April 16 is National Healthcare Decisions Day

National Healthcare Decisions Day is a National campaign to raise awareness about the importance of having advance care planning documents prepared and ready to go in case of an emergency.  Living Wills, Health Care Powers of Attorney, Physicians Orders for Life-Sustaining Treatment (POLST), Do Not Resuscitate (DNR) Orders – all these are advance planning tools that allow you to express your wishes and designate the person you want making decisions for you when a medical emergency arises.

To celebrate NHDD, I will be presenting on the topic at Lutheran Manor in Bethlehem, Pennsylvania. I will also cover Financial Powers of Attorney – the benefits and pitfalls.  I am looking forward to helping people understand these important legal documents, and I am always available to make these presentations for groups in the Lehigh Valley.

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TEMPO IN Depth special on Elder Care

On March 28, 2013, PBS 39 aired an episode of Tempo InDepth that focuses on Elder Care in the Lehigh Valley.  Guests provided a number of insights across a range of topics:

  • Family members describe how to cope when a loved one is diagnosed with dementia.
  • Residents of local assisted living or skilled care facilities discuss what types of questions to ask and amenities to look for in residential care facilities.
  • A geriatric care manager discusses care management services.
  • An independent senior describes how she has been able to remain in her home despite health difficulties.
  • The Director of the Lehigh Valley Alliance on Aging discusses the 2-1-1 program that allows Lehigh Valley residents to call 2-1-1- free of charge to find confidential referrals for help with food, housing, employment, health care, counseling, and more.

To watch the hour-long show, please click on this link –> Tempo InDepth


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L.V. Legislative Breakfast Save the Date!

Save the Date!

The Public Policy Committee of CARIE of the Lehigh Valley is planning a Legislative Breakfast during Older Americans Month.

Members of the Pennsylvania legislature who represent the Lehigh Valley are being invited to talk about issues related to older adults and answer questions from the audience.

Friday, May 31, 2013
8 AM – 10 AM
Lehigh University Mountaintop Campus
Iacocca Hall
The Wood Dining Room
111 Research Drive
Bethlehem, Pennsylvania 18015

The event is free but reservations will be required.
More information about the event will be available soon.

Print the Flyer for more details!

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Saving the Aging Waiver

As I described in my last post, the Aging Waiver program allows Medicaid-eligible patients who can be safely served in a home setting to receive in-home care on Medicaid’s dime; a dime which goes a lot farther in a home-based care setting than in a nursing home facility.  The bad news is that the Aging Waiver program is being threatened by new regulations that make it financially impossible for many County Agencies on Aging to continue to provide waiver services.


In 2011, the PA General Assembly amended the Public Welfare Code when they passed Act 22.  The amendments enabled the PA Department of Public Welfare (DPW) to use an expedited process for rulemaking when a regulation relates to Commonwealth grants or benefits like the Aging Waiver.  In  2012, DPW used this new expedited rulemaking authority to make changes to provider payment rates and reimbursement models for the Aging Waiver.  The changes are going into effect now, without any meaningful public comment period or regulatory oversight, and the effects may be devastating.

The Changes:

Prior to the new regulations, the Aging Waiver was managed by Area Agencies on Aging (AAAs) using a care management model.  Under this model, the AAAs received state funding in a bundled amount to cover the cost of case management that would include in-home patient visits and RN oversight of care plans.  The care management model was only performed by the AAAs, and included help with enrollment, selection of services, and a focus on matching consumers with appropriate caregivers in an ongoing way.

The new regulations changed the service model from one of care management to one of service coordination, which can be performed by AAAs and community providers.  The service coordination model focuses more on consumer choice and responsibility, and less on holistic management of the patient’s care plan.  Most damaging, the state no longer funds waiver services through bundled payments to the AAAs, which allows for more intensive case management.  Instead, the state reimburses service coordination in 15-minute units of direct work with and on behalf of the patient/consumer.  This makes frequent home visits and check-ins impractical and expensive.  Service coordinators are now only required to make one phone call or home visit per quarter.  The case worker has essentially been transformed into a schedule coordinator;  the state isn’t paying the AAAs to care about the consumer’s need, but to sign them up for services and check in every three months.

Many AAAs have been forced to lay off case workers due to the rate changes, and other AAAs have found they cannot afford to continue to administer the Aging Waiver program.  As a result, in-home care has become unavailable to people who could benefit from it.  The options for Medicaid-eligible seniors have been narrowed to nursing home care, or no care at all.  If you would like more information on this issue, see the C.A.R.I.E. website or call your local legislator.



