Things You Can Do to Relieve Caregiver Stress

Hospitals are Required to Train a Family Caregiver Prior to Discharge

 

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Q. My father, … [Read More…]

Hospitals are Required to Train a Family Caregiver Prior to Discharge

Q. My father, Marty, was in a serious car accident last year, where he broke several bones. During the week that followed his discharge from the hospital, my step-mother, Carolyn, struggled as she tried to get dad from the car to his wheelchair, and he ended up falling on his head and having a concussion. According to Carolyn, nobody at the hospital explained to her how to transport dad safely or what to do after they left.

I can’t fathom how a hospital can just discharge someone without training the caregiver on follow-up care and treatment. Especially in cases where a lay person is tasked with administering medication and treating wounds. Are there any laws that require hospitals to train a designated caregiver before a person is discharged?

—–

A. Currently, as many as 42 million Americans take care of a family member at any given time. Traditionally, these family caregivers provide loved ones with assistance in bathing, dressing, eating, shopping for groceries, managing finances, and more. But as the number of seniors with chronic conditions has grown, family caregivers have taken on medical tasks once provided only in hospitals, nursing homes, or by home care professionals. In fact, nearly half of family caregivers administer multiple medications, treat wounds, or operate specialized medical equipment, according to an AARP survey released in 2012. Despite frequent emergency department visits and overnight hospital stays, few of the survey respondents reported receiving any assistance or training from health professionals.

With the new responsibilities of caregivers to take on certain medical tasks, a law took effect in Oklahoma last year, requiring hospitals to train a designated family caregiver to tend to the medical needs of a released patient. Since then, 12 more states (Arkansas, Colorado, Connecticut, Indiana, Mississippi, New Hampshire, New Jersey, New Mexico, Nevada, Oregon, Virginia, and West Virginia) have followed suit, approving Caregiver Advise, Record, Enable (CARE) laws. While the laws and legislation will differ in certain states, all contain three requirements:

• The name of a family caregiver is recorded when someone is admitted to a hospital or rehabilitation center;

• The caregiver is notified if the patient is going to be released or transferred to another facility;

• The facility must provide information and personal instruction on how the caregiver will manage medical and physical tasks, such as medication, injections, caring for wounds, use of medical equipment, and moving the family member.

Local CARE Laws

In Virginia, House Bill 1413 and Senate Bill 851 require hospitals to notify family caregivers when their loved one is being discharged from the hospital and provide instruction on how to do the required medical tasks at home. The summary of the law, as passed, is as follows:

Hospital discharge procedures; designation of individual to receive information and instructions. Requires hospitals to provide each patient admitted as an inpatient or his legal guardian the opportunity to designate an individual who will care for or assist the patient in his residence following discharge from the hospital and to whom the hospital shall provide information regarding the patient’s discharge plan and any follow-up care, treatment, and services that the patient may require. This bill is identical to SB 851.

In Maryland, SB 572 is currently under consideration, with an unfavorable review by the state’s Finance Committee. No details could be found on CARE laws being enacted in DC.

Why are CARE Laws Important?

Patients stand the risk of ending up back in the hospital if their recovery isn’t handled properly. In fact, one of the factors contributing to high readmission rates is inadequate coordination and follow-up care in the community, according to the federal government. A 2013 report by the Robert Wood Johnson Foundation found that in 2010, one out of eight Medicare patients was readmitted to the hospital within 30 days after surgery. For non-surgical patients, the percentage was nearly one in six. The numbers do not include readmissions for Medicaid and private insurers, which are also “high.” CARE laws help prevent readmissions by ensuring that discharge instructions are provided.

What if You End Up in the Hospital?

Serious car accidents, strokes, or other instances that require medical care are never planned for, as you can see from the unfortunate situation with your father. This is why thought needs to be given (in advance, if possible) to what your preferences are for how care will be delivered. Will it be at home, an assisted living facility, or a nursing home? Of course, you cannot predict the exact outcome of your long-term care needs, but before anything happens, it is a wise idea to start a discussion now with the people who might be involved in helping to coordinate your care needs in the future, and include your preferences in your planning documents.

