Meeting Notes 2006

Caring for a Loved One with Alzheimer’s Disease or Dementia

The American Red Cross has produced a series of nine Family Caregiving modules, designed as a resource for all caregivers. Rachel Sato, former caregiver, American Red Cross Family Caregiver Leader Trainer, and past facilitator of the Wahiawa/Mililani Alzheimer’s Support Group, presented information from Module 8, “Caring for a Loved One with Alzheimer’s Disease or Dementia.” An abbreviated version of her presentation follows:

Rachel began by highlighting the six guiding principles of care: (1) safety, (2) privacy, (3) dignity, (4) communication, (5) independence, and (6) infection control. These principles, repeated in each module, form a guiding approach for caregivers.

One of the biggest challenges a caregiver of an Alzheimer’s or dementia patient faces is dealing with difficult behaviors. The module defines dementia as any chronic brain disorder that affects normal thought processes and that cannot be reversed. The most common symptoms of dementia are: (1) memory loss; (2) personality changes; and (3) problems with reasoning, orientation and personal care. Dementia is not caused by stress or a crisis, but it is often during times of crisis that others may notice something is wrong. It isn’t caused by too much or too little mental activity and it is not a normal part of growing older.

There are several types of dementia; the Alzheimer’s Disease (AD) type is the most common. Behavior of a person with AD has some common patterns: (1) pacing and wandering; (2) rummaging and hoarding; (3) displaying extreme catastrophic reactions; and (4) sundowning (becoming more restless and confused as evening approaches). “People who have dementia don’t all have the same symptoms; some are difficult, some are easier to handle,” explained Rachel. “Everyone will not behave in exactly the same way, but eventually they will all need help with their activities of daily living, such as dressing, toileting, and feeding. That is when the caregiver’s involvement becomes more difficult and intense.”

The American Red Cross, The Alzheimer’s Association, local libraries, and other sources have literature available that provide tips and techniques for communicating, assisting with daily activities, responding to behavioral problems, and maintaining a safe environment. “Learn as much as you can about dementia, seek advice from your doctor, join a support group, and seek help. Understanding helps everyone better cope and adjust,” explained Rachel.

According to the American Red Cross, depression is found in up to 50 percent of Alzheimer caregivers. Caring for someone with dementia or Alzheimer’s Disease requires more time, more energy, and more patience. Coping with difficult behaviors causes more stress. Around-the-clock care may mean insufficient sleep. Consistent lack of sleep can lead to depression. If you suspect you have depression, or are feeling “down,” don’t hesitate to see your heathcare provider and/or a mental health professional. Check with your health insurance provider for a list of mental health professionals who accept your insurance.

Being with other caregivers in a support group setting provides information on resources and ideas on coping with daily stresses. Individuals should also seek advice from medical, legal, and financial professionals. Anyone interested in receiving additional copies of the handbook or learning more about the Family Caregiving sessions may contact the American Red Cross, Hawaii Chapter at 739-8145 or “visit” www.hawaiiredcross.org.

Eldercare Hawai‘i

Former caregiver and eldercare consultant Deborah Jackson’s own caregiving journey began suddenly, with an unexpected phone call from her mother’s doctor that led to a hurried plane trip from California to Hawaii. Her hospitalized mom, who had long been caring for her dad, now also required attention.

“The onset of dementia, the debilitating effects of hospitalization, and extreme caregiver burnout had left my mother incapacitated,” Deborah explained. She left her mainland life and career and quickly moved back to the islands to care for her parents. Like so many other Hawaii caregivers, she discovered waiting lists, few affordable services, and difficulty finding reliable assistance. “In the beginning, I didn’t know the questions to ask or who to ask,” she explained, describing the situation common to all new caregivers.

Eventually, the Franciscan Adult Day Center in Manoa provided daytime respite and the opportunity to start a support group and other services, which formed the beginning of Eldercare Hawai‘i. Modeled, in part, on a resource center she had founded on the mainland, Eldercare Hawai‘i soon included classes, workshops, and other eldercare planning resources in its growing list of services.

Deborah recalls that despite all the difficulties, she and her mother developed a “connection on the deepest level, a closeness that often occurs between caregiver and care receiver, that would probably never otherwise happen. You discover that you can help someone in their end-of-life journey by giving care, by honoring them, respecting their dignity, and giving comfort.”

