Senior Living Options Event

Sensible Financial partnered with Karen Wasserman from Your Elder Experts, a leader in elder care, to create a presentation for our clients and the community. Karen’s talk provided the audience with much-needed information about options in Senior Living. The event was lively and informative and provided the audience with lots of opportunities to ask questions. If you weren’t able to attend, you can still see snippets from the Q&A and the entire video and transcript from the event below.


What is Congregate Housing?

What is a Village?

What is Private Home Care?

Do retirement communities or independent/assisted living facilities accept Section-VIII vouchers?

How does Section-VIII housing differ from place to place?

What’s your opinion on for profit/non-profit housing and do you have a bias?

In your practice as an elder management professional, how do you tell the good places from the bad ones?

How does a life care manager charge for services?

Do you have any recommendation for online resources that might help me make a decision?

Watch the presentation.

Read the transcript below.

Rick Fine: Hi everyone. For years we’ve been helping clients prepare for a comfortable retirement. But when we talk with clients, a question that often comes up is, “Now that we’re almost retired or in retirement, where are we going to live? Would we stay in our home and age in place, as it were? Should we downsize? What about a continuing care retirement community, CCRC? What are those like? Can we afford it?” So I started to do some research on the whole topic of older adult living a few years ago, and I discovered two things. One is that this is a very complicated topic with a big variety of options. And number two, one name kept coming up as I was talking to people in the community working with older adults, and that name was Karen Wasserman and her organization, Your Elder Experts.

Rick Fine: So I reached out to Karen, and now I know why her name kept coming up, because she knows about the needs of older adults, and she’s very familiar with various communities, facilities, and programs that can cater to older adults and their individual needs. So when we put together this event, the most logical choice for a speaker was Karen. So Karen founded the Jewish Family and Children Service Care Management Program in 1999 and has built it into one of the Boston area’s leading care management practices. She leads educational programs in the community on elder services, housing, and care management, and is a nationally certified care manager. She’s a member of the National Association of Social Workers, and both the national and New England chapters of the Aging Life Care Association. I’m very pleased to introduce Karen Wasserman.

Karen Wasserman: I’ve never had anybody clap before I spoke, so thank you. I didn’t realize … Actually, I was planning on speaking in the middle of the room, but I realize I can’t. Okay, so I like to start off explaining what a care manager is. And some of you might have heard of us as geriatric care managers, and so we’ve rebranded ourselves recently, as I segue over here, to Aging Life Care Managers. One, because geriatric sort of fell out of vogue, and second, because we work with people over a continuum. Not all of our clients are geriatric. A lot of our clients might be younger with chronic illnesses, some of our clients are adult children. And so we actually help people as people age, which is healthy and normal aging. So a care manager is someone who, hopefully, has a lot of experience working in the field of older adults, whether it’s as a social worker, a nurse, a physical therapist, occupational therapist. They’re people who have had contact and learned about what it’s like for older adults to go through crises, experiences in the hospital, rehab, what the resources in the community are, and it’s hard to just open a book and read about those things. You really get to know them well by working with people and helping them through it, so most Aging Life Care Managers are people who have years of experience working in the field.

Karen Wasserman: I started out in a community organization that served low income older adults in the greater Boston area with subsidized home care. And then I moved into a hospital setting, and then a nursing and rehab setting, and then I decided that my path led me right to being a care manager. And so what we try and do is help people assess what their needs are. You know, you can be in a crisis but not necessarily know where to go and what to do. So a couple examples are, you’ve wound up in the hospital and you realize you can’t go home, and you’ve been presented with a list of 150 local nursing and rehab settings, and you get to choose which ones you want to go to. And no one in the hospital leads you in the direction of the ones that actually are going to really provide great care because social work in the hospital doesn’t do the discharge plan anymore, it’s a case manager. And case managers actually, the difference between a care manager and a case manager is that usually the case manager works for the hospital, works for the insurance company, works in many different places, but they’re not working for you, per se. When you hire a care manager, they’re looking out for you. They’re going to advocate for you.

Karen Wasserman: They’re going to make sure that when you get discharged you go to a place that we know, as best as we can, you’re going to get good care. So the care manager, the case manager, there is a huge difference. And the goal of the care manager is to either give you a lot of education and send you off in a direction that you can handle yourself, or be there to manage and monitor. I have staff that are the sole point people for healthcare issues. They take our clients to the doctors, they know the history, they know the medication that the person’s on, and they actually keep notes so we remember what led up to this doctor’s appointment. First of all, when we take older adults to doctors, they look better than they’ve ever looked before. That day they remember they have a doctor’s appointment, they are dressed, the women have makeup on, the men look dapper, and they get to the doctors and they look great. And the doctor says, “What’s wrong?” And they say, “Things are great.” Inevitable, if we weren’t there, the doctor wouldn’t actually know why that person arrived. And if it came out in conversation and they were given a new prescription or referred to a specialist or for some kind of rehab in the home, that referral goes in the pocket and it doesn’t go anywhere. So our job is to keep the ball rolling.

Karen Wasserman: And to make sure that the 12 specialists that you have in your life are communicating, if not individually, at least with you. “Wow, can I tell you what the cardiologist said?” “Well, let me tell you what the neurologist said.” And we’re facilitating communication, and we’re helping a lot of adult children figure out how to help their parents, either in a crisis or for planning purposes. So that, in a somewhat general way, is what a care manager does. And the days vary, and you never really know what you’re going to be doing that week. Okay. Oh, you know what I realized? I didn’t say why you would hire one. You’d hire a care manager because you wanted a team with someone, you didn’t want to go it alone, and you want someone to help you understand the decisions that you’re going to be making. And also for many people who are caregivers who are either only children or have a sibling that they do not communicate with, having a care manager is someone who you can bounce things off of and rely on. I remember one time I was working with a client, and I met his daughter for the first time. She took me around the corner in the assisted living facility, and she just looked at me.

