Dying at Home

Most people (70%) want to die at home, in a familiar place surrounded by loved ones. However, only about 25% do. Nearly 50% of Americans die in a hospital, and another 20% die in a nursing home or long-term care facility.

The trend is for more people to die at home, with a 29.5 percent increase from 2000 to 2014, according to the Centers for Disease Control and Prevention. During the same time period, the percentage of deaths in hospitals, nursing homes and long-term care facilities has dropped.

Seven out of ten Americans die from chronic disease, and more than 90 million Americans are living with at least one chronic disease. The Centers for Disease Control (2007) listed the ten leading causes of death in America (in order):
heart disease
chronic lower respiratory disease
7. diabetes
kidney disease and sepsis.

Almost a third of Americans see ten or more physicians in the last six months of their life. And almost 30% of Medicare’s budget each year is spent on patients who are in the last 12 months of their lives.

According to LongTermCare.gov about 70% of Americans over age 65 will require long-term care. If a person has an extended illness requiring long-term care, long-term care insurance will help cover those expenses whether in a hospital or at home. Studies show that those with long-term care insurance stay at home longer because the insurance provides more money for care. This includes extra money for home modifications like a wheel-chair ramp, a medical alert system and a stair lift.


It is often the lack of money that prevents people from staying at home when they need care. Who pays for long-term care? In some cases they will spend all their savings and now are forced to rely on Medicaid (welfare health care). With a Partnership asset-protection insurance policy you will be exempt from the Medicaid spend-down requirement, the exemption is based on the total benefits your policy has paid out for care.

More than 80% of patients with chronic diseases say they want to avoid being in a hospital or intensive care unit when they are dying. While dying at home is usually preferred by the patient, it can be difficult for the caregiver. Hospice services can help.

Hospice care is for those in the last six months of their lives. More than 88% of hospice patients are Medicare beneficiaries.

Traditionally, for a patient to qualify for Medicare-supported hospice, a doctor must certify that the patient has: a home, a diagnosis of six months or less to live, a full-time caregiver, and a willingness to give up curative care and receive only palliative care.

In 2016 the Medicare Care Choices Model began offering some patients “concurrent care”: the choice of continuing curative care while starting palliative care and hospice care. An evaluation of concurrent hospice in non-elderly patients showed this plan improves quality of life and reduces costs.

The Medicare hospice benefit emphasizes home care, with almost 60% of patients receiving their care at home as of 2014. Medicare coverage is limited, additional care would be paid for out-of-pocket. Do you really want to spend-down your hard-earned savings and investments leaving open the option that Medicaid will require your estate to repay Medicaid for your care costs? There are 30 states with a filial responsibility law that could require your family to reimburse Medicaid.

Home care is much less expensive. Inpatient hospice services are used when the patient’s pain and symptoms must be closely monitored in order to be controlled, when medical intervention is required to control pain or symptoms, or when the family needs a rest from the stress of care giving.

A hospice team arranges for doctors, nursing care, medical equipment like wheelchairs and walkers, medical supplies, prescription drugs, hospice aide and homemaker services, physical and occupational therapy, speech-language pathology services, social workers, dietary counseling, grief and loss counseling for the patient and family, short-term inpatient care, and short-term respite care.

After evaluation by a doctor, a patient can enroll in hospice care for two 90-day benefit periods, followed by an unlimited number of 60-day benefit extensions. A patient can decide to stop hospice care at any time.

A recently proposed bill, The Patient Choice and Quality Care Act of 2017 (H.R. 2797), aims to give patients and families living with advanced and life-limiting illnesses the information and services they need.

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Have You Had The Conversation?

The Conversation Project is dedicated to helping people talk about their wishes for end of life care. They offer a collection of “Conversation Starter Kits” that you can download for free.

Talking with loved ones openly and honestly, before a medical crisis happens, ensures that everyone understands what matters most to each individual at the end of life. You can use a starter kit for yourself, or to help others communicate their wishes.

conversation2There are several different kits: for families and loved ones of people with Alzheimer’s or other dementias; how to choose a health care proxy and how to be a health care proxy; how to talk to your doctor or nurse about your wishes; and one for parents of a seriously ill child.

There are starter kits in English, Spanish, Mandarin, French, Hebrew, Korean, Russian, Vietnamese, and Hindi.

Organizations can purchase printed copies to distribute and add their logos.

The cost of care can be devastating, the national average is over $7,000 per month. To plan means to be insured before needing care, even before the diagnosis and not everyone can health-qualify for insurance (Can You Qualify?).

To find out more about long term care insurance see the Guide To Long Term Care

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How your nose can expose your risk of Alzheimer’s disease

Alzheimer’s researchers found that a person’s sense of smell declines strongly in the early stages of Alzheimer’s disease, suggesting a noninvasive “sniff test” for diagnosis.

