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This is the first time we've dealt with a disagreement between the two. Seems to me that the one who holds the purse strings is going to win. But the one who is making the health decisions is better placed to determine which facility is best suited to the person's needs, I think. But if the financial power of attorney won't release the funds.....


It boils down to a disagreement about how long the money needs to last. No Medicaid is involved. Anyone know how this will play out?

Alicew234, excellent, and thank you for updating us that the problem was solved by your husband negotiating a discount for the facility preferred by his sibling.  That's a great outcome for their parent as well as for both of them.

It does make me regret that in my prior replies I neglected to mention the possibility of getting a discount, which I was also able to do for my dad -- both where he lived and where I was going to have to move him (except that he died).  The discount where he lived was a permanent, flat $1,200 per month (about 17%) and a little higher percent at the not-yet-opened, thus empty, new place.  I'm sorry I forgot to mention the discount, as that might have saved your family members a few days of angst.  This industry is undergoing a lot of changes and I think the possibility of negotiating discounts may be relatively new -- one of my sisters and her husband owned and operated nursing homes before they retired and they had told me that discounted rates were not possible, so they were very surprised by the discount.
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Update: I thought I'd update this.
The financial POA negotiated a discount with the Health Care POA's preferred facility. Problem solved.

I did not know these fees can be negotiated! I thought that information might be helpful.
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Alicew234, thanks for clarifying the genesis of the family disagreement.  Obviously, as others have said, the parent's remaining years and future care needs are unknowns and, as you've said, the future of any care facility is also an unknown, which seems to be the norm in the caregiving industry.

My experience as my dad's guardian and conservator may or may not be helpful for your family.  In looking for a place for my dad for more than a year (with countless visits at varying hours and days of the week), I saw many facilities change their care practices and had their ratings change as either the cause or the effect of ownership and/or management changes.  One facility manager advised me that it isn't worth the effort of trying to make a plan for much longer than a year because there are too many changing variables negating the value of long-term plans.  Adding to the difficulty of finding the right place close enough for daily visits was that several of my siblings wanted our dad to move to a less expensive place rather than the best place (with the most training and highest staff to resident ratio), even though he was in stage 6/7 Alzheimer's, was 95 years old, and I had a 5-year financial plan to keep him at the best place.  (And I was told the best place had an endowment that could be used to help pay for his care if he ran out of assets after 5 years, but that wasn't in writing.)  Unfortunately, 14 months after moving him to the best place, I was told he needed hospice help to allow him to remain there, so I got him on hospice, but after a few months was told he still needed to relocate because hospice help was no longer sufficient.  Then, after completing another arduous facility search process, my dad died before I was able to move him.  All of this caused me to recall the words of the facility manager who had advised me that making plans for much longer than a year isn't worth the effort.

Again, best wishes for your family's decision-making process during this hard time.
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Alicew234 Mar 1, 2020
Oh my goodness, that's a lot of moves. What a lot of anxiety for your family!
I hope that as the dementia progresses in our loved one, the moves aren't too traumatic. There is an option for a place that has an endowment like you mention, but it has a three year wait! Thank you for sharing your experience. I will make sure I mention this experience if I am asked to weigh in.
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How long will the funds last is no set rule unless the elder has a wellspring of monies. Doubtful then Medicaid may be needed.
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The financial POA can't refuse to meet the principal's legitimately incurred liabilities purely on the grounds that he's having a snit about the choice of venue.

He can oppose the choice on the grounds that it is unaffordable for the principal and therefore not likely to be the best for her long-term interests. And he would probably have to sign the contract, wouldn't he. So he can certainly stall it, I suppose.

A disagreement about how long the money needs to last..? And which of you is the certified clairvoyant?

So, does that mean, that the health person believes that the parent is not long for this world and should live in luxury for less time; whereas the money person is anxious to husband resources to ensure that they will outlive the parent?

How about you both keep looking and find a compromise facility. Either that, or you find a friendly actuary to tell you which of you has the arithmetic in your corner.

