What is exactly the long term care?

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flyingaway
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What is exactly the long term care?

Post by flyingaway »

I have seen many discussions about long term care costs and insurance against it. I have also seen discussions and mentioning of assisted living, CCRC, memory care, skilled nursing care, etc. Frankly speaking, I do not know the big differences between these definitions and do not know which ones are exactly what we may need in the future.

I think many of the "cares" that people needed before many not be needed now or in the future. People can now stay at their homes much longer than before. For example, if you cannot shop in stores, you can order grocery deliveries, food deliveries, and drug deliveries. You don't have to walk out of your door or drive your car and survive for a few years. That might cut the cost of long term care cost dramatically.

So what is exactly the long term care that you are talking about?
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Re: What is exactly the long term care?

Post by jebmke »

I doubt that there is a simple answer. It is going to depend on many factors like what the trajectory of your decline is like, what your family situation is and even where you live. Where I live (semi-rural), in home care and things like grocery delivery are very limited. The local senior center has a meals on wheels program but that, too, is quite limited.
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ResearchMed
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Re: What is exactly the long term care?

Post by ResearchMed »

flyingaway wrote: Mon Oct 04, 2021 11:31 am I have seen many discussions about long term care costs and insurance against it. I have also seen discussions and mentioning of assisted living, CCRC, memory care, skilled nursing care, etc. Frankly speaking, I do not know the big differences between these definitions and do not know which ones are exactly what we may need in the future.

I think many of the "cares" that people needed before many not be needed now or in the future. People can now stay at their homes much longer than before. For example, if you cannot shop in stores, you can order grocery deliveries, food deliveries, and drug deliveries. You don't have to walk out of your door or drive your car and survive for a few years. That might cut the cost of long term care cost dramatically.

So what is exactly the long term care that you are talking about?
You might want to do a search on those terms to get a summary of each (and perhaps more than a summary).
There is likely a very wide variation under each of these terms, and there may be geographical differences as well.

Very briefly:

For the most part, these facilities/care aren't for those who "only" can't drive (some people don't own cars at all, after all), or don't want to/can't shop in stores. Deliveries have been available for quite some time.
Back 1980, there was a big name supermarket in my new neighborhood, and they delivered "as much as you ordered" for $5.
And back in the 1960s, groceries could be delivered. (Back then, it might have been more the higher end, smaller grocers who did that, but I'm not sure.)
And some pharmacies have delivered for a very long time, also. In some cases, that's one key feature that used to distinguish them from the larger "chain drug stores".

Excluding the "Independent Living" stage, these facilities are more for those who need help inside the home, and might need it throughout the day (or night). So there is always "someone there, on call".
Assisted living usually means your own apartment, but restaurant style meals, and room service if needed/requested. And help dressing or bathing if needed, also. Or wheelchair assistance as needed or all the time.
Skilled Nursing is what you probably already think of as "nursing home", more like a hospital style facility, with medical staff right there.
Independent Living tends to be your own apartment (or cottage, etc.), but meals available if desired, and shared facilities if desired, too.
Some facilities run the full gamut, soup to nuts, so to speak.
CCRCs usually have the full range, and are more likely to accept you when healthy, and "keep you" as you need more help. However, some "non-CCRCs" seem to be a bit "quasi-CCRC" in the sense of vetting one by health/assets/income, and then they'll "keep you" and switch you to Medicaid if necessary. The good ones will keep you at the SAME level of care in that case, but this needs to be explored carefully in advance.
If you wait until you need Medicaid, or are very close to it, then you probably can't get into one of the nicer facilities.

There are going to be many different arrangements within each separate facility.
You'd need to investigate each specific facility to see just how they arrange these services, or whether they even offer them.

And one can always pay extra for extra care at any of them, just as one could at home (at least for some of the services).

RM
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pennywise
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Re: What is exactly the long term care?

Post by pennywise »

ResearchMed wrote: Mon Oct 04, 2021 11:52 am
flyingaway wrote: Mon Oct 04, 2021 11:31 am I have seen many discussions about long term care costs and insurance against it. I have also seen discussions and mentioning of assisted living, CCRC, memory care, skilled nursing care, etc. Frankly speaking, I do not know the big differences between these definitions and do not know which ones are exactly what we may need in the future.

I think many of the "cares" that people needed before many not be needed now or in the future. People can now stay at their homes much longer than before. For example, if you cannot shop in stores, you can order grocery deliveries, food deliveries, and drug deliveries. You don't have to walk out of your door or drive your car and survive for a few years. That might cut the cost of long term care cost dramatically.

So what is exactly the long term care that you are talking about?

You might want to do a search on those terms to get a summary of each (and perhaps more than a summary).
There is likely a very wide variation under each of these terms, and there may be geographical differences as well.

Very briefly:

[Excellent summary of various options deleted]

There are going to be many different arrangements within each separate facility.
You'd need to investigate each specific facility to see just how they arrange these services, or whether they even offer them.

And one can always pay extra for extra care at any of them, just as one could at home (at least for some of the services).

RM
Right, the primary issue that drives people to enter non-home care facilities is not primarily one of logistics. It's certainly possible to order groceries but when the individual can no longer remember how to create an accurate list of what's needed, or how to follow the steps to call and activate a delivery service or how to answer the door and take the groceries then put them away...it really doesn't matter how many Instacart accounts you have.

As noted by ResearchMed long term care is a continuum of services provided for people who have limitations that are physical or mental.

With longevity increasing the likelihood of dementia especially mandates care options that range from having a help button with someone close monitoring it to having somebody come to your bedside and spoon ground up food into your mouth several times daily followed by somebody changing your adult diaper.
J295
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Re: What is exactly the long term care?

Post by J295 »

Set up visits at a few facilities. They are generally happy to provide tours as part of their marketing. For example my parents visited a few facilities and put their name on a wait list in their early 80s and we’re periodically called about an opening and declined because they weren’t ready to leave home. Five years later they needed assisted care on short notice broken hip) and got in — it was very helpful to have a facility decided and a relationship with their team.
lws
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Re: What is exactly the long term care?

Post by lws »

A person considers the following:

Bathing - The ability to clean oneself and perform grooming activities like shaving and brushing teeth.
Dressing - The ability to get dressed by oneself without struggling with buttons and zippers.
Eating - The ability to feed oneself.
Transferring - Being able to either walk or move oneself from a bed to a wheelchair and back again.
Toileting - The ability to get on and off the toilet.
Continence - The ability to control one's bladder and bowel functions.

Then asks:
What will it cost to pay someone to do them for me if I can not do two of them myself.

Ref:
https://www.elderlawanswers.com/activit ... ance-15395
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Ben Mathew
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Re: What is exactly the long term care?

Post by Ben Mathew »

flyingaway wrote: Mon Oct 04, 2021 11:31 am I have seen many discussions about long term care costs and insurance against it. I have also seen discussions and mentioning of assisted living, CCRC, memory care, skilled nursing care, etc. Frankly speaking, I do not know the big differences between these definitions and do not know which ones are exactly what we may need in the future.

I think many of the "cares" that people needed before many not be needed now or in the future. People can now stay at their homes much longer than before. For example, if you cannot shop in stores, you can order grocery deliveries, food deliveries, and drug deliveries. You don't have to walk out of your door or drive your car and survive for a few years. That might cut the cost of long term care cost dramatically.

So what is exactly the long term care that you are talking about?
From Elder Law Answers:
The long-term care community measures personal needs by looking at whether an individual requires help with six basic activities that most people do every day without assistance, called activities of daily living (ADLs). ADLs are important to understand because they are used to gauge an individual’s level of functioning, which in turn determines whether the individual qualifies for assistance like Medicaid or has triggered long-term care insurance coverage.

The six ADLs are generally recognized as:

Bathing. The ability to clean oneself and perform grooming activities like shaving and brushing teeth.
Dressing. The ability to get dressed by oneself without struggling with buttons and zippers.
Eating. The ability to feed oneself.
Transferring. Being able to either walk or move oneself from a bed to a wheelchair and back again.
Toileting. The ability to get on and off the toilet.
Continence. The ability to control one's bladder and bowel functions.
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ResearchMed
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Re: What is exactly the long term care?

Post by ResearchMed »

J295 wrote: Mon Oct 04, 2021 12:35 pm Set up visits at a few facilities. They are generally happy to provide tours as part of their marketing. For example my parents visited a few facilities and put their name on a wait list in their early 80s and we’re periodically called about an opening and declined because they weren’t ready to leave home. Five years later they needed assisted care on short notice broken hip) and got in — it was very helpful to have a facility decided and a relationship with their team.
Yes, in person visits can be critical. They'll often include invitations to enjoy a few meals.
We had investigated quite a few facilities in advance of moving MIL near us, and we visited several.

The place MIL ended up was terrific, and we really got to know it up close and personal after several years, and use of several of the units (Assisted, Rehab, Skilled Nursing).
NOTE: When she first arrived, we made a point of making some UNANNOUNCED visits, to see how things were when "a visitor" was not expected. (We had no unpleasant surprises, other than a possibly napping - or cranky - MIL not wanting us to stay long. That was obviously fine.)

