Caregiving

Family dynamics that hamper caregiving success

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A team is only as good as its members.  If the playbook isn’t carefully followed, success is unattainable.

The scenario for this article centers around care for Mom.  It doesn’t matter if Mom is still living at home and cared for primarily by one of her adult children OR Mom is living in a care facility receiving care for her day-to-day needs outside of the home.  Either way, the brothers and sisters of this caregiving team are in for the challenge of their lives.  What follows is a simple, yet complex, listing of destructive traits that could get in the way of the family’s caregiving goal.  All definitions are directly from the Oxford English Dictionary, 11th Edition, 2004.

  • EGO. n. a person’s sense of self-esteem or self-importance.  Brothers and sisters, please check your egos at the door.  The exercise of one’s ego is so self-involved that the input of others, most likely controlled by their own egos, clashes with an individual’s perspective.  Acknowledge that egos are front and center, but either check them at the door, or put them high up on a bookshelf to be retrieved at a more appropriate time, and work together for the common good, not one’s own good.
  • SELFISH(NESS). adj. concerned chiefly with one’s own personal profit or pleasure at the expense of consideration for others.  I’m seeing a trend here.  Ego and selfishness go hand-in-hand and truly have no place in a team dynamic.
  • COMPETITION. n. the activity or condition of competing against others.  A successful sports team does not compete against its own members – it saves that for its opponents.  Your brothers and sisters are your allies, not your opponents, so you will all benefit from considering each other as such.  You want the same thing – the best care experience for your mother – so your common goal will be more effectively reached when all of you play on and for the same team.
  • SENIOR(ITY). n. a person who is a specified number of years older than someone else.  Just because you’re older than your sister doesn’t mean your input is more valuable than hers.  Your younger siblings are just that – they’re younger, not stupid.  I know that sounds harsh but I’ve seen this time and again where siblings maintain the same perspective of their childhood sibling relationships and it becomes a barrier towards moving forward as adults.  Once you reach a certain adult age, those differences no longer exist.  It’s hard to break away from the age hierarchy paradigm, but break away you must.
  • SHARED RESPONSIBILITY.  You’ll rarely find a family that carries the caregiving burden equally.  Some members will do more than others, either by virtue of their proximity to Mom, and/or due to their abilities.  But a greater percentage of tasks does not necessarily equate to a greater percentage of input regarding Mom’s caregiving.  Arguably one could say, “You don’t care enough to help out so we don’t care about what you have to say.”  One could say that but doing so is counterproductive.

I list the above traits because they can be very destructive when complex issues of aging and caregiving come into play.  Imagine trying to come to a consensus of opinion regarding an appropriate level of care for Mom at any given time, or managing the financial dilemmas often inherent with the caregiving process; or the emotion-packed subject of end-of-life issues.  Respect for each others’ opinions will go a long way towards paving the road with fewer speed bumps.

A caveat:  I acknowledge that some family histories are far more complicated, and more dysfunctional, than others.  Because of the unhealthy years that many children have experienced growing up, far more is on the table when working with one’s siblings.  In those circumstances, a third-party unbiased counselor can be a valuable addition to the care team.

My question to you wonderful caregivers out there who have wrestled with this caregiving team challenge: how did you iron out the difficulties, or did you?

If you do not have any family members, please look at my article Solo Caregiving.

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Caregiving: The Ultimate Team Sport

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What’s a pitcher without a catcher?  A quarterback without a receiver?  A point guard without a center?  Individuals – that’s what they are.  They are not a team.  Caregiving should never be an individual effort because quite frankly, one person can not do it all.

Take a deep breath; think happy thoughts; and do your best.

