How do you find a reasonable ALF for elder when they are on a set fixed income with little to no assets?

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We live in PA and are having a very difficult time with this. We have been looking for the past 6 months and keep coming up with one road block after another. We reached the point that she can no longer stay with us since she is always nasty to the grandchildren to the point where they hate to even ask their friends to come over to their house and when she isn't nasty to them she is nasty to us. I sort of get the previous post about entitlement and while I sort of get it she is just way too demanding. Of course she is of no help since she doesn't feel the need to leave our home but it is reaching the point where either she goes or my hubby goes!!

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I don't no how it works in you state and county, but I would start with calling your county's human services department and asking for a needs assessment for Mother. Here the intake worker comes out and asks a lot of questions. He or she will interview your mother but it is important for you to be present, to help ensure objective truth. (My mother kept insisting, for example, that she didn't need help keeping her apartment clean, setting up her medicines, etc. etc. Not true.)

The intake person should know about resources in the community, not just county programs, and can explain options and what public funds, if any, might be available to help defray costs. She or he might suggest applying for Medicaid, for example. Might your mother qualify for any VA benefits?

Also make it crystal clear that Mother cannot continue to stay with you -- that you have to be responsible parents and put your children's welfare first.

Good luck ... and keep us posted.
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An ALF does not take "nasty" residents. First you need to have the MD prescribe an anxiolytic or antidepressant medication. If you can do this she may mellow out right where she is.
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Does she have anything that she really needs help with? For example, does she need help administering her medication? Often dementia makes it impossible for someone to handle this even with reminders. Does she need help with bathing, dressing, walking, etc. In my state, if the doctor will sign off on things she needs, but can't get at home, she may qualify for financial assistance for an Assisted Living facility, assuming her income and assets are not too much.

In that case, it doesn't matter how much the facility charges, if they accept residents that receive that public assistance, they have to accept her amount of social security, minus a monthly set amount for her maintenance, along with the amount the state or medicaid supplements. (You might ignore those who are private pay only.) I'm sure a person in your county who handles these type of cases could explain it to you.

I would just make sure you have a very accurate account of her medical, mental and physical needs so they know she needs assistance with daily living. If she doesn't need help, but just has no where to live, I'm not sure what the options might be.
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I don't really know where to begin. My mother has lived with us for over a year and although she has severe memory problems, she thinks she is fine, too. I would recommend some of the same advice already given to you. The first piece is have her see a geriatric specialist as they are well-equipped to understand your mother's needs, offer medications, advice to you, etc. My mother goes minimally every 3 months. She also had a baseline pychiatric review to measure her cognitive ability so we better understand her present functioning ability, memory loss, etc. My other siblings do not live near me, but I have learned to ask. My sister has taken my mother for a week (a few times now) and I have asked each of my 3 brothers to come to my house for a few days so my husband and/or my family could attend needed functions, etc. I also set up with a senior helper service in case we need someone to come into the home for any given time (should my husband and I need or want to go away for any length of time... something planned like a party or dinner or a movie... or something not planned like an emergency, etc.) I looked online for the nearest place I could find, and called them. They came for an interview and I filled out all of the paperwork, etc. and gave a deposit, which I get back if my mother does not receive any services thus far. This is a back-up plan just in case. As it is now, my husband or I are always home with my mother as she is getting progressively worse. I have visited 6 facilites in the area to find one when my mother no longer can live with us. I have decided to go to the smaller memory care unit even though it is 2 times as more expensive as others;my mother is all registered and we paid a deposit to hold the cost for the future when she goes there. My mother did wander once when we were at the cottage this summer... and after 45 minutes of looking for her on a hot day late in the afternoon... with 40 acres of treed land and 2 lakes surrounding us... I called the police and the DNR...they organized a search party of 20 people and 2 dogs and we found her... So I know what you are talking about... my mother is generally not kind to anyone and it is really hard to see her being so negative and so forgetful... etc. My mother (fortunately) is a widow of a veteran (my father) so I have processed the paperwork for her to receive some funds for homecare. It would be advantageous for you to keep checking out facilities... and set everything up. And like I mentioned earlier, don't be afraid to ask for help. I wish you well. God Bless!
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What was her behavior like before you moved her in? Get on the phone and start calling every social service your state has to offer.Look on the computer for any govt.agencies in your state and start calling. I feel your pain.
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If she is oblivious to everything around her on some days, I would be concerned. Do you or someone have Durable Power of Attorney and Health Care POA? If not, it's going to be difficult to do much with her or for her. I would see about getting it ASAP and before she is diagnosed with dementia.