About 2 years ago, we put our names on the waitlist; the deposit was far less than we expected: less than $1k, although non-refundable.

The way that wait list works (ours is for Independent Living, but we may change and wait until we need Assisted Living) is that you specify what type/size of apartment you want. Then you estimate when you think you'll be ready. So they have sort of a soon, later, and distant timing separate wait lists, and one can request to be moved from one type to another if preferences or needs change.

So when a unit becomes available, they go down the list of those people who are "ready to move in soon", and who prefer something like the unit coming available. If that "next" person "isn't quite ready", no problem... they move on to the next name, and that first one does not lose their place in the queue.
Those who are most flexible are likely to get in sooner. It can be years for certain very specific requests.

MIL "accepted" an Assisted Living apartment that was more space (and more money) than she needed. Once "in", she was able to move reasonably quickly to a smaller unit, freeing up the larger one for someone else, etc.

For the better places, at least in some areas, it can really make a difference to plan ahead.

One thing I cannot emphasize enough, given the frequent (and appropriate) comments here about some "Medicaid Skilled Nursing homes". Some of them can be... a bit grim.

However, IF one plans ahead, and has "enough money saved" (this amount can vary a lot, and there are huge geographical differences as well), then some nicer facilities may accept one with the agreement that if/when one runs out of money, it would switch to Medicaid payment (including taking any pensions or SS income) --> at the SAME level of care. That might mean being moved to a semi-private room or shared bath (if the facility has no semi-private rooms), or a smaller room, etc., but NOT to some sort of "lesser standard of care wing" or even needing to move out to an entirely different Medicaid facility.
The choices can be extremely limited if one has already "spent down".

RM
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Kagord
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Re: What is exactly the long term care?

Post by Kagord »

lws wrote: Mon Oct 04, 2021 12:57 pm A person considers the following:

Bathing - The ability to clean oneself and perform grooming activities like shaving and brushing teeth.
Dressing - The ability to get dressed by oneself without struggling with buttons and zippers.
Eating - The ability to feed oneself.
Transferring - Being able to either walk or move oneself from a bed to a wheelchair and back again.
Toileting - The ability to get on and off the toilet.
Continence - The ability to control one's bladder and bowel functions.

Then asks:
What will it cost to pay someone to do them for me if I can not do two of them myself.

Ref:
https://www.elderlawanswers.com/activit ... ance-15395
+1, LTC is the above list of six things, it's not about having groceries and prescriptions delivered, or being able to drive. The costs for the above, $7K-15K a month, LTC insurance usually has a 3-6 month benefit waiting/starting period after eligibility is determined, there is a reason for this if you look at the statistics.
EnjoyIt
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Re: What is exactly the long term care?

Post by EnjoyIt »

One way to minimize nursing home or long term care is to make sure you have a living will. This doesn't preclude all long term care needs, but at the very least it will preclude you from living just for the sake of being alive with no quality of care.

Basically this means having a DNR (Do Not Resuscitate) order in place. Last thing I or my spouse want is to be brought back to life and have little to no mental capacity. We do not want to be bedridden either. We not want want catheters placed through our skin into our stomach to feed us. We want to make sure that our loved one's do not enforce this type of torture onto us and for that we have a living will. With that in mind, the odds of needing skilled nursing for medical care decrease substantially. This doesn't preclude severe cognitive decline without any other organ injury such as Alzheimers disease, but it is a start.

If anything, Alzheimers scares me the most because one can be physically healthy but mentally incapacitated. This type of existence can last for a very long time. From my experience, family is usually good at managing this, but eventually the cognitive decline becomes too much and a nursing facility will be required.

The average stay in a nursing facility is under 3 years. If you take into account a living will, that number will decrease. With that in mind, personally, I do not think we need LTC insurance. If one of us is in need of medical care, that means we are spending a lot less money on travel, toys, entertainment, etc. Our expenses would plummet significantly and that money can be sent to a nursing facility. This is during the last X years of our lives. SS will still keep coming in, our portfolio should still be providing 4% (3% for some bogleheads.) That alone should cover a good chunk of nursing home cost. We then deplete some of our portfolio for the remainder. Even 10 years like this the surfing spouse would have plenty of money for the remainder of their life even if it includes also requiring nursing home care.
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Watty
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Re: What is exactly the long term care?

Post by Watty »

The cost of LTC varies a lot by where you live so one good thing to do is to look at what it costs in your area and you can see that on this web site.

https://www.genworth.com/aging-and-you/ ... -care.html

I live in an area with below average costs so the lower cost level of assisted living($48K a year) is less than our normal retirement budget so if only one surviving when assisted living is needed then that should not be a problem. Even the higher skilled nursing facility which is $90K a year according to that web site is not dramatically higher than our normal budget so we could handle that for one person for a very long time.

In a high cost of living area the costs could easily be double that.

For us the biggest risk is that some form of LTC will be needed while we are both still alive.

EnjoyIt wrote: Mon Oct 04, 2021 1:31 pm The average stay in a nursing facility is under 3 years.
There are lots and lots of statistics about long term care. Christine Benz at Morningstar has a long list of them that she updates each year.

https://www.morningstar.com/articles/10 ... ic-edition

Here is a sample.
Paying for Care
63%: Estimated percentage of individuals age 65 today who will have no out-of-pocket long-term-care costs during their lifetimes.
13%: Estimated percentage of individuals age 65 today who will incur out-of-pocket long-term-care costs of between $0.01 and $50,000 during their lifetimes.
11%: Estimated percentage of individuals age 65 today who will incur out-of-pocket long-term-care costs of between $50,000 and $150,000 during their lifetimes.
4%: Estimated percentage of individuals age 65 today who will incur out-of-pocket long-term-care costs of between $150,000 and $250,000 during their lifetimes.
9%: Estimated percentage of individuals age 65 today who will incur out-of-pocket long-term-care costs of more than $250,000 during their lifetimes.
$321,780: Estimated lifetime cost of care for someone with dementia.
I respect her and she does a good job but whenever you deal with statistics about LTC you need to be cautious and think and dig through the details since they are easy to misunderstand.

For example the last one about someone with dementia needing over $300K for care sounds real scary. When you think about that though that $300K would be needed over a number of years. For a single person though many of their other expenses will stop when they go into LTC so if their normal retirement budget was something like $50K a year then that could cover a lot of the costs. Likewise if they were getting $30K a year in Social Security and they end up in a memory care unit for five years then that would give them $150K to help pay for their LTC.
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Re: What is exactly the long term care?

Post by Escapevelocity »

ResearchMed wrote: Mon Oct 04, 2021 1:05 pm
One thing I cannot emphasize enough, given the frequent (and appropriate) comments here about some "Medicaid Skilled Nursing homes". Some of them can be... a bit grim.

However, IF one plans ahead, and has "enough money saved" (this amount can vary a lot, and there are huge geographical differences as well), then some nicer facilities may accept one with the agreement that if/when one runs out of money, it would switch to Medicaid payment (including taking any pensions or SS income) --> at the SAME level of care. That might mean being moved to a semi-private room or shared bath (if the facility has no semi-private rooms), or a smaller room, etc., but NOT to some sort of "lesser standard of care wing" or even needing to move out to an entirely different Medicaid facility.
The choices can be extremely limited if one has already "spent down".

RM
This is an excellent point and consistent with my experience with my Mom who had dementia and spent several years in an assisted living facility and a much briefer period in SNF before she passed away in 2019. One potential problem/pitfall with the above "strategy" is that if the facility is an assisted living facility, the facility may not be able to care for you all the way until your demise. In my Mom's case, she had a stroke in 2018, after which, her level of care progressed from assisted living memory care to skilled nursing (SNF). At that point, she had spent down her assets and the original "arrangement" she had with the assisted living was of no benefit when it came to finding a SNF that would accept her as a Medicaid recipient. Unfortunately, the SNF had some deficiencies in their care routines and my Mom developed bed sores which led to an accelerated death.
EnjoyIt
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Re: What is exactly the long term care?

Post by EnjoyIt »

Watty wrote: Mon Oct 04, 2021 3:44 pm The cost of LTC varies a lot by where you live so one good thing to do is to look at what it costs in your area and you can see that on this web site.

https://www.genworth.com/aging-and-you/ ... -care.html

I live in an area with below average costs so the lower cost level of assisted living($48K a year) is less than our normal retirement budget so if only one surviving when assisted living is needed then that should not be a problem. Even the higher skilled nursing facility which is $90K a year according to that web site is not dramatically higher than our normal budget so we could handle that for one person for a very long time.

In a high cost of living area the costs could easily be double that.

For us the biggest risk is that some form of LTC will be needed while we are both still alive.