By the way. The parent may be incompetent, that after all is why you are both making these decisions; but that doesn't mean you can't try to ascertain which facility s/he prefers. Is s/he well enough for a visit?
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Alicew234 Mar 1, 2020
That's it exactly. The HCPOA thinks we are on a 5 year plan and the Financial POA wants to make sure that she doesn't ever go into a Medicaid status. There have been problems in their area with nursing homes closing or turning into rehab only facilities and Medicaid patients being sent hours away from their families. Both have good intentions and are thinking of the patient's needs. The patient cannot participate in this discussion at all. Thanks for your input, as always!
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Impossible for anyone to figure out how long funds need to last. In the end if funds run out, you apply for Medicaid (state paid) bed.

Is there some reason the two people involved cannot get together to visit facilities and choose one geared toward care needed?
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If the funds are long longer available, the financial POA would need to help get Medicaid set up for the dependent. I suggest that person get all the forms and start completing them... since this is probably their concern. Meanwhile, the medical POA needs to do research to discover all reasonable care options: round the clock home health aides, assisted living, and full care residential facility. Once all the options are researched, the 2 POAs should meet.... involve a elder lawyer, social worker, or counsellor if needed to be the objective mediator.
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Alicew234, legally, the person with financial POA must pay all legitimate bills (unless the POA document contains unusual restrictions). Thus, the person with health care proxy will "win" this well-intentioned disagreement, absent further legal action (e.g. guardianship/conservatorship). It's good to recognize that, as you said, "...the one who is making the health decisions is better placed to determine which facility is best suited to the person's needs..." 

That said, the dependent person's long-term financial viability is a legitimate consideration (but not heirs' possible future inheritances), so obviously it would be ideal for your husband to reach an amicable agreement with the other person (the one with health care proxy, I presume). If your husband hasn't already thoroughly researched and visited the alternative residences (many times at different hours and days) and otherwise tried hard to understand why the more expensive residence is preferred by the close-by, hands-on person, then he should do that. Getting a complete understanding of why the more expensive residence was chosen by the other person might help resolve the disagreement.

You said Medicaid is not involved, but recognize the absence of Medicaid could be temporary because dementia care is costly and people suffering from it can live many years, sometimes decades, even in late-stage dementia. Also know that many of the best memory care facilities will only accept Medicaid's lower-than-market reimbursement rates after a resident has private paid for a certain number of months or years.

Best wishes in getting these family disagreements resolved. It is a hard time for all and sometimes difficult to stay focused on the person whose well-being is completely dependent on others.
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This is very difficult. VERY. Both sides have very valid points, and this is a conference that would take into account many things. All assets involved. Prognosis (doctor can help here given age and probable survival times). Work together the best you can. Huge arguments can result in someone seeking guardianship; this would completely freeze out the other person. Wishing you the very best of luck. Hoping you will update us.
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My understanding is that the HCP can choose wherever they want. However, if the financial POA feels the cost is unwise financially, they can refuse to pay the bills. In this case, a court battle may be in everyone's future.
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Alicew234 Mar 1, 2020
Oh, I hope not!!
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I’m both HCP and POA. Has made all the decision making easier than arguing with siblings who want their inheritance now instead of mom’s well being. Once the doctor filed the HCP paperwork with rehab then the POA also kicked in. Honestly, make it easier to have one person appointed before the dementia patient can’t make any decisions. After that it will turn into a legal battle.
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Alicew234 Mar 1, 2020
I admire you. The health care POA looks like a death by a thousand cuts. Doctors appointments, treatment decisions....I would far rather write checks!
Thank you for your comment.
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I think in most states it is health care POA who has the decision making authority.

Can you check with the lawyer who produced the documents?
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Alicew234 Feb 27, 2020
Hopefully it won't come to that. I'm on the sidelines. They both have good intent. These are hard decisions and everyone is doing their best. I just wondered.
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Financial POA handles the money part. Not sure if health care proxy makes the decision where the person goes. You handle her health wishes.

It comes down to the nicest, cheapest place I guess. Sorry, no help huh.
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I am my father's health care proxy and he has a state appointed Power of Attorney. I have the legal authority to choose where my father will reside. The POA handles all financial matters for my father.
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Legally, this decision is for the person with the financial POA to make. Ideally, the two agents would consult and pick a place together.
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