Michael T. Coler & Associates, LLC
Plan Development for Responsible Aging
Coler and Associates, LLC has worked with hundreds of clients over more than fifteen years, assisting in the development of individualized plans, planning and interventions for various progressive challenges related to inevitable aging, associated and psychosocial healthcare challenges and an organized approach to manage both.
We have determined that the following factors are very important. Unfortunately, few providers consider the total needs of the individual, choosing to focus on their one discipline as opposed to a total living plan. A significant change in any factor can precipitate a fundamental change in an individual’s plan and focus. An important point of this material is to consider how they might be applied to yourself or your family in a proactive, intentional manner. Our organization’s philosophy is that each client is an individual with unique needs. No one community or private home, providers of service or category experts can meet all the clinical and psychosocial needs of all persons requiring assistance. Eight factors changing constantly result in over 40,000 combinations which gives credence to Coler and Associates, LLC philosophy that each senior is an individual and generalizations are, for the most part, not productive.
We base our work on what is best for our clients. We have no affiliations with any health care provider, retirement community, bank or attorney. We receive no compensation from service providers of any kind, but rather focus on the best options and providers, working to preserve the dignity of each client. Our only compensation is our hourly fee paid by our clients.
1. Medical, Nutritional, Pharmaceutical Status and Personal Documentation
It is important to have an objective, complete and evolving understanding with specific documentation of all major clinical conditions, mental status changes, progression or timing and co-morbidities present; general ongoing nutritional intake, including alcohol use and frequency; a detailed listing of all prescriptions, over-the-counter, herbal, naturopathic and topical medications used routinely or occasionally; and all of this should be committed to a document carried in your wallet or thumb drive on your key chain or your cell phone, including a copy of recent clinical laboratory values, immunizations, etc. By providing these documents as well as trends in vital signs such as blood pressure, pulse rate and sugar levels to each practitioner, appropriate and comprehensive care can be implemented expeditiously with less redundancy and related costs in testing to determine personal data.
Preferably this medical, psychosocial and pharmacologic evaluation can be developed and supervised with the assistance of a physician or multi-specialty group, specifically trained and certified as geriatric specialists. As we age, many parameters change and objective laboratory values, drug regimens and interventions need to be adjusted. For the same reasons an adult does not have their medical care managed by a pediatrician, an older adult should choose to have their care managed by physicians and other care providers certified in geriatric medicine.
This assessment is noted in its primary position because Coler and Associates, LLC thinks that an objective healthcare status summary leads the development of an individual’s plan for their future. Primary foci on wellness and a holistic orientation are also important to implement as well.
2. Available Financial Resources/Estimate of Financial Requirements Over Time
All financial resources should be explored and documented, including values of investments, savings, house, insurance, pensions, Social Security, and other tangible assets. These should be kept current and consolidated in a convenient place. The goal here is to determine how much income, on an annual basis can be directed to an individual’s lifestyle and support. Financial requirements will vary but they need to be objectively identified and estimated. The potential for support by children needs to be addressed as well.
Consideration of long-term care insurance, high-quality Medicare supplemental provider choices and gap-filler coverage, and other potential employer-related coverage need to be decided, probably in coordination with an experienced financial manager or bank. We also recommend this information be centralized with another person. For example, a trust officer, an attorney, a child or good friend could be designated to be in charge in case of serious illness or disability. When there is no support or centrality of key information, decision-making is rarely correct.
Planning for and thinking about one’s financial future is important for a variety of reasons. For example, asset allocation and continuing financial planning is totally different for a sixty-five year old with some form of dementia and no other medical complications versus a ninety year old with lung cancer, diabetes and hypertension.
Coler and Associates, LLC works routinely with clients of very limited resources, for whom Medicaid eligibility or H.U.D. housing might be appropriate and necessary. We also work with clients with seemingly unlimited resources. Each care plan needs to be developed with quality care, available financial resources and the personal wishes of each client emphasized.
3. Status of Legal Requirements and Wishes
Based on individual state requirements the following documents typically need to be individually designed, implemented and available. Copies should be provided to spouses, personal attorneys, children and possibly physicians, hospitals and retirement living providers. These include: Last Will and Testament; Trust Agreements protecting tangible assets; General Durable Power of Attorney; Durable Power of Attorney for Healthcare; Living Will; HIPAA (Health Insurance Portability and Accountability Act of 1996); Resuscitation Wishes including Comfort Care Documents; wishes for end of life and funeral plans; organ donation, etc. Many of these documents are state-specific, needing to be adjusted as necessary.
Copies of all above-mentioned documents need to be given to the executors of your will and those designated as your advocate during any period of incapacitation as soon as feasible, with actual financial information not necessarily to be included.
One’s last will and testament is not the time for any major surprises. We also recommend that one person be given the ultimate responsibility and this person need not be the spouse or eldest child. Too many times do our clients designate “all of my children” to work as a team for directing their care and this rarely works. This causes too many opinions and controversy in many cases.