EnjoyIt wrote: Mon Oct 04, 2021 1:31 pm The average stay in a nursing facility is under 3 years.
There are lots and lots of statistics about long term care. Christine Benz at Morningstar has a long list of them that she updates each year.

https://www.morningstar.com/articles/10 ... ic-edition

Here is a sample.
Paying for Care
63%: Estimated percentage of individuals age 65 today who will have no out-of-pocket long-term-care costs during their lifetimes.
13%: Estimated percentage of individuals age 65 today who will incur out-of-pocket long-term-care costs of between $0.01 and $50,000 during their lifetimes.
11%: Estimated percentage of individuals age 65 today who will incur out-of-pocket long-term-care costs of between $50,000 and $150,000 during their lifetimes.
4%: Estimated percentage of individuals age 65 today who will incur out-of-pocket long-term-care costs of between $150,000 and $250,000 during their lifetimes.
9%: Estimated percentage of individuals age 65 today who will incur out-of-pocket long-term-care costs of more than $250,000 during their lifetimes.
$321,780: Estimated lifetime cost of care for someone with dementia.
I respect her and she does a good job but whenever you deal with statistics about LTC you need to be cautious and think and dig through the details since they are easy to misunderstand.

For example the last one about someone with dementia needing over $300K for care sounds real scary. When you think about that though that $300K would be needed over a number of years. For a single person though many of their other expenses will stop when they go into LTC so if their normal retirement budget was something like $50K a year then that could cover a lot of the costs. Likewise if they were getting $30K a year in Social Security and they end up in a memory care unit for five years then that would give them $150K to help pay for their LTC.
Thanks for sharing the data. A few comments about those stats.

Averages are great, but what does that mean for an individual and what can I do get me to average or below?
For one, decide if you would want to live like a vegetable or are you willing to have a living will as I described in my previous post. This will greatly decrease all your averages. Also, one common reason someone ends up in a nursing home is due to strokes. Now anyone can have a stroke, but there are mechanisms to decrease those risks. Maybe worth discussing those with your doctor as medical advice is prohibited here. Lastly, be good to your family and if needed, one day they will be good to you and provide assistance delaying the need for nursing home care.

I suspect if you look at your own risks and desires one may be able to keep their nursing home costs down.

Again, worst case scenario, spend down a little bit of your own money. It wont be as catastrophic as one may think outside of some very rare and extreme circumstances.

We here on bogleheads love to discuss our risks. There are some worth talking about and mitigating against, there are others that are so rare that it is pointless to even try. I don't worry about the risk of being hit by a meteor and I don't worry about the risk of needing to pay millions in nursing home care.
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flyingaway
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Re: What is exactly the long term care?

Post by flyingaway »

Watty wrote: Mon Oct 04, 2021 3:44 pm The cost of LTC varies a lot by where you live so one good thing to do is to look at what it costs in your area and you can see that on this web site.

https://www.genworth.com/aging-and-you/ ... -care.html

I live in an area with below average costs so the lower cost level of assisted living($48K a year) is less than our normal retirement budget so if only one surviving when assisted living is needed then that should not be a problem. Even the higher skilled nursing facility which is $90K a year according to that web site is not dramatically higher than our normal budget so we could handle that for one person for a very long time.

In a high cost of living area the costs could easily be double that.

For us the biggest risk is that some form of LTC will be needed while we are both still alive.

EnjoyIt wrote: Mon Oct 04, 2021 1:31 pm The average stay in a nursing facility is under 3 years.
There are lots and lots of statistics about long term care. Christine Benz at Morningstar has a long list of them that she updates each year.

https://www.morningstar.com/articles/10 ... ic-edition

Here is a sample.
Paying for Care
63%: Estimated percentage of individuals age 65 today who will have no out-of-pocket long-term-care costs during their lifetimes.
13%: Estimated percentage of individuals age 65 today who will incur out-of-pocket long-term-care costs of between $0.01 and $50,000 during their lifetimes.
11%: Estimated percentage of individuals age 65 today who will incur out-of-pocket long-term-care costs of between $50,000 and $150,000 during their lifetimes.
4%: Estimated percentage of individuals age 65 today who will incur out-of-pocket long-term-care costs of between $150,000 and $250,000 during their lifetimes.
9%: Estimated percentage of individuals age 65 today who will incur out-of-pocket long-term-care costs of more than $250,000 during their lifetimes.
$321,780: Estimated lifetime cost of care for someone with dementia.
I respect her and she does a good job but whenever you deal with statistics about LTC you need to be cautious and think and dig through the details since they are easy to misunderstand.

For example the last one about someone with dementia needing over $300K for care sounds real scary. When you think about that though that $300K would be needed over a number of years. For a single person though many of their other expenses will stop when they go into LTC so if their normal retirement budget was something like $50K a year then that could cover a lot of the costs. Likewise if they were getting $30K a year in Social Security and they end up in a memory care unit for five years then that would give them $150K to help pay for their LTC.
I think this is a good point. Many people on this forum are budgeting more than $100,000 per year as their normal living expenses. If they go to a long term care facility for $70,000 a year, they may have some surplus.

On the other hand, if you are lean FIREed with a budget of $30,000 a year, you still have Medicaid to pay the bill.
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Re: What is exactly the long term care?

Post by TN_Boy »

EnjoyIt wrote: Mon Oct 04, 2021 1:31 pm One way to minimize nursing home or long term care is to make sure you have a living will. This doesn't preclude all long term care needs, but at the very least it will preclude you from living just for the sake of being alive with no quality of care.

Basically this means having a DNR (Do Not Resuscitate) order in place. Last thing I or my spouse want is to be brought back to life and have little to no mental capacity. We do not want to be bedridden either. We not want want catheters placed through our skin into our stomach to feed us. We want to make sure that our loved one's do not enforce this type of torture onto us and for that we have a living will. With that in mind, the odds of needing skilled nursing for medical care decrease substantially. This doesn't preclude severe cognitive decline without any other organ injury such as Alzheimers disease, but it is a start.

If anything, Alzheimers scares me the most because one can be physically healthy but mentally incapacitated. This type of existence can last for a very long time. From my experience, family is usually good at managing this, but eventually the cognitive decline becomes too much and a nursing facility will be required.

The average stay in a nursing facility is under 3 years. If you take into account a living will, that number will decrease. With that in mind, personally, I do not think we need LTC insurance. If one of us is in need of medical care, that means we are spending a lot less money on travel, toys, entertainment, etc. Our expenses would plummet significantly and that money can be sent to a nursing facility. This is during the last X years of our lives. SS will still keep coming in, our portfolio should still be providing 4% (3% for some bogleheads.) That alone should cover a good chunk of nursing home cost. We then deplete some of our portfolio for the remainder. Even 10 years like this the surfing spouse would have plenty of money for the remainder of their life even if it includes also requiring nursing home care.
While everyone should have a living will, I think you are overstating how much such a document will reduce long term care needs for most people.

Many many people in LTC never develop, or develop after a long time IN LTC, the sort of issues you mention: need for feeding tubes, have a stroke, etc. More commonly, various maladies raise their heads, many if not most of which can be readily treated even in older ailing patients. Even if the patient falls and breaks a hip, a DNR is not going to affect treatment for this patient. A lot of people in memory care truck along for years without the need for CPR or feeding tubes.

It's a good idea, but I wouldn't consider proper paperwork as a way to reduce long term costs.
EnjoyIt
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Re: What is exactly the long term care?

Post by EnjoyIt »

TN_Boy wrote: Mon Oct 04, 2021 9:35 pm
EnjoyIt wrote: Mon Oct 04, 2021 1:31 pm One way to minimize nursing home or long term care is to make sure you have a living will. This doesn't preclude all long term care needs, but at the very least it will preclude you from living just for the sake of being alive with no quality of care.

Basically this means having a DNR (Do Not Resuscitate) order in place. Last thing I or my spouse want is to be brought back to life and have little to no mental capacity. We do not want to be bedridden either. We not want want catheters placed through our skin into our stomach to feed us. We want to make sure that our loved one's do not enforce this type of torture onto us and for that we have a living will. With that in mind, the odds of needing skilled nursing for medical care decrease substantially. This doesn't preclude severe cognitive decline without any other organ injury such as Alzheimers disease, but it is a start.

If anything, Alzheimers scares me the most because one can be physically healthy but mentally incapacitated. This type of existence can last for a very long time. From my experience, family is usually good at managing this, but eventually the cognitive decline becomes too much and a nursing facility will be required.

The average stay in a nursing facility is under 3 years. If you take into account a living will, that number will decrease. With that in mind, personally, I do not think we need LTC insurance. If one of us is in need of medical care, that means we are spending a lot less money on travel, toys, entertainment, etc. Our expenses would plummet significantly and that money can be sent to a nursing facility. This is during the last X years of our lives. SS will still keep coming in, our portfolio should still be providing 4% (3% for some bogleheads.) That alone should cover a good chunk of nursing home cost. We then deplete some of our portfolio for the remainder. Even 10 years like this the surfing spouse would have plenty of money for the remainder of their life even if it includes also requiring nursing home care.
While everyone should have a living will, I think you are overstating how much such a document will reduce long term care needs for most people.