The test can help identify the pre-dementia condition called mild cognitive impairment (MCI), which often progresses to Alzheimer’s dementia in a few years.

David Roalf, Assistant Professor at the Perelman School of Medicine, University of Pennsylvania, led a study in which scientists used a simple, commercially available test called the Sniffin’ Sticks Odour Identification Test. Subjects have 16 different odours to identify.

Along with the sniff test, researchers administered a standard cognitive test (the Montreal Cognitive Assessment) to 728 elderly people who had already been diagnosed by doctors as healthy, having mild cognitive impairment, or having Alzheimer’s disease.

The research team found that the sniff test, when combined with the cognitive test, increased diagnostic accuracy. The cognitive test alone identified 75% of people with mild cognitive impairment; after adding the sniff test, 87% of cases were identified.

Using the two tests together also helped the researchers to detect subjects with Alzheimer’s and those who were healthy, and to determine the degree of cognitive impairment.

Doctors believe it is more possible to help people with Alzheimer’s disease if they begin treatment before dementia symptoms appear.
Genworth 2015 Cost of Long-Term Care Survey Chart

Many people get Long Term Care Insurance to protect themselves and their families against the debilitating effects of Alzheimer’s and other dementias.



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Using technology to keep track of Alzheimer’s patients

The city of Iruma in Japan has a new plan to keep track of people with Alzheimer’s and dementia.

Each patient will have a little square QR code that is attached to a fingernail or toenail. The code carries personal information including a unique identification number, an address, and a telephone number. The information will help families find loved ones who have wandered away. The adhesive chips remain attached to the nail for about two weeks, even if they get wet.

alzWandering is a common problem with Alzheimer’s and dementia patients. Sometimes confusion and memory problems cause them to get lost even in familiar surroundings. Various technologies are available for keeping track of elderly loved ones. Some methods resemble technology used for tracking packages, children, or pets.

A variety of GPS tracking devices can help a user find the location of a lost person. Some enable the user to set up a safe zone, with notification when the patient goes outside a designated area. Some trackers can keep track of several people at the same time.

An SOS button is another common feature, so the person wearing it can call for help. Some devices facilitate audio conversation between the patient and caregiver.

Many of these devices are battery operated, but the batteries are rechargeable and may keep a charge for as long as three years. Some are connected with services that operate by monthly subscription.

GPS trackers can be worn around the ankle or wrist, or as a pendant. They can be locked on. One model looks like a wristwatch. A small personal transmitter emits an individualized tracking signal. GPS Smart Sole wearable technology puts satellite monitoring in a shoe insert to allow real time tracking of the wearer in areas with T-Mobile coverage.

Some GPS tracking watches provide international monitoring. An alarm will sound if the watch and GPS receiver get separated.

MedicAlert ID bracelets carry important medical information, and provide emergency hotline and family notification.

Cellular tracking uses cellular towers to determine the person’s location. The device used is the size of a credit card, and the user can follow its location with a mobile application.

The caregiver will usually carry a small tracking device, smart phone, tablet or web browser to monitor the patient. Some apps provide updates through email and text.

Hospitals can use special technology to monitor entry and exit doors. A door can be programmed to lock down when a tagged patient approaches. In a home setting, door alarms and locks, motion detectors, and intercoms can be helpful in monitoring a patient.
By 2050, the number of people with Alzheimer’s disease worldwide could triple, from 5.1 million to 13.8 million. About six in ten will wander. Traditional search and rescue operations can cost thousands of dollars an hour, and take days. New technology makes it possible to find a person much faster and with fewer people needed in the search. The tracking technology saves a lot of money and helps rescue people sooner, before they may get hurt.

For information on insuring for Alzheimer’s and dementia care, see the Guide To Long Term Care

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Eli Lilly’s latest Alzheimer’s drug fails clinical trials

Eli Lilly’s drug solanezumab, designed to treat dementia caused by Alzheimer’s disease, failed to show significant benefits in a large multi-national trial. The trial, which began in 2013, involved over 2,100 Alzheimer’s patients with mild dementia.

The pharmaceutical company announced that in the Phase 3 clinical trial of solanezumab, patients taking the drug did not show a significant slowdown in cognitive decline compared to those who took a placebo.

Solanezumab was designed to reduce the buildup of amyloid plaques in the brain. Some researchers have postulated that amyloid plaques may cause or contribute to the memory loss associated with Alzheimer’s disease. The failure of this trial brings that theory into question.

Some scientists say there is still no convincing evidence of a clear relationship between amyloid plaques and dementia. Amyloid deposits begin to form up to twenty years before the onset of Alzheimer’s disease, but may not cause it. Some people who have the plaques do not show cognitive decline.