“Some of the chaos can be lessened by planning and organizing,” she emphasized. “How many of you have completed emergency checklists?“ When no hands were raised, she explained that “we all need to list medications, organize insurance papers, gather documents, and tell someone where everything is. Imagine trying to find it all during an emergency.”

Her emphasis on eldercare planning extends to the workshops she offers at the University of Hawaii Outreach Program and in the family caregiving training program she conducts in partnership with The Franciscan Adult Day Center. A training session that began on February 18 will be held every Saturday until April 1 at the Central Union Church. Topics include: (1) safety, mobility, fall prevention; (2) providing care in the home; (3) assisting with personal care; (4) perspective on aging; (5) nutrition and medications; and (6) legal issues and money matters.

Ms. Jackson served as editor and project coordinator of Residential Options for Hawaii’s Seniors, a planning guidebook that assists understanding of the various alternative living options available to Hawaii’s elderly population. “None of us can predict how we will age,” Jackson describes. “We need to look ahead, plan, explore our options, and prepare for the possibility of incapacity.”

Eldercare Hawai‘i’s website at www.eldercarehawaii.com provides a number of convenient services, from browsing through resources to ordering books. In addition, anyone interested in learning more about Eldercare Hawai’i’s services can call Ms. Jackson at 988-6300 or email info@eldercarehawaii.com.

University of Hawaii Elder Law Program (UHELP)

Ms. Christy Matsuba, a law student at the William S. Richardson School of Law at the University of Hawaii Manoa, and Ms. Holly McPherson, a recent law school graduate, both serve as law clerks for the University of Hawaii Elder Law Program (UHELP). The UHELP staff provides legal services to older individuals (60 and above) who meet certain criteria. “Prepare for the worst and expect the best” has been a guiding strategy underlying their efforts to enhance, protect, and preserve the independence of elders.

In addition, UHELP addresses the potential of incapacity by introducing planning tools, legal options, and end-of-life choices in their publication Deciding “What If?”— A Legal Handbook for Hawaii Caregivers, Families and Older Persons. The 2006 revised edition reflects recent changes in the law, updates public benefit amounts for 2006, gives cautionary advice on identity theft, and provides an expanded resource list that includes all organizations and public agencies throughout the state that can assist caregivers and care receivers.

Incapacity. “Does the person have the capacity to make decisions, to evaluate options, to understand the consequences of decisions?” Depending on the situation, different levels of decisional capacity may be appropriate. “Sometimes a nod is enough.” According to Ms. Matsuba, a Judge could determine that a person is incapable of managing financial affairs but capable of executing a will, completing an advance health care directive, or providing informed consent for medical treatment.

Power of Attorney. Ms. Matsuba explained that different types of Power of Attorney documents exist, some with limited powers, some with specific powers, and others with broad powers:

• General Power of Attorney. A designated Agent can do whatever the Principal can do.
• Limited Power of Attorney. Transaction can be one-time or specific to a situation.
• Durable Power of Attorney. This document is valid beyond the Principal’s incapacity. It can be broad or limited, such as one for health care. Phrases such as “these powers will not be affected by my disability or incapacity” or “these powers will only be effective upon my incapacity or disability” would serve to create a durable power of attorney. Without these references to durable powers, the Agent’s authority ends at the Principal’s mental disability. Ms. Matsuba added that some institutions may require completion of additional forms.

Advance Health Care Directive. Ms. McPherson explained that a few years ago only about 30 percent of Hawaii’s residents over 18 had some type of advance directive. In Hawaii, the Advance Health Care Directive (AHCD) combines provisions of the Health Care Power of Attorney and Individual Instructions for Health Care. (Formerly, a separate Living Will document was prepared to specify end-of-life decisions.)

Under Hawaii law, there is no required format for the AHCD, and UHELP has developed both a long and a short version. Part 1 of the AHCD form contains a section where the Principal can name an Agent or Agents and select when the Agent’s authority becomes effective (immediately or when a physician determines incapacity). “Name someone you trust to be your Agent,” emphasized Ms. McPherson.