Many many people in LTC never develop, or develop after a long time IN LTC, the sort of issues you mention: need for feeding tubes, have a stroke, etc. More commonly, various maladies raise their heads, many if not most of which can be readily treated even in older ailing patients. Even if the patient falls and breaks a hip, a DNR is not going to affect treatment for this patient. A lot of people in memory care truck along for years without the need for CPR or feeding tubes.

It's a good idea, but I wouldn't consider proper paperwork as a way to reduce long term costs.
I mentioned how a DNR does not prevent the need for memory care and I wrote how a DNR does not eliminate the risk, it decreases it.

Broken hip equals rehab not LTC though not working at rehab could end up in LTC. Rehab is paid by Medicare.
A time to EVALUATE your jitters: | viewtopic.php?p=1139732#p1139732
TN_Boy
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Re: What is exactly the long term care?

Post by TN_Boy »

EnjoyIt wrote: Mon Oct 04, 2021 10:41 pm
TN_Boy wrote: Mon Oct 04, 2021 9:35 pm
EnjoyIt wrote: Mon Oct 04, 2021 1:31 pm One way to minimize nursing home or long term care is to make sure you have a living will. This doesn't preclude all long term care needs, but at the very least it will preclude you from living just for the sake of being alive with no quality of care.

Basically this means having a DNR (Do Not Resuscitate) order in place. Last thing I or my spouse want is to be brought back to life and have little to no mental capacity. We do not want to be bedridden either. We not want want catheters placed through our skin into our stomach to feed us. We want to make sure that our loved one's do not enforce this type of torture onto us and for that we have a living will. With that in mind, the odds of needing skilled nursing for medical care decrease substantially. This doesn't preclude severe cognitive decline without any other organ injury such as Alzheimers disease, but it is a start.

If anything, Alzheimers scares me the most because one can be physically healthy but mentally incapacitated. This type of existence can last for a very long time. From my experience, family is usually good at managing this, but eventually the cognitive decline becomes too much and a nursing facility will be required.

The average stay in a nursing facility is under 3 years. If you take into account a living will, that number will decrease. With that in mind, personally, I do not think we need LTC insurance. If one of us is in need of medical care, that means we are spending a lot less money on travel, toys, entertainment, etc. Our expenses would plummet significantly and that money can be sent to a nursing facility. This is during the last X years of our lives. SS will still keep coming in, our portfolio should still be providing 4% (3% for some bogleheads.) That alone should cover a good chunk of nursing home cost. We then deplete some of our portfolio for the remainder. Even 10 years like this the surfing spouse would have plenty of money for the remainder of their life even if it includes also requiring nursing home care.
While everyone should have a living will, I think you are overstating how much such a document will reduce long term care needs for most people.

Many many people in LTC never develop, or develop after a long time IN LTC, the sort of issues you mention: need for feeding tubes, have a stroke, etc. More commonly, various maladies raise their heads, many if not most of which can be readily treated even in older ailing patients. Even if the patient falls and breaks a hip, a DNR is not going to affect treatment for this patient. A lot of people in memory care truck along for years without the need for CPR or feeding tubes.

It's a good idea, but I wouldn't consider proper paperwork as a way to reduce long term costs.
I mentioned how a DNR does not prevent the need for memory care and I wrote how a DNR does not eliminate the risk, it decreases it.

Broken hip equals rehab not LTC though not working at rehab could end up in LTC. Rehab is paid by Medicare.
It's possible we are talking past each other. I was responding to this:
One way to minimize nursing home or long term care is to make sure you have a living will.
and in particular this:
The average stay in a nursing facility is under 3 years. If you take into account a living will, that number will decrease*. With that in mind, personally, I do not think we need LTC insurance.
Emphasis mine on those last two sentences.

I'd put it this way. Suppose I was worried about the cost of LTC, so I decided I wanted (via LTC insurance, savings, SPIAs, SS, etc) to be sure I could handle $X worth of long term care expenses. Now, how much would *I* reduce X by knowing that I had proper advance directives? The answer is 0, since there are so many expensive LTC problems that having a DNR would not change the $$ outcome.

There is also a bit of fuzziness around "The average stay in a nursing facility is under 3 years." I thought the average stay in skilled nursing was quite a bit less than three years, though different sources show different numbers ... also the median is probably less than the average.

That's all I was saying. We might still be disagreeing, :-) but that's my take on the situation. None of which is disagreeing that advance directives are not really good things.

* I don't think I've ever seen a study showing that people with a DNR have shorter LTC stays than people without one; if you've seen that give me a pointer.
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Re: What is exactly the long term care?

Post by crefwatch »

When someone with reduced capacity breaks a hip, they may be unable to learn to walk again. This increases the danger of becoming bed-bound. That exposes you to new complications, and facility policies (like transferring you to a wheelchair for as long as possible) can extend your life.

There have been some reports of CCRC residents in independent living objecting to an independent spouse bringing the Skilled Nursing partner to the Independent dining room. It's a painful reminder of their mortality, I suppose. But anytime you move from private housing to a group (even a condo or gated community), it's very important to read every word of the rules and bylaws.
EnjoyIt
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Re: What is exactly the long term care?

Post by EnjoyIt »

TN_Boy wrote: Tue Oct 05, 2021 9:19 am
EnjoyIt wrote: Mon Oct 04, 2021 10:41 pm
TN_Boy wrote: Mon Oct 04, 2021 9:35 pm
EnjoyIt wrote: Mon Oct 04, 2021 1:31 pm One way to minimize nursing home or long term care is to make sure you have a living will. This doesn't preclude all long term care needs, but at the very least it will preclude you from living just for the sake of being alive with no quality of care.

Basically this means having a DNR (Do Not Resuscitate) order in place. Last thing I or my spouse want is to be brought back to life and have little to no mental capacity. We do not want to be bedridden either. We not want want catheters placed through our skin into our stomach to feed us. We want to make sure that our loved one's do not enforce this type of torture onto us and for that we have a living will. With that in mind, the odds of needing skilled nursing for medical care decrease substantially. This doesn't preclude severe cognitive decline without any other organ injury such as Alzheimers disease, but it is a start.

If anything, Alzheimers scares me the most because one can be physically healthy but mentally incapacitated. This type of existence can last for a very long time. From my experience, family is usually good at managing this, but eventually the cognitive decline becomes too much and a nursing facility will be required.

The average stay in a nursing facility is under 3 years. If you take into account a living will, that number will decrease. With that in mind, personally, I do not think we need LTC insurance. If one of us is in need of medical care, that means we are spending a lot less money on travel, toys, entertainment, etc. Our expenses would plummet significantly and that money can be sent to a nursing facility. This is during the last X years of our lives. SS will still keep coming in, our portfolio should still be providing 4% (3% for some bogleheads.) That alone should cover a good chunk of nursing home cost. We then deplete some of our portfolio for the remainder. Even 10 years like this the surfing spouse would have plenty of money for the remainder of their life even if it includes also requiring nursing home care.
While everyone should have a living will, I think you are overstating how much such a document will reduce long term care needs for most people.

Many many people in LTC never develop, or develop after a long time IN LTC, the sort of issues you mention: need for feeding tubes, have a stroke, etc. More commonly, various maladies raise their heads, many if not most of which can be readily treated even in older ailing patients. Even if the patient falls and breaks a hip, a DNR is not going to affect treatment for this patient. A lot of people in memory care truck along for years without the need for CPR or feeding tubes.

It's a good idea, but I wouldn't consider proper paperwork as a way to reduce long term costs.
I mentioned how a DNR does not prevent the need for memory care and I wrote how a DNR does not eliminate the risk, it decreases it.

Broken hip equals rehab not LTC though not working at rehab could end up in LTC. Rehab is paid by Medicare.
It's possible we are talking past each other. I was responding to this:
One way to minimize nursing home or long term care is to make sure you have a living will.
and in particular this:
The average stay in a nursing facility is under 3 years. If you take into account a living will, that number will decrease*. With that in mind, personally, I do not think we need LTC insurance.
Emphasis mine on those last two sentences.

I'd put it this way. Suppose I was worried about the cost of LTC, so I decided I wanted (via LTC insurance, savings, SPIAs, SS, etc) to be sure I could handle $X worth of long term care expenses. Now, how much would *I* reduce X by knowing that I had proper advance directives? The answer is 0, since there are so many expensive LTC problems that having a DNR would not change the $$ outcome.

There is also a bit of fuzziness around "The average stay in a nursing facility is under 3 years." I thought the average stay in skilled nursing was quite a bit less than three years, though different sources show different numbers ... also the median is probably less than the average.

That's all I was saying. We might still be disagreeing, :-) but that's my take on the situation. None of which is disagreeing that advance directives are not really good things.

* I don't think I've ever seen a study showing that people with a DNR have shorter LTC stays than people without one; if you've seen that give me a pointer.
I would also like to point out that it is not just a DNR that is needed, but a living will which incorporates a DNR.

So yeah, sure, a living will isn't the end all be all. It just decreases your own risk of requiring long term care compared to someone without a living will. Again, that risk is not eliminated, and if this is something you really worry about or if there is significant family history of dementia one may need to hedge their bets.

