Aging Answers - Episode 2: Tips for finding the right senior living facility with Connie Pizarro Transcript - Norris McLaughlin, P.A., Attorneys at Law

Episode 2: Tips for finding the right senior living facility with Connie Pizzaro

Transcript: Shana Siegel, Connie Pizarro

Welcome to Norris McLaughlin’s Aging Answers, a limited podcast series discussing the key topics of elder law planning and long-term care. I’m your host Shana Siegel, Practice Group leader of the Elder Law Group and member at Norris McLaughlin. In this episode, I’m joined by Senior Placement Specialist Connie Pizarro, to talk about tips for finding the right senior living facility. How are you, Connie?

I’m fine, Shana.

Terrific. So, you and I have worked together many times when I have clients who are looking for placement, but sometimes clients ask me whether they need to work with a placement specialist. They say, Well, you know, they can go on tours or look up information online. So why is it helpful to work with someone like you?

Well, most of the time when a family is looking to do placement, it’s never an easy task. They’re usually very, very stressed. It’s usually during a crisis. And most of the times it’s something that needs to happen within maybe two weeks or maybe even a month. When you work with a specialist, we can give you answers to questions that are not online. For example, if you go online, you’re not gonna find out pricing, any pricing that you find is never inclusive of care. They’ll just tell you the room rate and you think that’s the cost, and then you’re surprised. We have a lot of our seniors who have pets and they want to take those pets with them. You’re not gonna find out if the community allows pets or not online. So, when you work with a Senior Placement Specialist, we have all that information and we can recommend to you facilities or communities that fit your specific needs so we know if it’ll fit your budget, if it’s a great location for you, if it fits your medical needs and your social needs. Let’s say you are a very high-functioning senior. Most high-functioning seniors don’t wanna be around seniors who are not like them. They don’t wanna see a lot of wheelchairs. They’ll say to their kids, I don’t wanna be with these old people.

Yep.

And some of them, you know, they may be older than, but it appears as though they’re old because they’re high functioning. So, you wanna make sure you find the place that have other people who are high functioning, we can reduce the amount of time that you need to do your search drastically, and our services are free.

Oh, so your services are free. All right. Well, that’s great. You were telling me about a situation once where you were helping again, finding the right match with somebody who was a smoker. I didn’t know that some facilities will accept smokers, so you wanna talk a little bit about that?

Absolutely. That’s one of the little specialties. A lot of seniors, I’d say they’re 90, 85 years old. They’re a smoker. They’ve been smoking most of their lives. It’s unrealistic to think that all of a sudden now they’re gonna stop smoking. And so, there are some communities that allow smoking. Now, they do not allow smoking inside of the apartment, but they have designated smoking areas around the premises. Where you can go and you can congregate with other smokers and you can have a smoke and then come back inside.

When should a person consider looking at facility options?

Mm, That’s a good question. I am not a person that will insist upon someone placing their loved one or pushing them in that direction. I kind of utilized and stress the same strategy I utilized for my own mother-in-law, and that we cared for her at home for as long as we could. And that’s what I tell people. Care for your loved one at home for as long as you can. And then when you can’t Look for placement. So, what does, can’t look like? Can’t, could look like a person who has dementia and has become aggressive. By aggressive, I mean they’re hitting, kicking, spitting. They’re fighting you. Now, It’s not safe for you and it’s not safe for them. That’s a time you want to start to look for placement. Another thing that might be a challenge is that you as the caregiver, find yourself very stressed out. You can’t focus on your job. You’re trying to work, care for your loved one, raise children. You find yourself where you just can’t think, you are exhausted. That is a time to start looking for placement. One of the things too, when you look for placement. A lot of people think that it’s permanent, that it’s till death do us part, but it’s not. All the communities where you can place your loved one. It’s a month-to-month lease. You do sign a contract and that basically ties in your price for the year, but it doesn’t lock you in. You can give 30 days’ notice at any time, and you can leave. You could also do what they call a respite stay.

Right. I was just gonna mention that yeah.

Which is a temporary stay that sometimes you could use for while a caregiver goes on vacation. Or you can utilize it to try out the community to see if it’s a good fit. A lot of times families feel guilty when they’ve reached a point of considering placement, and I say to them, don’t feel guilty. You’re not a trained caregiver, you’re not a trained medical professional, and even if you are a doctor or a nurse, you’re not trained to care for someone 24/7. And sometimes that’s what our loved ones need, and we become impatient. When you have caregivers in a community, that person’s not there 24/7, they get a break and someone else comes on who’s fresh and can work with your loved one and take care of them and have the patience that’s needed. So, you can look at is it time for placement when you as the caregiver, are just totally fatigued you can’t take it anymore. The person that you’re caring for has become very aggressive and therefore you can’t handle it, because now it’s a danger for you and them.