Karen Wasserman: We had been communicating for, like, I don’t know, almost a year. She said, “You’re the sister I never had.” Yeah. Okay. So what goes into how you plan for the future and how you’d like to see yourself. Now, not everyone plans, so there are going to be some people in this room who are going to write down everything I say and think about what they want for their future. And there are going to be other people who are going to listen to what I have to say and put it away in the drawer, and take it out when the crisis happens. There are just different people out there. One isn’t better than the other because you can do a lot of planning, and then things can change. But if it makes you feel better to plan, you should. And sometimes it actually works out that way. Wow, I was right. So I made the right decision, okay. So obviously, being able to take care on oneself, or have the cognitive ability to care for oneself is a huge factor. And you can be physically capable but cognitively impaired, and then you have to come up with the plan. I think the problem comes in when people appear to be okay, but are actually missing some things. There’s a little slipping. And unless there’s someone involved in their daily life, no one’s going to pick it up for a long time.

Karen Wasserman: And so we do find that we get more calls from adult children around holiday, or I should say right after a holiday. When it’s been a couple of months since they’ve seen their parents or relative, and there’s a huge change going on. So if I were to think about how you guide people around physical and cognitive health issues, you want to always live someplace where you can be safe. Are there stairs? Can you get in and out of your home without having someone come with a stretcher? Can you get transportation to the doctor? Can people easily access you? A person who’s living in the community who has no supports is in a different place from someone living in the community who has a lot of supports. Whether they be informal supports, relatives, so it’s about your resources and the supports that you have in your life, whether they be financial or in-person supports are going to help guide how you plan for your future. Or how you tackle the crisis that comes along. The personal preference is what allows people who want to plan to actually take control over their future. If you know what you’d like, and you actually do something about that, you’re being involved in the plan.

Karen Wasserman: If you’re not sure what your personal preference is, or you’re not a planner, in some ways you’re allowing the person who’s going to be your caregiver to make those decisions for you. And some people just prefer not to make decisions, and so abdicating your position of making your future works for some people. In my own case, my parents were completely in denial about where they were going, completely in denial about my father’s cognitive limitations, completely in denial that shouldn’t have been driving, and completely in denial that my mother was failing in place rapidly. So how did they wind up? They wound up where I took them. They wound up what my decision was about how to care for them. And sadly, even though I’d been giving them opportunities for years to talk about what they wanted, I think in the end what they wanted was to be taken care of, and so I did. It didn’t feel that good, and my siblings didn’t really believe me, that we just had to do it, but in the end that’s how it worked out. And maybe that’s how they wanted it to work out, I don’t know.

Karen Wasserman: So if you’re planning, you might be planning about managing your finances, you might be planning about having a community of people that you engage to support you. There are people who don’t necessarily have big families or big families nearby, but they have good friends, they have good relationships with professionals. You can actually create those communities of care if you don’t have the natural family community around you. You can have lawyers who take on a piece, you can have financial planner that take on a piece, you can have medical professionals who take on a piece, sometimes the care manager is part of the circle of people that actually help care for you. And as long as we’re all communicating with you and with each other, that’s a support team too. I’m going to leave the long-term care pieces. Something that these guys talk about better than I can, and to be honest, it is important for many people to have it, but if you don’t have it, it doesn’t mean you won’t get the care that you need. It just might be a little bit different twist on things.

Karen Wasserman: Some people say that home is where I’m living, it’s actually the house that I live in. And you hear people say, “I’m going out feet first.” Is that the phrase? Did I get that right? Okay. Feet first. I’m constantly saying things the wrong way. And you know what? It doesn’t always work that way. It’d be nice if everyone could stay in their home and go out when they want to. But we all know that it doesn’t work that way, and all of our homes are no the same. So sometimes I try to help people think about what is our home. A home could also be someplace where I’m appreciated, it’s where I have the support that I need. A nursing home can be a home if you need the care that’s provided by the caregivers in a nursing home. It might not be the home that you choose, but it can still be a home. Just like when work with people who are no longer able to remain in their home, in their house that they’ve lived in for 50 years. Sometimes when they move to another environment, they realize it’s so much nicer there because they don’t have the worries anymore of caring for the home that had become way too much for them, the burden.

Karen Wasserman: As one client said, “My army of providers for me to stay in my home. The snow removal people, the handymen, the gardeners, the roof guy, the electrician, the plumber.” So it’s great if you have that list, but if you can no longer manage all those people, it’s overwhelming, so home can be almost anywhere. There’s a big movement lately about staying at home, and there’s nothing wrong with staying at home as long as your home is appropriate. So people stay at home when they can afford to bring in the care that they need, when there’s someone to manage the care that they need if they’re not able to. You can stay at home if you can renovate. I’ve seen amazing renovations, a dining room can be made into a bedroom with a shower in the middle of the room, with privacy. It’s amazing what you can do. You can put in a stair lift or an elevator. I’ve seen clients do all of these things. If you have the resources to do them, and if it makes sense over time that you’re going to be able to actually stay there and appreciate it. I work with some people who know that they have the finances to stay in their home, that no matter what that’s where they’re going to be.

Karen Wasserman: And I work with people who it makes no sense because there is no one to manage all the details of them staying in the home, making sure that the caregivers are doing what they’re supposed to be doing, doing the details of the finances and the mail that comes in. It becomes overwhelming unless there’s someone who’s going to manage their staying in their home. It might not make sense to be there anymore. It’s not safe to stay in your home if it’s not safe. If you can’t get to your bedroom or the only full bathroom, it’s upstairs. If you can’t put, or don’t want to ruin the value of your home by putting in the stair lift, it’s not safe to be there. It’s not safe to keep the laundry in the basement if you’re not steady on your feet. How many clients have I had that fell in the basement or on the stairs on the way down? Or people who fell on their staircase coming up and down in the morning or at night. It’s not feasible to stay in place and thrive if it’s an unsafe environment. And some people don’t like to change anything in their home. They don’t want to pick up the throw rug they’re going to trip on. They don’t want to actually put the grab bar in the bathroom because it will destroy a tile that they love.

Karen Wasserman: There are people who really don’t want to put the grab bars in the shower or put a raised toilet seat in the bathroom they use because there’s only one bathroom downstairs and they don’t want anybody else to see that that’s what they need. If you won’t do the things that make you safe, then staying there is just going to be a crisis waiting to happen. There are so many other options other than staying in an unsafe environment. For my clients who come, the adult children who tell me, “You know, my mother is never going to leave that house. I have tried. I have hired people. She fires them. I’ve taken her on tours of assisted livings, she’s hated them. They’re for old people. There are people there who are infirm. There are people there … I’ll never belong there, that’s not me.” And I love it when I take a tour with someone who’s 90, and they say, “Oh, so many old people there.” Because your own perception of who you are is sometimes very different from the reality, you know? You feel different inside. And for some people that’s something that they want to preserve.