For us, I'm not too worried about needing insurance as we can cashflow the few years that it may be needed. And if it is not just a few years but much longer, I just don't see a pathway that would make the surviving spouse in financial trouble.

As for studies regarding a living will and decreasing the need for LTC (again not eliminating,) no, I do not know of any studies. But we constantly perform heroic measures to prolong the life of a loved one who has absolutely no quality of life and little to no mental capacity. These often times are nursing home patients whose family just wont let their loved one's go. Also, we sometimes are lucky with CPR and bring a patient back. Unless CPR was started quickly and the patient returns circulation quickly then odds are there will be consequences. Those consequences can leave a patient bedridden and in a nursing home for many years to come.

At the end of the day, I don't think we disagree with each other on the big picture. We maybe disagree on the need for allocating funds in some way to cover the costs of LTC needs.
A time to EVALUATE your jitters: | viewtopic.php?p=1139732#p1139732
TN_Boy
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Re: What is exactly the long term care?

Post by TN_Boy »

EnjoyIt wrote: Mon Oct 04, 2021 1:31 pm
Much stuff deleted

I would also like to point out that it is not just a DNR that is needed, but a living will which incorporates a DNR.

So yeah, sure, a living will isn't the end all be all. It just decreases your own risk of requiring long term care compared to someone without a living will. Again, that risk is not eliminated, and if this is something you really worry about or if there is significant family history of dementia one may need to hedge their bets.

For us, I'm not too worried about needing insurance as we can cashflow the few years that it may be needed. And if it is not just a few years but much longer, I just don't see a pathway that would make the surviving spouse in financial trouble.

As for studies regarding a living will and decreasing the need for LTC (again not eliminating,) no, I do not know of any studies. But we constantly perform heroic measures to prolong the life of a loved one who has absolutely no quality of life and little to no mental capacity. These often times are nursing home patients whose family just wont let their loved one's go. Also, we sometimes are lucky with CPR and bring a patient back. Unless CPR was started quickly and the patient returns circulation quickly then odds are there will be consequences. Those consequences can leave a patient bedridden and in a nursing home for many years to come.

At the end of the day, I don't think we disagree with each other on the big picture. We maybe disagree on the need for allocating funds in some way to cover the costs of LTC needs.
It's not even just a living will and DNR. Some states have MOST documents -- The Medical Order for Scope of Treatment -- which is more detailed around treatment options.

My wording may have been confusing -- I don't advocate segregating funds for LTC; I'm not a bucket guy. I was just stating that if I wanted to have $X available somehow for LTC, I don't think having a good set of documents would make me think I need $X - some number. I.e. less money because I've made sure they don't do DNR.

As far as heroic measures.... I don't know how common that is for elderly patients in really bad shape. Of the situations I'm aware of, I think the families of most elderly patients are 100% onboard with DNR, etc. I've not personally seen families (though I'm sure that it happens) keep mom, dad, or grandpa alive though heroic interventions when the quality of life is very low. Candidly, most families feel sadness and relief when the family member in that state leaves this world.

The ... "problem" .... is that many people continue on without actually needing CPR, or becoming unable to feed themselves, at least not for a very long time.

So then you get into very hard situations. Mom or dad has dementia. But not end stage. They still know you and can hold a conversation with you. They'll tell how good the fried chicken was at lunch. Now they get pneumonia. Do you treat that? Left alone it will kill them. But it can be treated and they will probably get better. Or they fall and have a fracture. Without treatment they will be constant pain. Treat that?

The care decisions can be difficult. What I've seen is that once the person gets near the end, nobody in the family wants major interventions. It's the mid-stages, when the person is at least partly "there" that decisions are wrenching.
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ResearchMed
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Re: What is exactly the long term care?

Post by ResearchMed »

TN_Boy wrote: Tue Oct 05, 2021 7:00 pm
EnjoyIt wrote: Mon Oct 04, 2021 1:31 pm
Much stuff deleted

I would also like to point out that it is not just a DNR that is needed, but a living will which incorporates a DNR.

So yeah, sure, a living will isn't the end all be all. It just decreases your own risk of requiring long term care compared to someone without a living will. Again, that risk is not eliminated, and if this is something you really worry about or if there is significant family history of dementia one may need to hedge their bets.

For us, I'm not too worried about needing insurance as we can cashflow the few years that it may be needed. And if it is not just a few years but much longer, I just don't see a pathway that would make the surviving spouse in financial trouble.

As for studies regarding a living will and decreasing the need for LTC (again not eliminating,) no, I do not know of any studies. But we constantly perform heroic measures to prolong the life of a loved one who has absolutely no quality of life and little to no mental capacity. These often times are nursing home patients whose family just wont let their loved one's go. Also, we sometimes are lucky with CPR and bring a patient back. Unless CPR was started quickly and the patient returns circulation quickly then odds are there will be consequences. Those consequences can leave a patient bedridden and in a nursing home for many years to come.

At the end of the day, I don't think we disagree with each other on the big picture. We maybe disagree on the need for allocating funds in some way to cover the costs of LTC needs.
It's not even just a living will and DNR. Some states have MOST documents -- The Medical Order for Scope of Treatment -- which is more detailed around treatment options.

My wording may have been confusing -- I don't advocate segregating funds for LTC; I'm not a bucket guy. I was just stating that if I wanted to have $X available somehow for LTC, I don't think having a good set of documents would make me think I need $X - some number. I.e. less money because I've made sure they don't do DNR.

As far as heroic measures.... I don't know how common that is for elderly patients in really bad shape. Of the situations I'm aware of, I think the families of most elderly patients are 100% onboard with DNR, etc. I've not personally seen families (though I'm sure that it happens) keep mom, dad, or grandpa alive though heroic interventions when the quality of life is very low. Candidly, most families feel sadness and relief when the family member in that state leaves this world.

The ... "problem" .... is that many people continue on without actually needing CPR, or becoming unable to feed themselves, at least not for a very long time.

So then you get into very hard situations. Mom or dad has dementia. But not end stage. They still know you and can hold a conversation with you. They'll tell how good the fried chicken was at lunch. Now they get pneumonia. Do you treat that? Left alone it will kill them. But it can be treated and they will probably get better. Or they fall and have a fracture. Without treatment they will be constant pain. Treat that?

The care decisions can be difficult. What I've seen is that once the person gets near the end, nobody in the family wants major interventions. It's the mid-stages, when the person is at least partly "there" that decisions are wrenching.
Important issues, to be sure.

Some end-of-life directives include "no antibiotics", etc. It can be more like hospice care.
But DO treat the pain.
(I can't really imagine someone directing that pain-controlling meds be stopped towards the end, for self or other. If anything, this is a way that can help smooth things along, keeping "comfort" as a primary goal...)

RM
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ncbill
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Re: What is exactly the long term care?

Post by ncbill »

EnjoyIt wrote: Tue Oct 05, 2021 3:08 pm
TN_Boy wrote: Tue Oct 05, 2021 9:19 am
EnjoyIt wrote: Mon Oct 04, 2021 10:41 pm
TN_Boy wrote: Mon Oct 04, 2021 9:35 pm
EnjoyIt wrote: Mon Oct 04, 2021 1:31 pm One way to minimize nursing home or long term care is to make sure you have a living will. This doesn't preclude all long term care needs, but at the very least it will preclude you from living just for the sake of being alive with no quality of care.

Basically this means having a DNR (Do Not Resuscitate) order in place. Last thing I or my spouse want is to be brought back to life and have little to no mental capacity. We do not want to be bedridden either. We not want want catheters placed through our skin into our stomach to feed us. We want to make sure that our loved one's do not enforce this type of torture onto us and for that we have a living will. With that in mind, the odds of needing skilled nursing for medical care decrease substantially. This doesn't preclude severe cognitive decline without any other organ injury such as Alzheimers disease, but it is a start.

If anything, Alzheimers scares me the most because one can be physically healthy but mentally incapacitated. This type of existence can last for a very long time. From my experience, family is usually good at managing this, but eventually the cognitive decline becomes too much and a nursing facility will be required.

The average stay in a nursing facility is under 3 years. If you take into account a living will, that number will decrease. With that in mind, personally, I do not think we need LTC insurance. If one of us is in need of medical care, that means we are spending a lot less money on travel, toys, entertainment, etc. Our expenses would plummet significantly and that money can be sent to a nursing facility. This is during the last X years of our lives. SS will still keep coming in, our portfolio should still be providing 4% (3% for some bogleheads.) That alone should cover a good chunk of nursing home cost. We then deplete some of our portfolio for the remainder. Even 10 years like this the surfing spouse would have plenty of money for the remainder of their life even if it includes also requiring nursing home care.
While everyone should have a living will, I think you are overstating how much such a document will reduce long term care needs for most people.

Many many people in LTC never develop, or develop after a long time IN LTC, the sort of issues you mention: need for feeding tubes, have a stroke, etc. More commonly, various maladies raise their heads, many if not most of which can be readily treated even in older ailing patients. Even if the patient falls and breaks a hip, a DNR is not going to affect treatment for this patient. A lot of people in memory care truck along for years without the need for CPR or feeding tubes.