Planning for Long-Term Care

Medicaid planning can be started while a person is still able to make legal and financial decisions, or can be initiated by an adult child acting as agent under a properly-drafted Power of Attorney, even if a person isalready in a nursing home or receiving other long-term care.  Please visit our Website for more details on Lifecare Planning and Medicaid Asset Protection Planning. If you or your loved ones have not done Long-Term Care Planning, Incapacity Planning, or Estate Planning, please call us as soon as possible to make an appointment for a no-cost consultation:

New Models of Support for Aging in Place

Most American seniors choose to live independently as long as possible, while maintaining strong relationships with family and friends. A major concern, however, is access to the support and services they need. There is a growing sense of urgency about this, as more of us are determined to remain as independent as possible throughout our lives.

With strong community support services, a senior who loses his or her ability to perform certain tasks can remain in his or her home. However, for a senior to age-in-place comfortably, the following is also ideal: 1) affordable and accessible housing, 2) convenient transportation, 3) work, education, and volunteer opportunities, 4) access to health and support services, 5) participation in civic and cultural activities, and 6) intergenerational connections. When communities rise to effectively address these challenges, they become more livable and welcoming for people of all ages, across the life cycle.

Certain community support models are designed to meet the need of seniors who are aging-in-place. These can include:

Naturally Occurring Retirement Communities (NORCs)

The term NORC — coined in 1984 by Michael Hunt, a professor of urban planning at the University of Wisconsin–Madison — denotes any geographically defined community in which at least 40% of the population is 60 or older and live in their own homes. NORCs can take many forms, such as vibrant communities that encourage seniors to stay engaged.

  • A NORC is a community or neighborhood where residents remain for years, and age as neighbors.
  • Nearly 27% of seniors live in a NORC.
  • Fair housing laws provide for a complex with 80% of its residents over 55 to become officially age restricted. Another classification for restricted age is for 100% of residents to be above the age of 62, but this is rare in an evolving NORC.
  • For many years, the law required an age restricted community to offer significant  amenities and services if it was age restricted. That is no longer the case, but to compete and attract residents, some NORCs are offering amenities and services including social and recreational programs, continuing education programs, information and counseling, emergency and preventive health care programs, and more.

Read more about NORCs (or Senior Villages) in the DC Metro Area here.

Fraternal and Religious Organizations

For many years, fraternal and religious organizations such as the Masons, churches of all denominations, synagogues, etc., have been giving back to their communities and to their own members.

  • They help their fellow members with anything from repairing a broken toilet to meal preparation or transportation.
  • The organization will also help with emergency funds for things such as lapsed utility bills. In one case, a member in Ohio needed a wheelchair ramp.  Volunteers built the ramp, and when the member could not afford to pay for the supplies, the local Masons covered the cost.

“If you can’t get these things done, you run the risk of falls, of depression, of not eating well,” says CEO Tom Stofac. “Those kinds of issues start to escalate, and seniors may end up in the hospital because they’re malnourished.  What we haven’t done a good job of in the aging field is to look upstream at these little things. That’s what I’m finding is really helpful.”

Learn more about Masonic senior care here.

Grand-Aides

A home care model that is spreading globally is called Grand-Aides, which now operates at 20 sites in the U.S. Grand-Aides provide an innovative health care delivery program with caring, experienced nurse extenders making home visits to develop a trusting relationship, and connecting the patient and care team quickly and cost-effectively. Please see short video for more information on Grand-Aides.

  • Grand-Aides, who are employed by health systems at no charge to patients, have the temperament of kindly grandparents and the skills of specially-trained certified nursing assistants, according to program founder Dr. Arthur (Tim) Garson.
  • Armed with computer tablets, Grand-Aides provide home care to people at risk of hospital admission or an emergency room visit.
  • A Grand-Aide will visit the patient several times the first week. Using a computer tablet, he or she will video the patient and his medications, with a registered nurse on the other end viewing the encounter and double-checking the meds.
  • By troubleshooting problems and offering clear guidance and reassurance, Grand-Aides affordably provide home health care and may reduce readmissions, a major goal of hospitals and of Medicare.

“Everybody is pushing towards trying to manage patients with ‘apps,’” says Garson. “It turns out that some people just need  people.”

Technology-Based Living

Engineers and health experts are developing new ways to keep people in their homes longer. Current technology includes sensors, tracking devices for sleep, medication reminders, mobile doctors, and more. Unfortunately,  many seniors are resistant to adopting new technology that can help them age-in-place safely. Please see our recent article on this topic for details on helping seniors overcome their reluctance to trying new age-in-place technology.