Sections in Part 2 record the Principal’s choices regarding life prolonging measures, artificial nutrition and hydration (food and water), relief from pain, and other matters. The document can be notarized or witnessed and signed by two individuals (not the Agent or a health care provider). Ms. McPherson stressed that the preparer may customize the directive by deleting or writing in specific wishes. Changes can be later made, but all parties should be informed and new copies distributed.

What happens when an individual becomes mentally incapacitated and does not have an AHCD that specifies choices? Ms. McPherson and Ms. Matsuba briefly explained the sometimes lengthy and costly Guardianship proceedings. Other options could include a Surrogate Decisionmaker. In this instance, the patient designates a surrogate for healthcare decisions and informs the attending physician or other supervising heathcare provider. In Hawaii, Non-Designated Surrogate Decisionmakers are also recognized. This involves the attending physician locating “interested persons” who may select, by consensus, a Surrogate Decisionmaker on behalf of the incapacitated individual. “Interested persons,” as defined by Hawaii law, can include persons not related to the individual. In many instances, difficulties could arise with this latter approach.

Both presenters stressed that the presentation should not be construed as legal advice and that individuals should seek answers from legal professionals.

In addition, Deciding “What If?” contains information on a number of other “lifetime planning” documents and tools, such as financing health care, long-term care insurance, hiring a caregiver, donation of organs, signing for others, coping with death and dying, and more.

Anyone desiring to contact the UH Elder Law Program should call 956-6544.

Visiting Our Lawmakers

In past years, the Central Oahu Caregivers’ Support Group has participated in a legislative walkthrough, visiting the offices of every legislator and asking support for caregiver-related bills. This year we did something different.

On March 24, Rachel Sato and Lani Nedbalek accompanied Wes Lum, UH Center on Aging, and Dr. Eldon Wegner and Diane Stowell, members of PABEA (Policy Advisory Board for Elderly Affairs). Dr. Wegner took the lead during scheduled appointments with members of the Ways and Means and Finance Committees. The first meeting started at 8:30 a.m. with Senator Gordon Trimble followed by meetings with Rep. Clift Tsuji, Rep. Marilyn Lee, Senator Norman Sakamoto, and Rep. Glenn Wakai.

Aging- and Caregiver-Related Legislation 2006

This legislative year has proven to be a landmark for passage of aging- and caregiver-related legislation. In gratitude we thank the many legislators who supported our efforts and Wes Lum, who guided our way.

We weren’t sure about the status of this year’s caregiver legislation, but hoped that our guest, Wes Lum, UH Center on Aging, Caregiver Resource Initiatives Project Coordinator, would have some good news. For caregivers, passage of bills means more services and resources and recognition by others that critical caregiving issues exist.

“I am happy to report that a number of aging and family caregiving measures passed the session,” Wes reported with a smile as he passed sheets of paper, printed on both sides, around the table. The following is a list of bills that met the legislative milestone:

Family Caregiving

Training and Education (H.B. No. 1900). This measure enables family caregivers to receive ongoing education and training in order to meet their caregiving responsibilities and assures a highly qualified and sustainable eldercare workforce by appropriating $206,000 to Kapiolani Community College to establish a Long-Term Care Training Initiative for para-professional and family caregivers.

Respite Services (S.B. No. 3252). This measure provides much-needed respite for families by appropriating $500,000 to expand the Kupuna Care Program. Services provided by Kupuna Care are statewide and are intended to help meet the needs of older adults who cannot live at home without adequate help from family or formal services, and includes such services as adult day care, assisted transportation, attendant care, case management, chore, home delivered meals, homemaker, and personal care.

Coordination of Family Caregiver Support Services and Policies (S.B. No. 3252). This measure ensures that families will have affordable, readily available, high quality, comprehensive services and policies that are coordinated across all care settings by appropriating $80,000 to the Executive Office on Aging to coordinate caregiver support services and policies statewide.

Legislative Leadership (S.B. No. 3253). This measure facilitates the development of comprehensive public policy to strengthen support for family caregivers by establishing a Joint Legislative Committee on Family Caregiving to address the looming eldercare crisis.

Balancing Work and Caregiving (S.C.R. No. 13). This measure requests the Governor to convene a Work-Family Task Force to review Hawaii’s work-family laws and policies, and requests the Legislative Reference Bureau to study other states’ laws and practices that promote good work-family policy.