It's a good idea, but I wouldn't consider proper paperwork as a way to reduce long term costs.
I mentioned how a DNR does not prevent the need for memory care and I wrote how a DNR does not eliminate the risk, it decreases it.

Broken hip equals rehab not LTC though not working at rehab could end up in LTC. Rehab is paid by Medicare.
It's possible we are talking past each other. I was responding to this:
One way to minimize nursing home or long term care is to make sure you have a living will.
and in particular this:
The average stay in a nursing facility is under 3 years. If you take into account a living will, that number will decrease*. With that in mind, personally, I do not think we need LTC insurance.
Emphasis mine on those last two sentences.

I'd put it this way. Suppose I was worried about the cost of LTC, so I decided I wanted (via LTC insurance, savings, SPIAs, SS, etc) to be sure I could handle $X worth of long term care expenses. Now, how much would *I* reduce X by knowing that I had proper advance directives? The answer is 0, since there are so many expensive LTC problems that having a DNR would not change the $$ outcome.

There is also a bit of fuzziness around "The average stay in a nursing facility is under 3 years." I thought the average stay in skilled nursing was quite a bit less than three years, though different sources show different numbers ... also the median is probably less than the average.

That's all I was saying. We might still be disagreeing, :-) but that's my take on the situation. None of which is disagreeing that advance directives are not really good things.

* I don't think I've ever seen a study showing that people with a DNR have shorter LTC stays than people without one; if you've seen that give me a pointer.
I would also like to point out that it is not just a DNR that is needed, but a living will which incorporates a DNR.

So yeah, sure, a living will isn't the end all be all. It just decreases your own risk of requiring long term care compared to someone without a living will. Again, that risk is not eliminated, and if this is something you really worry about or if there is significant family history of dementia one may need to hedge their bets.

For us, I'm not too worried about needing insurance as we can cashflow the few years that it may be needed. And if it is not just a few years but much longer, I just don't see a pathway that would make the surviving spouse in financial trouble.

As for studies regarding a living will and decreasing the need for LTC (again not eliminating,) no, I do not know of any studies. But we constantly perform heroic measures to prolong the life of a loved one who has absolutely no quality of life and little to no mental capacity. These often times are nursing home patients whose family just wont let their loved one's go. Also, we sometimes are lucky with CPR and bring a patient back. Unless CPR was started quickly and the patient returns circulation quickly then odds are there will be consequences. Those consequences can leave a patient bedridden and in a nursing home for many years to come.

At the end of the day, I don't think we disagree with each other on the big picture. We maybe disagree on the need for allocating funds in some way to cover the costs of LTC needs.
I have to disagree with the recommendation of a living will since those, unfortunately, usually contain vague language & more importantly leave the interpretation of the expressed wishes within up to the medical staff.

The best option, by far, at least for those of us living in the USA is to prepare a health care power of attorney (HCPOA) instead.
There are usually model forms for your particular state available.

A HCPOA allows you to appoint a health care agent who is legally empowered to make all medical decisions on your behalf.

I've posted on this many times before...I watched a parent lie in bed for nearly the last decade of their life thanks to the regular use of antibiotics to 'cure' the many infections they developed during their final years.

EDIT: And by the time they were bedridden they were completely uncommunicative & unresponsive simply due to the progress of their dementia, unlike the hypotheticals some other posters have mentioned.

So I have written a restrictive HCPOA which in the event of terminal illness, including any form of dementia, prohibits anything but palliative care, even if I don't (yet) qualify for Hospice.

To stay on topic, my goal is to minimize LTC required (if any) & so preserve as much as possible of my assets for my heirs.
EnjoyIt
Posts: 8272
Joined: Sun Dec 29, 2013 7:06 pm

Re: What is exactly the long term care?

Post by EnjoyIt »

TN_Boy wrote: Tue Oct 05, 2021 7:00 pm
EnjoyIt wrote: Mon Oct 04, 2021 1:31 pm
Much stuff deleted

I would also like to point out that it is not just a DNR that is needed, but a living will which incorporates a DNR.

So yeah, sure, a living will isn't the end all be all. It just decreases your own risk of requiring long term care compared to someone without a living will. Again, that risk is not eliminated, and if this is something you really worry about or if there is significant family history of dementia one may need to hedge their bets.

For us, I'm not too worried about needing insurance as we can cashflow the few years that it may be needed. And if it is not just a few years but much longer, I just don't see a pathway that would make the surviving spouse in financial trouble.

As for studies regarding a living will and decreasing the need for LTC (again not eliminating,) no, I do not know of any studies. But we constantly perform heroic measures to prolong the life of a loved one who has absolutely no quality of life and little to no mental capacity. These often times are nursing home patients whose family just wont let their loved one's go. Also, we sometimes are lucky with CPR and bring a patient back. Unless CPR was started quickly and the patient returns circulation quickly then odds are there will be consequences. Those consequences can leave a patient bedridden and in a nursing home for many years to come.

At the end of the day, I don't think we disagree with each other on the big picture. We maybe disagree on the need for allocating funds in some way to cover the costs of LTC needs.
It's not even just a living will and DNR. Some states have MOST documents -- The Medical Order for Scope of Treatment -- which is more detailed around treatment options.

My wording may have been confusing -- I don't advocate segregating funds for LTC; I'm not a bucket guy. I was just stating that if I wanted to have $X available somehow for LTC, I don't think having a good set of documents would make me think I need $X - some number. I.e. less money because I've made sure they don't do DNR.

As far as heroic measures.... I don't know how common that is for elderly patients in really bad shape. Of the situations I'm aware of, I think the families of most elderly patients are 100% onboard with DNR, etc. I've not personally seen families (though I'm sure that it happens) keep mom, dad, or grandpa alive though heroic interventions when the quality of life is very low. Candidly, most families feel sadness and relief when the family member in that state leaves this world.

The ... "problem" .... is that many people continue on without actually needing CPR, or becoming unable to feed themselves, at least not for a very long time.

So then you get into very hard situations. Mom or dad has dementia. But not end stage. They still know you and can hold a conversation with you. They'll tell how good the fried chicken was at lunch. Now they get pneumonia. Do you treat that? Left alone it will kill them. But it can be treated and they will probably get better. Or they fall and have a fracture. Without treatment they will be constant pain. Treat that?

The care decisions can be difficult. What I've seen is that once the person gets near the end, nobody in the family wants major interventions. It's the mid-stages, when the person is at least partly "there" that decisions are wrenching.
That’s amazing because I see so many examples of the exact opposite where families will keep treating those infections of their bedridden with no mental activity loved one. I see families request feeding tubes. I see semi-elective surgeries done on similar patients.

Maybe this is location dependent and we see different things.
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EnjoyIt
Posts: 8272
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Re: What is exactly the long term care?

Post by EnjoyIt »

ncbill wrote: Tue Oct 05, 2021 7:24 pm
EnjoyIt wrote: Tue Oct 05, 2021 3:08 pm
TN_Boy wrote: Tue Oct 05, 2021 9:19 am
EnjoyIt wrote: Mon Oct 04, 2021 10:41 pm
TN_Boy wrote: Mon Oct 04, 2021 9:35 pm

While everyone should have a living will, I think you are overstating how much such a document will reduce long term care needs for most people.

Many many people in LTC never develop, or develop after a long time IN LTC, the sort of issues you mention: need for feeding tubes, have a stroke, etc. More commonly, various maladies raise their heads, many if not most of which can be readily treated even in older ailing patients. Even if the patient falls and breaks a hip, a DNR is not going to affect treatment for this patient. A lot of people in memory care truck along for years without the need for CPR or feeding tubes.

It's a good idea, but I wouldn't consider proper paperwork as a way to reduce long term costs.
I mentioned how a DNR does not prevent the need for memory care and I wrote how a DNR does not eliminate the risk, it decreases it.

Broken hip equals rehab not LTC though not working at rehab could end up in LTC. Rehab is paid by Medicare.
It's possible we are talking past each other. I was responding to this:
One way to minimize nursing home or long term care is to make sure you have a living will.
and in particular this:
The average stay in a nursing facility is under 3 years. If you take into account a living will, that number will decrease*. With that in mind, personally, I do not think we need LTC insurance.
Emphasis mine on those last two sentences.

I'd put it this way. Suppose I was worried about the cost of LTC, so I decided I wanted (via LTC insurance, savings, SPIAs, SS, etc) to be sure I could handle $X worth of long term care expenses. Now, how much would *I* reduce X by knowing that I had proper advance directives? The answer is 0, since there are so many expensive LTC problems that having a DNR would not change the $$ outcome.

There is also a bit of fuzziness around "The average stay in a nursing facility is under 3 years." I thought the average stay in skilled nursing was quite a bit less than three years, though different sources show different numbers ... also the median is probably less than the average.

That's all I was saying. We might still be disagreeing, :-) but that's my take on the situation. None of which is disagreeing that advance directives are not really good things.