Karen Wasserman: But what I found is that older adults that don’t like people to come into their home to do things, to provide care, to clean their home because no one can clean their home the way they do, they do fine in assisted living. You know why? It’s not their home. It’s amazing. I have seen people who refused to have anybody help them with personal care, it’s just part of the plan there. A lot of people get help with personal care. Everyone gets their apartment cleaned, and it’s not the home, it’s a new setting. Somehow, a lot of the resistance goes away. And also there’s so much more to look forward to when you’re not isolated in your home. When you actually have things that look interesting, you have people to eat with. It’s amazing how many people stop eating or they lose weight or they gain weight because eating can be a social thing for many people, and if they’re eating alone it’s not the same. So the either don’t eat regular meals, or they just don’t eat at all. There is a lot of confusion about what kind of housing there is out there. There’s lots of different levels.

Karen Wasserman: There’s also, you know, for people who want to downsize out of a home that you might be living in that’s now too big, people just, they move into condos, they move into smaller homes. When you make a move, when you’ve been living in your home for a really long time, and you’re thinking about making a move, there are certain things you might think of. And it dawned on me when a colleague who was about 10 years older than me told me that she was downsizing. She and her husband were selling their house and moving into a condo community, and her condo was on three floors. And I was thing, “God, she’s probably not planning on staying there very long.” But people do it all the time. They move into an environment that they hadn’t thought, “Well, if I want to really stay here for a long time, maybe this isn’t the best move.” And to be honest, that’s part of planning. Let’s think about how long I want to stay in this condo, and what’s going to be a good environment for me? One where I have to walk up stairs to get to everywhere, one where I don’t have a place to park near my front door?

Karen Wasserman: There are all sorts of ways in which downsizing is a great thing, and it’s a great precursor to another move, if you have to go, because you’ve already divested of all those things that you had in the attic and in the basement, and I guarantee many of you have your own parents’ belongings in your attic or your basement because they didn’t get rid of anything, and you had to take them all in. And how do you get rid of those things? One, it’s exhausting to think about. Two, it’s really hard to part with things that have meaning because maybe your folks aren’t around anymore but you still have their end tables and everything that was inside just the way it was. So you’ve now accumulated stuff, and the idea of moving is overwhelming. How do you get out of a home when you’re getting a little older yourself? It’s a huge task physically sometimes, people aren’t up to it. And you know what? There are lots of people out there who make a living doing this now. You can team with someone who will make it happen. You can be part of every little inch of belongings and decisions about where things go, but you don’t have to physically and cognitively be able to do it yourself. You can hire someone who’s physically strong and executive function tuned, and make it all happen for you.

Karen Wasserman: And I’ve seen people in my office go, “Really?” Because that’s a game changer for some people. When they know that they don’t have to orchestrate the move, and someone’s going to actually help them pack, divest, throw out, make sure that their kids know what their options are, and set them up where they’re going. “Oh, well maybe I could do that.” Because it’s really hard to get yourself out of that space which is laden in with your life and your history. So there are these retirement communities out there, so some people, they want to make the move, they want to live someplace where it’s convenient. Where there’s a little built in social life maybe, maybe there’s easier living on one floor, there might be an occasional … Some of them have dining rooms, some of them don’t. People go in and they’re pretty independent. There are retirement communities out there that you can buy into or you can rent. They can also be a retirement community that you go into that has some services in place should you need them. And there’s independent living. There are apartments out there for people who just know that they’re still functioning well in the community but this brings them closer to maybe family or a community, a church, a synagogue, a place where you can live a little more freely.

Karen Wasserman: So I hate to do this, but my favorite place to live like that is Coolidge Corner, because if you live in Coolidge Corner, you can get almost anything. It’s sort of like a miniature Manhattan, where you never need to leave the block. Everything’s there. The dry cleaners, the supermarket, the place you get takeout, the doctor’s office, and the senior center, so everything’s right there. And there’s transportation, which is really important. Then we heard a little bit about continuing care retirement communities, which is a great plan if you are still independent. If you’re independent and you have the finances to buy into a continuing care retirement community, and it makes sense for you, and they are all different, each and every one. And there are many of them in the area. They offer different services, they cost different prices. There are more expensive ones and less expensive ones. And they have different continuum of care. Some of them, you move in and you’re almost like buying another insurance policy because they are going to see you through. Whatever your needs are they are going to be somewhat discounted because you’re living in their community, and you’re going to be taken care of for the rest of your life. Some of them you’re on your own if you need services, if you’re living in the independent section, until you need to be in the nursing home.

Karen Wasserman: Some of them financially take a piece of the money you invested in them and take it, a portion of it, and if you live long enough, they’ve got it and you don’t. Because many of the communities, when you buy in a percentage of it goes to your estate when you die. So for some people who want to be able to preserve some assets for their family, that’s a beautiful thing, but not all the communities do that. So you need someone who’s going to actually read the contract, and you have to ask the right questions when you’re touring to know exactly what they provide and how it is provided. But if you get the right one, and they all have different personalities, there are the ones that are a little bit more Yankee and traditional, there are the ones that are a little more cultural and … Like, they are theater goers. Or there’s some that a lot of retired academics feel comfortable in because they offer so many courses or interesting lectures. There are some that are constantly traveling into Boston to museums and to theater and to symphony. There is a community out there for you, it might not be the same one for all of you. It will probably be a different one because each one has a different personality.

Karen Wasserman: So what’s an assisted living? An assisted living facility, which has evolved over time, I’d say 20 years ago an assisted living facility was mostly for people who wanted a little structure and three meals a day. They didn’t want to have to clean their apartment, they didn’t want to have to cook, they didn’t want to have to shop for groceries, they wanted some activities in place, and they wanted their newspaper every morning. Nowadays, those people still go to assisted livings, but people have aged in place in the assisted living, so there are some people who really just need a little bit of help, a little structure, some community, some eyes looking at them for day to day. But there are other people who need a lot more help. They need more personal care. And assisted living usually offers anywhere from 45 minutes to an hour of personal care a day, and that could be split up in 15 minute increments throughout the day. Help with shower, help with getting to bed, help escorting to meals, help getting to activities, whatever it is that you need. And every assisted living functions differently. They have al a carte services where you pick A, B, and C, you pay for A, B, and C.