Yeah, I’m glad you mentioned about the guilt. I see that all the time. But you know, a lot of family members, the senior will say, You know, I have to stay at home no matter what. But then often when they actually go into a facility. They’ll say, Why did I wait so long? Right.

You’re right. You’re right.

So, what do you think about that in terms of that consideration of how do we get people to be more open to the idea of a facility?

Well, one of the things is that I say go and tour a facility because a lot of our seniors have in their head a nursing home.

Absolutely, yep.

And most people are familiar with nursing homes, and they’re not so familiar with assisted living communities. Very different, very different model. And by going to visit the assisted living, they go, oh, this is not at all what I thought it was going to be. So, visiting them, doing a respite stay, are ways to get people to open their minds so that they can see it’s not that grim picture that they had in their head.

A lot of people that I speak to think that that’s fine for healthy seniors, but if their family member has a little bit of a memory issue, maybe some early cognitive impairment that then they need to be in a nursing home. Can you talk a little bit about memory care, how it’s different from traditional assisted living and where you might see it?

Sure, absolutely. Well, memory care is used when a person has a diagnosis of some form of dementia. So, Alzheimer’s is what most people are familiar with that is a form of dementia. But you can have a form of dementia and still live in the assisted living community. But if you are exhibiting exit-seeking behaviors, meaning that you’re trying to leave, then you need a memory care community. Because the memory care community is secured in assisted living, you can come and go as you please in the memory care you cannot. There’s usually a code that you need in order to get in and out of the area. Now with a nursing home, some people go to a nursing home because as I said before, that’s what they know, and nursing homes end up getting overly utilized. But there are about five or six things that indicate a person must be in a nursing home. One of them is if they have a trach or if the person needs to be on a ventilator if they need to have a feeding tube. And if the person is taking some type of antibiotics intravenously, or if they have a very bad wound that needs wound care, or if the person cannot turn themselves over in the bed, then they need a nursing home.

Sure.

So, if a person cannot walk or needs help bathing and dressing, and going to the bathroom. They can go to an assisted living. A lot of people think assisted living is only for seniors that need a little bit of help,

Right.

They’re different models of assisted living. They have more social models, and then they have the very medical model, and then they have those in between. When you work with a specialist and meeting with the family, we get to see what model works best and fits best for your loved one. And those are the ones that we would recommend to you that best are suited for them. So, if they can fit in more into a social model, we are not gonna take you to a medical model community. But if they need more of a medical model community, that’s where we’re gonna go, and not the social model. People sometimes walk into an assisted living, and they are impressed with the glitz and glam. They see a beautiful chandelier and they see this wonderful decorative place and the beautiful tablecloths, linen tablecloths, and they go, oh my goodness. This is where I wanna place my mom or dad, don’t be fooled by that.

Absolutely. Yep.

It’s the care. At the end of the day, it is the care. Now being in a nice pretty place may make you feel better.

Mm-hmm. 

about placing your loved one.

It can be important.

So that you can, when your friends or someone comes to visit them, they say, Okay, at least she’s in a nice place. So yes, but you have to balance that. Don’t go for all glitz and glam. Make sure that you’re looking at the care.

Well, it’s also a personality match. I mean, I know that there are some people who would feel very uncomfortable in a very, you know ritzy place. But other people, that’s what they’re looking for.

Mm-hmm.

So that’s where you get to meet people and you can really get a good sense of where they might fit in personality-wise.

You’re absolutely right because some people say, oh no, I don’t wanna be there. Those people are Hoity Toity you know. Or you go someplace else, and they say, oh no, these people are too country. So, you, have to know the person’s personality, what they like to do. Also, you have people who were, let’s say, professors in a university and they are not bingo players, but they prefer activities like lectures.

Sure.

Or going to the theater. So, you wanna look at the activities that the place has too, to make sure it’s something that’s going to engage them.

Yeah, no, absolutely. That’s important. I would imagine since you’re in facilities all the time, you have a good sense of that care piece, right? You would have a good sense of maybe how long that director of Nursing has been there or whatever. So that can be a real help. Otherwise, people are just kind of going by reputation.

Absolutely. So, because we are local, we go into the communities. We will not recommend a place that we haven’t gone into ourselves. So yes, we know the management and when we see a place where the management is turning over, it’s like, I call today and I have one person, and then in two weeks I call, that person is gone and someone else is there. I call two weeks later and someone else is there. That’s my antennas are up.