While disappointing, the failure of this trial will not end efforts to find a cure. The results of this test will stimulate the scientific community to look in other directions. Even failed trials can provide helpful information and point to new avenues for research.

The next drug to be tested will be aducanumab by Biogen, which also attacks plaques but in a different way.

Alzheimer’s disease is involved in 60 to 80 percent of dementia cases. Almost 47 million people worldwide have Alzheimer’s disease and other dementias, and many require special care whether at home or in an institution.

Alzheimer’s disease is the leading cause of Long Term Care Insurance claims.


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Dental services are underused in nursing homes

Residents at long term care facilities often will not go to the dentist even when it’s free.

A University of Buffalo study reviewed dental and medical records of over 2,500 residents at a nursing and rehabilitation center. Only 10 percent of them got a dental examination while in the facility.

The State of New York requires long term care facilities to offer dental services at admission and yearly during a patient’s stay.

For the patients in the study, the average length of stay was two years, but almost half of them were there for less than a month. Among patients who stayed less than a month, only 7 percent took advantage of available dental services. Use of the dentists rose to 30 percent among those who stayed a month to two years, and to 55 percent for those who stayed longer than two years.

Involved family members could encourage residents to get a dental checkup. For more information on paying for nursing home costs, see Who Pays for Long Term Care at Guide To Long Term Care.


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California Partnership Plan: Changes Needed

After age 65, 70% of people will need long term care at some point. The costs are potentially staggering. Financial advisors recommend long term care insurance to protect oneself against the excessive costs of nursing home care or home services.

Medicare pays for doctors, hospital costs, drugs, and some other health care needs, but not for long term care – longtermcare.gov

Long term care is the care needed by someone who has difficulty with two or more activities of daily living (ADLs) over a period of 90 days or more. Over 12 million people in the United States need long term care now, with almost half of them under 65 years old.

One of the incentives for people to get long term care insurance is state Partnership plans, which allow insureds to protect their assets if they use up their insurance and need to apply for Medicaid (called Medi-Cal in California).

In the 1990s, California, New York, Indiana, and Connecticut were pioneer states in creating Partnership programs, where insurance payouts for long term care can be deducted from the insured’s assets if the plan runs out and Medicaid is needed. Partnership programs save states money by encouraging people to buy long term care insurance.

To encourage more Americans to plan for the risk of needing long term care Congress passed the Deficit Reduction Act of 2005 (DRA). The new law permits the creation of beneficial public/private partnerships; a joint-effort between states and insurance companies who offer Qualified Long Term Care Insurance Partnership Policies. States would then amended their Mediciad law(s) to allow for the Partnership.

Insurance companies have agreed to offer high-quality, affordable long term care insurance protection that meets the stringent requirements set by the federal legislation and states.

Not all policies sold in your state are Partnership qualified. The most common non-Partnership policies are sold through employers, unions, associations – these are group policies and only individual policies are Partnership. Not all insurance companies policies qualify for Partnership in every state, check with us about your state or a specific company.

Partnership policies not only offer benefits to pay for long-term care costs. They offer the special additional benefit of Asset Protection should you ever need to apply for Medicaid assistance.

Now most states have Partnership programs, but California’s program needs to be updated.

To qualify for the state Partnership, California requires a long term care insurance policy to have a minimum of  $190* a day in coverage and a 5% compound interest inflation protection for someone under age 70. But these requirements may make the premiums out of reach for average Californians.

In  Partnership states created after 2005,  inflation protection is the only requirement for a plan to qualify for Partnership and 3% compound is about half the cost of 5% compound, making a comparable California Partnership policy about twice the cost.

The requirements can change from year to year. But another problem is that California long term care insurance Partnership policies do not have reciprocity; that is, if the insured moves to another state, although the insurance policy moves with the insured, the Partnership asset protection no longer applies. You would have to move back to California to use the Partnership asset protection part of the policy.

All the other Partnership states have reciprocity – even the other Partnership pioneer states New York, Indiana, and Connecticut.

California spends over $14 billion annually on long term care through its Medicaid program (called Medi-Cal). The only state that spends more is New York at over $15 billion. Total long term care Medicaid spending for the United States is over $118 billion.

In 2005, about 1.5 million Californians used long term care services. That number is expected to skyrocket: 6.5 million Californians will be 65 and older by 2025. Nearly a million will be 85 and older, and many of them will need long term care.

It is obviously in the interest of states to encourage people to get long term care insurance. However, the policies have to be affordable or people will not insure. Also, since people move around, reciprocity between states is essential. California needs to make these changes to its Partnership program so it can include more people.

To find out more about Partnership plans nationwide, click here.

*2016 minimum daily requirement

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