Hidden Liabilities of Home Companions

At-home care using home companions or home health aides is the single largest, yet informal system for the delivery of healthcare services in this country today accounting for an estimated 95% of care delivered. Families that hire caregivers or outside contractors such as home health aides or home companions to perform a variety of services may unknowingly be exposing themselves to a variety of risks that may not be covered through their homeowner's or general liability insurance policies. In addition, as an employer, there are certain tax consequences associated with the employment of a home companion for which they may be unaware.

Tax Consequences

Domestic employment practices first received media attention when Attorney General-designate Zoe Baird, was unable to secure what was expected to be a unanimous approval during her January 1993 Senate confirmation hearings due to the failure to pay employment taxes and violation of immigration laws relating to the employment of her domestic help. She was also found to be subject to penalties and fines relating to her employment practices. The Internal Revenue Service requires payroll tax filings by a domestic employer who pays a caregiver more than $1,200 cash wages in a calendar year. These payroll tax obligations may include: Social Security and Medicare Taxes (7.65% of Gross Wages), Federal Unemployment Tax (FUTA), State unemployment and disability insurance taxes levied on the employer, and advance payment of earned income credit for eligible employees. The employer (often the family of the elderly person in need) is required to collect the employee's social security and Medicare taxes. Should the employer fail to collect, they still remain responsible to remit these taxes for the employee. Congress revised the "Nanny Tax" legislation in October 1994, offering employers alternative means to remit the federal payroll taxes for wages paid. This legislation requires employers to disclose the wages paid to household staff on the employer's personal income tax return. Failure to disclose this information will compromise the integrity of your personal tax return. Additionally, there is no statute of limitations on the failure to report and remit federal payroll taxes. You are most likely to be "caught" when a former employee files for unemployment, disability or social security benefits. The state then realizes that the person was receiving unreported compensation. Employers are generally required to pay back taxes, penalties and interest charges, and usually professional fees for an accountant and/or attorney. Employers are required to give their employee a wage and tax statement (Form W-2) no later than January 31.

Additionally, domestic employees must be paid at least the Federal minimum wage, currently $5.15 (9/1/97). Live-in employees must be paid for every hour worked; all employees must be paid overtime for any hours exceeding 40 hours per week. If the person lives on site then the Department of Labor assumes 8 hours sleeping or 16 hours working per day, or 112 hours per week. Since anything in excess of 40 hours per week is required to be paid at time and one half, this situation would result in 72 weekly hours of overtime. This translates to $2,600 per month for 24-hour coverage, not including loading for payroll taxes, which is comparable to the cost of assisted living. For a live-in, fair value of room and board can be deducted from straight pay. Failure to observe employment regulations relating to the payment overtime can subject the employer to multiple damages for the unpaid amounts. Also you are legally required to verify your candidate's employment eligibility under immigration laws using Form I-9.

Insurance

While most home health agencies normally carry comprehensive general liability insurance and professional liability insurance each with separate limits of $1 million per occurrence, and workers compensation insurance, most independent home companions do not. This means that if the home companion that you hired is injured on the job while providing care for your family member you may be liable personally for their injury. New Jersey is one of several states that take the decision for workers' compensation insurance out of your hands by mandating the coverage. Prices vary, but a typical policy costs around $400 for employees making at least $15,000 annually. A typical back injury, which is very common among caregivers, can easily reach $50,000 in medical expenses and lost wages. If the injury results in a disabling condition the employer may be liable for long-term loss of income. Additionally, should there be no workers' compensation insurance in place, the injured caregiver's remedy could entail a law suit against the employer claiming negligence, and typical homeowners policies will not cover any injury to an employee. Be aware that experience among employers has proven that, caregivers tend to have a high incidence of injuries when they realize that their employment may be coming to an end.

