Studies show that older Americans prefer to stay in their own homes if they possibly can. It is no surprise, then, that most care of older persons is provided at home, whether by family or by hired help. While many consider in-home care preferable to institutional care, there are public benefits and legal considerations, some of which may be quite unexpected.

To begin with, family members shoulder most of the burden of caring for the elderly at home. Being the primary caretaker for someone who requires assistance with activities of daily living, such as walking, eating and toileting, can be a consuming and sometimes exhausting task. One important consideration when one family member has the sole responsibility of caring for a parent or other older relative is the question of equity with other family members. For example, is the family member being fairly compensated for her work? If the older person is living with a child, does the elder help pay for the house? If the care is taking place in the elder’s home, does the child have an ownership interest in the house?

For parents with only one child, such arrangements may not be so complicated, but if the parent has more than one child, it can be difficult to know what’s fair. An arrangement that seems equitable today may not seem that way after a child has devoted, say, five years to the care of the parent. And if a plan is set up that is fair for five years of care, what happens if the parent suddenly moves into a nursing home during the first year? With no planning for such eventualities, the care of an older person can foster resentment and guilt among family members. Fortunately, most elder law attorneys are skilled in helping families devise creative solutions to such problems.

At the same time, state and federal government officials are slowly recognizing that home care can be more cost-effective than institutional care. This means that, depending on the state, financial or other assistance may be available for those who choose to remain in their homes despite declining capabilities.

Getting Outside Help

Public and private agencies offer a variety of home care services that may be available to you:

• Home health care, either part-time or 24-hour care
• Personal care and homemaking services, such as shopping, cooking and cleaning
• Services delivered to the home, such as meals programs, transportation and home repair
• Adult day care centers that offer more intensive services than senior centers. There are more than 2,000 such centers around the nation and they are usually affiliated with churches or non-profit community agencies. (See below for more information).

Money management

Respite services. These programs provide caretakers a periodic break. A home care professional or aide substitutes for the caretaker for a specified period of time. (See below for more information).

Medicare and Medicaid provide some coverage of the medical portion of home health care. Although the coverage is often inadequate, when combined with other resources available to the client and his family, it may be enough to keep a fragile older person at home for a longer period of time. For an explanation of the coverage of home health care available under Medicare, click here. Medicaid offers very little in the way of home care except in New York State, which provides home care to all Medicaid recipients who need it. Recognizing that home care can cost far less than nursing home care, a few other states — notably Hawaii, Oregon and Wisconsin — are pioneering efforts to provide services to those who remain in their homes.

There are thousands of private home care agencies around the nation. About half of these are Medicare or Medicaid Certified Home Care Agencies, meaning that these two federal programs will reimburse for services provided by the agency if the services are covered. Such certification also means that the agency has met certain minimum federal standards regarding patient care and finances. Home care agencies can also gain accreditation from private accrediting organizations. The three major accrediting groups for home care agencies are the Community Health Accreditation Program http://www.chapinc.org; the Joint Commission on Accreditation of Healthcare Organizations www.jcaho.org; and the National Association for Home Care http://www.nahc.org

Non-medical services are also available to help older persons remain independent. The Older Americans Act funds more than 10,000 senior centers and makes grants to State and Area Agencies on Aging to provide services to seniors that include Meals-on-Wheels, transportation, respite care, housekeeping and personal care, money management, and shopping. Services are usually free but staffing may be limited. To find Area Agencies on Aging programs across the country, visit the Eldercare Locator Web site at www.eldercare.gov or call the nationwide, toll-free Eldercare Locator at 1-800-677-1116. In many cases, these agencies may offer case management and coordination services.

The new profession of “private geriatric care manager” has evolved to help coordinate services for seniors. Private geriatric care managers usually have a background in either social work, nursing, or psychology and they are experts in helping older persons and their families make arrangements for various kinds of long-term health care. These care managers evaluate an older person’s needs, review the options available, and monitor care once it is being delivered. To find a geriatric care manager in your area, visit the Web site of the National Association of Professional Geriatric Care Managers at www.findacaremanager.org.