Eldercare Residential Homes/Facilities

Criminal History Record Checks (S.B. No. 2343). This measure ensures the safety of elderly and disabled persons by authorizing the Departments of Health and Human Services to conduct criminal background checks of persons providing care or having access to elderly and disabled residents of healthcare facilities.

Long-Term Home Care Services (S.B. No. 3254). This measure ensures that individuals receiving services from home- and community-based case management agencies and community care foster family homes receive continued quality care at reasonable costs by permanently establishing the statutory authority for the licensing and certification of home- and community-based case management agencies and community care foster family homes.

Increased Level of Payments (H.B. 1821). This measure adequately compensates adult residential care home operators by:

• Increasing the maximum level of care payments for Type I facilities, licensed developmental disabilities domiciliary homes, community care foster family homes, and certified adult foster homes to $621.90; and
• Increasing the maximum level of care payments for Type II facilities to $729.90.

Increased Capacity (S.B. No. 3247). This measure ensures the continuation of adult residential care homes and the availability of care home facilities to Medicaid recipients by:

• For Type I homes, authorizing the Department of Health (DOH) to allow up to six residents at its discretion, provided that the primary caregiver or home operator is a certified nurse aide who has completed a state-approved training program and other training required by DOH; and
• For Community Care Foster Family Homes, the DOH may certify the home for a third adult at its discretion, provided that (a) the resident is at the nursing level of care and a Medicaid recipient, and (b) the primary and substitute caregivers are certified nurse aides who have completed a state-approved training program and other training required by DOH.

Long-Term Care Infrastructure Plan (S.C.R. No. 144). Measure enables stakeholders to examine the challenges facing the State’s aging population, review available services, analyze existing state and county laws and regulations, consider the current long-term care bed capacity and projections for future needs, and develop a comprehensive long-term care infrastructure plan to ensure public safety while supporting aging-in-place initiatives.

Prescription Drugs

Hawaii Pharmacy Assistance Program (S.B. No. 3003). Measure enables more people to qualify for the State Pharmacy Assistance Program by extending the income eligibility requirement to 150% of the Federal Poverty Level.

Social Security and Medicare

Medicare Part D (H.C.R. No. 80). This measure requests the President and Congress of the United States to adopt changes to the Medicare Part D program.

Social Security (S.C.R. No. 6) Measure urges the Executive and Legislative Branches of the Federal Government to avoid privatization of Social Security, and specifically warns the Federal Government of possible financial and economic perils resulting from such a privatization of Social Security.

Kupuna and Caregiver Recognition

Kupuna Recognition Day (H.B. No. 3217). Measure recognizes the significant role that older adults play in Hawaii’s culture, history, and traditions by designating the fourth Saturday of July as Kupuna Recognition Day.

Caregiver’s Month (S.C.R. No. 204). Measure designates the month of March as Caregiver’s Month in Hawaii and proclaims the worthy deeds of all caregivers as a lasting memorial to their continuing service to Hawaii’s older adults and disabled persons.

Wes explained future efforts will be directed toward financial assistance for caregivers and emphasizing balancing work and caregiving. Anyone interested in assisting next year’s effort can call Wes Lum at 586-7319 or contact him at wes.lum@doh.hawaii.gov.

Central Oahu Family Caregivers’ Workshop

Senior Fraud

Gary Powell, LUTCF, CLTC, owner of PacConLTD., an insurance and estate planning firm, also teaches a continuing education class on Senior Fraud at one of the local high schools. He provided a few highlights of his nine-week course.

Illegal or inappropriate? “As caregivers, we must attempt to protect our elders from being victimized. Sometimes actions are not illegal, but could be highly inappropriate for the individual.” Gary described the numerous phone calls he receives from families inquiring about annuities, insurance plans, equity loans, and other financial “purchases” made by elderly family members. “My father didn’t understand and it sounded like a good deal to him.”

“In some cases,” explained Gary, “a salesperson makes a commission on a product that doesn’t benefit the individual. Seniors often are not up-to-date on fraud potentials, thus could be enticed by sweepstakes offers, telephone solicitations, requests for charitable contributions, real estate fraud, and the suggestion that they will somehow gain from a product. He described an individual who wrote a check for every donation request received, and the requests came in large numbers on a regular basis.