Personnel Screening

It is estimated that over 2 million older adults are mistreated each year in the United States. Elder mistreatment first gained attention as a medical and social problem about 20 years ago, when the term "granny battering" first appeared in a British medical journal. The American Medical Association defines elder mistreatment as "an act or omission, which results in harm or threatened harm to the health or welfare of an elderly person." Recognizing mistreatment is often very difficult. The older adult may be unable or unwilling to provide information due to a cognitive impairment or out of fear of retaliation by the abuser. Older adults are often fearful of being placed in a nursing home, and some may prefer to be abused in their own home rather than moved to such a facility. The elderly have been found to be taken advantage of, stolen from, verbally and even physically abused. Most states now require employers to perform a criminal offender record information check prior to providing employment to caregivers. This is a simple procedure that is often overlooked by families hiring home companions. Often these individuals are available for employment because they failed the screening process and were unable to secure full time employment due to past employment difficulties. It is also important to verify the status of your companion's certification, and if they are qualified or trained to provide the services that the elderly person requires. Many home companions may be forced to provide treatments or medication administration that is not permitted by state law under their license simply because there is no one else available to provide it.

Understanding your liability exposure when employing independent home care companions can be a complex task. While the access to this apparently inexpensive pool of help for an aging parent may at first glance be an attractive option for many families seeking to help their aging parents remain at home, the ultimate risks to the family could be devastating. Further, as the level of care increases over time, it is often much less expensive and more advantageous to seek healthcare professionals to deliver this care in a safe, homelike environment where the quality of life can be very high.

Quiet the Guilt

Feeling a Little Guilty?

There are few people on earth better equipped with the natural innate ability to make us feel guilty than our mothers. In our culture guilt has been instinctively crafted to an art form designed to influence our behaviors. It is a learned behavior passed on from generation to generation. Feelings of guilt can be self-inflicted or can be imposed upon us by other people. When guilt is legitimate, it spurs us to do better. When it is unwarranted, it only causes anxiety and hinders our ability to make sound decisions and provide quality care.

As a parent's care needs increase while they undergo the natural aging process, the amount of time and energy required of the caregiver increases exponentially. It is very normal to have feelings of resentment as demands on our time begin to radically change our daily routines. Often adult children already have their hands full caring for the needs of their own children. The average woman in America today will spend more time caring for her parents than for her children. She is typically 45 to 65-year-old married female with children at home, in college, or with families of their own and thus can feel herself sandwiched between two generations. As her parents' needs for assistance increase over time, she often feels as though she simply cannot do enough for them. Often she will become frustrated when her efforts to try to "fix" things that go wrong in her parents life begin to create conflicts in her own life, and the fixes never seem to last. Ultimately she begins to feel that she is losing control of her life and realizes that things that were once routine for her and easily manageable are quickly becoming more than she can handle. Conflicting priorities can often lead to feelings of helplessness and guilt that she is not doing anything well. This self-imposed guilt then becomes her constant companion.

Others can also impose guilt upon us. Failures in our elder caring duties, and obligations to our own families can lead to criticism from those whose opinions we value most. One is never really prepared to accept responsibilities thrust upon them by their aging parents. Few people understand the complexities of health problems, insurance coverage, assisted living and nursing homes, drug plans, Medicare, legal obligations and other senior-related issues. Caregivers continuously bombarded by these issues are bound to make mistakes, which will frustrate them even further. Uninformed family members, and siblings seeking to offer help, often only serve to highlight the primary caregiver's shortcomings. Just remember, there is nothing out there that you can't learn, seek out the advice of professionals such as Geriatric Care Managers, Eldercare Attorneys, local support groups, and the local library.

Feelings of responsibility set us up for the probability of occasional feelings of guilt. We must be able to distinguish between legitimate guilt that motivates us to do better and harmful guilt that might be undeserved and leave us dispirited.

Sometimes it might be helpful to write down the things that make you feel guilty. Examine the underlying reasons and determine if a solution is within your power. Sometimes compartmentalizing a large problem into several smaller, issues can make things more manageable. Constantly fretting over what seems to be an insurmountable responsibility can only lead to more anguish and more guilt. Tackling and completing a few problems can give you a sense of accomplishment and build your confidence to handle those never-ending new surprises as they arise. Consider that your parent may be feeling guilty because of they are imposing on you, while you are feeling guilty that you don't have the time to do more.1 Also, it is never helpful anguish about the past, concentrate on what can be done now and resist the temptation to allow old conflicts to create guilt today.

