Caring for Elderly Parents How to care for elderly parents is a major concern of many Foreign Service families. Our concerns mirror those of other American families, but how to ensure good health care, find the right living situation, and handle legal questions is often complicated for Foreign Service families by being posted abroad. The distance involved makes it harder to get information and help so contingency planning is essential.
Often Foreign Service families only have short visits during R & R or on home leave and hate to spend the precious time with their parents talking about serious business or unpleasant possibilities. Or we may be caught up in hectic preparations for an overseas assignment and not want to take the time to do contingency planning with parents. While it is difficult to discuss the issues of aging, the family who has discussed the options and agreed on plans will be better able to handle whatever happens. It will be worth the time taken, if there is an emergency.
The ideal situation is when the parents take control of their own situations and make decisions in advance of an emergency. They should investigate the types of retirement options and decide which is most appropriate, make informed decisions about life-sustaining medical care, and make sure that documents, instructions, and powers of attorney are available to those who must take responsibility in an emergency. The American Association of Retired Persons recommends that elderly people use a document locator list (scroll to bottom of this page) to make sure their papers are in order.
This list can then be given to the person(s) who will be responsible for them should an emergency arise. Going through the list with your parents should ensure that their wishes are understood. Communicating with Elderly Parents Talking with our elderly parents about their living situations and the possible need for change is not always easy. A successful conversation depends to an extent upon the relationship we have with the parent, as well, of course, as on the parent’s mental, emotional and physical condition.
While many people put off serious conversations to avoid conflict or awkwardness, both parent and adult child may lose an opportunity for closeness, understanding, access to information that may affect the decision, and optimum peace of mind. To the extent possible, talk with your elderly parents gently and honestly about their wishes, their abilities and their options. Far more often than not, these conversations are helpful and put the adult child in a better position to make decisions later when the parent may not be able to do so.
The following are suggestions for conversations with your elderly parent: * Share your own feelings, and reassure the parent that you will support them and can be depended upon to help them solve their problems. * Help the parent to retain whatever control is possible in making his or her own decisions. Respect and try to honor their wishes wherever feasible. * Encourage the smallest change possible at each step, so that the parent is more able to adjust to the change. Educate yourself on legal, financial and medical matters that pertain to your parent as background for your conversations, including current knowledge on the aging process. * Respect your own needs – be honest with your parents about your time and energy limits. If this kind of conversation seems impossible or the situation and relationship with the elderly parent become overwhelming, professional counseling may be very helpful. You may also consider using the Department of State’s resources to approach this delicate issue somewhat indirectly.
Filling out FIVE WISHES for yourself and sharing your decisions with your parents may encourage them to open up on the subject. You may also wish to raise the subject of long-term care insurance as a practical matter. (For more information about FIVE WISHES and Long-Term Care Insurance, see below). When a Lifestyle Change May Be Necessary Physicians and geriatric social workers warn that there are a number of danger signs that indicate an elderly person needs extra help or a change in living arrangement. Any marked change in personality or behavior should be heeded.
However, no change in lifestyle should be made without discussions with the elderly person, other family members, and doctors or other health professionals. Danger Signals * Sudden weight loss could be an indication that the elderly person is simply not eating or not preparing foods. * Failure to take medication or over-dosing may indicate confusion, forgetfulness, or a misunderstanding of the doctor’s instructions. * Burns or injury marks may indicate physical problems involving general weakness, forgetfulness, or a possible misuse of alcohol. Deterioration of personal habits such as infrequent bathing and shampooing, not shaving, or not wearing dentures could be the result of either mental or physical problems. * Increased car accidents can indicate slowed reflexes, poor vision, physical weakness, or general inability to handle a vehicle. * General forgetfulness such as not paying bills, missing appointments, or consistently forgetting name, address, phone number, and meal times could be a signal. * Extreme suspiciousness could indicate some thought disorder.
Your parents thinking that their neighbors, friends, family, doctor, and lawyer are all conspiring against them would be an example. Intense ungrounded fears about dire consequences may be a danger signal. * A series of small fires could be caused by dozing off, forgetting to turn off the stove or appliances, or carelessness with matches. They may indicate blackouts or dizzy spells. * Bizarre behavior of any kind could be a warning sign. This behavior could be dressing in heavy gloves and overcoat in 90 degree weather or going outside without shoes when it’s snowing. Watch for uncharacteristic actions or speech. Disorientation of a consistent nature may indicate a need for help. Examples include not knowing who one is, where one is, who the family is, or talking to people who are not there. Elder Care Options If you see danger signals in your parent’s behavior, it is important to discuss the changes and do some research. (See IQ: Information Quest below for information about the Department of State’s free resource referral service. ) There are many housing options available to the elderly. Choosing the best one will depend on the elderly person’s preference, age, health, and financial condition.