Karen Wasserman: They have all inclusive services where whatever you need, you get it for the same cost. There are for profit ones and not for profit ones. It’s crazy out there, and they’re just cropping up everywhere. I live in Newton. In Newton alone there are two brand new ones being built right now. There are assisted livings just for people who are what they call traditional assisted living, it’s for people who are supposedly cognitively intact and able to manage a certain amount of their day. There are others that are a combo. There’s traditional and then there’s the memory unit for people who need more cuing, more structure, more activities during the day. There’s more staff keeping an eye out for them, and some of them are secure and others are not. There are now sort of a hybrid. There are two new hybrids. One is just memory support, an entire community just for memory support. And then the other one is a combination of independent, so if you imagine one building is you can start out independent or you can start out needing a little assistance. You stay in that one apartment, so they bring in the assistance as you need it. And then if you need a memory unit, there’s one next door, or attached. So that you can still be part of the community where you have made connections, and where you know the staff.

Karen Wasserman: And for couples sometimes that works out well because the hardest thing is that we don’t age alike. And when you have either a parent or yourselves where one person needs a lot of help and one person doesn’t need a lot of help, it’s harder to find places in the community to go. It’s challenging. And so when there are communities that allow you to be part of your spouse’s or your partner’s life, but not have to be the sole caregiver, it makes it a lot easier to get through your day. And then there’s the nursing home. And many of us grew up with parents who said, “Promise me you’ll never put me in a nursing home.” Right? And that would be great, but there’s a reason for having nursing homes. And the truth is as we are aging longer, and being kept alive even when we have major chronic illnesses, some of us are going to need nursing homes. And there are good ones out there, they’re not all bad. Okay? They’re not all bad, there are some good ones. There’s no perfect nursing homes, but there are better ones. And they serve a purpose.

Karen Wasserman: I had a client who was living in a independent apartment, she was constantly going to doctor’s appointments. She was never happy. There was always something wrong, always anxious about this or that physically. It got to the point where I would schedule someone to come in to help her and she would fire the person. Back and forth. She would only allow people from this one … Everyone had to be Russian. I was like, “Okay.” She wasn’t Russian. Okay? And she had a community in, I think it was Framingham, of Russian caregivers. And she would only use them, but sometimes she couldn’t find one so I’d hire someone. And I remember this conversation where she’s on the phone and I’m saying, “Did the person arrive?” “It’s a man.” I said, “No, it’s not. I know who it is. It’s so and so.” “It’s a man, and I’ve made him stand outside the house.” It was like, “Okay.” I gave up. From that moment on I realized there was not way to make the home environment work. This woman really did need a lot of attention, and when I finally got her to move to the nursing home she thrived for two more years. Much happier than she was in her home where she was just riddled with anxiety about her every ailment.

Karen Wasserman: But in the nursing home she had a nurse attending to her, who talked to the doctor, who was able to assure her that she was okay, or to pursue what was going on. So for some people being in an environment that’s medical makes all the sense in the world. And there are tidbits that I share and ways for family to make it work in a nursing home. Inevitably, people say to me, “When should I move? If I’m going to have to move, when do I move?” And the answer is always sooner than you think because if you wait for the crisis, it’s a miserable time to move. And you think about it, there’s a medical crisis, you’re in the hospital. Then you’re going to have to go to rehab, and from rehab you’re going to have to think about where you’re going to go next if you can’t come home. And now you’ve put yourself through so many transitions, and you’re arriving at either the continuing care retirement community or the assisted living, and you’re not at your best. Matter of fact, you might be at your worst, and it’s really hard to engage people and to create community when you’re at your worst. And it’s so much nicer to try and make the move before you are that impaired, where you can build community. You can participate in activities and get to know the people and the staff.

Karen Wasserman: And then as you do need help, you’re in a friendly environment already. You know, sometimes when I work with couples where it’s clear that one of them is terminally ill and the other person needs some help and will get very ill sooner rather than later if they continue being the sole caregiver, and making the move into a new community seems like it’s unbearable because they’re exhausted, they’re stressed out, and everyone’s focused on the person who is terminally ill with, however, six months to a year. And they say, “I’m going to wait. I’m going to wait, we’re going to be right here. It’s going to be great. When they die, then I’ll think about moving.” But you know what? When you’re alone, left in your own home without community, it’s hard. It’s a little bit harder. If you make the move, as difficult as it is, when your spouse or partner dies, you’re already living in a supportive place. It’s not to say that these people will substitute for family that’s going to be around or good friends that live nearby, but it won’t be a brand new place where no one knows about your loss.

Karen Wasserman: It’ll be a place where people understand, and they feel bad too because they’ve lost a member of their community. And you might pooh-pooh the relationships that get connected with at assisted living, or the quality of community that exists, but I have seen it many times where someone who has been in a community for a year, two years, three years, even if they weren’t someone who was really good friends with everybody, that community pulls together and they support one another through the loss. It’s remarkable how that happens. I had a client in assisted living who was the bane of the assisted living’s existence. I got calls all the time as if were a family member, “You’ve got to control that woman. She said blah, blah, blah. She stood up in the dining room and said something really nasty.” And she was with it, that was just her. She was a little harsh and caustic, and she didn’t care what people thought. But when she was dying, everybody in that community came to say goodbye to her, to tell her how much they thought of her. It was so moving, and so amazing that this woman had that. She was a character but she had community.

Karen Wasserman: So we talked a little bit about when a couple has different needs, and it is complicated, but there are ways of planning so that both people get their needs met. An example is I worked with a couple, they were living independently, doing great, in a suburb of Boston. The wife started to have memory issues, the husband got me involved early to try and connect her with companions, support, because she was going to have to give up driving, which is a really complicated process. And it was really hard to make this work, and at some point it was clear they had missed the boat for moving to a continuing care retirement community because it’s hard to get in once you already have the diagnosis of dementia. And the goal was to get them into a supportive environment where she would be good during the day, going to programs, being around people, and he could continue with his activities because he was still part of a retirement education program in the community, he was driving. And so they lived in assisted living together, and he had his car and he took off, and she was great until it wasn’t working anymore and she needed a memory unit.