* I don't think I've ever seen a study showing that people with a DNR have shorter LTC stays than people without one; if you've seen that give me a pointer.
I would also like to point out that it is not just a DNR that is needed, but a living will which incorporates a DNR.

So yeah, sure, a living will isn't the end all be all. It just decreases your own risk of requiring long term care compared to someone without a living will. Again, that risk is not eliminated, and if this is something you really worry about or if there is significant family history of dementia one may need to hedge their bets.

For us, I'm not too worried about needing insurance as we can cashflow the few years that it may be needed. And if it is not just a few years but much longer, I just don't see a pathway that would make the surviving spouse in financial trouble.

As for studies regarding a living will and decreasing the need for LTC (again not eliminating,) no, I do not know of any studies. But we constantly perform heroic measures to prolong the life of a loved one who has absolutely no quality of life and little to no mental capacity. These often times are nursing home patients whose family just wont let their loved one's go. Also, we sometimes are lucky with CPR and bring a patient back. Unless CPR was started quickly and the patient returns circulation quickly then odds are there will be consequences. Those consequences can leave a patient bedridden and in a nursing home for many years to come.

At the end of the day, I don't think we disagree with each other on the big picture. We maybe disagree on the need for allocating funds in some way to cover the costs of LTC needs.
I have to disagree with the recommendation of a living will since those, unfortunately, usually contain vague language & more importantly leave the interpretation of the expressed wishes within up to the medical staff.

The best option, by far, at least for those of us living in the USA is to prepare a health care power of attorney (HCPOA) instead.
There are usually model forms for your particular state available.

A HCPOA allows you to appoint a health care agent who is legally empowered to make all medical decisions on your behalf.

I've posted on this many times before...I watched a parent lie in bed for nearly the last decade of their life thanks to the regular use of antibiotics to 'cure' the many infections they developed during their final years.

EDIT: And by the time they were bedridden they were completely uncommunicative & unresponsive simply due to the progress of their dementia, unlike the hypotheticals some other posters have mentioned.

So I have written a restrictive HCPOA which in the event of terminal illness, including any form of dementia, prohibits anything but palliative care, even if I don't (yet) qualify for Hospice.

To stay on topic, my goal is to minimize LTC required (if any) & so preserve as much as possible of my assets for my heirs.
You are so right about a power of attorney.
A time to EVALUATE your jitters: | viewtopic.php?p=1139732#p1139732
TN_Boy
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Re: What is exactly the long term care?

Post by TN_Boy »

ncbill wrote: Tue Oct 05, 2021 7:24 pm
EnjoyIt wrote: Tue Oct 05, 2021 3:08 pm
TN_Boy wrote: Tue Oct 05, 2021 9:19 am
EnjoyIt wrote: Mon Oct 04, 2021 10:41 pm
TN_Boy wrote: Mon Oct 04, 2021 9:35 pm

While everyone should have a living will, I think you are overstating how much such a document will reduce long term care needs for most people.

Many many people in LTC never develop, or develop after a long time IN LTC, the sort of issues you mention: need for feeding tubes, have a stroke, etc. More commonly, various maladies raise their heads, many if not most of which can be readily treated even in older ailing patients. Even if the patient falls and breaks a hip, a DNR is not going to affect treatment for this patient. A lot of people in memory care truck along for years without the need for CPR or feeding tubes.

It's a good idea, but I wouldn't consider proper paperwork as a way to reduce long term costs.
I mentioned how a DNR does not prevent the need for memory care and I wrote how a DNR does not eliminate the risk, it decreases it.

Broken hip equals rehab not LTC though not working at rehab could end up in LTC. Rehab is paid by Medicare.
It's possible we are talking past each other. I was responding to this:
One way to minimize nursing home or long term care is to make sure you have a living will.
and in particular this:
The average stay in a nursing facility is under 3 years. If you take into account a living will, that number will decrease*. With that in mind, personally, I do not think we need LTC insurance.
Emphasis mine on those last two sentences.

I'd put it this way. Suppose I was worried about the cost of LTC, so I decided I wanted (via LTC insurance, savings, SPIAs, SS, etc) to be sure I could handle $X worth of long term care expenses. Now, how much would *I* reduce X by knowing that I had proper advance directives? The answer is 0, since there are so many expensive LTC problems that having a DNR would not change the $$ outcome.

There is also a bit of fuzziness around "The average stay in a nursing facility is under 3 years." I thought the average stay in skilled nursing was quite a bit less than three years, though different sources show different numbers ... also the median is probably less than the average.

That's all I was saying. We might still be disagreeing, :-) but that's my take on the situation. None of which is disagreeing that advance directives are not really good things.

* I don't think I've ever seen a study showing that people with a DNR have shorter LTC stays than people without one; if you've seen that give me a pointer.
I would also like to point out that it is not just a DNR that is needed, but a living will which incorporates a DNR.

So yeah, sure, a living will isn't the end all be all. It just decreases your own risk of requiring long term care compared to someone without a living will. Again, that risk is not eliminated, and if this is something you really worry about or if there is significant family history of dementia one may need to hedge their bets.

For us, I'm not too worried about needing insurance as we can cashflow the few years that it may be needed. And if it is not just a few years but much longer, I just don't see a pathway that would make the surviving spouse in financial trouble.

As for studies regarding a living will and decreasing the need for LTC (again not eliminating,) no, I do not know of any studies. But we constantly perform heroic measures to prolong the life of a loved one who has absolutely no quality of life and little to no mental capacity. These often times are nursing home patients whose family just wont let their loved one's go. Also, we sometimes are lucky with CPR and bring a patient back. Unless CPR was started quickly and the patient returns circulation quickly then odds are there will be consequences. Those consequences can leave a patient bedridden and in a nursing home for many years to come.

At the end of the day, I don't think we disagree with each other on the big picture. We maybe disagree on the need for allocating funds in some way to cover the costs of LTC needs.
I have to disagree with the recommendation of a living will since those, unfortunately, usually contain vague language & more importantly leave the interpretation of the expressed wishes within up to the medical staff.

The best option, by far, at least for those of us living in the USA is to prepare a health care power of attorney (HCPOA) instead.
There are usually model forms for your particular state available.

A HCPOA allows you to appoint a health care agent who is legally empowered to make all medical decisions on your behalf.

I've posted on this many times before...I watched a parent lie in bed for nearly the last decade of their life thanks to the regular use of antibiotics to 'cure' the many infections they developed during their final years.

EDIT: And by the time they were bedridden they were completely uncommunicative & unresponsive simply due to the progress of their dementia, unlike the hypotheticals some other posters have mentioned.

So I have written a restrictive HCPOA which in the event of terminal illness, including any form of dementia, prohibits anything but palliative care, even if I don't (yet) qualify for Hospice.

To stay on topic, my goal is to minimize LTC required (if any) & so preserve as much as possible of my assets for my heirs.
If "ncbill" actually lives in NC, you should probably look up MOST documents, as I believe they are used in that state.

And actually, you raise a good point, one that I was assuming, but did not state that I was:

Some human should be your health care power of attorney, and backed up with appropriate paperwork ensure the right thing happens. You do not want to depend upon paperwork only. You need an advocate.

(incidentally, the situation I was describing, if that's what you are referring to, was not hypothetical).
TN_Boy
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Re: What is exactly the long term care?

Post by TN_Boy »

EnjoyIt wrote: Tue Oct 05, 2021 7:46 pm
TN_Boy wrote: Tue Oct 05, 2021 7:00 pm
EnjoyIt wrote: Mon Oct 04, 2021 1:31 pm
Much stuff deleted

I would also like to point out that it is not just a DNR that is needed, but a living will which incorporates a DNR.

So yeah, sure, a living will isn't the end all be all. It just decreases your own risk of requiring long term care compared to someone without a living will. Again, that risk is not eliminated, and if this is something you really worry about or if there is significant family history of dementia one may need to hedge their bets.

For us, I'm not too worried about needing insurance as we can cashflow the few years that it may be needed. And if it is not just a few years but much longer, I just don't see a pathway that would make the surviving spouse in financial trouble.

As for studies regarding a living will and decreasing the need for LTC (again not eliminating,) no, I do not know of any studies. But we constantly perform heroic measures to prolong the life of a loved one who has absolutely no quality of life and little to no mental capacity. These often times are nursing home patients whose family just wont let their loved one's go. Also, we sometimes are lucky with CPR and bring a patient back. Unless CPR was started quickly and the patient returns circulation quickly then odds are there will be consequences. Those consequences can leave a patient bedridden and in a nursing home for many years to come.

At the end of the day, I don't think we disagree with each other on the big picture. We maybe disagree on the need for allocating funds in some way to cover the costs of LTC needs.
It's not even just a living will and DNR. Some states have MOST documents -- The Medical Order for Scope of Treatment -- which is more detailed around treatment options.

My wording may have been confusing -- I don't advocate segregating funds for LTC; I'm not a bucket guy. I was just stating that if I wanted to have $X available somehow for LTC, I don't think having a good set of documents would make me think I need $X - some number. I.e. less money because I've made sure they don't do DNR.

