Is my cousin getting bad advice?

[Anonymous]

Our family is dealing with trying to figure out the next best steps for my 85+yo aunt and uncle. My aunt is cognitively fine, while my uncle is has been slipping into dementia the last couple of years. He is currently in a rehab place after a hospitalization for a UTI. My aunt has been caring for him without much help but can’t really continue at that level.

My aunt and uncle live in the NY metro area, which is expensive for everything. Their son, “Jim” lives in NJ and daughter “Jill” lives in a rural Midwest college area. Initially the kids didn’t really know much about their parent’s finances, but I went up to help my aunt and uncovered the fact that they take in close to $9k per month from pensions and SS. They’ve donated large amounts to charities over the years, so outside of the income they have about $200k cash and a home worth $300k. My uncle served in the army for a few years and qualifies for veteran’s benefits of about $2300/m, in addition to the pension/ss.

We’ve identified a place near my cousin in the rural area that say they can take the two of them for about $7500/m. It seems like a good option, as my cousin Jill would be close enough by to visit frequently, but would not have to take on day-to-day care.

My cousin Jim has engaged a lawyer and a couple of social workers to help navigate everything. For some reason they seem to be pushing him (and hence, him pushing the rest of us), to put my uncle in skilled nursing care ($12k/m) and drain/hide their assets so that Medicaid/Medicare pays. The argument is that they’ll run out of money at a self-pay facility, that assisted living won’t take him, that he could end up aggressive and an elopement risk so we should put him in skilled nursing now, rather than start at assisted living and move him later because no facility will want him once he’s aggressive/an elopement risk.

Second component of my uncle going into skilled nursing is that my aunt would then have to live with her daughter, Jill. Jill has a full-time job, a husband with mobility issues, and is generally-speaking, not big on caretaking duties.

I don’t understand why my cousin is pushing the skilled-nursing route. Can government pensions be hidden from Medicare? Do assisted living facilities routinely reject/evict residents with dementia? I’ve spoken to them directly and they say that they care for patients through end of life, that they will do hospice care as needed. Uncle does not have complex medical needs. At a recent care meeting the rehab place said they felt he could be discharged to assisted living. He’s currently a high fall risk but they are impressed with the speed that he is rebuilding his mobility.

The family dynamics are a bit of a hot mess. My sibling and I are a step removed obviously, and just want a reasonably good outcome for my aunt and uncle. Sending him straight to skilled nursing and having my cousin Jill take care of my aunt seems like one of the least-desirable outcomes, especially when there’s an assisted living option near family that they could afford that would allow them to stay together. I just genuinely don’t get what he might be being told, or why.

[Anonymous]

Op here. Sorry, that’s a novel!

[Anonymous]

Even if a place has the capability to provide all levels of care, you have to have a payor source. Sounds like they have like 1.5 years at an assisted living level. That’s not a lot. The advice from the professionals is based on their experience with people who run out of money. They are trying to keep your family from getting to this point. Based on my experience as a social worker and my spouse’s experience in running elder care programs, I think the advice applied ears to be sound. Caveat is that I really don’t know your uncle’s condition and I don’t know the facility you’ve been looking at.

Since he’s currently in rehab, what are their thoughts?

[Anonymous]

Anonymous wrote:Even if a place has the capability to provide all levels of care, you have to have a payor source. Sounds like they have like 1.5 years at an assisted living level. That’s not a lot. The advice from the professionals is based on their experience with people who run out of money. They are trying to keep your family from getting to this point. Based on my experience as a social worker and my spouse’s experience in running elder care programs, I think the advice applied ears to be sound. Caveat is that I really don’t know your uncle’s condition and I don’t know the facility you’ve been looking at.

Since he’s currently in rehab, what are their thoughts?

Why do you say 1.5 years if their monthly income exceeds the cost?

[Anonymous]

Lots of places offer step level of care. Start in the door at assisted, add skilled care, then within same facility to dementia (secure ward). That way spouses have access to each other.

If they don't mind being separated, father could look for a veteran's care center. It offers transportation & schedules appts at local VA hospital for off site needs.

I would not suggest your cousin take on care for mother, unless she wants. She'll turn into a taxi service for both of them for appointments and visits with husband. Bringing him home for holidays and such too
.

[Anonymous]

Anonymous wrote:

Anonymous wrote:Even if a place has the capability to provide all levels of care, you have to have a payor source. Sounds like they have like 1.5 years at an assisted living level. That’s not a lot. The advice from the professionals is based on their experience with people who run out of money. They are trying to keep your family from getting to this point. Based on my experience as a social worker and my spouse’s experience in running elder care programs, I think the advice applied ears to be sound. Caveat is that I really don’t know your uncle’s condition and I don’t know the facility you’ve been looking at.