“’I don’t need help,’ our parents or other seniors will say, ‘I can take care of myself.’ Don’t argue, but do try to discreetly be aware of where their money is going and whether it is being used wisely. We can be their eyes and ears, the ones to say ‘no’ for them,” Gary described. “We can check out the ‘good deal’ to see whether it is appropriate. We should never hesitate to report suspicious practices.”

Hired caregivers. Don’t hire someone you don’t know “off the street.” In most instances, it is not recommended that hired caregivers pay the bills, write the checks, or pick up the mail. Reputable companies can be hired to do an individual’s finances, bill paying, and accounting. “The majority of hired caregivers are trustworthy and compassionate,” Gary described, “but there have been instances of gross caregiver crimes, where valuables are stolen, checking accounts have been emptied, social security numbers have been sold, and home titles have been transferred. Ensure that a background check is done — if not by you, then by an agency.”

Grief fraud. Grieving family members are sometimes “encouraged” to upgrade products, despite an existing funeral plan. If you purchase a plan, tell your loved ones not to make any changes, or feel pressured to spend more on any items.

Shred, shred, shred. “Shred everything with a cross-cut shredder,” Gary emphasized. He explained that papers run through a ribbon-type shredder can by taped together. “Everyone should shred credit card offers; people can open an account using your name.” (Note: an attempt was recently made to open a credit card account in this editor’s spouse’s name, apparently from a solicitation tossed in the trash. Capital One called because the addresses did not match.) Shred the blank checks that your banks send you as short-time offers; someone could just sign one and send it in. Don’t use a debit card; software is cheaply and readily available to identify your password and code, and your checking account could be swiftly emptied.

Credit rating. The Fair Credit Reporting Act requires each of the nationwide consumer reporting companies — Experian, Equifax, and TransUnion — to provide you with a free copy of your credit report, at your request, once every 12 months. The report will provide you with clues on any suspicious activity or errors that might exist. To order your free annual report from one or all of the national consumer reporting companies, visit online at www.annualcreditreport.com or call toll-free 1-877-322-8228. To stop most telephone solicitations, contact www.donotcall.gov or call 1-888-382-1222 from the home. To opt out of receiving prescreened solicitations from major consumer companies call 1-888-5-OPTOUT or visit www.optoutprescreen.com. You will continue to receive solicitations from local charities, merchants, and associations with which you already do business. Contact them directly.

Gary encourages everyone to protect themselves against identity theft, fraud, or inappropriate purchases. “If it looks too good to be true, it probably is.” Contact Gary about this topic, about his company, or the seminars he schedules at 625-3782 or 722-1903. He accepts email messages at pacconltd@yahoo.com.

Elderly Affairs Division

The Elderly Affairs Division, Department of Community Services, City and County of Honolulu is the designated Area Agency on Aging for the County. Established in 1973 under the Older Americans Act of 1965, its mission includes developing a coordinated and comprehensive system of services for the elderly on Oahu.

Mr. Tony Baccay, a Community Service Aide Supervisor with the Elderly Affairs Division (EAD) Information and Assistance Section, clarified the various federal, state, and city procedures and funding arrangements that allow EAD to provide a wide range of affordable services for caregivers and people 60 years and older. “Most of the services are provided through contracted agencies,” he explained. Those provided directly by EAD staff include the Senior Hotline, community outreach, client assessment and referrals, home consultations, and information services.

Senior Hotline. “If you have ever called the Senior Hotline you might have spoken to me,” Mr. Baccay said with a smile. “Staff members who answer the Senior Hotline provide information on elderly resources and services. Occasionally, seniors just want to talk to someone or inquire about something that puzzles them. There have been times, “ he added, “that calls put staff on alert to an immediate need. In those cases we schedule a home visit and try to arrange for assistance. Some of the elderly need home-delivered meals, door-to-door transportation, or help locating case managers to sort through their multiple requirements.” The Hotline staff answers calls from Monday to Friday, 7:45 a.m. to 4:30 p.m. Recorded messages left on weekends or after hours are answered the next workday. Many of the agencies contracted by EAD charge nothing but will accept a donation, or charge on a sliding income scale.