Yeah, right.

Something is wrong. And I’m gonna find out what is going on that the staff is turning around. If there’s usually a problem with staff turnover, then the care is not good. The care is not good because that means the staff is leaving, they’re unhappy. If they’re unhappy, it’s very hard for them to do a good job.

Yeah, no, that makes sense. What about people always ask me, can they negotiate? So, if they’re given a quote, is that something that you get involved with helping negotiate rates and increases and things like that?

Funny you should ask that question Shana, I do. Sometimes there are specials that are advertised and then sometimes they’re unadvertised specials. And it really depends upon when you’re looking, so when you’re looking at the end of the year. December, last two weeks of December, you can get some good deals. So, people say, why does it depend upon the time of the year? Sometimes assisted living placement is almost like selling cars. They have to move them off the lot. They need heads in beds. And so if the salesperson’s gonna get a bonus, if the end of the year, if the building is full, well, if giving you a thousand dollars off is going to fill up that building, then guess what? You’re gonna get that thousand dollars off. There are also times too, where the communities will work a deal because these people are really nice. And even though it is a business, they do what they can to help the family. Most communities will require a 24-month spend down, meaning that you have enough money to pay for at least two years before you would apply for Medicaid. Some families don’t have that. Letting the community know going in, that you only have 20 months. Some of them will negotiate that and say, okay we’ll accept 20 months and then allow you to apply for Medicaid and we’ll accept it. So sometimes the negotiation is on your spend down, and sometimes the negotiation is on the price point. When we negotiate the price point, it’s on the room.

Right.

That is where we can do some negotiation. The room meaning the apartment, the care is what the care is. We cannot negotiate that away. So, we can negotiate sometimes the spend down the cost of the apartment and most places have what’s called a community fee or move-in fee, and sometimes we are able to negotiate it. Now notice each time I’ve said sometimes because there are times when there’s no flexibility. When we have a brand-new community, there is little to no flexibility there.

Excellent.

Okay. But when a community has a census problem, you know, it’s not enough residents in there and they have a well-established place, they will negotiate because they want to get that building filled up. So, in working with a specialist, we know which buildings have census issues.

Right. That could make it work, yeah.

And we will make it work for you. So, you may think, I don’t have enough. We can take what you have and make it stretch. Now there are some things that’s like impossible. If you have $500 a month, I can’t help you.

So, while we’re talking about cost, I wanna come back around to Medicaid, but we’re talking about cost. Can you give us kind of an idea of the range? It’s a huge range I know.

It is, if you’re looking at someone who needs memory care, you are gonna be looking to spend between eight and $10,000 a month for memory care. When I say that, I’m thinking of a person who’s in a studio apartment. They need help with their medication management, and they will need help bathing and dressing, and there may be some incontinence that’s between eight and $10,000 a month. When we are looking at assisted living meaning that the person is not exit seeking, they don’t need the secure unit. If they’re looking at a studio apartment, which is basically one large room. We are talking anywhere between 65 and $7,500 a month. The more care you need, the more the cost goes up. When the care is where they have to physically touch you such as bathing you and dressing you it’s more expensive.

Okay, that makes sense. Are there situations where someone can come and bring an aid in? I’ve kind of seen that and sometimes that can be really a nice lifestyle for people because they can be in the more independent, but then they might have an aid come in from the outside, either live in or you know, on some occasion. You know, just kind of hourly.

Yes, you can do that. You can be in a facility and not have any care charges by the facility and bringing your own aid, and that aid is caring for you. And then you’re paying that aid separately from paying the community. And then you basically have two bills because with the community, you’re paying for your room and board, which would include your meals and housekeeping. Sometimes it includes laundry and cable. Sometimes laundry and cable are extra fees, but you can do that and it might allow you to be in a different type of apartment. So, a lot of the independent apartments have a stove, have a full kitchen. But when you’re in an assisted living apartment, you have a kitchenette, which means no stove. Some people still wanna have that kitchen, but they need more help. And so in order to have that kitchen, they’d go into an independent apartment and bring in the help, and then they get the help and they have their kitchen.

So, let’s talk about Medicaid, because I know a lot of times people come to me and they say, Oh, well, the facility told me I could convert to Medicaid after 20 months or 24 months. And now all of a sudden they’re saying that. So how do you help with, first of all, trying to avoid that, giving consumers the information about what that means and the spend down, but also what’s that experience like? How does that work?