This week, AARP announced the launch of its AARP TEK Academy, a free, easy-to-use online classroom designed to help 50-plus Americans get the most out of technology to connect with family and friends, explore employment opportunities, access health information, enjoy entertainment, and more. Located at AARPTEK.org, the site offers dozens of tutorials on a range of helpful topics, from social media to staying safe online.

When Aging-in-Place is no Longer an Option

Most people want to stay in their home for as long as possible, but even with the aging-in-place supports described above, they can’t. If you or a loved one cannot live independently and are showing signs that living alone is a strain, it may be time to consider other alternatives.

Whether the outcome is in-home care, assisted living, or nursing home care in the future, it is always wise to plan ahead. Life Care Planning and Medicaid Asset Protection is the process of protecting assets from having to be spent down in connection with entry into assisted living or nursing home care, while also helping ensure that you and your loved ones get the best possible care and maintain the highest possible quality of life, whether at home, in an assisted living facility, or in a nursing home. Please contact The Law Firm of Evan H. Farr, P.C. as soon as possible to make an appointment for a no-cost consultation:

Fairfax Medicaid Asset Protection Attorney: 703-691-1888
Fredericksburg Medicaid Asset Protection Attorney: 540-479-1435
Rockville Medicaid Asset Protection Attorney: 301-519-8041
DC Medicaid Asset Protection Attorney: 202-587-2797

Critter Corner: New IRA Rules Close the Loopholes

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Dear Commander Bun Bun,

I heard that there are some new rules that were proposed by President Obama that IRA owners should know before planning their estate or transferring money between IRAs. Do you know about them and, if so, can you explain?

Thanks for your help!

Ira Nurooles

—-

Dear Ira,

Under President Obama’s FY2016 budget, some of the tax strategies used to contribute to Roth IRAs or maximize the tax benefits on inherited IRAs will go away.

Currently, to make full or partial contributions to a tax-friendly Roth IRA, income must be under $131,000 for an individual and $193,000 for a married couple. High earners have gotten around this by making nondeductible contributions — up to $6,500 a year for older investors — to a traditional IRA, which doesn’t have income limits as long as investors aren’t claiming a deduction. After that, they convert the traditional IRA to a Roth.

In addition, workers who are allowed to make after-tax contributions to their 401(k) plans can also roll that money into a Roth. In this scenario, after-tax contribution limits are even higher, so savers could sock away $30,000 or more a year into a Roth IRA.

Under the president’s proposal, these loopholes would be shut starting in 2016. Below is what it would mean:

  • Money contributed on an after-tax basis to a traditional IRA or retirement plan could not be converted to a Roth.
  • The president would require that non-spouses who inherit IRAs — with a few exceptions — take all the money out of the account within five years. Currently, they can take distributions over their own life expectancy, which means the funds can remain in the account for decades and continue to grow while taxes are spread out.
  • Owners of Roth IRAs would be required to take minimum distributions after age 70½, as people do with traditional IRAs, 401(k)s and even Roth 401(k) accounts. However, people who have a combined value of up to $100,000 in all IRAs, 401(k)s and retirement accounts will be exempt from mandatory minimum distributions.
  • Unemployed individuals can tap IRAs before age 59½ on a limited basis without triggering a 10% penalty. A new proposal would expand this, allowing the long-term unemployed — those out of work for more than 26 weeks — to withdraw money from IRAs and 401(k)s early without penalty. It would apply to distributions of up to $50,000 annually over two years.
  • If your employer offers an annuity through its retirement plan and later drops it as an investment option, you would be able to roll over that annuity into an IRA or other retirement plan. Otherwise, a worker would be forced to liquidate the annuity.

The administration argues that these inherited IRAs were meant to provide retirement security to the original owner, not become a tax shelter for heirs. Of course, these changes would require the backing of Congress, which is unlikely to happen at this point, says Jeffrey Levine, an IRA technical consultant with Ed Slott and Co.

Hop this is helpful,

Commander Bun Bun

Secrets of Centenarians

Q. The other day, I was reading about Susannah Mushatt Jones, who turned 116 last month in New York. She was born in 1899 and retired in 1965. She never smoked or drank, and says lots of sleep is the secret to her longevity.