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The Aging Waiver: An Overview

The Aging Waiver (also known as the 60+ Waiver) is a Medicaid program in Pennsylvania that provides in-home care for people who would otherwise need care in a nursing home or skilled care facility.  To be eligible for the waiver, a person must:

  1. Be a U.S. Citizen or qualified non-citizen
  2. Be a resident of PA
  3. Have a social security number
  4. Be age sixty (60) or over
  5. Be assessed medically as being clinically eligible for nursing facility care.  The County Area Agency on Aging (AAA) conducts this assessment.
  6. Can be safely served in a community setting at a cost to Medicaid of 80% of the average monthly Medicaid payment to a skilled nursing facility, and
  7. Be financially eligible.

A person is financially eligible if she is within the income and resource limits for the program.  A person is income qualified who earns less than $2,094 per month.  Only the patient’s income is considered;  spousal income is not taken into account.  A person is resource qualified who has non-exempt resources of at or under $8,000 ($2,000 plus a $6,000 disregard).

Approved applicants will receive in-home care through Medicaid-Certified home health agencies.  The services are paid for by Medicaid.  There is no patient pay liability; the patient can retain all of her income for household expenses.

Most importantly, a person who is financially needy and for whom skilled nursing care is necessary can receive care in the comfort of her own home.  The family, and taxpayers, save on Medicaid payments to nursing homes, which are much more expensive.  If this sounds too good to be true, it may be.

The Aging Waiver is currently under attack in Pennsylvania.  My next post will explain how, and provide you with some resources to fight back…

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Voting Rights in Pennsylvania

As you have probably heard, the state of Pennsylvania passed a law mandating that voters must show valid i.d. in order to cast a ballot.  The law goes into effect for the November, 2012 election.  There has been a lot of speculation about how this new law will affect voters, especially older voters.  Voting rights have been hard-won over time.  It is not a right to be taken lightly.

Make sure you have what you need to vote this year.  The ACLU lists these as acceptable forms of ID under the new law:

  •  A current Pennsylvania driver’s license, or one that expired after November 2011;
  • A current non-driver Pennsylvania photo ID card issued by PennDOT, or one that expired after November 2011;
  •  A current U.S. passport;
  • A U.S. military (active duty or retired) or reserve, including the Pennsylvania National Guard, photo ID (but the fine print in the new law says that, if your ID doesn’t have a specific expiration date, the ID must include “a designation that the expiration date is indefinite” (Department of Veterans Affairs IDs do NOT qualify for voting);
  • A U.S. government-issued photo ID, with an expiration date;
  • A photo ID issued by the commonwealth of Pennsylvania (such as a PA State Employee ID);
  • A current employee photo ID issued by a municipality in Pennsylvania. The PA Department of State has interpreted this to include county employee photo IDs, but it does not include school district employees;
  • A current photo ID issued by an “accredited Pennsylvania public or private institution of higher learning.” This applies to students, faculty, and staff, but there are certain important limits.  The ID must have an expiration date, and private licensed schools such as career institutes, technical institutes, massage schools, cosmetology schools, bartending schools, truck driving schools, etc., do not count
  • A current photo ID issued by a “Pennsylvania care facility.” This term includes long-term care nursing facilities, assisted living residences, and personal care homes. To be valid they must contain an expiration date.

See the ACLU website for more information; see it even if you think you hate the ACLU.  I would hate for you to miss the opportunity to vote.

If you do not have one of these valid IDs, the Pennsylvania Department of Transportation is supposed to be providing FREE non-driver voter ID at their Driver Licensing Centers.  You will need to fill out an affidavit that you do not have other acceptable valid ID, and a form DL-54a.  You will need your official Social Security Card and one of the following: Official Birth Certificate, Valid U.S. Passport, Certificate of U.S. citizenship, or Certificate of Naturalization.  If you were born in PA, but you don’t have a copy of your birth certificate, you can ask PennDOT to verify your birth record when you are at the Driver Licensing Center.  Otherwise, you will need an official copy with a raised seal.  You will also need two proofs of residency.

Sounds like a lot to go through to do something you have probably been doing for years with no hassle.  All in the name of preventing voter fraud, which may exist structurally, but has almost never occurred or been prosecuted at the level of the individual voter.  For more details and information on this and other issues, see the C.A.R.I.E. Connection monthly newsletter.