Whether the primary caregiver actually does hands-on-care or is the primary “manager” of a loved one’s day-to-day life, that caregiver needs all the support he or she can get.  For the purposes of this article we’re going to assume that the loved one, Mom, lives in a long-term care (LTC) facility cared for by professionals.  As with every sports team, there is a General Manager of the team – responsible for the overall smooth running of the team, and then there are the individual team members without whom there would be no support whatsoever.  Let’s look at the responsibilities of each person on the team. GENERAL MANAGER: whether self-assigned or chosen, the GM is usually Mom’s primary contact/visitor.  He or she will also be the main point of contact with the staff at the LTC facility and as such, should definitely be on the “approved list” of people with whom the care staff can discuss every aspect of Mom’s care.  Getting on the approved list might involve one or both of the following:

  • Facility Care Plan/Residential Agreement.  Because of the restrictions resulting from the enactment of HIPAA anyone other than the actual patient/resident must be given permission to receive confidential information regarding another individual’s health condition.  There is usually a section on LTC facility agreements and/or care plans wherein a primary family member is listed and approved as the person who can have access to all confidential information regarding the resident’s/loved one’s care.  Similarly you’ll want to be on the approved list for Mom’s doctors so you’re able to freely communicate with medical personnel regarding any ongoing health concerns.  If Mom is able, she will need to sign the necessary documents that indicate her decision to allow that confidential health information be shared with you.
  • Power of Attorney for Health Care.  This legal document allows someone, usually a family member, to speak on behalf of a loved one who may not be able to do so on her own.  I’m not a lawyer so I’m not offering any advice regarding this document but the attached link will give you a thumbnail sketch addressing when the appropriateness of such a document comes into play.

Now back to the General Manager’s duties: the GM needs to play on the strengths of each team member.

Alzheimer’s Walking Team: myself, my hubby and my brother

Hold a family meeting – even involving those living out of town via telephone or skype – to discuss the strengths that each possesses and ones’ willingness to exercise those strengths.  Once those team members’ tasks have been assigned or volunteered for, it’s up to the General Manager to provide oversight to assure each task is being accomplished, and to discern if any team member needs assistance completing tasks.  As you can see, taking on the role of General Manager carries a lot of responsibility and quite frankly, anyone who assumes this role needs to be good and ready to carry a heavy load.  The good news, however, is that the GM is not alone – there are additional members of the team.

FINANCE MANAGER.  Your older sister is a finance whiz who’s very comfortable crunching numbers.  She gets to take over the day-to-day system of bill paying, investment monitoring, and the like.  You might even arrange for all mail to go to this sister’s home so that she has immediate access to timely financial information.

INSURANCE MANAGER.  One of your brothers who works in the health insurance industry understands the ins and outs of private insurance and as it relates to Medicare.  Congratulations, his strength will contribute greatly to the whole.  But you don’t have to work for an insurance company to excel at this task.  Some of us – yes, I’m one of them – really “gets it” when it comes to reconciling Explanations of Benefits (EOB) documents from health insurance companies.  The Insurance Manager will work hand in hand with the Finance Manager to assure that any balances due a particular medical professional or institution is paid.  This can really get sticky when attempting to make sure that everyone who is responsible for paying a part of the medical service – private insurance companies and Medicare – have paid their part prior to sending out a check for the balance.  But effective Finance & Insurance Managers can successfully get the job done.

TRANSPORTATION MANAGER.Your other sister has recently retired, or has a very flexible work schedule, and has the ability to take Mom to the various doctor appointments that occur each month.  Terrific.

Anyone need a cab?

That sister will be doing the running around with Mom and can make sure each appointment is scheduled, attended, and summarized.  Since she’s going to these appointments with Mom, she can sit in on the appointment and bring up issues about which the family has concerns; she can take notes on what transpires during the doctor visit; then she can report the medical updates to the family so everyone is on the same page every step of the way.  This sister will also need to be on the approved HIPAA document that the physician’s office requires in order for her to communicate and interact in such a way as to be on top of Mom’s ongoing health care.

FAMILY DYNAMICS THAT GET IN THE WAY OF EFFECTIVE MANAGING.  Let’s face it, not every family gets along well enough to avoid the bumps in the caregiving road.  If family dynamics were strained to begin with, you can certainly expect those dynamics to be heightened in stressful situations – and caring for Mom is certainly one of them.  My article “Family dynamics that hamper caregiving success,” addresses family dysfunction and offers advice on how to lessen its impact on your caregiving team.

A team’s success is attainable – but each member has to dedicate themselves to the task at hand  for that to happen.

Selecting a Senior housing community – easy for some, not for the rest of us.