I am in my 80’s and still have lots of energy and a zest for life. I hope to live as long as Ms. Jones, to see my grandchildren and great-grandchildren grow up. I know you have a lot of clients in their 80’s and 90’s, and maybe even over 100. What do you surmise is the secret to their longevity?

A. One in 26 baby boomers is now expected to live to 100 and many more will reach the mid-to-late 90s, according to the book, Celebrate 100: Centenarian Secrets to Success in Business and Life. The book shares advice from interviews and surveys of more than 500 centenarians, who answer the question, “Will we still be having fun when we reach 100?” with a resounding “Yes!”

Born just a decade or so after the turn of the century, centenarians were teenagers during the Great Depression, young people during World War II, and, for some, grandparents by the time the 1960s rolled around. Their stories are different, but they share common themes.

Understanding centenarians is important to inform strategies to improve the delivery of health services for many individuals who will approach or achieve this milestone in the future. It is also important for seniors to understand the lifestyle choices that can influence longevity. Here are the “secrets” the 500 seniors interviewed cite for living a long and happy life (from the  Celebrate 100. . . book):

1. A Positive Attitude – Almost all of the centenarians interviewed believe a positive yet realistic attitude is critical throughout one’s life and described themselves as optimistic people. As an example, Trudi Fletcher of Tubac, Arizona, a lifelong artist, remains a professional painter at 100 and recently had a gallery exhibition showing off her new style. She credits her creative longevity to her positive, can-do attitude, and her love of painting.

2. Diet – The centenarians surveyed were critical of today’s supersized portions and the majority advised just eating nutritious food in moderation. Only 20% said they had ever been on a specialized diet plan, although some had become vegetarians. Lillian Cox, 107, of Tallahassee, Florida, confided that in her 50s she was overweight, but resolved to lose the weight. She did so and kept it off by just eating less, and continues to do so to this day.

3. Exercise – “You’ve got to exercise your mind as well as your body — everyone knows that, but I wonder how many are actually doing it,” says Louise Caulder, 101. “I don’t leave my bedroom before doing 30 minutes of stretches. Later, I walk a mile. Three times a week I play bridge.”

A few centenarians who successfully maintained their athleticism or gained new skills in later years have competed in the Senior Games. “I always thought of myself as an ordinary guy, but once I was in my 90s, I looked around and realized I was the oldest one at the bowling lanes and I could still keep up my score,” says George Blevins, 100. “So I entered the Senior Games and have enjoyed winning several medals, even at 100.”

Joe Meyser, 102, took up golf at 70, got pretty good and began competing in the Senior Games himself. “I drove to wherever they were holding them that year in my camper,” he says. “It was fun. I gave up the camper when I was 97, but won a gold medal at 100.”

4. Faith – For the centenarians interviewed, family and faith bring them contentment and cheer. They share a sense of wonderment at why and how they’ve lived this long. In fact, almost all the centenarians said that their faith has sustained them. Most believe they will be here as long as God has a purpose for them. “Perhaps we are here to be an example to others in hard times,” says Roberta McRaney, 101, whose original home was struck by lightning and burned to the ground, as did her rebuilt house.

5. Clean Living – Nearly 75% of the centenarians surveyed never smoked; most of the others stopped between the ages of 40 and 70. And while some never drank, most said they enjoyed only an occasional cocktail or a glass of wine; some still do.

For those interviewed, “clean living” also refers to doing what’s right and following your conscience. Harry Adler, 101, says it’s this simple: “Just stay out of trouble.”

6. A Loving Family – Family was universally important to centenarians surveyed. Although hard work and frugality characterized much of their lives, they now enjoy sharing their stories with great and great-great-grandchildren. Many spoke of the pleasure of watching younger generations grow and flourish. One respondent credited her longevity to “a wonderful and loving family, the good Lord, and a rum and Coke every afternoon.”

7. Genetics – All of the “secrets” mentioned so far reflect lifestyle choices that can influence longevity to varying degrees, but our genetic makeup makes a difference as well. Until medical science devises new ways to help us work with the genes we’ve been dealt, the secret is that some of us will be more prone to longevity than others. But there’s no reason to be discouraged: a large percentage of centenarians we surveyed said their parents and grandparents were not especially long-lived.