Karen Wasserman: And so they moved. They moved to a facility closer to his life so that he wouldn’t have far, he could walk to his classes that he was taking. And he could spend as much or as little during the day with her because she was in the memory area of the assisted living. And they went to activities together, he visited her every day. The community even in the memory support area knew him and looked forward to him visiting, and that facility supported them as a couple even though they had completely different needs. If you don’t agree, that’s often what keeps people stuck, not being able to come to an agreement about what the next step is, where you want to go. “My husband doesn’t want to move and I want to move.” Or, “My father would be willing to jump ship anytime now, but my mother says I’m never leaving this house.” Or it’s the siblings that don’t agree. And that is very painful. When you have a family and there’s the siblings either that don’t believe, or cannot actually accept that there is a memory problem going on because they talk to the person on the phone and they sound fine.

Karen Wasserman: They might be at another state or another country, and they haven’t noticed anything different. Or they’re seeing them regularly and they don’t notice the changes that are happening. And then there’s another sibling who is totally clued in that nothing’s going right because they’re the ones who are overseeing some of the finances, and bills are being paid more than once, some bills aren’t being paid at all. There’s a lot of issues going on, and your siblings are pooh-poohing that there’s really a problem. And so sometimes it’s a contentious situation and that’s really a ripe situation to come in for a little family consultation because sometimes people really … You can stay in denial even longer if you’re not educated about, “Well, What is dementia? What are the things that might be signs of dementia?” And once there’s a little more education going on, and it’s not just your annoying sibling telling you this, it’s easier. It’s just like some people don’t like their adult children telling them what to do, and so I say, “Stop telling them what to do. Let them talk to professionals. Have them go see an elder law attorney and talk about their estate, see what their options are. Maybe I could meet with them. I could come into the home and do a little visit and talk to them about resources.”

Karen Wasserman: I always low-ball it, okay? For people who think that I work at Jewish Family and Children’s Service, I’m that free social worker provided by the human service agency who’s coming in to tell you about what services are in the community. I get a long way by doing that. For others, “Look, there’s this professional from Your Elder Experts. This is all she does in life, is help people understand what their options are.” And the adult children aren’t there, and it’s just me with them. And it’s amazing, it’s a different conversation because they don’t want to be told. Their kids should not tell them what to do, and there’s a way to talk about it and there’s another way, and it’s really tricky in families, not always. Of course, I see a certain segment of the population where there’s an issue, but occasionally I meet families where they’re all doing the thing. They’ve divvied up the tasks, they’re making the parents’ lives livable, and they’re all on board with the support, whatever needs to happen. It happens sometimes, and it’s nice to see that happen sometimes. But the truth is there are a lot of people out there struggling.

Karen Wasserman: And there are a lot of adult children who I say, “Put on your bike helmet, so when you pound your head against the wall you won’t get a head injury.” You can plan at any point, you can get support in a crisis, you don’t have to do it alone. If you’re thinking about what the next steps are, find out what they are. If you’re already in the hospital and you’re overwhelmed, find out who can help you through that too. It’s amazing what a difference a hospitalization is when you have an advocate. It’s a sad state of medical care that going to the hospital without someone who’s going to advocate for you, it’s scary. It’s a scary thing. When I worked at Beth Israel Hospital, someone who came in for a hip fracture was there for two weeks. I knew that person, I knew their family, and I knew where they should go next. And there was a lot of conversation about it. You come in with a hip fracture now, you’re gone in three days. No one asks you where you want to go next, or maybe what was going on at home. There’s not a lot of time for conversation with family. And sometimes people get discharged before a conversation has happened. I say, “How did they wind up there?” “I’m not totally sure,” people say to me.

Karen Wasserman: And when they say the social worker did it, I say, “mm-mm (negative), that wasn’t your social worker. That was someone posing as a social worker.” So who do you turn to for advocacy, guidance, education? You want to turn to professionals. What kind of professionals? So every city and town has either a senior center or a council on aging where there are social workers who are there to do a home visit, to educate you about resources in the community. There are aging life care managers who are usually for hire, who can consult with you about what your options are. There are people called SHINE counselors who are volunteers but incredibly well-educated, who can help you figure out your insurance situation. People who go from private insurance to Medicare, and don’t realize that when you get Medicare not only do you need a secondary insurance to pick up the copayments, but you need one that covers your prescription drugs. And if you don’t do it at that moment when you get on Medicare, and you don’t have any other coverage, you’re going to be penalized for every year you didn’t have coverage, to the point where you then need it. So there are all these details that it’s really helpful to know. And every community has SHINE volunteers who will schedule an hour to meet with you and go through your needs, and help you understand what the options are.

Karen Wasserman: There are these free housing placement services. There’s places like A Place For Mom, or a lot of private home care agencies also say that they do placement, and they don’t charge for it. And they don’t charge for it because they’re getting commissions from the retirement communities or assisted livings that they send you to. For every place you go to that they sent you to, they get thousands of dollars. And where do they send you? 95% of those places, they send you only to the places where they have contracts. Someone in the industry said to me, in the assisted living industry, told me that only 75% of the referrals they get from the free referral services last for more than a year. No, no, 75% don’t last for more than a year. Sorry. Because you’re going to someone whose goal is to get a commission, not to make the right placement for you. Each and every community has a different personality, and it’s not the right fit for everybody. It’s truly, it’s not just an assisted living facility, it actually has a reputation. And you can only know the true reputation from professionals that have been in and out of these places. So if you want to know the scoop, don’t go for free advice. Go for someone who’s going to actually say, “I wouldn’t send you there. I’m not getting anything. You’re paying me for my advice. I’m not being paid for sending you there.”

Speaker 1: Questions. Karen will take questions, she tells us.

Karen Wasserman: Yes. Any questions.

Speaker 1: So if you have a question just raise your hand.

Karen Wasserman: Or if I wasn’t clear about something and you want to have me redo it. Yes.

Audience member 1: I just have question, on this list here, what is congregate housing?