Think about the most objective and responsible person to be responsible for insuring your wishes are implemented. We recommend as well a letter stating personal philosophy and feelings be written and given to the person you direct as your representative.
An important distinction should be made here in that the person given authority under most states’ Durable Power of Attorney for Health Care is not making decisions but rather insuring that decisions made by the person conveying their will and intentions are implemented. Each state is slightly different in this area.
A good family plan might include different responsibilities for different children, based on their ability to provide any assistance. For example, one person could be responsible for paying bills; one person could be responsible for maintaining medical records and communicating with physicians, escorting their parent to medical visits, etc.; one person could be responsible for maintaining the house and grocery trips. It’s important to think about these things in advance of real need. Coler and Associates LLC recommends that our clients consider who best should be designated to carry out their wishes once the clients make decisions related to the above, within the context of intentional plan development.
There are some people who choose to prepare an Ethical Will, in order to pass down wisdom learned during one’s life. We think this is a great way to “pass on” various thoughts and values to children and grandchildren.
4. Mental and Spiritual Stimulation Needs and How They Are Being Met
In order to maintain mental health and an overall feeling of “wellness” and holistic health, one needs to be connected with the world, being mentally stimulated and enriched on an ongoing, daily basis. Reading; interaction with friends and family; personal interests and hobbies in specific activities such as bridge, the Internet or blogging; volunteering, mentoring or tutoring; spiritual growth and interaction---all lead to a more fulfilling day. We think the brain needs to be stimulated and engaged on a daily, routine basis. Some clients prefer to be totally independent while others see this as “lonely isolation.” Personal honesty is important as to what environment is most appropriate. Again, everyone’s needs and interests are unique and should be addressed on an individual basis. Helping find an interest that can keep one focused outside themselves is vital.
For example, some of our clients like the commonality of age and interests represented within various assertive senior lifestyle activities. Other clients routinely reject any such group and wish to associate only with those significantly younger. Our efforts here are to determine what each client does to maximize each day in the manner most meaningful for that client, not generalizations and aggregations.
In addition, Coler and Associates, LLC continues to represent clients of all faiths and denominations. We encourage all to carefully consider their unique and personal spiritual needs, finding direction and solace as they have been educated, experienced and practiced. These needs and wishes require communication and support, particularly at this stage of one’s life. If appropriate, the philosophy of “growing old with God,” may provide a benefit as well.
5. Status of Physical Stimulation (independent activity and/or planned, directed activity) With Future Needs and Plans Projected
Coler and Associates, LLC cannot over emphasize the need for a personal plan for physical activity. Research objectively demonstrates that a moderate amount of basic physical activity (walking, steps, formal exercise program and frequency, stretching, gardening, swimming or use of low level weights) is important. Thirty minutes per day, five days per week, exerting approximately 1200-1500 calories per week would be a reasonable goal.
Current research indicates that a small amount of weight resistance during exercise improves muscle tone, coordination and fall risk alleviation. Coupling this type of effort with good nutrition can significantly improve and maintain mental alertness and overall quality of life.
With appropriate physician’s orders and evaluation, Medicare provides some homecare and ambulatory benefits for physical therapy in many cases, on a reoccurring annual basis. There are also a variety of personal trainer possibilities, usually on an hourly basis, available in most communities. Senior centers, YMCA’s, YWCA’s, healthcare organization-sponsored recreational centers and other community resources may be available to assist. Many clients also utilize “Silver Sneakers” programming as well.
6. Bioethical Discussion and Decisions
Decisions reached during the execution of a Living Will or a Durable Power of Attorney are important in that we encourage our clients to think about what measures they wish taken in case of a medical emergency. Complete resuscitation efforts, regardless of age or physical condition, can easily lead to cracked ribs and significant pain. How important is pain management and maintenance of personal comfort, regardless of impact on mental alertness? To what degree should various interventional therapies be explored, implemented or not utilized? In Ohio, there is a ‘middle ground’ document referred to as a Comfort Care document. Many prefer this approach and implement such a directive routinely and not just when serious illness or physical incapacitation is present.
Regardless of religious or spiritual direction, most major religions have a philosophy of “Do no harm…Don’t prolong.” These matters are individual decisions to be made thoughtfully and then communicated, but need to be developed over time and conveyed to family members, friends and care providers.
Each person should consider these issues individually, discuss them with spouses and children, even if it’s just in letter to a spouse, child, attorney or good friend, as recommended in previously and take the appropriate state-applicable legal steps to insure their wishes are to be observed.
Recently another tool has been initiated by national hospice organizations. Referred to as “Starting the Conversation,” there is a valuable program designed to spark conversation about end of life issues, using a downloadable format. This is important because all hospice organizations are not the same, most being for-profit, with owner return on investment removing more substantial percentages of revenue.