Aging in Place Under this option, the elderly person continues to live in his/her own apartment. Many elderly people live in Naturally Occurring Retirement Communities (NORCs), apartment buildings, condominiums, or cooperatives not designed as retirement communities but where at least 50 percent of the residents are 62 years old or older. These buildings often have amenities such as grocery stores, pharmacies, limousine service, or shopping services. Recent technological advances often make aging in place easier: Velcro asteners, lightweight wheelchairs, devices to control appliances and dial telephone numbers. There is even a “walk-in bathtub” for people who have difficulty climbing into an ordinary bathtub. Many services are available to help the elderly person stay in his/her home. Information about them can be obtained from contacting IQ: Information Quest (see below) or your local Area Agency on Aging. * Home care services are available in many communities, providing appropriate, supervised personnel to help older persons with either health care (giving medications, changing dressings, catheter care, etc. or personal care (bathing, dressing, and grooming). * Meals and transportation are available to older people to help them retain some independence. Group or home-delivered meal programs help ensure an adequate diet. Meals-On-Wheels programs are available in most parts of the United States. A number of communities offer door-to-door transportation services to help older people get to and from medical facilities, community facilities, and other services. * Adult day care is similar to child day care. The elderly person goes to a community facility daily or 2 or 3 days per week.
Activities include exercise programs, singing, guest lectures, and current events discussions. Cost varies and there are often long waiting lists at such centers. * Respite care brings a trained person into the home to give the full-time caregiver time off to get a haircut, visit the dentist, or take a vacation. Service is generally offered through area Departments of Social Services and is based on a sliding fee scale. Other Housing Options There are several types of retirement communities that provide living arrangements and services to meet the needs of both independent seniors and those who need assistance.
Large hotel corporations are in this field and other facilities are set up for members of a certain organization (retired military, Elks, etc. ). It is important when investigating these housing options to understand completely the services provided and the cost. * Adult congregate communities are designed for the fully able-bodied, 55 and older. Residents buy co-ops or condominiums and pay a monthly fee for grass mowing, leaf raking, and snow shoveling. A pay-as-you-go medical center is on site and a nurse is on duty 24 hours a day to make home visits in emergencies. Leisure World is the most famous example of an adult congregate ommunity. * Assisted living communities are rental retirement communities for independent seniors who need some assistance. A homelike atmosphere, three meals a day, maid, linen, and laundry service, availability of a registered nurse, and many personal care services are provided in the all-inclusive rent. * Rental retirement communities with fee-for-service nursing units charge residents an entrance fee plus a substantial monthly rent. When the need for nursing care arises, residents pay an extra daily fee and stay in a nursing unit, usually located on site or nearby. Life care or continuing care communities provide a continuum of care from independent living to nursing home care on the premises. The individual must be independent when s/he enters the community. These communities require a substantial entrance fee and monthly service fee. Residents get one meal a day in a dining room, maid service, linen service, maintenance, transportation to shopping and cultural events, travel planning, and a pull cord to an emergency nurse. If nursing care is needed, it is provided at no extra cost. Personal care homes (board and care) are licensed in many communities to provide shelter, supervision, meals, and personal care to a small number of residents. * Subsidized housing for the elderly is an option for the elderly poor in reasonably good health. Subsidized by Department of Housing and Urban Development, income limits apply. No round-the-clock care is provided but nurses come in to check blood pressure and assess a resident’s functioning. Residents take meals in a dining room and may have use of a library, recreation area, or beauty shop. Nursing Facilities
If the elderly person is not capable of independent living, a nursing home may be the appropriate option. Nursing homes offer two levels of care – skilled nursing and intermediate care – depending on the patient’s needs. Most nursing homes offer both levels of care on a single site. * Skilled nursing facilities provide 24-hour nursing services for people who have serious health care needs but do not require the intense level of care provided in a hospital. Rehabilitation services may also be provided. * Intermediate care facilities provide less extensive health care than skilled nursing facilities.