For the Centenarian Wannabes

Despite the inevitable ups and downs, the biggest secret these centenarians shared is that living to 100 is worth the effort.  So how can you follow in their footsteps? As you can see from the research, commonalities are that few centenarians are obese and few smoke or drink. In addition, most seem skilled at handling stress and find ways to process problems quickly, brushing them away rather than dwelling on them. In fact, another study of centenarians from the state of Georgia found they were more emotionally stable, extroverted, conscientious, and active in the community than their shorter-lived peers.

Who and where are the oldest living centenarians? The U.S. based Gerontology Research Group keeps a list. Learn more here.

Life Span vs. Health Span

When looking at centenarians, keep in mind that life span in the United States is not necessarily matched by increases in “health span,” or time spent living in good health. Longer life spans have been accompanied by a tremendous increase in the disease burden due to Alzheimer’s disease and other types of dementia. In fact, according to the Alzheimer’s Association, 1 in 9 Americans over 65 has Alzheimer’s disease. And, when the first wave of baby boomers reaches age 85 (in 2031), it is projected that more than 3 million people age 85 and older will have Alzheimer’s. Unless a cure is found, more than 16 million Americans will have the disease by 2050.

Planning for Your Future

Luck and genetics play roles in longevity, of course, but you can’t control that. If you want to better your odds of hitting 100, focus on what you can do, such as eating healthy, exercising, and cutting down on stress. As you are taking care of yourself and enjoying your life, it is also a good idea to plan for your future and for your loved ones. Our firm is dedicated to helping protect seniors preserve dignity, quality of life, and financial security. If you have not done Long-Term Care Planning, Estate Planning, or Incapacity Planning (or had your Planning documents reviewed in the past several years), or if you have a loved one who is nearing the need for long-term care or already receiving long-term care, call us to make an appointment for a no-cost consultation:

Fairfax Elder Law Attorney: 703-691-1888
Fredericksburg Elder Law Attorney: 540-479-1435
Rockville Elder Law Attorney: 301-519-8041
DC Elder Law Attorney: 202-587-2797

When is it Time to Hang Up the Keys?

With years of experience behind the wheel, senior drivers are among the safest on the road. However, skills and abilities required for safe driving — such as vision, memory, physical strength, reaction time, and flexibility — may decline with advanced age, which could make continuing to drive risky. Understandably, driving is not a privilege that most older Americans typically want to relinquish willingly. Still, safety must come first.

To decide whether driving is safe, loved ones and medical professionals need to keep the following three things in mind: life and health (older drivers are more likely to be seriously injured or killed in a car accident); the safety of others (including family passengers, pedestrians, and other drivers); and the potential financial liability of a serious accident that damages property and/or destroys lives.

As with any skill, it is important to honestly evaluate the ability of yourself and your loved ones  to remain on the road, particularly because it impacts your safety and the safety of others. In fact, almost anyone can benefit from a comprehensive driving evaluation conducted by a professional or an organization, such as the American Automobile Association (AAA). You should seriously consider a driving evaluation, if you are:

Verifying your confidence: If you feel your driving continues to be fine, you may appreciate having your opinion seconded by a professional with the background and experience to verify your confidence.

Feeling your age: If you are not seeing quite as well as you once did, experiencing slowed reaction time or a loss of flexibility, then you may benefit from an assessment and tips to keep your driving skills sharp.

Experiencing medical conditions: If you have one or more medical conditions – chronic diseases such as arthritis or diabetic neuropathy, or physical limitations that may lead to a loss of range of motion, flexibility, or strength in your arms or legs – you may also benefit from an evaluation. Moreover, an evaluation may provide you with a plan for rehabilitation, if appropriate.

Loss of vision: If you suffer from a loss of peripheral vision, depth perception, or other vision-related change, a driving evaluation would be most helpful.

Second opinions: If you have been told that you should stop driving, but you’re not sure that you agree, you could benefit by getting an opinion from a comprehensive driving evaluator. The evaluation is an extremely thorough process; you will get a recommendation that takes a complete picture of your driving skills and abilities into account. It will include an assessment of your current driving ability and your potential for improvement.

Driving again after stopping: If you would like to resume driving after a period of non-driving, you could benefit from getting a driving “checkup.” People sometimes find that, after a period of recovery time, some coaching and retraining can help prepare them to get back behind the wheel.

Changes in life circumstances: If a change of circumstances affects where or how much you drive, you may benefit from a driving evaluation to sharpen skills and build confidence. Some examples of changes include recently moving or changing family roles.