To determine if the guilt you are feeling is warranted, ask yourself if you have done everything that is practical and necessary within your own limitations. What is important is ensuring the quality of life and meeting the realistic needs of the elderly. It is not your role to insure everyone's happiness, only your own. Perhaps much of the guilt comes from thinking that you have more influence than you really do.

Often as the caregiver is pulled in conflicting directions, she may invite her aging parent to come live with them. Caring for a loved one at home may not be the best solution for either. Many people have made promises to each other about their elder care when they are young thinking the day will never come, but it always does. Often the caregiver struggles to meet the ever-increasing needs of their loved one at great personal sacrifice. Be realistic about what level of care that you can safely provide. Financial resources should be applied before the caregiver themselves begin to weaken. Often the decision to move out of the home is delayed until a nursing home is the only option. Consider using the financial resources while she can still gain some benefit from them in a more social environment. Once the funds are exhausted, the Medicaid alternative is always available in the nursing home setting. Many senior living environments can provide the additional cushion of care for your parent when they really need it. This way professionals can deal with the issues that may be unfamiliar to you and when you visit your parent, your time with them can be spent more relaxed. This will help to relieve the stress that may be building in your relationship, and help to quiet the guilt.

Financial Resources for Assisted Living

Today's seniors enjoy a life expectancy longer than any generation in history. An American who turned 65 in 1998 could expect to live nearly another 18 years beyond their 65th birthday. And while additional years are generally considered a blessing, it is also true that the older one grows, the more likely it is that they will need health care services. Today's seniors, who often consider themselves among the best informed, would do well to learn about three crucial areas that pertain to their future health care needs: the potential that they may need long term care, the cost of long term care and the limited federal and state aid available.

According to a study by the Agency for Health Care Policy and Research, more Americans than ever will expect to utilize some type of long term care during the remainder of their lives. And with the number of people over age 65 expected to grow to 20 percent of the U.S. population by 2030, there is little doubt that demand for long term care services is poised to increase dramatically.

Long term care services have evolved dramatically over the past several years. The majority of long term care was once provided only in skilled nursing homes, long term care services today are provided in a wide range of settings, ranging from in-home care to community-based facilities such as adult day care and assisted care facilities to nursing homes. The cost of long term care can be significant, regardless of the setting in which it is provided. The average cost of a nursing home nationally is approximately $70,000 a year, and home care costs can reach up to $300 a day.

Medicare and Medicaid provide only limited help for nursing home care. Medicare is our Nation's basic health insurance program for people 65 and older, regardless of their income, who qualify for Social Security benefits. Medicare has two Parts: Hospital insurance (Part A) which helps pay for inpatient hospital care and certain follow-up services; and Medical Insurance (Part B) which helps pay for doctors' services, outpatient hospital care, home health care, hospice and other medical services. Medicare only pays for the first 20 days in a skilled nursing facility - and only after a hospital stay of three days or more. The patient or their family pays the first $99 per day from the 21st day through the 100th day, after which Medicare pays nothing. Medicaid rules vary from state to state, but as former U.S. Senator David Durenburger told the U.S. Senate Special Committee on Aging, Medicaid "dictates that people must effectively impoverish themselves in order to receive government assistance." Medicaid is essentially medical aide for those who have already spent down their assets.