7. Living/Care Plan Process and Definition
Once serious consideration is given to the six factors noted above, the development of a thoughtful plan is possible. Everyone is different. Medical condition, financial requirements and available resources, personal choices on independent living versus some form of communal living, decisions made for after death legal distribution of assets and bioethical wishes are unique to each individual. There are literally 1000’s of potential combinations of factors, which combine to create such personalization.
Further there are many ways to accomplish unique solutions for each person, and that’s what needs to occur to maximize each person’s potential for successfully maturation and living one’s life to the fullest of their capacity.
One definition of management, personal or business, includes the tenets of planning, organizing, directing and controlling. The theory is that the more one plans and organizes, the less one has to direct or control, or react in times of crisis, possibly inappropriately. With some forethought and “what if” conversations, the less one has to react, sometimes hysterically, to emergencies. It’s important to discuss some scenarios in advance, preferably with spouses and families. Coler and Associates, LLC recognizes the issue of denial as one thinks about aging and death. Unfortunately that concept doesn’t work.
Independent senior living communities where residents can maximize their unique lives, assisted living and skilled nursing communities and physical medicine and rehabilitation units have changed and improved dramatically in the last few years.
A broken hip or serious illness may debilitate someone to the point that independent living may not be possible on an interim basis, or even permanently. As we live longer lives unfortunately dementia related symptoms and diseases might need to be addressed. There are literally hundreds of potential providers of appropriate expert assistance after the real and objective individual care requirements are determined. The inevitable demonstrated by current research indicates 50% of persons living over 85 years will demonstrate some form of dementia.
Coler and Associates, LLC, recommends exploring several community providers, not just interacting with marketing or admissions personnel. Rather, ask to meet with the Director of Nursing, that person with the 24/7 responsibility for clinical care. Ask them to review your unique care requirements and receive at least a verbal assurance that the staffing, facilities, equipment and ancillary personnel are on site or available to provide the known care requirements at the time. Demonstrate this by making detailed notes and even confirm this in a letter to the chosen community. Meet with the Activities Director and look at the actual programming provided. It should be interactive and frequent, several times per day, seven days per week. Note that “watching television” is not an activity.
Do not be “sold” on spacious and well appointed lobbies with crystal chandeliers. Know that “community representatives” may well be very well trained and financially incented sales professionals, skilled in conveying the positives but not stating the less than optimal features or failures of the community in question. Also be advised that “free referral” services that advertise support and knowledge in community selection are typically paid referral fees for channeling clients to those communities that pay them.
If home care is a viable alternative, do the same due diligence, as noted above. Many states have no licensure, certification or accreditation requirements for home care agencies. Yes, there are some wonderful organizations. However, there are also some providers that are less than expert and high on assurances. We recommend utilization only of those organizations that are Medicare or Medicaid providers, preferably accredited by a national organization such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
Kickbacks, rebates and fees for “steering referrals” are illegal in most cases when Medicare is involved, but, unfortunately, there are some less than reliable providers who use them to receive recommendations for their services. Be cautious when choosing care for your loved ones or yourself. Also, unfortunately, please ensure that valuables and personal jewelry are secured or removed for safekeeping.
Medicare recently started publishing a “Five Star Quality Rating System” available on the Internet. If a skilled nursing unit is on site, review their most recent survey results using www.medicare.gov/nhcompare. This report looks at three major criteria: state inspection reports, using approximately 180 categories; facility-specific, self-reported staffing ratios; care acuity data reported on Medicare residents. Communities providing good care can do a poor job completing required government information submissions. Communities providing poor care can receive high ratings, “playing” to the data. Regardless of the rating system, each resident and family has to make their own determination as to whether or not a community meets their unique needs over a period of time.
Some families choose to retain homecare individual assistance and coordinate schedules and payroll themselves. This is possible and may well be perceived as the only alternative. The problem here is that this responsibility can be huge, many times more than one person can handle.
Coupling this responsibility with paying bills, securing of food, transportation to appointments, providing mental stimulation and other activities frequently evolves into a toxic environment for both the aging or disabled person as well as the family “care manager.”
8. Communication of Plans and Wishes to Family and Others
Finally, after all the time and effort is put into the above noted assessments, thought, resource evaluation and planning, it is important to communicate personalized choices to all appropriate persons, including family and friends, legal and financial counsel, and other potentially involved persons.
We recommend that families make an effort to approach these issues, possibly with some one responsible party facilitating a discussion related to the topics explained previously. We have found one way is to lead off with one’s personal point of view as to what one would wish to happen with themselves were they to become incapacitated, either for a short duration or long term. When former President Ronald Reagan publicly announced his dementia, we began to use that as means to open discussion. “Dad, if, God-forbid, this happened to you, what would you want to occur?”
Where are important documents maintained? What are the overall financial resources and where are the records kept? Denial is not assistance. Who and how documents and information be accessed must be determined. The key here is that family and friends need to listen more and support, as opposed to dictate and direct.
In summary, this is obviously a complex subject and this presentation is but a brief description. However, Coler and Associates, LLC does represent these eight concepts as being a good beginning, providing a basis for thoughtful aging and responsible care plan development.