Karen Wasserman: Oh, so what is congregate housing? Congregate housing is a subsidized, it’s part of subsidized housing. So it’s usually part of either the Housing Authority buildings in a community or sometimes they’re run by area agency on aging. They are communal living. You have your own bedroom, you might even have your own half bath, some of them have full baths, most of them don’t. There are communal showers, and then people share the living space. They have big kitchens with lots of room in the refrigerator for the people who live there. It is really designed for a specific kind of person. So it’s going to be that person who wants to live in the community, who can’t afford maybe assisted living or another type of retirement community, who can cope living communally. I meet a lot of people who don’t, and I meet some people who do. We have a segment of my program that gets grant funding for us to provide free care for low income people, and for someone who’s going to be homeless it’s a lot better to be in congregate housing than to be on the street. And so for some people it’s the right option, and for some people it’s the only option while they’re waiting for something that they might like more.

Audience member 2: On one of your slides you had the word villages.

Karen Wasserman: Oh. I didn’t talk about … Sorry. Okay. It’s really bad because I’m on the board of a village. Okay, so first there was Beacon Hill Village. It was the first of the villages. So a village is this concept for people who want to maintain their staying in the same community. So it might not be staying in your same apartment or a house or condo, but staying in the same town or city. They create a whole slew of different programs. Some of them are more social villages where they offer courses and groups, outings, social things to do. Others of them offer vetted services, so you want a handy person, but you don’t want to take that off the web because you don’t know these people. But you can join the village and then say, “I need someone who’s going to fix something in my house.” And you’re going to get the name and contact information for someone that the village knows. And if you’re a member of the village, which usually people can join. You can’t really access the services or advice unless you’re going to join. You know that you’re probably going to get a discount using that professional as well.

Karen Wasserman: So the village, you know, you go to the village in your community, you chat with the people there. The costs are anywhere from like $300 a year to $800 a year, and the services that are provided. So I’m on the board on Newton At Home, which is the Newton community village, and they do a lot of volunteer stuff. So if you’re a member of Newton At Home, you have access to volunteer who will drive you. They’ll drive you to the airport, they’ll drive you to your doctor’s appointment and make sure you’re in the door at the doctor’s appointment. They’re not going to just drive you and drop you at the front door. They’re going to stay and bring you home. You can have people rake your lawn, they have teams of volunteers who do these things. There are people who bring your garbage pail out to the curb and then bring it back. They have people who will tinker with your electronics if you want, teach you how to use your computer. There is some overlap with the senior center, but the village is there to provide resources for people who want to volunteer in their community and receive care from their community. And they’re everywhere, and they’re still growing.

Audience member 3: Just a little bit about continuing care at home arrangements, pluses and minuses.

Karen Wasserman: Yup. For staying at home?

Audience member 3: Yeah.

Karen Wasserman: So it depends on what your needs are, but private home care, usually what happens when you’re getting care at home is that if you’re transitioning from an acute medical situation your doctor might have referred you to a visiting nurse association. And they might provide what they call skilled care, through a nurse visiting, a physical therapy coming a couple of times a week. And when you’re on service, you’re receiving those therapies, you’re also eligible for some home health aid care for personal care. And it’s covered under your insurance. Once your acute situation changes, and the visiting nurses are no longer there, you’re responsible for paying for services. If you have long-term care, it might cover you after a period of time that you’ve paid privately, but we’re talking about out-of-pocket expense for daily care if you need it. So if you’re staying at home and you need that kind of attention, you can hire people either for groups of time, usually there’s a minimum. If you go through an agency, there’s usually on average a four hour minimum. So you hire someone to come in for specific tasks. If you need more than that, you can hire people round the clock. You can have someone who’s awake 24 hours a day if you’re someone who needs assistance at night, but you’re paying for, by the hour, two shifts, two awake shifts.

Karen Wasserman: If you’re someone who doesn’t need much attention at night, you can buy care as a live in. So someone who’s getting rest at night, who’s sleeping in your home so they’re there if there is a need, but they’re going to be there during your waking hours caring for you. The difference is cost. If you’re paying for awake care 24 hours, you’re paying anywhere from $25 to $35 an hour for 24 hours. If you have a live in person, you’re paying for the entire day, you’re paying anywhere from $300 a day to $450 a day, depending on the agency. You don’t always need to go through an agency. There’s always that network of people that you find out about word of mouth who provide the care that you might need, that are not part of an agency. Some of those people are paid under the table, some of those people are paid over the table. If you want it to be above board and you’re hiring independently, you’re going to responsible for doing the finances, of dealing with the taxes and insurance and stuff. And for some people that’s too overwhelming. When you go through an agency, they’re vetted, they’re supervised, something happens to them, there’s a replacement. And there’s someone to call when it’s not going right.

Audience member 3: My question was more something a little different.

Karen Wasserman: Sorry.

Audience member 3: That’s okay. That was interesting. CCRCs that have an option for you to stay at home, then when it’s time to do more care you can move into their assisted living facility or a nursing home.

Audience member 4: Northville has-

Audience member 3: Yeah, we’re from Nashua, New Ham. There’s a place there called-

Karen Wasserman: And they’ll provide you with some services.

Audience member 3: Right.

Karen Wasserman: Right. I have to say that I have not seen that happen much. What I have seen is people who are on wait lists being told that they could have some guidance as needed while they’re waiting, but I have not come across many people who have taken advantage of it.

Audience member 3: Yeah.

Karen Wasserman: But the thing that I know about waiting lists is that in many places the waiting list is only as good as the people who are in front of you, and many times communities say, “Oh, there’s a waiting list,” because it sounds really good, makes it look really like it’s going to be hard to get in. But if the people who are before you have moved already, no longer appropriate to live in the community, or sadly, passed away, the waiting list becomes much shorter. Sorry.

Audience member 5: I was just going to respond. I think other than Lexington, and I’ve had ads from Carleton-Willard At Home, which again, I get promises to be part of the community while you’re still at home. But I’m planning on [inaudible 01:02:54], so.

Karen Wasserman: Right. Carleton-Willard in Bedford has an at home program. I believe it is the Bedford At Home program, but I’m not positive. And you know, it is a way to support the potential community and to bring you in, you have access to the programs that are going on, and a chance to meet people before you move in. One, and then two.