Medicaid Waiver Programs

Under Section 1915(c) of the Social Security Act, Medicaid law authorizes the Secretary of the U.S. Department of Health and Human Services to waive certain Medicaid statutory requirements.  These Medicaid Waiver programs enable States to cover a broad array of home and community-based services (HCBS) for targeted populations as an alternative to institutionalization.  Waiver services may be optional State Plan services which either are not covered by a particular State or which enhance the State's coverage.  Waivers may also include services not covered through the State Plan such as respite care, environmental modifications, or family training. To be a waiver participant, an individual must be medically qualified, certified for the waiver's institutional level of care, choose to enroll in the waiver as an alternative to institutionalization, cost Medicaid no more in the community under the waiver than he or she would have cost Medicaid in an institution, and be financially eligible based on their income and assets. In addition, most Assisted Living Communities that do participate in the waiver program allocate only assisted living apartments for this not dementia units in their special care unit. Also Medicaid will only pay for a semi-private room, so they may need to double up with a room mate. They may however receive supplementation from their family or from an irrevocable trust to cover the cost of an upgrade to a private room. Those assisted living communities who do participate in the program offer it first to their existing residents and normally require two years of private pay to even be considered for it. Also remember that since February, 2006 the look back period for Medicaid was lengthened to five years. Though 38 states pay for some assisted living, the programs are miniscule, covering fewer than 100,000 poor people, so waiting lists are long. Medicare covers home care, but just 100 visits in the weeks following a hospital stay. Contact your state Department of Health and Senior services to learn more about waiver programs.

The White House recently authorized Medicare coverage for the treatment of Alzheimer's disease. This means that Medicare beneficiaries can now receive reimbursement for mental health services that were formerly denied because the government rationalized that people with the disease did not respond to mental and physical therapy; this has since been proven incorrect, hence the reversal of their position. Medicare was never intended to cover the costs associated with custodial care, which is room and board, and activities of daily living, and these coverage changes still do not reimburse for this, further Medicare requires a three-day prequalifying hospital stay before they pay for care in a nursing home. Medicare covers certain care procedures, and some limited rehabilitation therapies. The physicians who visit our homes are all Medicare certified providers, so the cost of their visits is often covered by Medicare, subject to the co-payment.

Veteran's Benefits

Veterans and surviving spouses may be entitled to V.A. Aid and Attendance.

To Qualify: The Veteran must have been "honorably" discharged. The Veteran must have served at least 90 days, 1 day during wartime. Individual must be over age 65, or permanently and totally disabled.

Income qualifications to Determine Eligibility: The gross household income less out-of-pocket medical expenses (including AL, skilled care or home care) is the income counted by the V.A. -- V.A. will not pay benefits if income is GREATER than the Maximum Available Pension Resource (MAPR).

Limits on Net Worth

• Couple: About $80,000

• Single (Veteran or Surviving Spouse): About $40,000

Maximum Monthly Payout (Subject to change)

• Single Veteran: $1644

• Married Veteran: $1949

• Surviving Spouse of a Veteran: $1056

Exempt Assets: Primary Residence, Car, Term Life Insurance and Certain Investments (in payout status)

The cash value of life insurance is countable.

If assets exceed the allowable amount, this is where a good Elder Attorney comes in to play, i.e., sets up a trust and moves assets to a trust, thereby meeting the asset qualification thresholds.

Have the right documents in hand before calling the V.A.: Veteran's Honorable Discharge: DD-214 or 53-55 • Marriage Certificate and Death Certificate (if applicable)

For more information on Veterans programs or to see if you qualify for the VA Aide and Attendance benefit contact Yale Hauptman, elder law attorney at www.hauptmanlaw.com

Prepared 2-18-11 (Consult the Veteran's Administration on benefit and qualifications).

Long-term Care Insurance

Long-term care insurance is one other way you may pay for long-term care. This type of insurance will pay for some or all of your care depending upon the benefit amount and the setting. Many newer policies feature endorsements to cover costs of home health care and assisted living. The Health Insurance Portability and Accountability Act of 1996, or HIPAA, gives some federal income tax advantages to people who buy certain long-term care insurance policies. These Tax-qualified policies offer deduction of premiums, and other benefits. One national study1 projecting nursing home use noted: "Of the approximately 2.2 million persons who turned 65 in 1990, more than 900,000 (43%) are expected to enter a nursing home at least once before they die." The same study reported that 1 in 3 will spend three months or more in a nursing home and 1 in 4 will spend a year or more. Many seniors opt to purchase a policy with a benefit amount that covers a portion of the expected monthly costs so as to hedge their expected use. Insurer rating services such as www.ambest.com can help to compare insurer's financial strength and offerings, or you can check for free at your local public library. Seniors who purchase these policies early will pay dramatically lower premiums then those who wait until they are 60 or older.