Nursing and rehabilitation services are provided but not on a 24-hour basis. These facilities are for people who cannot live alone but need a minimum of medical assistance and help with personal and/or social care. Paying for Long-Term Care It is important to understand the different types of insurance that are available to older people. Many people believe that Medicare will cover long-term care needs. It will not. Medicare Medicare is a Federal health insurance program which helps defray many of the medical expenses of most Americans over the age of 65.
Medicare has two parts: (Part A) Hospital Insurance helps pay the cost of inpatient hospital care. The number of days in the hospital paid for by Medicare is governed by a system based upon patient diagnosis and medical necessity for hospital care. Once it is no longer medically necessary for the person to remain in the hospital, the physician will begin the discharge process. If the person or the family disagrees with this decision, they may appeal to the state’s Peer Review Organization. Medicare does not pay for custodial care or nursing home care.
It will, however, cover up to 60 days in a nursing home as part of convalescence after hospitalization. (Part B) Medical Insurance pays for many medically necessary doctors’ services, outpatient services, and some other medical services. Enrollees pay a monthly premium. Medicaid Medicaid is a joint federal-state health care program for people with a low income. The program is administered by each state and the type of services covered differs. There are strict income requirements so it is necessary for the person to “spend down” all income and assets to poverty levels before becoming eligible.
Medicaid is the major payer of nursing home care. The Medicaid requirement to “spend down” all income and assets created a great hardship for the spouse of a person needing nursing home care. Changes in the Medicaid rules now allow the spouse to keep a monthly income and some assets, including the primary residence. The amounts allowed change, so you must check for current levels. Other Insurance Why buy other insurance? The purchase of additional insurance gives the policy holder access to a greater choice of facilities without dipping into additional financial resources. Medigap is the name given to rivately-purchased supplemental health insurance. It is designed to help cover some of the gaps in Medicare coverage but does not cover long-term care. Study Medigap policies carefully to be sure they provide the protection needed and do not duplicate other health insurance. Long-Term Care Insurance is a private insurance that is usually either an indemnity policy or part of an individual life insurance policy. An indemnity policy pays a set amount per day for nursing home or home health care. Under the life insurance policy, a certain percentage of the death benefit is paid for each month the policyholder requires long-term care.
Policies are priced differently depending on the age of the policyholder, the deductible periods chosen, and indemnity value or duration of benefits. Information about other long-term insurance policies are available from: The American Foreign Service Association (AFSA) Retiree Liaison 2101 E Street, NW Washington, DC 20037 Tel: 202-338-4045 , ext. 528 Fax: 202-338-6820 E-mail: [email protected] org http://www. afsa. org American Foreign Service Protective Association (AFSPA) 1716 N Street, NW Washington, DC 20036 Tel: 202-833-4910 Fax: 202-883-4918 ttp://www. afspa. org As with Medigap health insurance, it is important to read the policy carefully and understand its restrictions before purchasing. Who Can Help? IQ: Information Quest (formerly LifeCare? ) IQ: Information Quest is a free 24-hour/ 7 days per week counseling, education and referral service that can help Department of State employees find the programs, providers, information, and resources they need to manage personal and professional responsibilities. IQ: Information Quest makes referrals, not recommendations. IQ: Information Quest counselors will help etermine what services are needed and available in any U. S. locality and refer to appropriate providers. In addition to other services, they provide referrals in the area of adult care services (anywhere in the U. S. ), including case management, emergency and respite care, home health care, long-distance care giving and legal and financial issues. Their web site features information on caring for an aging loved one, discussing caregiving options with your loved one, adult care information worksheet, caregivers of older adults, managing work while caring for your loved one, and geriatric care management services.
IQ: Information Quest will also provide an “Eldercare Kit” upon request which features caregiving guidance, checklists, and resources information, as well as a few useful practical items such as a pill sorter, night light and jar opener. Permanent employees of the Department of State, The U. S. Agency for International Development, the Department of Justice, the Department of Labor, and FMAs overseas are eligible to use IQ: Information Quest. For the Department of State, this includes both Civil Service and Foreign Service employees serving at any Department assignment location nationwide and worldwide.
Other employees working for the Department are not covered at this time (contractors, Foreign Service Nationals, PITs, PSCs). Spouses, children or others who are members of the employee’s immediate household may use IQ: Information Quest. They verify eligibility by providing the name and date of birth (month and day) of the eligible employee. Employees of agencies other than the Department of State should check with their headquarters for guidance in how to contact and use IQ: Information Quest services. IQ: Information Quest
Tel: 1-800-222-0364 or 1-888-222-0364 for the hearing impaired http://www. worklife4you. com For access to the passworded area of the site, contact your agency’s HR Bureau. The Employee Consultation Service (ECS) The Employee Consultation Service (ECS) at the Department of State should be the first stop for Foreign Service members with eldercare concerns. The clinical social workers offer brief counseling and help in coordinating an evaluation and assessment anywhere in the United States.