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Even if you think you will never move into a Senior housing facility you should at least do some research so that in an emergent situation, you’ll be well-enough informed to start moving forward with a plan.  This is not the time to be making snap decisions.  Your well-being, or that of a loved one, deserves more attention than that.  Making an advanced decision, and thinking ahead regarding future living circumstances, will afford you the opportunity to make a decision that you want, not what others have decided for you.  What follows may be too basic for those who are already familiar with Senior housing options, but for many, this blog entry will serve as a first step primer towards getting ones’ feet wet.

INDEPENDENT LIVING – sometimes called After 55 Housing.

These complexes are designed for adults who want an independent lifestyle in which they can relinquish yardwork and house maintenance tasks to someone else.  Now you’re talking!  If the independent complex has a common dining room they will either provide meals in a restaurant setting (ordering off the menu) and/or buffet-style selections.  Depending upon the particular independent community you’re considering, other amenities such as housekeeping, transportation and on and off-site activities may also be available to its residents.  It’s important to know that although these communities may offer wellness programs in which you can become involved, e.g. exercise or nutrition classes, there are typically no care options offered unless the community is licensed as a residential care facility for the elderly.

ASSISTED LIVING.

This category of facility promotes independence while also offering personal assistance for specific care needs such as bathing & toileting, dressing, walking assistance, and/or medication assistance.  These needs are called Activities of Daily Living (ADLs).  Assisted living communities may be a stand-alone building or an extension of an independent residential community.  If an assisted living facility is also licensed to provide dementia/memory care, a resident could readily move from general assisted living care to dementia care in the same facility.

GROUP HOME/ADULT FAMILY HOME (AFH)

An Adult Family Home is typically a single family home with a State-imposed maximum allowable number of residents – in Washington State, this number is six.  These residences offer assistance with ADLs.  This is a desirable option for those looking for a residential situation that is more home-like than facility-like.  Many adult family homes also provide specialized care for those with dementia.

ALZHEIMER’S/DEMENTIA CARE.

These facilities provide all the expected assisted living services plus specialized services that meet the needs of the memory impaired adult and is usually always a secured unit to protect a resident who might be a wandering risk.  By secured, I mean that in order to exit to a public hallway or common area, such as a lobby, a person would need to punch a code into a keypad that one with dementia would most likely not be able to navigate.  A secure dementia care unit can exist as a stand-alone building or can be found within an assisted living complex, a nursing home complex, or a continuing care retirement community.

NURSING HOME/SKILLED NURSING FACILITY/REHABILITATION FACILITY.

This facility provides 24-hour medical care on a short-term or long-term basis.  Additionally, rehabilitation programs are offered.  If someone living in an assisted living community has orthopedic surgery, he would probably undergo a certain amount of rehabilitation at a nursing home and then return to his previous residential situation.  A nursing home can sometimes become a permanent care option for those requiring a higher level of care.  Since assisted living and dementia care facilities have certain limits on the level of care they can provide, a nursing home may be necessary in order to receive the advanced care needed by a resident.

CONTINUING CARE RETIREMENT COMMUNITY (CCRC)

A CCRC has all levels of Senior living – therefore it’s usually quite expensive: independent, assisted, dementia care and nursing home care.  The benefit of a Continuing Care Retirement Community is that you can age in place regardless of your growing medical or cognitive needs.  This type of community exists on a larger campus that truly does provide an entire spectrum of care.  You can move into a CCRC totally independent – without any care needs whatsoever – and gradually move through the campus property without leaving your friends and without greatly changing your surroundings, thus assuring a continuum of experience for many years to come.

Housing for Seniors is addressed in the attached Federal Seniors Resource website that provides an extensive list of pertinent resources.  I hope you’ll find it helpful – not just for senior housing information but for many topics about which you may have an interest.

My wonderful dad and I taking a stroll in 2006.

What challenges have you faced – or what concerns do you have about either your future or the future of a loved one who might need Senior housing?  Let’s talk about it – let us hope that what each of us contributes benefits those tuning into this blog.

Navigating the maze of long-term care housing choices.