Audience member 6: Okay. Do you have a bias, or are there pros and cons between a for profit and a nonprofit provider?

Karen Wasserman: Okay. For across the board?

Audience member 6: Maybe across the board, or maybe CC, whatever it is.

Karen Wasserman: CCRCs?

Audience member 6: CCRCs, yeah.

Karen Wasserman: Okay. I worked in a nursing home briefly, and it was a corporate nursing home. So I got to see firsthand what it’s like when healthcare and business are together. And it was a scary awakening for me to see how increasing your profits, what it does to the people who you’re serving, so I was appalled to find out that the corporation would cut the budget for food, which was already minuscule. But they were in Arizona, and they didn’t really care. So yeah, I have a bias. It’s not that the not for profits aren’t trying to cover their butts and keep the place running, but there is a slightly different feel to them. That said, there are a lot of corporately owned businesses, communities out there, whether they’re assisted livings nursing homes, because there are very few nursing homes at this point that are owned by families. And I point that out to people during consultations, and some people come in with the bias themselves, but I do refer to these other places because some of them provide decent care, and some of them will be a good fit. And that might mean that I get over my pet peeve about some of their policies and the run their business, but if I think that my client’s going to get the best care or it’s going to be the best fit I would refer to a for profit place.

Audience member 7: If you already have a long-term care policy, is there a certain models that are better, or worse?

Karen Wasserman: Did you say if you don’t already have?

Audience member 7: No, if you do already have.

Karen Wasserman: If you do already have a long-term care … I’m sorry I missed the exact question that you’re asking.

Audience member 7: Well, like in my understanding you said there’s different models for these CCRCs.

Karen Wasserman: Oh, of the CCRCs, thank you. Yes, there are different models, but they’re going to vary depending on where you are, like where you’re located, where you want to live, and what services you think you’re going to need. So if you’re someone who’s got a chronic illness but is currently independent, if you’re going to be needing care you want to go to one that really provide excellent care along the spectrum.

Rick Miller: Karen, I think that the question is, if he has a long-term care insurance policy.

Karen Wasserman: Oh, sorry. Yeah.

Rick Miller: If he has a long-term care insurance policy, are there certain CCRCs that are going to make better use of the benefits, I guess is the question.

Karen Wasserman: I actually don’t think that that is a deterrent for going one place over another. I think what you want to make sure is that you understand the benefit of your … This is what I see happen more often is that people don’t understand what their benefit is, and what triggers the benefit. And that’s the most important thing because you can access your benefit once you’ve reached their benchmark for needing it, but you want to make sure that it’s going to cover you. Like, there are older policies that don’t cover assisted living. There are some policies that are just for nursing homes, or there are some that are just for home care. So knowing what your policy is going to cover, and what the waiting period is can also help you think about when you start applying for the assistance.

Karen Wasserman: Like, some people might be pushing it off because they want to save the benefit, but if you need the care and you should start the 90 days or the hundred days elimination period as soon as you can so that the care can be provided. But I don’t think it matters where you’re getting it, as long as the benefit’s going to cover you. And a CCRC … Like, even an assisted living, people who are covered for assisted living, they’re getting a benefit based on a percentage of your rental because part of the rental is just custodial care, so to speak. But part of it is considered hands-on care, and so that percentage is going to be covered by your insurance, and that would be true no matter where you lived. Did that sort of get at it?

Audience member 7: Not really.

Karen Wasserman: I’m sorry, but maybe afterwards I can dig in a little deeper, sorry.

Audience member 8: My understanding from long-term care insurance is that the client has to fail a certain number of stipulations that they put in at the beginning, like can they dress themselves-

Karen Wasserman: Activities of daily living.

Audience member 8: What’s that?

Karen Wasserman: Activities of daily living.

Audience member 8: Right, so there’s five categories, I think.

Karen Wasserman: Yeah.

Audience member 8: I thought that if you failed three or four of them, then you qualify. So I’m not sure how this gentleman’s question would be impacted by what facility you go to.

Karen Wasserman: It wouldn’t. The facility is not important. What your needs are, and your ability to have a doctor document those needs is the most important piece.

Audience member 8: Well, I think what I meant was that I didn’t want to pay twice for the same thing.

Karen Wasserman: Right.

Audience member 7: So if going into a particular facility that already provided me with certain kinds of care, that I wouldn’t want to go into a facility where that’s built in and I’m paying for that if I’m eligible to receive that benefit from my long-term care insurance already.

Karen Wasserman: But if it covers some of the cost in that community, it reimburses you for what you’ve paid for certain percentage of the care you’re getting, depending on physically what you need help with.

Audience member 7: I see, and the facility would take care of that for me, because that sounds very new?

Karen Wasserman: It would document what care you’re receiving, and usually then you are then responsible for submitting it. If you’re at home and you have long-term care, and you’re receiving care, often an agency will take care of that for you. They’ll submit their bills, they’ll submit their notes. But usually in a facility it’s more up to the family or the individual to seek out the reimbursement.

Audience member 9: Do the retirement community or independent living or assisted living accept Section 8 vouchers? When will we be seeing that? They say it’s five years waiting, two years waiting, and then we never get … And by that time we find something the timeframe is over.

Karen Wasserman: There are some assisted livings that have a whole list of subsidies, different ways in which you can pay your monthly rent. They have tax credit units, they have state and federal programs called PACE and group adult foster care. These are all income based. Some of them, very few of them though, accept Section 8 in assisted living. Not usually in a retirement community, although there are some independent elder housing that will accept it because it’s not a service based thing, it’s just housing. And they have a certain amount of apartments that they rent with the Section 8. And you can use a Section 8 voucher in the housing authority buildings in each town and city. It’s much harder to get the Section 8 because there’s a long waiting list, than it is to find a place to use it.

Audience member 9: Every town and every city has a different pricing. Some in Waltham is $1,900, Framingham is $1,600. Well, you like housing authority says that you cannot rent this thing.

Karen Wasserman: Can you repeat the last sentence?

Audience member 9: Suppose I like something in Framingham, when I go to the housing authority of Waltham, they said, “You cannot.” Framingham is a lower pricing.