Well, it’s, it’s a little tricky to try to avoid it because the way it works is the community based upon when it was built is mandated to have about 10% of their beds to be Medicaid. They reserve those beds for people who’ve already been in their community and have paid down the 24 months. So, let’s say the community has a hundred residents, 10% of a hundred is 10. That means they have 10 beds that can be Medicaid. Now along comes your loved one, and you would make number 11. The community could say, Okay, we’ll go over the mandate and have 11. Or they could say, I’m sorry, we have what we are mandated to have. You now have to make other arrangements and those other arrangements could look like finding another community that will take Medicaid or the family paying until a bed becomes available. So how do we avoid that? There are some communities, that on a regular basis go over their mandated 10%. We know who they are, so the ones who will go over their mandated 10%, you have a good chance that when it’s your loved one’s turn to go into Medicaid, that they’ll give him or her a bed. Those who strictly stick to their 10% you basically rolling the dice.

Right. But at least you’re there to be able to provide that information because so many times people go in without a placement specialist, they’re given a sales job. They don’t really understand that isn’t a guarantee, that after spend down, that’s it, right? Spend downs.

It is not a guarantee. Now, there are some, and I wanna say something. Sometimes I’m seeing community and facility. Those two words are, I’m using them interchangeably. When I say facility or community, some almost might say, Oh, what’s the facility, What’s the community? But sometimes there are some communities that have more Medicaid beds than others.

Sure.

And those, you know, you have a really good shot of never having to leave because they do not adhere to the 10%. And as soon as a person goes on Medicaid, they will make a Medicaid bed for you. And yes, we know those places and working with us helps and we can let the family know. And sometimes it’s a deal breaker.

Sure.

You know,

cause you, what else are you gonna do? You don’t have that extra money to pay for sure.

And no one knows how long someone’s going to live. And then there are some communities that don’t take Medicaid at all.

Right. And I don’t think people know that either. So that’s another good reason, to work with someone with that kind of knowledge.

And that is how some people prematurely end up in nursing homes.

Right.

Because a nursing home will accept the Medicaid.

Right.

Not all, but most nursing homes will take direct Medicaid, and what I mean by direct Medicaid is that you’re coming in without any private funds. You’ve already been approved for Medicaid, and you have what’s called MLTSS that’s the type of Medicaid in place. They will accept you.

Mm-hmm.

So sometimes people end up in a nursing home because of finances.

Yeah. There are assisted livings that have nursing homes along on the same campus. That can be a good situation also for somebody who absolutely has to have a guarantee, because they could always, if there’s no room in the assisted living, they could always go over to the nursing home side. Right?

Well, people like to think that it’s just that easy, but some of them will still say, Okay, how much money you have?

Mm-hmm.

Even though you’ve spent the money.

Mm-hmm. 

On their assisted living side. They’re two different branches within that same company.

Right. You’d have to have that conversation.

So, you have to have that conversation and have that understanding too. And sometimes people see the nursing home and they don’t realize that it’s only for subacute care and not long-term care.

Sure.

So, they think. Oh, my loved one can go there. But it’s only for subacute, which is for physical therapy and rehab and occupational therapy. It’s not for long-term care.

Mm. Okay. Let’s talk about subacute a little bit. I wanna talk about finances and how people afford it. We’ve talked about that a little bit, but if you have somebody who’s very limited finances, and then they have a fall, they go into rehab. Is that one way to kind of, you know, potentially get into a facility if you don’t necessarily have a spin down?

That is a way, and sometimes when I’m speaking with families and they say, just don’t know how we were gonna do this. And I say, I hate to tell you this, but the next time your loved one falls, don’t pick them up. Call the ambulance, and when you call the ambulance the ambulance is gonna take their loved one to the hospital, and from hospital they’ll go to the subacute, and then from the subacute, they could end up in long-term care. Because once you get into the system, they have to do something with you.

Right.

It’s getting into the system. So, it depends on which door you come in. And when you come in through the hospital door and then go to the subacute door, then you can end up in the long-term care door. And they will help you to get your loved one onto Medicaid because it’s in their best interest, because if not, you’re basically sitting there without a payer source, so they will work to get you on Medicaid. So at least Medicaid is paying them for your stay at their facility.

That two-year spin down, that’s another reason that, you know, I really urge people to think about assisted living. Even if they’re in that, well, we wanna take care of mom at home for as long as we can, because very often then they run out of money and then they can’t go into assisted living.

Mm-hmm.

So, you know, I guess that’s another place where if people were kind of, consulting you, even if they weren’t quite ready to make a move, then that’s a conversation that you could have with them.