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The most comfortable decisions you can make in life are well-informed ones.  Whether you are choosing a vehicle, the vacation of a lifetime, or a potential residence, doing so is made easier when you’re armed with essential information.  Oftentimes when inundated with too many choices, we exclaim that we would rather have fewer options from which to choose.  “Give me two choices and I’ll be able to decide – six or more? Forgetaboutit!”  There is one time, however, when you will welcome a diversity of options: selecting appropriate care in your Senior years.

Identifying the person in need of care.

Gazebo at dementia unit where my father lived.

This quest upon which you are embarking may be your own personal quest.  You know staying in your current home might prove dangerous to you – and therefore inadvisable – in the years to come.  Or perhaps you just want to retire from doing house repairs and weekend yard work –and who doesn’t?  Whatever the reason, you’re considering your options for when you might be less able to take care of your daily needs.

Another scenario is that your spouse, parent or sibling is in need of some sort of long-term care resultant from a debilitating condition such as cognitive decline, mobility restrictions and/or advancing age, so you’re trying to discern how best to address the care needs associated with their condition.

There are two primary care options from which to choose:

  • Aging in Place – This blog posting addresses the option of staying put and making adjustments that modify a residence to suit your needs or that of your loved one.  Also included in this option is the potential for hiring in-home care.  Both of these options allow a person to remain in their home for as long as possible.
  • Long-term care (LTC) housing options.  In a future posting I will address the available categories of long-term care (LTC) housing and will provide resources that should be helpful towards choosing a replacement for your current residential situation.

Both options have Pros and Cons involved with them.  But only you know what best fits your personal situation.

Aging in Place: I don’t even want to think about moving!

Aging in Place refers to living where you have lived for many years using products, services and conveniences to enable you to remain where you are.  To successfully age in place without moving you will most likely need to accommodate the physical and cognitive changes that may accompany aging.

Structural changes.  Both the inside and outside of the home could eventually require some structural adjustments to accommodate a person’s current – and future – needs.

  • If you live in a two-story house and your primary bedroom and bathroom are upstairs, does your bottom floor afford a bedroom/bathroom alternative?
  • Are you financially prepared for the costs of making the inside of your home more accessible, e.g. wider doors for wheelchairs or walkers; lowered counters to accommodate same; showers that can accommodate someone confined to a mobility aid?
  • Does the outside of your home allow for the addition of ramps and railings for easier access to the residence?
  • If one of you has cognitive decline and is prone to wandering outside of the house – what measures, if any, will assure this resident’s safety?
  • If you need care assistance during the day, are you comfortable having a health care provider in the home?  The costs and logistics of hiring and scheduling staff to come into your home can prove to be overwhelming and oftentimes more expensive than if a person moved into a residential community that readily offers the needed care.

How expensive is in-home care these days?  Caveat: I will not be addressing financing sources such as long-term care insurance, Medicare, Medicaid and the like.  My intent in these articles is simply to provide an overview of care options and potential costs.

The U.S. Department of Health and Human Services gives a 2009 run-down on costs for care options both in the home and in a long-term care residential setting.  I know that in Washington State, where I reside, the average Home Health Aide hourly rate is $22; the average monthly cost of an Assisted Living (AL) facility is $2870; and the average daily cost of a semi-private room in a nursing home is $225 which is approximately $6700/month.

Focusing on Home Health Aide/In-home care: based on the average hourly rate of $22, one could expect to pay close to $528 per day if based on an hourly rate.  Keep in mind, however, that most staffing agencies offer a monthly rate which will be less than the hourly rate.  But even with that “discounted” rate, in-home care can be very cost prohibitive.  A great many of us may not have access to that amount of cash and if the need extends out to several years – now it’s really adding up.

So why even think of remaining in one’s own home if it’s so %#^%($ expensive?

All of the above is not to suggest that Aging in Place is not doable.  Many people around the nation are successfully aging in place so why shouldn’t you have a crack at it?  Consider this alternative: some people start out Aging in Place and then transition into a long-term care housing situation when finances, or circumstances, warrant such a move.

The articles, Avoiding the pitfalls of selecting senior housing, and Selecting a senior housing community – easy for some, not for the rest of us, provide some tips for your selection process.

Some links of interest: Alzheimer’s Association Carefinder service; Leading Age; Federal Govt Senior Topics.