Most strange in all of this is that there are no ID requirements for casting an absentee ballot.  So if you do not have valid ID and cannot obtain it by November 6, 2012 in order to vote, find yourself an absentee ballot, send it in, and hope for the best.

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Family Care Contracts and the Outsourced Life

Caring for a parent or older relative who is in ill health can be a slippery slope.  What begins as a weekly visit to make sure everything is OK may gradually turn into daily visits, weekly grocery shopping trips, driving to frequent doctors appointments, and so on.  Most people are happy to provide this sort of care and companionship to a loved one, but such care can cut into work time and family life.

Care providers may find themselves working fewer paid hours, or needing to take unpaid time off from work to help a loved one.  The financial impact can really become a problem.  You may wish you could hire someone to do the work for you, but can’t imagine (or can’t afford) paying a stranger to spend time with Mom.

One solution to this problem is to enter into a Family Care Contract or Caregiver Agreement.  A Caregiver Agreement is a contract between the elderly relative and the caregiver, setting forth the types  of services that will be provided, and the rate of pay for those services.  It is a way for the elder to pay for the care they are receiving without having to hire a stranger; and a way for the caregiver child to provide high-quality care without losing (or without losing as much) necessary income.

Many people are uncomfortable with the concept of a parent paying an adult child for care, arguing that the child should care for the parent simply out of love, affection and duty.  Respected sociologist Arlie Russell Hochschild recently published a book –The Outsourced Life: Intimate Life in Market Times – that critiques our growing societal tendency to hire professionals to handle the intimate details of our daily lives, such as caring for loved ones.  In light of this trend, a Caregiver Agreement is a good compromise: it can maintain important family bonds while making it financially possible for a child to provide necessary, loving care for an elderly parent.

There are rules for Caregiver Agreements.  The rate of pay must be basically equivalent to what the service would cost if you instead hired a home health aid or companion.  The contract must be very specific in terms of what care is provided, when, and for how long.  There are also tax considerations, for both the elder as an employer and the caregiver as a wage-earner.  It is important that all family members are on board, to prevent conflict.

Caregiver Agreements are especially useful in planning for long-term care needs.  In Pennsylvania, Medical Assistance (Medicaid) pays for most long-term care, such as nursing home care.  There are strict and complicated rules governing eligibility for Medicaid.  Having a valid Caregiver Agreement in place can help you prove to the State when you apply for Medicaid that payments made to a caregiver child were not “gifts” that can be penalized, but rather wages paid under a properly negotiated family-care contract.

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I recently gave a talk on Guardianship for HealthNet, a Lehigh Valley Networking group usually hosted by the friendly folks at Traditions of Hanover, but this time held at the lovely Atria Senior Living facility in Bethlehem.  Guardianship is a process by which a court will appoint a Guardian to make decisions for an incapacitated person.

A person is incapacitated when her “ability to receive and evaluate information effectively and communicate decisions in any way is impaired to such significant extent that she is partially or totally unable to manage her financial resources or to meet essential requirements for her physical health and safety.” See 20 Pa.C.S.A. § 5501.  That is a long and exhausting way to say that a person is incapacitated when she is unable to make decisions for herself regarding her physical and financial health.

When a Guardian is appointed for an incapacitated person, then the person loses the legal right to make any contract or gift or instrument in writing.  See 20 Pa.C.S.A. § 5524.  The Guardianship can be specifically tailored to the person’s level of incapacity – for example, the Guardian may only be allowed to handle certain financial transactions.  The purpose of Guardianship is to protect vulnerable incapacitated adults from fraud or from physically dangerous living conditions.

Since Guardianship sets extreme limits on personal rights and freedoms, the court must have clear and convincing evidence of the need of a Guardianship before they will find a person incapacitated and appoint a Guardian.  If the alleged incapacitated person’s issues can be resolved with help from social service agencies, or the execution of a power of attorney, the court will recommend these steps in place of Guardianship.

While Guardianship is intended to protect incapacitated adults, the appointment of the wrong person as Guardian can open the door to financial and even physical abuse.  For this reason, there are safeguards built into the Guardianship system.  Guardians are fiduciaries, meaning they have certain duties and are bound to act in the interest of the incapacitated person.  A Guardian must file annual reports and accounts with the Court, explaining in detail the actions they have taken.  The Court has supervision of the Guardianship, and can order the Guardian to correct mistakes or right wrongs.