ECS social workers act as a liaison in providing appropriate and necessary services for the elderly. All services are free and confidential. In Washington, make an appointment for a personal consultation; from overseas write or cable for advice. ECS also conducts support groups for employees and their families who are responsible for an aging relative. The groups meet at the State Department to share issues, resources, and approaches to the problems that arise as an elderly person declines, including the issue of emotional stress that occurs for family members watching such decline.
Employee Consultation Service (M/MED/ECS) Columbia Plaza, Room H246 Washington, DC 20520 Tel: 202-663-1815 FAX: 202-663-1456 Email: [email protected] gov The Administration on Aging (AoA) The Administration on Aging (AoA) is part of the U. S. Department of Health and Human Services. It was set up to “remove barriers to the economic and personal independence of older persons and to assure the availability of a range of appropriate community and family based services for older persons in social or economic need. AoA supports a network of the state and Area Agencies on Aging that reinforce and supplement the daily support that the elderly receive from family, friends, and neighbors. Administration on Aging Department of Health and Human Services 330 Independence Avenue, SW Washington, DC 20201 Tel: 202-619-0724 http://www. aoa. gov To get information on eldercare services in a particular community, contact the Area Agency on Aging. One can locate a specific state agency on aging through the Eldercare Locator Service via telephone ( 1-800-677-1116 ) or the website at http://www. ldercare. gov. The Eldercare Locator Service is sponsored by the AoA and operated by the National Association of Area Agencies on Aging. National Association of Area Agencies on Aging 927 15th Street, NW Washington, DC 20005 Tele: 202-296-8130 http://www. n4a. org Services provided by Area Agencies on Aging include information and referral, homemaker/home health aides, transportation, congregate and home delivered meals, chore and other supportive services. Types of services available vary in each community based upon needs and resources. Private Geriatric Care Managers
Private geriatric care managers are professional social workers and nurses who assist the elderly and their families by assessing need, coordinating services, and monitoring care for a fee. They are particularly helpful when long-distance care giving is necessary. Fees vary and are sometimes covered by Medicare or private insurance. The Department of State’s Employee Consultation Service or IQ: Information Quest, the local Area Agency on Aging, and community agencies can provide referrals nationwide. If the older person has been hospitalized, hospital discharge planners can also provide information and referrals for after-care.
Services Offered by the Private Sector Some private companies have set up programs to help their employees with eldercare. Foreign Service spouses who work in the private sector should investigate any eldercare options offered by their employers. These programs can include seed money for eldercare services, flexible work schedules for caregivers, subsidies for eldercare expenses, unpaid leave for up to a year, referral services, inter-generational day care centers (for both the elderly and children), geriatric assessment and case management, and group rates for long-term care insurance.
Unfortunately, many of the services provided by companies require that the elderly person meet the tax-law definition of a dependent. This increases the burden for families whose elderly relatives are not financially dependent or who are not living with the employee. Eldercare in the Foreign Service Putting Parents on Your Orders Foreign Service employees may request that their elderly relative(s) (including step parents and legally adopted parents) be approved as an eligible family member and added to their Post Assignment Travel Orders for an overseas assignment.
The employee must complete an OF-126 Foreign Service Residence and Dependency Report. This form can be found on the Department of State Infoforms with instructions on completion. Each new OF-126 replaces the old OF-126, therefore all blocks must be filled out each time a new OF-126 is done. The new OF-126 must be forwarded to the employee’s personnel technician in HR/CDA/ASD, Room 2419, Truman Building (Main State). Travel orders can not be authorized for newly-acquired eligible family members until the personnel technician receives the OF-126 form.
Along with a completed OF-126 form, the officer must prove that the relative is at least 51 percent dependent for support (subject to review and approval per 6 FAM 117; USAID employees should also see Supplement 1B to HB 32, Chapter 1). The officer must quantify that he/she has provided more than 51% of support by submitting an affidavit or notarized statement testifying to that fact. This is termed passing the “financial support test. ” An explanation regarding the parent’s residency is also required, with an explanation as to why the application is being made to add the parent to the travel orders.