Yes, it is. And there’s some people who come to me early on and say, hey, how can I do this? And it says, well what you can do is make sure you have about $200,000. If you have about $200,000, we should be able to negotiate somewhere that you could go that’s decent and meet that two-year spend down or negotiate you to a 20-month spend down. It’s hard when you spent the money and your loved one does not have a good monthly income because the monthly income comes into consideration too.

Oh, absolutely.

Because that can be utilized toward the cost of being in the community. So if you wanna stay at home and you’re utilizing your personal funds, just make sure you save for a rainy day. When it’s raining, and you need to go to that community because you can no longer be cared for at home.

What about when people have a house? They don’t have $200,000 in cash, but they have a house. How does that work?

So, if you have a house, your house is considered an asset and it can work a couple of ways. One, if the senior who owns the house is willing to, they can sell the house and then use the proceeds of the home for their care. If we have, let’s say a couple and one needs care and one does not, then you can get the, and there’s no liquid asset. The one that needs the care could go into Medicaid sooner because the well spouse is living in the house and then the house doesn’t count as an asset, and they won’t make you sell the house. But if that well spouse passes away, then you will have to sell the house. So, your house can be used as an asset. There are some places that will admit you, accept you into the assisted living with a promissory note if you have a house. If you have no cash.

Right.

There are companies that will give you a bridge loan based upon the fact that you have a house. So, now the thing to keep in mind when I say have a this is a house that is not fully mortgaged.

Sure.

Because if it is fully mortgaged when you sell it, you’re not getting any money.

Right.

And you also have to think about reverse mortgages too, because a lot of seniors get reverse mortgages. Those have to be paid off before you can consider what you’re going to get from that house.

Right, right, and that would be actually a situation where they’d wanna talk to somebody like me because we’d wanna take a look at that reverse mortgage, look at the promissory note, make some planning for the spouse. So those would all be situations where, You know, you and I would work together.

Absolutely.

You confirmed to me for those, For those pieces. So the last thing I wanted to talk to you about was veteran’s benefits.

Mm.

So, a lot of times people don’t know about veterans’ benefits, and this is something certainly I can help with, but can you talk a little bit about how clients will use that as a potential way to pay for care?

I’m really glad you asked about that, and hopefully there’s some veterans that are gonna be listening to this because that is one of the most underutilized benefits.

Absolutely.

Is the veteran aid in attendance pension, and that is not only for the veteran, but it’s also for the surviving spouse or for the veteran and the spouse while the veteran is alive. So, depending upon whether it’s just the veteran, the veteran, and the spouse, or the surviving spouse determines how much money they would receive. But if they qualify, and part of the qualifications is that that veteran had to serve during wartime. Now, it doesn’t mean they had to be on the front line. They could be anywhere. They just had to have active duty. During wartime and that they will have a discharge that’s anything other than dishonorable.

Right.

And then they will look at your finances. Now, once you, it takes about three months once you submit the application to start receiving funds if you qualify. But the great thing about it is from the moment you submit that application if you qualify that first check goes back to when you submitted that application. So, your first check is a big check, and then you get a monthly check after that. Those funds can be used for your care if you have someone coming in your home or if you go into an assisted living and you can now utilize those funds. The good thing about it is those are funds you can use anywhere you want to, at any place you want to. So sometimes people say, Well, I’m gonna go to the veterans administration and they’re gonna provide my care, and they can. But now you don’t really have a choice. It’s the veteran employees and who they’ve decided is going to care for you. When you have the Veteran Aid and attendance pension and you’re receiving those funds, you can hire an aid from any agency you want and come in and then pay with that money.

Right, or choose any facility.

Or choose any facility.

And I find a lot of times, you know, between, an individual social security, maybe they have a small pension. And then when you add that veterans, that can really cover the bulk of care. And so, for somebody who doesn’t have a lot of liquid assets that can meet, really be the difference and allow them to be able to be there.

It can, and I wanted to mention since you mentioned veterans. There are a lot of communities that offer veterans discounts and people don’t know about it.

Yeah.

Because it’s not widely advertised. But when you go there, if you are a veteran, you can get like a seven-and-a-half percent lifetime discount. That can be the difference between you being there or not. Or making a two-year spend down or not. So, there are places that will offer, you know, veteran discounts and that’s good to know.

Great, well thank you so much for spending some time with us today, Connie.

Absolutely. It’s always good times spent with you, Shana, you’re one of my favorite people. Thank you.

This has been Norris McLaughlin’s Aging Answers a limited podcast series discussing the important topics revolving around elder law planning, and long-term care. I wanna thank again my guest, Connie Pizarro, and you the listener for being a part of the conversation. Be sure to tune in next time for a brand-new episode. If you’d like to learn more about our work, please email me at aginganswers@norris law.com.