Since he’s currently in rehab, what are their thoughts?

Why do you say 1.5 years if their monthly income exceeds the cost?

Op here. This is my thinking. Their $9k income is unusual, and I have to think, combined with their assets, should allow them to self-pay for decent care rather than try to hide it and go into a Medicare/medicaid nursing home. When we started researching this we all assumed they were broke with maybe something like a $2k to $4k monthly income. The kids didn’t know how much the pensions were. He had many years in federal service and enough in their state to get pensions from both. I feel like that amount of income is a gamechanger, but he’s getting advice that it’s not.

[Anonymous]

I would hire some help for now if your aunt can still handle things. Most facilities are bad and he'd end up in a memory care unit and they aren't great. It would also be very expensive.

[Anonymous]

Anonymous wrote:I would hire some help for now if your aunt can still handle things. Most facilities are bad and he'd end up in a memory care unit and they aren't great. It would also be very expensive.

My aunt would want that, but my cousin would go apoplectic. He does not consider letting them remain in the location they are to be an option at all. I really thought we had found a good solution when we found the assisted living place near my other cousin, as it would allow my aunt and uncle to be together, which is important to both of them, but they'd still be near family, and not near him. And it's much less expensive than what it would cost in the NY metro area for the same level of services.

[Anonymous]

Anonymous wrote:

Anonymous wrote:Even if a place has the capability to provide all levels of care, you have to have a payor source. Sounds like they have like 1.5 years at an assisted living level. That’s not a lot. The advice from the professionals is based on their experience with people who run out of money. They are trying to keep your family from getting to this point. Based on my experience as a social worker and my spouse’s experience in running elder care programs, I think the advice applied ears to be sound. Caveat is that I really don’t know your uncle’s condition and I don’t know the facility you’ve been looking at.

Since he’s currently in rehab, what are their thoughts?

Why do you say 1.5 years if their monthly income exceeds the cost?

They have $200k assets which is like 1.5 years in care. The $7500 likely is just basics and there will be living costs which will come from their monthly income to pay. And then there is the aunt that will need monthly income for her separate expenses. OP does not have the whole financial picture. And, again, if you want excellent care in the future, you have to invest now. Talk to the rehab discharge planner and listen to the professionals who are being given the whole picture and understand elder care.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I would hire some help for now if your aunt can still handle things. Most facilities are bad and he'd end up in a memory care unit and they aren't great. It would also be very expensive.

My aunt would want that, but my cousin would go apoplectic. He does not consider letting them remain in the location they are to be an option at all. I really thought we had found a good solution when we found the assisted living place near my other cousin, as it would allow my aunt and uncle to be together, which is important to both of them, but they'd still be near family, and not near him. And it's much less expensive than what it would cost in the NY metro area for the same level of services.

Why are you involved, OP?

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:I would hire some help for now if your aunt can still handle things. Most facilities are bad and he'd end up in a memory care unit and they aren't great. It would also be very expensive.

My aunt would want that, but my cousin would go apoplectic. He does not consider letting them remain in the location they are to be an option at all. I really thought we had found a good solution when we found the assisted living place near my other cousin, as it would allow my aunt and uncle to be together, which is important to both of them, but they'd still be near family, and not near him. And it's much less expensive than what it would cost in the NY metro area for the same level of services.

Why are you involved, OP?

It's hard to explain in a way that DCUM will understand. My mother died when I was a teenager, so my aunt is like a second mom to me and my sister. My aunt and uncle were very into an extreme type of christianity when my cousins were young and so my cousins do not have a good view of their childhood as a result, and are not especially close to or helpful with their parents. When my aunt was struggling to care for my uncle this past year, my cousins did not really offer much help and my aunt was simply overwhelmed. My sister helped out by ordering food for them so they would at least eat. My uncle went into the hospital for a UTI then rehab right around Christmas. While he was still in there, the rest of us met for a post-holiday gathering. My aunt took a car service out for an overnight visit. She developed a stomach bug and because of her frail condition became severely dehydrated and was hospitalized for several days. After she was released, my cousins planned to send my aunt directly to the one in the midwest with basically just the clothes on her back leaving my uncle alone hundreds of miles away in the rehab place. My aunt was beside herself, so my sister and I arranged to take her back to her home and stay with her until a better plan was in place. She has a strong community of friends helping out and we've also arranged for "companion care" for a few hours a day for her. So now we are working on a longer-term plan for their care.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:I would hire some help for now if your aunt can still handle things. Most facilities are bad and he'd end up in a memory care unit and they aren't great. It would also be very expensive.