Learning you have Alzheimer’s or another type of dementia: If you have been diagnosed with Alzheimer’s or another type of dementia, but are in the early stages, you may not need to stop driving immediately. A comprehensive evaluation can determine whether you can continue to drive safely for the time being – and can help you make plans for a time in the future when you will not be able to drive.

How to Evaluate Driving Ability

To evaluate your ability to drive safely, AAA offers resources from self-screening exercises to professionally administered assessments, including:

Self-Rating Tool: Drivers 65 Plus is a brochure that features a 15-question self-rating driving assessment exercise designed to help you examine your driving performance. After answering the questions, follow the instructions to calculate your score and get information about your driving performance. The driving assessment will list your strengths and weaknesses, along with suggestions for how to improve your driving.

Interactive Driving Evaluation: The AAA Roadwise Review interactive driving evaluation can help. The confidential self-evaluation program features a series of computer-based exercises that can be completed in 30 to 45 minutes and help you identify steps to reduce driving risks in key areas, including leg strength, mobility, flexibility, working memory, processing speed, and more.

Professional Assessment: To really understand your current driving abilities, consider getting an in-depth driving skills evaluation or clinical assessment by a trained professional. According to AAA, not only can this help you recognize and correct possible shortcomings, it also can result in a specialized drivers’ training plan to help you continue driving safely.

Taking State Laws into Account

On January 1, 2015, older drivers in Virginia began facing greater scrutiny with requirements that they apply for license renewals in person and that they renew their licenses more frequently. For instance, drivers over 75 years of age are no longer permitted to renew their license online or by mail. They now have to apply in person at one of the Commonwealth’s Department of Motor Vehicles offices. And, rather than renew every eight years, they are now required to renew every five years.

In Maryland and DC, drivers 70 and older must get a physician’s approval to renew their driver’s license. In fact, Maryland’s Motor Vehicle Administration has a medical advisory board that assesses medical fitness to drive in those who may be impaired. Drivers with certain conditions (including history of stroke, epilepsy, and autism) must be medically reviewed. Doctors, family,and concerned citizens can also request a review of drivers they fear are unfit to drive.

In total, 33 states and the District of Columbia have special provisions for mature drivers, including accelerated renewal frequency; restriction of online or mailed renewals; vision tests; road tests; or reduced or waived renewal fees. Visit the Governor’s Highway Safety Association Website for details on specific states.

Having the Talk

No one looks forward to that talk with an aging parent or other loved one about whether they need to hang up the keys. However, approaching that conversation a bit differently can make all the difference.

When you’re ready to talk, focus not on whether the driver should hang up the keys, but on mobility and the continued need for it. Talk about where the person needs to go, and when. Talk about alternatives to driving, such as mass transit or cabs or someone picking them up.

It is also important to have the talk years before the declines that affect driving set in. More help on broaching the subject is available in a downloadable booklet, “We Need to Talk,” developed by The Hartford.

For more resources, please see our blog post, “Stricter Laws for Senior Drivers.”

The Advance Driving Directive

What happens when you are the person who should no longer be driving and the time has come for you to hand over your keys? Which loved one would you want to broach this important subject with you? Now, as part of your incapacity planning documents, you can indicate who you would trust to help you if you could no longer drive safely. Our firm can help you draw up an Advance Driving Directive to name the person that you want to initiate the discussion with you about continued driving (or not) when the time is right. Or you can use this one provided by AAA.

Planning in advance for cessation of driving or other alternatives can help keep you and others safe on the road, so be sure to incorporate an Advance Driving Directive as part of your planning. If you have not done Long-Term Care Planning, Estate Planning or Incapacity Planning (or had your planning documents reviewed in the past several years), or if you have a loved one who is nearing the need for long-term care or already receiving long-term care, please call us:

Fairfax Elder Law Attorney: 703-691-1888
Fredericksburg Elder Law Attorney: 540-479-143
Rockville Elder Law Attorney: 301-519-8041
DC Elder Law Attorney: 202-587-2797

Critter Corner: When Should I Hire Home Care for a Parent?

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70% of Americans turning 65 will need Long-Term Care

Correction: The title of our newsletter is incorrect. It should be “One in seven adults will have a disability for more than five years.” We  apologize for this error!

 


Photo from homeaidescny.org

 

 

 

 

 

 

 

 

 

 

 

 

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Dear Commander Bun Bun,

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