Karen Wasserman: Yes. Okay. Some Section 8 housing is project based, meaning that you have to live in their building, some of them are movable, a movable voucher, you can live anywhere, and some of them are really, I think, town based. But the amount of money that you’re allowed … that you would have to pay, you’re telling me that it’s different based on each town. So you have to just actually find out from each town what you would be responsible for. And yes, it’s complicated. I’m not saying it’s not, but I don’t have an answer to how you would be able to use it and not find out for each individual place.

Audience member 9: No, but they don’t give us the proper site where we can find suppose Framingham, suppose Maynard, or Marlborough. What is the price for Marlborough or Framingham or this? When you like something … I’m searching for the last one, month.

Karen Wasserman: Mm-hmm (affirmative).

Audience member 9: When I go to Waltham, I’ll say, “Well, it’s ready.”

Karen Wasserman: Yes.

Audience member 9: They said, “You cannot rent this property.” This is a lower price. Waltham is very high pricing. Waltham has nothing to offer us.

Karen Wasserman: You have the Section 8 voucher.

Audience member 9: Yes.

Karen Wasserman: Not every landlord is willing to accept it. I mean, that’s also an issue because they have to be willing to be regulated in terms of how much they’re going to be reimbursed. I can give you a phone number to call, though, afterwards, that will help you figure out how to manage that.

Audience member 9: Okay.

Karen Wasserman: Okay.

Audience member 9: Thank you.

Karen Wasserman: Yup.

Audience member 10: Recently there was something very scary that happened locally. There was a whole bunch of nursing closed at once. They were corporate nursing homes, the company went under.

Karen Wasserman: Yeah.

Audience member 10: In your practice as an elder care management professional, how soon do you become aware of places that are shaky or iffy, or financially eh?

Karen Wasserman: Well, partly what we’re aware of is which facilities are owned by whom, right?

Audience member 10: Yeah.

Karen Wasserman: And some facilities have reputations, you know? Sometimes those places, they change their name to avoid being able to Google such and such a place and find out that they were cited and closed for a period of time. But if you’re being recommended to a place, it’s going to be some place that we know. So the nursing homes that closed were not necessarily nursing homes that we would have referred to, and there are nursing homes that are not adequate. And you know, people always bring in those lists of the grade they got by, I think it was … Is it Social Security or Medicare that goes?

Audience member 11: Medicare.

Karen Wasserman: Medicare goes and they survey them, and they write up a little thing, you know? Well, first of all it’s not the same team that goes from nursing home to nursing home so there’s this wide variety of … It’s subjective, you know? So you have places that get cited for one thing that another place would have if they had bothered to look, and so I say those grades are useless. Useless. There’s one nursing home I see, several times a week I drive by it, and it always got the, “We got the five star whatever.” And I’m thinking, “God help the people who believe that.” So yes-

Audience member 10: It’s about as valid as a Yelp review.

Karen Wasserman: Exactly, and inevitably that restaurant has closed, and I don’t find out until I’m standing in front of the empty building, yeah. Yeah.

Audience member 12: How does an elder care manager charge for services?

Karen Wasserman: Sure. So we bill by the hour, and it varies from practice to practice. And some practices have a retainer, and others don’t. I have fought to keep ours to be one that does not have a retainer. I feel as though when people are in crisis it’s really doesn’t feel good to ask them to send us a check for a thousand dollars before we’re going to talk to them. So we’ve kept it quite simple, in my practice we charge for everything by the hour in 10 minute increments. And we charge a different rate for our travel time, it’s half of our hourly rate. And I’ll say that the rate for my time is $200 an hour, the rate for my team is $165. We have associates who do some of the work for us that work underneath one of the care managers. We bill less for their time as well. We are basically only doing what you ask us to do, so we’re not out there trying to build up our hours. We’re out there to try to accomplish what it is that you want to have accomplished. So sometimes I see people for an hour and I never see them again. They walk out with their map. Sometimes the direction they’re headed changes and I do see them again, usually a few years later.

Karen Wasserman: “Do you remember me? We didn’t really do anything since we last spoke to you, but the map had to change because X, Y, and Z happened.” Or it’s the adult child who comes back and says, “Okay, we’ve reached the crisis, and now I need your help because we’ve got to make a change.” Or there are people who say, “I can’t do that on my own. I want you to help me. I want you to come with me to tour some places because I don’t know what I’m looking for.” Or it’s an adult child who can’t bear to go into the nursing home alone, and wants someone to do it with them. And there are people who we manage and monitor their care because there’s no one else, or no one appropriate to do it. And they’re being billed by the hour. And for some people not in crisis, we might not see them for a few months. And for someone in a crisis, or coming to us in a crisis, it might be a lot of time, but it really varies. People ask me all the time, “What’s your average cost per month?” And I say, “Well, it could be zero, or it could be $5,000 if you’re in a major crisis in the ICU for a few weeks without anybody else there to advocate for you.”

Rick Miller: I think we have time for one more question.

Audience member 13: Do you have any recommendations for resources that gives you an idea about these CCRCs or assisted livings? Is there some impartial resource.

Karen Wasserman: So you asked for a resource that might help you figure out which places-

Audience member 13: I’m think like online, anything that can consolidate some of these.

Karen Wasserman: Honestly, online you can educate yourself about what they should offer, but online you’re not going to learn the real story about the places unless you speak to people who have been there. I hate to see people tour 15 assisted livings. It is a waste of time, you won’t remember the difference between one country kitchen and one dining room. They will blend. And I also really hate it when families take their older relatives on all these tours too because that’s cruel. It’s important to have the field narrowed down. When I meet with people, I never give more than four or five places that I think would meet their needs, and then they get to choose which ones feel comfortable to them. But online, it’s just all about marketing.

Rick Miller: Okay. Well, Karen, thank you very much

Karen Wasserman

Karen Wasserman

Karen Wasserman, LICSW founded the Jewish Family & Children’s Service care management program in 1999 and has managed its growth into one of the Boston area’s leading care management practices. She leads educational programs in the community about elder services, housing, and care management and is a nationally certified care manager.

Karen is a member of the National Association of Social Workers and both the national and New England chapters of the Aging Life Care Association. Karen earned her BA from Brandeis University and her master’s in social work from Simmons College.


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