Once you have that, I would see about getting her diagnosed. It's common for people with dementia or age related illnesses to resist seeing a doctor. They also may get nasty and act mean. That is very common. My cousin did the same thing. Eventually, they become unable to do much for themselves, so the meanness isn't as great. They become more like little children who are lost and in need of attention.

So, seeing a doctor is something that has to be done, so I would read on this site ways to get it done. Some people say the insurance company is requiring a routine checkup or vaccination review, or that you are going and need moral support. Anything to get them in the door. They may never agree if you tell her why you think she should really go.

When I took my cousin, I wrote a detailed narrative giving specific concerns and things she did, when her behavior started, etc. I took it to the doctor's office in advance so she would know what she was dealing with when we arrived. It helped a lot. The doctor did the physical exam and being very friendly asked her mental evaluation questions afterwards She could tell my cousin had significant dementia, along with her physical disability and immediately recommended to my cousin that she enter Assisted Living as she was not able to care for herself.

This may be a chance for you to stress to her that she deserves to be somewhere where she can have social activities, meals provided, transportation to dr. appointments and shops, laundry is done, etc. She may be happier with people who she can relate to.

Of course, you have to be prepared that your mom passes the evaluation and her mental status is not severe enough for the doctor to see. In the case, the Dr. may have suggestions.

If it is dementia, you aren't likely to be able to reason with her. Most dementia patients no longer have that ability. Good luck.
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have you considered a NH instead of AL? For my mom, she moved from IL to a NH and totally bypassed the AL stage. My take on this is that if they live long enough that they will eventually be at the phase of needing both a NH & the ability for Medicaid to pay for NH. Yes there are AL that take Medicaid as those AL participate in Medicaid diversion funding but by & large AL is all private pay which for most elders is not affordable over the long run. Plus with diversion funds there is always the risk that the AL facility will choose not to continue to participate or that the state will shift AL diversion monies to a "new" program like PACE. But if they live long enough, they will eventually need a higher level of care in a NH. In both the NH my mom has been in, there seems to be a group of residents who can still manage pretty well, the ladies who still dress for the day types, the ones who participate in activities or can do field trips but have the nursing care that they need. If any of the NH in your area seem to have residents like this, look to see if your mom could move into them as she would not need to move later on from AL.

Having them go from living at home to being qualified for needing skilled nursing care in a NH may require some things to be done by you all. Most NH admissions are post-rehab, the type of situation where they are discharged to rehab after a hospital stay; the rehab is within a NH; so once they stop "progressing" in rehab they move to being a purely NH resident. For these, they have the fat medical file to show the need for skilled nursing care; facility has been being paid by Medicare for the rehab period so they are all current for billing; and placing them as a "Medicaid Pending" resident can be done towards the wind-up of their rehab. But for those living at home or in IL, they may not have the medical file to clearly show the need for skilled nursing care. So how to do this?

For my mom, she was seen by a gerontologist who also was a medical director of a NH. All the geronotologists in this group (affiliated with health science center & medical school) are all medical directors of several NH. They know how the charts need to read to qualify. Just being old, incontinent, cognitive decline, etc just isn't enough to qualify medically. My mom had appointments every 4 -6 weeks and the one where she had a bad H&H and a 10% weight loss, she got the orders that she needed skilled nursing care. Moved from IL to NH 31 days later.

Now the IL mom was in, was a tiered facility that goes from IL to AL to NH and hospice. The medical director of the facility would not sign off on my mom needing skilled; she was not going to go into their NH, she was fine for their AL. Now since AL is almost always private pay, you cannot overlook the profit motive in this position. If mom moved into their private pay AL, then no 30 day notice required. But if she just moved out, then there would be unless a 30 day notice was done which I did. For tiered or AL/NH facilities, the AL is very much the profit center as they are private pay and can do all sorts of add on charges to the base rate.