As far as heroic measures.... I don't know how common that is for elderly patients in really bad shape. Of the situations I'm aware of, I think the families of most elderly patients are 100% onboard with DNR, etc. I've not personally seen families (though I'm sure that it happens) keep mom, dad, or grandpa alive though heroic interventions when the quality of life is very low. Candidly, most families feel sadness and relief when the family member in that state leaves this world.

The ... "problem" .... is that many people continue on without actually needing CPR, or becoming unable to feed themselves, at least not for a very long time.

So then you get into very hard situations. Mom or dad has dementia. But not end stage. They still know you and can hold a conversation with you. They'll tell how good the fried chicken was at lunch. Now they get pneumonia. Do you treat that? Left alone it will kill them. But it can be treated and they will probably get better. Or they fall and have a fracture. Without treatment they will be constant pain. Treat that?

The care decisions can be difficult. What I've seen is that once the person gets near the end, nobody in the family wants major interventions. It's the mid-stages, when the person is at least partly "there" that decisions are wrenching.
That’s amazing because I see so many examples of the exact opposite where families will keep treating those infections of their bedridden with no mental activity loved one. I see families request feeding tubes. I see semi-elective surgeries done on similar patients.

Maybe this is location dependent and we see different things.
Probably. This sort of intervention is not something I've seen. I cannot imagine keeping someone that far gone "alive."
Rex66
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Re: What is exactly the long term care?

Post by Rex66 »

In the context of the discussion and insurance, the best thing to do is look at the definition that would trigger benefits and what services are covered.
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Lon
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Re: What is exactly the long term care?

Post by Lon »

flyingaway wrote: Mon Oct 04, 2021 11:31 am I have seen many discussions about long term care costs and insurance against it. I have also seen discussions and mentioning of assisted living, CCRC, memory care, skilled nursing care, etc. Frankly speaking, I do not know the big differences between these definitions and do not know which ones are exactly what we may need in the future.

I think many of the "cares" that people needed before many not be needed now or in the future. People can now stay at their homes much longer than before. For example, if you cannot shop in stores, you can order grocery deliveries, food deliveries, and drug deliveries. You don't have to walk out of your door or drive your car and survive for a few years. That might cut the cost of long term care cost dramatically.

So what is exactly the long term care that you are talking about?
I am a single 87 year old Bogglehead living in a First Class Assisted Living/Memory Care one bedroom apartment.
My Long Term Care Policy pays for more than half of my $7,117.00 monthly costs and saves my Vanguard assets.
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flyingaway
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Re: What is exactly the long term care?

Post by flyingaway »

Lon wrote: Sat Oct 16, 2021 6:20 pm
flyingaway wrote: Mon Oct 04, 2021 11:31 am I have seen many discussions about long term care costs and insurance against it. I have also seen discussions and mentioning of assisted living, CCRC, memory care, skilled nursing care, etc. Frankly speaking, I do not know the big differences between these definitions and do not know which ones are exactly what we may need in the future.

I think many of the "cares" that people needed before many not be needed now or in the future. People can now stay at their homes much longer than before. For example, if you cannot shop in stores, you can order grocery deliveries, food deliveries, and drug deliveries. You don't have to walk out of your door or drive your car and survive for a few years. That might cut the cost of long term care cost dramatically.

So what is exactly the long term care that you are talking about?
I am a single 87 year old Bogglehead living in a First Class Assisted Living/Memory Care one bedroom apartment.
My Long Term Care Policy pays for more than half of my $7,117.00 monthly costs and saves my Vanguard assets.
Could you afford the cost if you did not have the long term care insurance policy?
HomeStretch
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Re: What is exactly the long term care?

Post by HomeStretch »

In addition to the good points already made by other posters, a few comments from my experience (n=4) in a HCOL area with parents/in-laws in their 80s-90s needing varying levels of care - 3 at home, 1 just entered a skilled nursing facility (SNF).

The costs per the Genworth link above are understated by ~40% in our areas.

While living at home, seniors needing assistance from family are more easily helped if they live with or within 15 minutes of a family member. For SNFs, be nearby family members who can make regular visits during the week.

Getting consistent, reliable, quality in-home help through an agency (we have tried several) in our area (at $29-$32/hour) is extremely difficult and is non-medical help. If the senior has dementia and cannot be left alone, in-home care was not reliable or skillful enough. Finding visiting nurse private-pay services to provide daily medical assistance (insulin administration, checking blood sugar/vitals, wound care, etc.) is near impossible even through traveling nurse agencies owned by large hospital groups.

SNFs are expensive, vary in quality, have long waiting lists (which can be bypassed if you start as a private pay patient), and not all accept Medicaid on Day 1 or if a private-pay patient runs out of funds. Annual SNF costs in our area range from $200k - $230k and most only offer semi-private rooms even for private pay.

IMO the hardest scenario to financially plan for is 1 spouse that is a “well” spouse that lives at home w/ or w/o light assistance and 1 spouse with dementia/needs assistance with ADLs and lives separately in a facility (memory care, SNF). Medicaid varies by state. In our state, the couple’s entire assets whether titled individually or jointly (except for the house the well spouse is living in and 1 car) is assumed to be available to pay for the institutionalized spouse’s care. In our example, this means $280k/yr net of SS income to support both spouses. It doesn’t take long to run through a modest portfolio before becoming eligible for Medicaid long term care benefits for the institutionalized spouse only. The younger “well” spouse in our case is left with enough funds to only pay for 2-3 more years of current independent living and without sufficient reserves for in-home care or to buy into a SNF for themselves, if needed.

My takeaway for financial planning:
I used to equate all “Medicaid planning” with people trying to impoverish themselves legally (by passing assets into trust or to family members) in order to have the state pay for their long-term care from Day 1. At best this seemed short-sighted as the better facilities require some level of private pay before accepting Medicaid, if at all.

Now seeing how a “well” spouse can be left without sufficient assets for their independent living or long-term care, I do think some level of Medicaid planning (well in advance due to Medicaid look-backs of up to 5 years) may be a necessity for any self-insured couple in a HCOL area without a portfolio of $2 million+ at age 80. This planning also includes revising DPOAs to include specific powers around gifting, etc. and, if a spouse develops dementia needing care, possibly revising titles/deeds for joint assets and changing will/TOD beneficiaries.
KansasDoc
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Re: What is exactly the long term care?

Post by KansasDoc »

Two thoughts:

1) if anticipated care is greater than five years out, then my crystal ball is cloudy. I am a primary care physician who is a medical Director of a nursing home I can tell you that whatever the current situation is it will be much different in 5 to 10 years. By nature, this makes it hard to plan for the future. Costs are rising exponentially and services are changing to be delivered at home.

2) as in with all healthcare please divorce the actual cost from what insurance covers. Remember there is good insurance and bad insurance coverage, now in primary care medicine there is direct primary care that cuts our insurance entirely. I don’t know what the future holds but costs are rising too fast for any sustainability in the insurance market. I predict there will be a significant opportunity for paying cash for the services you need when you need them.

This is an example of a market that is ripe for disruption
KansasDoc
Posts: 42
Joined: Sun Jul 21, 2019 7:44 pm

Re: What is exactly the long term care?

Post by KansasDoc »

Two thoughts:

1) if anticipated care is greater than five years out, then my crystal ball is cloudy. I am a primary care physician who is a medical Director of a nursing home I can tell you that whatever the current situation is it will be much different in 5 to 10 years. By nature, this makes it hard to plan for the future. Costs are rising exponentially and services are changing to be delivered at home.

2) as in with all healthcare please divorce the actual cost from what insurance covers. Remember there is good insurance and bad insurance coverage, now in primary care medicine there is direct primary care that cuts our insurance entirely. I don’t know what the future holds but costs are rising too fast for any sustainability in the insurance market. I predict there will be a significant opportunity for paying cash for the services you need when you need them.

This is an example of a market that is ripe for disruption
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Eagle33
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Re: What is exactly the long term care?

Post by Eagle33 »

Lon wrote: Sat Oct 16, 2021 6:20 pm I am a single 87 year old Bogglehead living in a First Class Assisted Living/Memory Care one bedroom apartment.
My Long Term Care Policy pays for more than half of my $7,117.00 monthly costs and saves my Vanguard assets.
How many months left before exhausting the policy total limit?
RudyS
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Re: What is exactly the long term care?

Post by RudyS »

crefwatch wrote: Tue Oct 05, 2021 10:29 am ...
There have been some reports of CCRC residents in independent living objecting to an independent spouse bringing the Skilled Nursing partner to the Independent dining room. It's a painful reminder of their mortality, I suppose. But anytime you move from private housing to a group (even a condo or gated community), it's very important to read every word of the rules and bylaws.
Visits to facilities to check them out are important. This type of situation hopefully would be seen. We are very lucky and happy in our CCRC. Everyone is welcome in all the levels of care. But realistically, the SNF residents are mostly not up to having an hour-long dining room experience.
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