FHA/HUD HECM Reverse Mortgage Program

A reverse mortgage is a home loan taken against the equity one has amassed in their home. Unlike conventional mortgages or home equity loans, the FHA/HUD HECM reverse mortgage currently allows homeowners over the age of 62 to borrow some of their home equity (a percentage of the appraised value of the home with a maximum home value of up to $625,500) with no income or credit score requirement and never have to repay it as long as one of the borrowers resides in the home. Eligible properties are 1-4 family homes, FHA approved Condominiums and PUD's.

Borrowers can receive funds in a lump sum, as a line of credit or get monthly payments every month. There are no restrictions on what the funds are to be used for and the payments are not considered income so they generally do not affect social security, Medicare and in some States can even be used in conjunction with Medicaid.

These loans are very safe, as there is no personal liability. The most one can ever owe is the appraised value of the home when the last borrower permanently leaves the home. In order to assure that homeowners are doing the right thing, FHA requires that borrowers attend a "Counseling" session with a FHA approved counselor before they can apply for a HECM reverse mortgage.

Wells Fargo is the leading national reverse mortgage lender and a local specialist can be found at www.reversemortgageguru.net

Medications

The Pharmaceutical Assistance to the Aged & Disabled (PAAD) program helps eligible New Jersey residents pay for prescription drugs, insulin, insulin needles, certain diabetic testing materials and syringes and needles for injectable medicines used for the treatment of multiple sclerosis. Only drugs approved by the Food and Drug Administration are covered. Drugs purchased outside the State of New Jersey are not covered, nor is any pharmaceutical product whose manufacturer has not agreed to provide rebates to the State of New Jersey. You are eligible for PAAD, Lifeline, or HAAADif you meet the following requirements: You are a New Jersey resident; your total income for 2009 is less than $24,432 if you are single and less than $29,956 if you are married; and you are at least 65 years of age, OR at least 18 years of age and receiving Social Security Disability benefits. PAAD will also pay up to $225 per year for a participant's heating bill. Call (800) 792 9745 for more information.

The Senior Gold program is also available to assist with the cost of prescription drugs. The senior pays $15 plus half of the remaining cost of the prescription. The income limit to access this program for an individual is $34,432 or for a married couple its $39,956. Call (800) 792 9745 for more information.

The Pharmaceutical Research and Manufacturers of America (PhRMA) maintains a directory of programs that provide drugs to physicians whose patients cannot otherwise afford them. For more information on this program call (800) 762-4636.

Walmart Pharmacy has recently instituted a prescription plan for just $4.00. The list of eligible drugs in the $4 Prescriptions Program — available at Walmart, Neighborhood Market and Sam's Club pharmacies nationwide — represents up to 95 percent of the prescriptions written in the majority of therapeutic categories. The affordable prices for these prescriptions are available for commonly prescribed dosages for up to 30-day or 90-day supplies. Ask your pharmacist or physician about switching to 90-day prescriptions for appropriate medications. Their extensive list of approved medications can be found at www.walmart.com/4prescriptions.

Home Repairs

The Chore Service helps senior citizens (age 60 and over) and disabled homeowners of all ages remain safe and secure in their homes by performing minor household repairs that they can neither do themselves nor get anyone else to do. Services are provided by Chore's crew of 21 volunteer handypersons working as teams with paid drivers. There is no charge for Chore's services, but clients are expected to pay for the parts necessary to complete the repair. Call (201) 489-7790 for more information.

Care Management

The State Health Insurance Assistance Program, or SHIP, is a national program that offers one-on-one counseling and assistance to people with Medicare and their families. Through federal grants directed to states, SHIPs provide free counseling and assistance via telephone and face-to-face interactive sessions, public education presentations and programs, and media activities. These programs have been very popular to help families decide which Medicare Supplement program is right for them. Call (201) 336-7400 for more information.