But I digress, for my mom, the doc also changed the delivery of her medications; like move from Exelon pill to patch as requires more "skill" to do; have medications compounded, again more "skill" to do; have co-mobilities that show the need for skilled care & this could be a simple as baby aspirin for coronary condition. I don't know if all states do this, but for my mom in TX to go onto NH Medicaid they send out a site assessment team to review the medical need for skilled nursing care, so mom had to have within her file the documentation showing that. She had a glitch with her in-take as only the RX she brought in were in her file & she was initially denied Medicaid as not medically needed. The RX's that her MD called in were not put in her chart. The NH did the appeal (NH has to take the lead on this although I had to sign the appeal request; for Medicaid medical items done by facility but all financial items done by family ) and all was OK.

Perhaps see if there is a NH that could be a good fit for her. Good luck too.
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Another option, ask a local church (you'd be surprised) they might know some options or just stop by an Assisted Living community and ask to speak with their sales person. You might not be financially qualified but they should be able to help you and point you in the right direction.
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Heidi - first of all Medicaid does not "seize" assets; secondly I'd find out exactly what your state Medicaid program has for asset & income limits and to the penny on those. As far as the whole "setting $ to the side to save" if that is what the AL told you well that is incorrect as is the whole "seize" statement. BTW I'd suggest that if you move her to this AL, you have a very precise read of the admissions contract. Most AL is not paid by Medicaid but is private pay. Now some AL do take Medicaid under a Medicaid diversion program. You need to clearly find out if mom's bed is guaranteed to be cover by the diversion funding and what happens if the AL elects not to participate OR if the diversion funding shifts from AL's to another program (like PACE as some states are funding PACE with diversion funds). Also ask if the AL takes her as Medicaid from day 1 or if they want a time period of private pay or if placement if from a waiting list - lots of NH require 2 years or so of private pay before they will move them to a Medicaid bed; or the list is based filled with other residents names so it will likely be months or a year plus before your mom's name gets to the top. Really if they need Medicaid to pay the safest option is to get them into a NH from the get-go.

What Medicaid does require is that:
- the applicant spend down all their non exempt assets to 2K. 2K seems to be the asset max by & large. Any asset - like a whole life policy, CD's, rental property - that has a cash value must be cashed out or liquidated as a spend-down.
- the applicant must have their monthly income below whatever your state has as it's income ceiling. Like for my mom in TX, the income limit was $ 2,094.00. She was under at $ 1,900.00. They are required to pay all their monthly income to the NH as a required SOC/share of cost or their co-pay. They get to keep a small personal needs allowance. For my mom (like yours) it is $ 60.00. Most NH set this amount into a personal trust account for them @ the NH - this pays for things that Medicaid doesn't like beauty salon @ NH. If they get cable or have a phone, then each month, their trust has that amount taken out. If could be between cable & twice a month beauty shop, there goes $ 60. This is what Pam was referring to as no $. Family will have to underwrite all the expenses on the home & car and can do so but if you go this route, you need to be prepare to pay for all for the rest of mom's lifetime. If you do this for 8 months & then can't anymore, well it's all been for nothing as the state's claim or lein on the property will pre-empt anything you are owed. Now realize that the state is required to do estate recovery after mom dies on her exempt assets as once she's dead they are not exempt. This is called MERP and it is done via probate. If you keep the house, you really need to see how MERP runs in your state and if you will have exemptions, exclusions or hardship and can provide the level of documentation needed to offset MERP's claim or lien on the estate. You kinda need to get a feel for how probate runs in your state and if it's so that you can place you claim or lien before MERP. Like for TX, MERP is a Class 7 claim but house maintenance claims are Class 1, 2 or 3. If you have the ability (& sense of humor) to pay on all for the house & car for the rest of mom's lifetime and length of probate, then go for it. It's very much like having a 2nd or 3rd home but without the benefit of true ownership. Most folks can't afford a 2nd home. Most family place mom's house up for sale and use the proceeds from the sale as a spend-down. But if you have the deeper pockets and it seems to make sense to keep the house, then go for it.
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I think we're lucky that my mom doesn't have a house anymore. That's one less thing to worry about. It's already bad enough driving her around, trying to explain things to her, etc. Ahead of consulting nursing homes, I might have to apply for guardianship because my mom fights everything. She won't see a neurologist, gerontologist, cardiac specialist or anything. Just her doctor to get more pills. Then she says she's a burden to do more or it's too expensive, but it ends up costing her more money to end up in the hospital after a fall or whatever, and it costs us our sanity (and unpaid time off) to deal with everything surrounding that.
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