My aunt would want that, but my cousin would go apoplectic. He does not consider letting them remain in the location they are to be an option at all. I really thought we had found a good solution when we found the assisted living place near my other cousin, as it would allow my aunt and uncle to be together, which is important to both of them, but they'd still be near family, and not near him. And it's much less expensive than what it would cost in the NY metro area for the same level of services.

Why are you involved, OP?

It's hard to explain in a way that DCUM will understand. My mother died when I was a teenager, so my aunt is like a second mom to me and my sister. My aunt and uncle were very into an extreme type of christianity when my cousins were young and so my cousins do not have a good view of their childhood as a result, and are not especially close to or helpful with their parents. When my aunt was struggling to care for my uncle this past year, my cousins did not really offer much help and my aunt was simply overwhelmed. My sister helped out by ordering food for them so they would at least eat. My uncle went into the hospital for a UTI then rehab right around Christmas. While he was still in there, the rest of us met for a post-holiday gathering. My aunt took a car service out for an overnight visit. She developed a stomach bug and because of her frail condition became severely dehydrated and was hospitalized for several days. After she was released, my cousins planned to send my aunt directly to the one in the midwest with basically just the clothes on her back leaving my uncle alone hundreds of miles away in the rehab place. My aunt was beside herself, so my sister and I arranged to take her back to her home and stay with her until a better plan was in place. She has a strong community of friends helping out and we've also arranged for "companion care" for a few hours a day for her. So now we are working on a longer-term plan for their care.

I’m sorry, I think you are way too involved. Let your cousins handle this.

[Anonymous]

Hiding assets is never a good idea. Aging in place often turns into a nightmare for person who lives closest and if they live long enough and decline it is totally unsustainable no matter how house is set up. You cannot force a sibling to take someone in. I would get council on aging and other experts involved to find a long term residential setting that fits their budget. Person who refuses needs to be willing to take them in.

[Anonymous]

Anonymous wrote:Hiding assets is never a good idea. Aging in place often turns into a nightmare for person who lives closest and if they live long enough and decline it is totally unsustainable no matter how house is set up. You cannot force a sibling to take someone in. I would get council on aging and other experts involved to find a long term residential setting that fits their budget. Person who refuses needs to be willing to take them in.

Yes, and honestly Medicaid/the state will find it and take it anyway. There’s a reason there’s an asset test for Medicaid. It is for indigent elderly, not for people who have assets they want to pass on to their children.

First, 9k is not much money. It’s at least 4k/month for independent living and AL goes up from there. That is just housing. If they need food, supplies, transportation, OOP medication, medical copay/coinsurance, clothing, non-covered medical services (e.g., PT where there’s no improvement expected) that’s all on top.

It does make sense if he can possibly qualify for IL/AL to get them both into a CCRC with a Medicaid-certified nursing home, and the sooner the better. They could stay together for a while and not need to reapply/get denied in the future when they need more care. What will happen then is that as they need higher levels of care, they can move up in intensity, draw down their assets, and qualify for Medicaid once they meet the income/asset tests. But you need a 1) CCRC that will move people along to higher levels of care without a waiting list; 2) an affiliated NH that takes Medicaid. AL/IL facilities with Medicaid NHs are also generally better equipped to handle behavioral problems (or at the very least are less likely to discharge someone for them).

[Anonymous]

Anonymous wrote:Hiding assets is never a good idea. Aging in place often turns into a nightmare for person who lives closest and if they live long enough and decline it is totally unsustainable no matter how house is set up. You cannot force a sibling to take someone in. I would get council on aging and other experts involved to find a long term residential setting that fits their budget. Person who refuses needs to be willing to take them in.

Yes, I'm not clear on what sort of advice he's getting on the income. From what I'm seeing there are trusts you can use to lower the income to a number that qualifies them for medicaid, but the money in the trust goes back to medicaid once they pass away. Looks like it's basically a tool for the "donut hole" patients who make too much to qualify, but not enough to pay for care. He started talking to lawyers before we had a handle on their income. We all assumed the monthly income was closer to maybe $3k or $4k, not $9k. And with the veteran's benefit, it's more like $11.5k per month.

My aunt wants to stay in NY, the kids are pushing hard for a move to the midwest and seem to be trying to make it happen with or without buy-in from my aunt. I found an assisted living place that will take them together in NY for just under $10k/m. I feel like there's a blowup coming.