pursuit of knowledge and insight to the laws and finances that affect our families and senior citizens. He brings this wealth of knowledge, his clear and common sense explanations, his patience, gentle humor and sensitivity to each of his legal consultations.To learn more about Elder Law, visit generationlaw.com.

States React to AARP Scorecard

Much has been made of AARP’s released report 2014 State Long-Term Services and Supports (LTSS) Scorecard. In fact, I covered the results in a recent blog.

Since the report’s release, state politicians and policy makers have been scrambling to either issue statements strongly urging for their state’s commitment to long term care improvement or stridently patting themselves on the back for a job well done.

Louisiana’s Times-Picayune article on nola.com about its senior population being over-institutionalized. Louisiana ranked 37th of the 50 states and Washington, D.C. in its overall long-term care policies. In that state, aging seniors are (predominantly) either placed in nursing homes or cared for at home by unpaid family members. And it ranked dead-last in effective transitions—meaning that a high number of nursing home residents are hospitalized because they’re not receiving the care they need. Funny, the same report found that there are a high number of nursing home residents with low-care needs. No doubt it is because of the lack of alternatives such as adult day care and other home and community-based services.

Not surprisingly, vociferous Louisiana AARP advocates call for increased funding of alternate care choices in an attempt to acquiesce to the majority of older Louisiana residents who wish to age in place, at home. Ironically, despite the article pointing to so many calls-to-action, they conclude optimistically, pointing out that “Louisiana's ranking in 2014 improved slightly from the 43rd slot, when scorecard was last issued in 2011.”

On the flip-side, Minnesota’s Office of the Governor Mark Dayton was quick to issue a press release extolling their number one spot on the scorecard for long term care access, choice, quality, and caregiver support. The release also pointed out that Minnesota ranked in first place on the 2011 Scorecard as well.

In the release, Gov. Dayton cited the following efforts that assist Minnesotans in “providing our parents, grandparents, and people with disabilities the best possible care.”

  • New incentives for providers to increase quality
  • More help for people who want to move from nursing homes and other congregate settings to homes of their own
  • More comprehensive information and referral services for individuals and family caregivers
  • Support for core community services that help people stay in their homes
  • More flexibility for consumers in choosing supports tailored to their needs
  • Promotion of competitive employment for people with disabilities
  • A stronger adult protection system; and
  • Own Your Future, an initiative that encourages Minnesotans to plan for their long-term care and is now exploring new ways Minnesotans can finance this care.


We at Caregiverlist® not only care for the caregiver, we advocate for seniors and their families. I hope that the Long-Term Care Scorecard elicits more than one-upmanship between states. It’s a great opportunity to see where your own system may be lacking and examine and adapt those state policies and approaches to long term senior care that appear to be working best.

Long Term Care Scorecard: Best and Worst States

When I was a kid, Florida and Arizona were the retirement states of choice. My parents and their friends decided that, after decades of Midwestern winters, the promise of warmth and sunshine, coupled with the notion of never picking up a snow shovel again proved too enticing to pass up. At their first opportunity, many of the “snowbirds” declared permanent residency in those sunshine states. Did they make the wrong move?

This week, AARP in conjunction with the Commonwealth Fund and the SCAN Foundation, released the 2014 State Long-Term Services and Supports (LTSS) Scorecard. In it, they rate states based on long-term services and support for the elderly, people with physical disabilities, and family caregivers. State performance was measured across five categories:

  • affordability and access,
  • choice of setting and provider,
  • quality of life and quality of care,
  • support for family caregivers, and
  • effective transitions

The report shows that in terms of quality of long-term care, Florida ranks in the bottom quartile compared to other states, although it fares better than Kentucky, Alabama, Mississippi, and Tennessee in affordability and transitions from nursing home care back to the community. This interactive map shows each state’s ranking:

The top-ranking states for long-term care and services are Minnesota, Washington, Oregon, Colorado, and Alaska; perhaps it’s not quite time to put those snow shovels on eBay.

It’s a well-known fact that few of us prepare for long-term care, although about 70% of people age 65 and up will need some sort of assistance with the activities of daily living. While most people would prefer to age at home, Medicare doesn’t cover the cost of home care provided by a Home Care Agency. Few of those in their 40s, 50s and 60s carry long-term care insurance and Medicaid is available only for low-income seniors with few assets. And before we all decide to retire to Minnesota or Washington, it’s important to note that long-term care is unaffordable for most middle-income seniors in all states.

The authors of the study see the need for a guide at the federal level to establish minimum long-term care performance standards below which no state should fall. No one anywhere in the U.S. should fear that their state cannot provide the needed level of assistance. Susan Reinhard, one of the study’s authors and senior vice president of Public Policy at AARP told Forbes magazine that she is optimistic in the incremental improvements she’s seen since a similar study was published in 2011, but admits all states can do better.

Caregiverlist® champions the need for change in the long-term care arena and urges you to contact your state legislature or your state’s Department on Aging and let them know how important it is to improve services in providing high-quality, well-coordinated, affordable long-term care.

Log in