Respite Services

Caring for a loved one with a long-term illness is a 24/7 job. Caregivers need occasional time away from their responsibilities to rejuvenate, pursue personal interests, or socialize. Respite services give caregivers that opportunity.

There are many different types of respite services:

• Round-the-clock. Assisted living facilities and nursing homes may provide overnight, weekend, and longer respite services for caregivers who need an extended period of time off. Not all assisted living facilities and nursing homes accept people for short-term stays, however, so contact your local facility.
• Adult day care. If a caregiver works, an adult day care facility can help. Adult day care facilities provide care and companionship outside of the home and give seniors the chance to interact with peers. The facility can provide social or therapeutic activities. Some day care facilities are especially designed for Alzheimer’s patients.
• In-home care. If you don’t want your loved one to have to leave your home, you can take advantage of one of the many in-home services that may be available. In-home care can involve a large range of services, including companionship services to help entertain your loved one, services to help the caregiver do housekeeping chores, personal care services, and skilled/medical care services. In addition, you can have someone come in to stay with your loved one while you work or for longer stays when you need to be out of town.

The cost of respite services varies from service to service. Medicare does not pay for these services, but Medicaid may pay for adult day care services. There may be other federal or state help available. Contact your local Area Agency on Aging for more information.

To find respite services, go to www.respitelocator.org or contact your local Area Agency on Aging. If you are caring for an Alzheimer’s patient, your local may have support groups and other help for caregivers.

Low-Income Housing for Seniors

Seniors who cannot afford other retirement homes may be able to qualify for federal or state funded low-income housing. Both the federal and state governments have specific housing programs for seniors. Seniors can also apply for regular multi-family government-funded housing.

There are two types of government-funded housing: public and subsidized. Public housing is housing owned by a housing authority, and the housing authority acts as your landlord. Once you apply and are admitted to public housing, you get an apartment. Subsidized housing is housing owned by a private landlord who receives subsidies in exchange for renting to low-income seniors. Some subsidized housing is similar to public housing — once you are admitted, you get an apartment — but, with some types of subsidized housing, once you apply and are admitted, you receive a rental voucher and have to find your own apartment.

In both programs, your rent is calculated as a percentage of your income. The exact percentage varies from program to program and state to state, but it is usually around 30 percent or 40 percent.

Each program has different eligibility requirements, and the exact requirements vary from state to state. In general, the criteria for eligibility are your age, household size, income level, and immigration status.

• Age: To be eligible for federally funded public housing, the head of household or a spouse must be at least 62 years of age. State funded programs may have different age limits. As long as the head of household meets the age requirement, you may have younger individuals living with you.
• Household size: The number of people in your household must be able to fit into the apartment, and senior housing usually consists of studios and one-bedroom apartments. You are allowed to have a live-in aide as part of your household.
• Income: Your household’s yearly income must be below a certain average income for the area, called the area median income. This amount changes every year, and it depends on family size and the area where the development is located. To see the income limits for your area, go to http://www.huduser.org/datasets/il.html.
• Immigration status: Federal housing requires that at least one member of your household be a U.S. citizen or have a certain type of legal immigration status.

To apply, you need to request an application from each housing authority or program you want to apply to. For information on what housing is available in your state, go to www.hud.gov/groups/seniors.cfm.

Unfortunately, there are often more applicants than housing available. As a result, housing authorities and landlords keep applicants on waiting lists. These waiting lists can be quite long. Because of the wait, it is important to apply to as many different housing programs as you can, and to keep track of your applications and your place on the waiting lists. Also, if you move, be sure to notify the places you submitted applications.

Certain applicants may be able to get a preference or priority status on the waiting list. The particular preferences and priorities vary from program to program but common ones include:

• Local residents
• People facing domestic violence
• Working people (This preference must always include people who cannot work due to disability or age)
• People who are homeless or at risk
• People with disabilities
• Veterans
• Elderly or near-elderly

If you fit into a preference or a priority, you may be moved up the waiting list.

Once you reach the top of the waiting list, the housing authority or landlord will determine whether you are income eligible. Then they will check certain information, such as credit reports, criminal record information, and landlord references, to determine if you are likely to be a good tenant. Once that is completed, you can move in.

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