Heightened Independence & Progress (hip) has administered two premier Centers for Independent Living in New Jersey for many years - since 1980 in Bergen County and in Hudson County since 1987.  Through the years, programs and initiatives have continued to expand.  In some situations identical services are provided, while in other instances programs are specific to each CIL which may have County boundaries or span the entire state. This program provides up to six months of free care management services. Contact (201) 996-9100 or www.hipcil.org for additional information.

Home Health Care Services

Effective January 1, 2009, the Department of Health and Senior Services (DHSS) received approval from the U.S. Centers for Medicare and Medicaid Services to consolidate three Medicaid-supported home and community-based service programs operated by DHSS into a single program known as Global Options (GO) for Long Term Care. The consolidation improves access to a wider range of in-home long-term supportive services for a greater number of seniors and adults with physical disabilities who meet the income, asset and nursing facility level of care requirements established by Medicaid. GO participants have the options to hire and direct their own service providers. GO is designed to supplement – not replace – the assistance already being provided by family, friends and neighbors. By providing a flexible package of services and supports, GO strengthens the ability of caregivers to continue in their vital role as primary support providers. GO participants work with a care manager to create an individualized plan of care based on a comprehensive assessment of the participant's healthcare needs. Once the plan of care is approved, community-based services are put in place and monitored to ensure quality and effectiveness. The GO program essentially replaces the Community Care Program for Elderly and Disabled (CCPED) which typically provides a maximum of 5 hours per day; 5 days a week in home care assistance. Participants must demonstrate need for assistance in at least three activities of dailiy livings (ADLs) or have a cognitive impairment. In order to be eligible, financial and clinical criteria must be met. Monthly income maximum $2,022, individual assets $2,000. Contact (877) 222-3737 for additional information.

Jersey Assistance for Community Caregiving (JACC). JACC is a State-funded program that provides a broad array of in-home services to enable an individual, at risk of placement in a nursing facility and who meets income and resource requirements, to remain in his or her community home. By providing a uniquely designed package of supports for the individual, JACC delays or prevents placement in a nursing facility. Cost caps are applied to specific services under JACC as well as to the cost per person per month. JACC services are limited to a maximum of $600 per month or $7,200 annually. The service package provided is based on an assessment of the individual's needs, unique care plan, and availability of services and funding. Participants share the cost of care on a sliding scale basis, and must be home bound. There is an asset test for qualification of below $40,000 for an individual, or $60,000 for a couple. Contact (877) 222-3737 for additional information.

The NJ Statewide Respite Care Program has been operational since April of 1988. This program provides up to 21 days per year respite care services for elderly and functionally impaired persons age 18 and older to relieve their unpaid caregivers of stress arising from the responsibility of providing daily care. A secondary goal of the program is to provide the support necessary to help families avoid making nursing home placement of their relatives. There is an asset test for qualification of below $40,000 for an individual, or $60,000 for a couple. To reach the Statewide Respite Care Program in your county, call NJEASE toll-free at 1-877-222-3737.

Other Programs

The Americans with Disabilities Act (ADA) of 1990 is a civil rights law that protects the rights of people with disabilities. The ADA requires public transportation systems to offer ADA paratransit service to individuals who are unable to use local bus service as a result of their disability. As New Jersey's public transportation provider, NJ TRANSIT has specific guidelines that must be followed in providing ADA paratransit. Access Link is a public transportation service developed to comply with the paratransit regulations of the ADA. Access Link service is comparable to the NJ TRANSIT local fixed route bus system. Access Link is for people with disabilities who are unable to use the local fixed route bus. In order to use Access Link, you must first apply for eligibility. All persons interested in applying for Access Link service are required to attend an in-person transportation assessment interview. To arrange for a transportation assessment appointment, please contact NJ TRANSIT by dialing 1-800-955-2321 between the hours of 8:30 a.m. to 5:00 p.m. Monday through Friday.