Contracted Services. According to Mr. Baccay, these include: (1) caregiver respite (adult day programs, in-home companions, information and referral), (2) case management and assistance (housekeeping, errands, shopping assistance, friendly visits), (3) exercise programs for frail or disabled elders, (4) home delivered and congregate meals, (5) housing assistance, (6) legal assistance, (7) bathing and grooming assistance, (8) senior centers, (9) transportation, (10) caregiver support groups, and (11) caregiver education and training.

EAD Publications. EAD produces the Family Caregiving Guide and the Senior Information & Assistance Handbook. Considered invaluable by caregivers, the publications list phone numbers and agencies by services provided. The Handbook is published every two years and available at American Savings Bank branches. Copies of the Family Caregiving Guide can be obtained by calling the Hotline. As editor of Aloha Pumehana, EAD’s quarterly newsletter, Mr. Baccay fills the pages with stories, upcoming events, and news to inform and entertain seniors and caregivers.

Anyone interested in receiving any of the publications mentioned or learning more about the many programs and services administered by EAD should call the Hotline. Ask for Mr. Tony Baccay — he might be available to take your call.

CSI Inc. — Money Management for the Frail and Elderly

CSI provides services as directed by the courts, the Social Security Administration, and the Veterans Administration, including guardianship, personal representative, representative payee, and custodian. CSI also helps individuals with public entitlement applications such as Medicaid.

Since 1987, CSI Inc. has been providing financial services for Hawaii’s elderly and disabled adults. The nonprofit organization specializes in daily money management. Trained staff assist clients by paying bills, providing budget counseling, managing checkbooks, and much more.

Our guest speaker, Ms. Karena Yee, CPA, Executive Director of CSI, has over 30 years of experience in finance, budgets, administrative services, business operations, human resources, and asset management in both the private and public sectors.

Her first job at a nursing home served as her primer to the needs of Hawaii’s senior population. Ms. Yee described talking to elderly patients and their families, listening to their stories, and discovering her concern for eldercare issues (she now serves on the State Kupuna Caucus). Her lengthy resume includes stints as CFO and Director of Administration for the Honolulu Board of Realtors and Asset Manager for HTH Corporation.

Who Uses CSI? Ms. Yee mentioned several situations where clients came to the company through appointment by the courts, referrals from government agencies, or other means. Ms. Yee described that family conflicts sometimes create a need for an objective third party money manager. “One sibling doesn’t trust another to handle mom’s finances, accusations are made, lawsuits occur, and the court will refer the case to CSI or other objective organizations or individuals.” CSI assists families manage the financial affairs of elderly parents or relatives and senior and nonsenior disabled, who are unable to efficiently handle their own finances. The latter includes disabled veterans or individuals receiving SSI.

Fees. In some cases, various government agencies set the fees that CSI can charge. “We charge 4% of a veteran’s benefits,” Ms. Yee explained. The nonprofit attempts to keep fees modest and will try to work out a sliding scale when needed.

Do’s and Don’ts. Ms. Yee described that everyone’s natural tendency is to assist another. But, she cautioned, when it comes to assisting with money, “we should all be very careful. The best intentions can sometimes lead to misunderstanding.”

“Each case is different,” said Ms. Yee. “We send our Client Support Specialist to speak to families or the individual account holders, if possible, to design a plan that will work best.” She explained that CSI is bonded and undergoes yearly reviews and audits. The organization belongs to the American Association of Daily Money Managers, National Guardianship Association, Hawaii Community Services Council, and the Hawaii Association of Case Managers.

Anyone interested in learning more about CSI’s services or fees can call 538-0353 or visit www.csihawaii.org.

Potential for Change: The 2005 Deficit Reduction Act

In February of this year, President George W. Bush signed the Deficit Reduction Act (DRA) of 2005. Among the many provisions, the Act estimates to reduce the growth in Medicare spending by more than $6 billion over the next five years and reduce the growth in Medicaid spending by nearly $5 billion over the next five years. Gary Powell, LUTCF, CLTC, owner of PACCONLTD, a local estate planning and insurance company, gave his point-of-view summary on some of the potential changes the new law could bring and the effect on our long-term care planning.