Other documentary evidence may be required by the employee’s agency. These documents are attached to the completed OF-126 form and sent to the officer’s agency as specified on the forms. Requests are reviewed for approval by a Personnel OF-126 Committee. Employees of the Department of State can obtain advice on how to put your parents on your orders through the Career Development and Assignments (CDA) division of the Bureau of Human Resources. Ask for an Assignments Support (CDA/AS) officer. Employees of other agencies should contact their HR representative.
See section below, Taking an Elderly Relative to Post, for details regarding official government support. Bringing Parents to Post Who Are Not on Your Orders If your relatives are not financially dependent on you, they may come to post as members of the employee’s household, but will receive no official support from the U. S. Government. No official support translates into no access to the U. S. embassy health unit, no airfare or allowance payments in the case of evacuation from post, and no diplomatic status with the host country.
Parents who come to live overseas for an extended period of time should consider having additional medical insurance (Medicare does not cover costs related to care overseas). In addition, parents should also maintain Air Medical Evacuation Insurance. A list of companies that provide this insurance can be found on theDepartment of State Consular Affairs web site. Family Medical Leave Act and Family-Friendly Leave If you think you may need to care for an elderly relative, be sure to check the provisions of the 1993 Family Leave Act on taking leave for this purpose and contact the a leave specialist in your agency.
Department of State employees can contact a Department leave specialist in the Office of Employee Relations (HR/ER/WLP) about paid and unpaid leave at 202-261-8180 . Eldercare Emergency Visitation Travel (Eldercare EVT) In January 2001, the Eldercare Emergency Visitation Travel (Eldercare EVT) provision was implemented, permitting travel at government expense for employees and eligible spouses serving at an overseas post who need to assist parents in declining health. Eldercare EVT allows an employee two trips over a career to visit his or her parents.
It is meant to support one mother and one father of the employee and of the eligible spouse. It does not mean a couple may pool their four eldercare visits to assist the parent(s) of only one member of the married couple. For more information, email the Family Liaison Office ([email protected] gov) for a copy of “Questions and Answers on Eldercare Emergency Visitation Travel. ” Taking an Elderly Relative to Post If elderly relatives are classified as eligible family members, they travel on diplomatic passports and have the same diplomatic immunity as a spouse or child.
If not classified as such, elderly parents use tourist passports and do not have diplomatic status. Housing assignments are based on the number of official eligible family members the employee brings to post. Travel to and from post (with the exception of medical travel) is also available to all elderly parents designated as eligible family members. Elderly parents, regardless of their status, are not covered by the Foreign Service medical insurance program. While the use of post’s health facilities is not promised as a benefit, these limited facilities are sometimes available depending on the location and an authorization by the Ambassador.
The medical officer has the authority to refuse to provide services should a patient have a complicated problem that the physician is unable to treat. Employees may, however, ask the Health Unit for names of local physicians who can provide medical services for their elderly parent. This kind of assistance from the Health Unit may also be requested during the bidding process, to determine if a post has adequate local heath care providers to meet the medical needs of a parent. The Department of State Office of Medical Services has a brochure entitled Medical Questions and Answers about Taking Your Parent Overseas.
The brochure addresses the questions of obtaining prescription medicines overseas, high altitude climates and the elderly, health unit access, hospitalization overseas, and more. For a copy of the brochure or more information about medical questions related to taking your parent overseas, contact the Office of Medical Services, Foreign Programs (MED/FP). Because elderly parents are not covered under the Foreign Service medical insurance program, they also do not have access to embassy medical evacuation (medevac) services.
Therefore, all parents coming to post for either a short or an extended period of time should purchase (and maintain) Air Medical Evacuation Insurance. A list of companies that provide this insurance can be found on the Department of State Consular Affairs website. Medical Insurance It is essential that a parent going overseas, either officially or unofficially, have adequate medical insurance. Medicare only pays medical expenses in the United States, and in Canada and Mexico under certain very limited circumstances.
The insurance companies listed below provide a variety of coverage and can be contacted for more information. Pay special attention to “age limit” noted in the policy. Clements and Company Under its GlobalCare Plus program, Clements and Company provides overseas major medical insurance, including full world-wide evacuation services. Coverage is offered for individuals as well as families. Substantial coverage is available at a reasonable cost. GlobalCare Plus is for policies lasting 6 months to one year. Clements also write policies for shorter-term travel (15 days to 4 months) through Patriot Travel Medical Insurance.
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