Caregiver Burnout

Many family members who find themselves caring for a loved one may be unable to recognize their own limitation before the strains and stress of their care giving activities turn them into a patient as well. This is especially true for someone who started out providing intermittent assistance to someone with simple tasks as shopping, errands, or bill paying who, as their loved one declines ends up providing heavy personal care such as bathing and dressing. Studies have shown recently that nearly 25% of American families are caring for an aging family member, friend or adult child with disabilities. Part of the art of being a successful caregiver in the ability to set expectations, see one’s own limitations and learn to care for ourselves as well as others.

In many cases, care giving responsibilities saturate one's life to the extent that we may not even recognize what was once our "normal" routine. The responsibilities for providing care for someone else can become gradually overwhelming as the personal needs of the loved one inevitably increase over time. But burnout isn't like the flu with defined and recognizable symptoms. It creeps up on you gradually over time. You may wake up one morning look into the mirror and not even recognize the person or professional that you once were.

Symptoms of burnout can have a profound influence on your quality of life. Most caregivers experience a heightened sense of helplessness and depression along with a sense of ongoing and constant fatigue. Care giving activities for others may force a withdrawal from social contacts and friends who are your primary support structure, or even cause you to lose interest in work where you may receive professional validation. Still others may experience a change in eating habits, or an increasing use of stimulants and alcohol. While most people can endure and recover from some of these symptoms, they tend to accumulate over time and increase in severity. Eventually they can have a dramatic impact on the overall health of the caregiver and their ability to effectively provide care for someone else. Ultimately this can lead to a collapse of the "cushion of care" that was originally intended and render the caregiver a patient himself or herself. This can create a cycle of failure, which becomes self-perpetuating.

Strategies to cope with burnout are critical to maintaining the health of both parties. Acknowledge your emotions and find an outlet for them. Feelings of anxiety, worry, anger, guilt, sadness and resentment are normal, and should be shared with others. Most communities have well-organized networks of support groups. These are groups of people who have experienced similar family crises and have banded together to help one another. Support group meetings such as those sponsored by the Alzheimer's Association provide a monthly forum for caregivers to receive feedback and coping strategies from others in the same predicament.

Recognize the importance of your own identity, and allocate some personal time for things you enjoy such as exercise, hobbies, other family members, and even some "quiet time." Establish some understandings regarding what an emergency is, and more importantly what is not an emergency requiring your immediate response or interruption. Do not hesitate to say "no" if the problem can wait, someone else's crisis only becomes yours if you accept it. Knowing what things can wait can provide you more control over your life. Also recognize that the more you do for someone, the more dependent they can become. Studies have shown that starting or completing tasks for people can offer more independence for both than doing it all for them "quickly." Try to focus of what abilities remain rather than those that have become lost or difficult. This helps to build confidence, rather than leaving you with the feeling that you can never do enough.

Don’t allow yourself to get into a rut. Often caregivers can become so wrapped-up in handling one problem after another that they can lose perspective. Varying the responsibilities of the caregiver is a way to stay fresh. If possible rotate tasks between other family members, or look into day care to give yourself some personal time during the day. Most senior living providers also offer respite programs to allow short-term residency while caregivers take a well-deserved rest or vacation. These programs can provide the caregiver some peace of mind in knowing that professionals are looking after Mother or Dad so that the caregiver can relax, recharge and regain their perspective. Respite can also serve to introduce your parents to the concept of assisted living so that they can overcome any fears they might have of living there one day. Once they see that others have made the choice to live there and how their lives and family relationships have improved as a result, they might consider the option for themselves.

Recognize that you do not have to do it all. Being a good caregiver doesn't mean that you have to be a martyr. If other family members are giving you direction and advice, then they should share in the burden. Learn to ask for and accept help from others, maintaining a balance in your life will help you avoid future burnout. Take time for yourself to recharge and to nurture your own family and friendships. Make time to protect your own health; you will need it now more than ever.

Is Alzheimer's Memory Care a Tax Deductible Expense?

Over the years I have been asked countless times by residents and families "Are the costs associated with the care they receive tax deductible?" While much of the tax code is subject to varied interpretations, and each individual should seek competent advice from their own professionals, it appears that the answer to this question is "likely."