The 300-plus page DRA is lengthy with changes in a variety of areas, designed to reduce the nation’s deficit. Gary Powell discussed a few of the provisions related to long-term care that could potentially change some of Hawaii’s rules and requirements related to Medicaid assistance. “The changes outlined in the DRA are many and could affect everything from rental of oxygen equipment to the look-back period for long-term care Medicaid assistance,” explained Gary. “Some states have adopted the Act in total, others have made allowable modifications. Many states, like Hawaii, have not completed their evaluations and changes have yet to be implemented.”

Medicaid Eligibility Look-Back Period. The new policy lengthens Medicaid’s look-back period from three to five years on assets transferred for less than market value. At the time of application for Medicaid assistance, any transfer of assets such as money, property, gifts, or payment of another’s school tuition made in the past five years must be listed. A review will occur to determine whether a penalty period for the transfer should be imposed. The period is determined by dividing the amount transferred by the state’s average private pay monthly cost for nursing home care. Prior to the DRA, the penalty period began from the date of the asset transfer. Under the DRA, the look-back period begins at (1) the date of transfer or (2) the date of first eligibility for Medicaid, whichever is later. The law includes hardship waivers to ensure that the penalty period will not result in endangering lives or depriving anyone of shelter, food, clothes, etc.

Home Equity. Under current law, the value of a person’s home is not considered in Medicaid eligibility. Under the DRA, equity in a home more than $500,000 renders certain individuals ineligible for nursing home Medicaid benefits. Exceptions exist when a spouse, disabled child, or other exempt persons are legally residing in the home. The states have the option of raising the equity provision to $750,000. Hawaii has yet to make a decision on the allowable equity amount.

Annuities. The DRA also created new rules regarding annuities, including allowing the states to be named as remainderman beneficiaries for certain annuities.

State Long-Term Care Partnership Program. The program is a joint Medicaid/private long-term care insurance venture designed to encourage individuals to purchase the insurance to save state and federal money. An individual could exempt a certain amount of their assets by purchasing the insurance and still qualify for Medicaid.

Gary emphasized that, Hawaii has yet to implement any of the DRA changes, with the exception of more comprehensive health care provider reporting procedures and additional paperwork requirements. He hopes that Hawaii at the very least will:

• Raise the home equity exemption to $750,000.
• Adopt a State Long-Term Care Partnership Program.
• Provide a 50% line item tax deduction on long term care premiums.

“Long-term care planning can be very complicated. To be safe, seek the advice of a professional,” Gary cautions. His discussion also included information on the Medicaid Waiver and Follow the Money programs and more. For additional details, please contact Gary Powell at 625-3782 or email pacconltd@yahoo.com.

Central Oahu Public Health Nursing Office

Ms. Joyce Tapia-Miyahira, BSN, RN, MPH, has been with the State Department of Health for 19 years. Twelve of those years have been spent working at the Department’s Central Oahu Public Health Nursing (PHN) Office, where she currently serves as Public Health Nurse and Case Manager of the Case Management Coordination Program (CMCP) for Central Oahu.

The Program, created to assist frail elderly 60 years and older, has been in existence for a number of years. According to Ms. Tapia-Miyahira, “By assessing the needs of families, helping them locate assistance, offering case management and instructional services, it was hoped that our elders could live safely at home as long as possible.”

Her area of responsibility stretches from Salt Lake/Red Hill through Haleiwa. Another public health nurse attends to the needs of the elderly on the Windward side of the island.

“Many families don’t know how to begin looking for help. They aren’t familiar with available resources. They don’t know who to call or what to ask for. We spend time explaining to families the type of services that will benefit their elder. We instruct them on the process of getting help. We also suggest appropriate government or private agencies that they can contact. Our main goal is to improve and maintain the health status of the client. Many caregivers feel they should do it alone. No one can do everything alone.”

“We try to be flexible as much as possible. We charge nothing for our assistance, but stress that most private companies on the list of suggested contacts will probably request payment for their services. I always tell families to give me feedback and to call me if difficulties arise because I truly want to know.”

Ms. Tapia-Miyahira explained that in addition to elderly services, the PHN office staff also provides assistance through public school health services, immunization clinics, and programs designed to help individuals in certain high risk and special needs situations. The PHN office is located in Pearl City, next to the District Court House at 860 Fourth Street. Please call 453-6190 for more information on the various services offered by the agency.