If you know an adult who is having problems making decisions, and as a result is in physical danger or facing financial harm, and your efforts to help have not succeeded in fixing the problem, then you may have to consider whether a Guardianship is appropriate.  An Elder Law attorney can help you weigh your options and prepare a compelling petition to keep your loved one from unnecessary harm.

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Drafting a deed today, I came across an interesting part of the statue, effective in 1901.  Interesting mostly because I had never come across the term “feme-sole” before.  I like it!  All you single ladies, you might want to think about using it as part of your signature on official documents:  “Ms. Jane Doe, Feme-Sole.”  Adds a certain amount of class, if you care to define yourself in that way.  Here it is in the statute:

Title 21 P.S. Deeds and Mortgages

§ 82 Acknowledgements by Married Woman

Acknowledgments of any married woman of any deeds, mortgages or other instruments of writing, required by law to be acknowledged, shall be taken by any judge, justice of the peace, notary public, or other person authorized by law to take acknowledgments of deeds, et cetera, in same manner and form as though said married woman were feme-sole; said acknowledgment to have the same force and effect as if taken separate and apart from the husband of said married woman.

To translate: in 1901 the PA Legislature passed a law that forced all judges, notaries, justices of the peace, and other people (men) to acknowledge a deed or mortgage signed by a married woman, whether or not her husband signed or gave permission for her to sign the deed or mortgage.  It gave a married women the right to own and convey real property, without the input or involvement of her husband.  And only 19 years later, women were allowed to vote, too!  We’ve come a long way.

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Understanding POLST.

Have you heard of POLST?  It stands for Physician’s Orders for Life Sustaining Treatment.  In Pennsylvania, it is known as the Pennsylvania – Orders for Life Sustaining Treatment.  (See what they did there?).  The use of POLST recently came up at a recent LVAA Policy Committee meeting hosted by C.A.R.I.E.  Here is what you need to know:

POLST is a program that allows a patient and his or her physician to create medical orders detailing treatment wishes for end-of-life care.  It is made to be used by people with serious or chronic illness.  The idea is that you will be given an opportunity to express your wishes for end-of-life care, and your medical attendants will follow these wishes.  There is a standardized form that will be completed by you and your doctor, which then becomes part of your medical record.  Other medical attendants can follow the POLST instructions when the form is signed by your doctor.  The instructions cover whether or not you want CPR, or other medical interventions such as intubation , IV fluids, antibiotics, and/or artificial nutrition or hydration.  The PA Department of Health has endorsed a PA-POLST form.  Use of the POLST form is completely voluntary.  There is no law in Pennsylvania requiring the use of a POLST form.

A potential problem with the use of a POLST is that, under current Pennsylvania law, Emergency Medical Services (EMS) protocols direct that even when a POLST is presented, CPR and/or resuscitation “should be initiated and medical command should be contacted as soon as possible.”1   In other words, if an ambulance comes to your house because you are unconscious, even if your POLST is provided to the EMS team, they will still start to resuscitate you until they can contact your physician for further instruction.  That is because Pennsylvania already has a legal framework for this situation, called the Out-of-Hospital Nonresuscitation Act.

The Out-of-Hospital Nonresuscitation Act, 20 Pa.C.S.A. § 5481, allows a physician for a patient with an end-stage illness, or who is permanently unconscious, to sign a Do Not Resuscitate (DNR) Order at the request of the patient or the patient’s surrogate decision-maker.  The patient can provide the Order, or an official DNR bracelet or necklace, to EMS technicians.  Once the EMS personnel see the order, bracelet, or necklace, they must comply with the order.  In contrast, EMS personnel do not have to legally comply with a POLST and, under current regulations, they are instructed NOT to comply with a POLST until your physician is contacted for further instruction.

In light of this, use of POLST in Pennsylvania will probably be most effective in a long-term care setting, where medical records are readily available.  POLST could be a useful tool when it is used as one part of your advance care plan.  To make sure that your end-of-life treatment goals are made known and followed by your family and physicians, you should also consider the complementary use of a Health Care Power of Attorney with Advance Directives, and/or a Do Not Resuscitate Order, if appropriate.

For more information on PA-POLST, visit The Aging Institute.

1. Pennsylvania Statewide Basic Life Support Protocols, Pennsylvania Department of Health, Bureau of Emergency Medical Services, Effective July 1, 2011.

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