Section #213 of the publication Selected Federal Taxation Statutes and Regulations states "There shall be allowed as a deduction the expenses paid during the taxable year not compensated for by insurance or otherwise for medical care of the taxpayer, his spouse or a dependent to the extent where that expense exceed 7.5 percent of adjusted gross income." The exact definition of medical care has been further explained in Section 1016 "If an individual in a nursing home or a home for the aged because of his physical condition and the availability of medical care is a principal reason for his presence there, the entire cost of maintenance, including meals and lodging is deductible." The key distinction is the purpose of living there. If it is for personal or family reasons, then only the portion of the cost attributable to medical or nursing cost is deductible. The reason that the deductibility becomes cloudy is that service fees in assisted living facilities bundle the medical care component with room and board, making it difficult to determine or justify what portion of the rent covers the care of the resident. Further, most assisted living facilities go out of their way to advertise that they are not a medical care facility. Officially it is defined as: "Assisted living facilities are a type of living arrangement which combines shelter with various personal support services, such as meals, housekeeping, laundry, and maintenance. Assisted living is designed for seniors who need regular help with activities of daily living (ADLs), but do not need nursing home care." Under this definition the deductibility of costs associated with these facilities may be hard to justify.

Publication 502 by the Department of the Treasury, Internal Revenue Service entitled Medical and Dental Expenses helps to clarify the question. "You can include in medical expenses the cost of medical care in a nursing home or home for the aged for yourself, your spouse, or your dependents. This includes the cost of meals and lodging in the home if the main reason for being there is to get medical care. Do not include the cost of meals and lodging if the reason for being in the home is personal. You can however, include in medical expenses the part of the cost that is for medical or nursing care." This means that in an assisted living facility, unless the purpose of the stay is to receive medical care, the cost of lodging and meals may not be deductible.

However, if the individual is chronically ill, as defined under the section entitled Qualified long-term care services all costs associated with the care and supervision of the individual may be tax deductible subject to the 7.5 percent adjustment. Chronically ill is defined in Publication 502: "A chronically ill individual is one who has been certified by a licensed health care practitioner within the previous 12 months as: 1) Being unable for at least 90 days, to perform at least two activities of daily living without substantial assistance from another individual, due to the loss of functional capacity. Activities of daily living are eating, toileting, transferring, bathing, dressing, and continence or 2) Requiring substantial supervision to be protected from threats to health and safety due to severe cognitive impairment." With the enactment of the Kennedy-Kassebaum bill, the law is now clear. Congress stated clearly that the tax code should provide equal consideration for persons with Alzheimer's disease or other irreversible dementia. The only cloudy area remaining is the fee structure of the facility in which they reside.

Another important consideration is the entrance fee, lifecare fee or "founder's fee". "You can include in medical expenses a part of the lifecare fee or founder's fee you pay either monthly or as a lump sum under an agreement with a retirement home. The part of the payment you include is the amount properly allocable to medical care." Many of today's assisted living communities charge an entrance or maintenance fee. This fee is intended to cover administrative processing and maintenance of the property, rendering it a non-tax deductible expense according to the Internal Revenue Service.

Memory Care Units, which are dedicated to caring for people with Alzheimer's disease and related dementia rendering substantial supervision to protect residents from threats to health and safety due to severe cognitive impairment, meet the test. Residents fall under the care of licensed health care practitioners who certify their status. In units specifically designed for the care of those with Alzheimer's disease and related dementia, the care, meals and lodging are in integral part of the complete service plan to constitute "medical care." An entrance fee, if it is intended to cover the cost of the initial assessment, and development of the plan of care for the resident and relates completely to medical care, should qualify it as tax deductible under the definition.

What does all this mean? Well, depending upon your personal income, the deductibility of your monthly fees in a special care unit properly qualified can result in an annual after tax savings of between 15 and 20 percent. If you are looking at several different providers offering similar environments and care, this after tax savings could be a deciding factor on who to choose. So it might be more than worth your while to check this out with your accountant or financial advisor prior to making your decision on where to place your loved one.