In times past family organized the funeral and the burial themselves. An undertaker may have been used for preparing the body for burial, providing a casket and providing a hearse to transport the body to a cemetery. Modern day funeral homes have made the arrangements more convenient, but also much more expensive. The funeral home or funeral director can handle everything from

• picking up the body after death,
• securing the death certificate,
• providing embalming,
• providing restoration services,
• printing funeral programs, sending invitations, providing guest books, etc.
• providing space for viewings and funeral services,
• submitting obituaries,
• obtaining required permits,
• making claim for Social Security or veterans benefits,
• providing a casket,
• securing cemetery lots,
• providing outer burial chamber, liner or vault,
• providing transportation to the cemetery,
• moving the flowers from the funeral to the grave,
• arranging for the opening of a grave,
• making arrangements for a graveside burial service,
• arranging for closing the grave
• making arrangements for grave markers
• and possibly more.

Any of these services might be bought separately and the family could make arrangements for the balance or forgo such things as viewings, embalming and restoration, but it is more common the family will buy a "full service package" which includes all or most of the services outlined above.

As a general rule family-owned funeral homes or mortuaries are in the business of providing trusted service to members of their community. There may be a few that take advantage but by and large integrity is an important part of most providers operations. Funeral directors have responded to criticism of their industry of pushing people into expensive and elaborate funeral services by providing more of the low cost services some families may desire. Not only do they offer cremation or simple burial without trying to pressure families into more costly programs, but a recent trend has been to offer memorial services instead of an elaborate funeral. With a memorial service there is no viewing, no embalming, usually no flowers except maybe a few at the grave and there is a simple service designed to memorialize the departed loved one. The service can be held at the grave site or it can be held at a suitable meeting place later during the day or a few days following the burial. A memorial service can save considerable money over a traditional funeral.

Some groups feel that funeral directors monopolize the business of final arrangements for the dead and that they might be crowding out competition or influencing state legislatures to ban other types of similar services. The concern is that by discouraging competition, funeral homes can charge more money than is reasonable for their services. In fact eight states require using a mortuary for funeral arrangements if a casket is involved. In these states only funeral homes are allowed to sell caskets.

There is also concern that individual funeral homes are being purchased by large corporations and the public is not aware of this, since the original business name will be retained. As a general rule people have more trust in the local family-owned mortuary than in a faceless corporation. Funeral directors or morticians are often highly respected citizens in the community. By owning all of the funeral service providers in a given area, the corporation essentially has no competition from other homes and can charge higher prices for services. The recommendation is to check prices and plans before picking a particular funeral provider. Federal law requires them to give consumers accurate, detailed and itemized quotes over the phone. In 42 states there are other alternatives to a funeral home or mortuary.

In those states where market forces prevail, a call to several funeral service providers in the area will demonstrate that the family may not have to pay $5,000-$10,000 for a funeral. Some competitive providers don't follow the funeral home model, with fancy showrooms, beautiful hallways, very expensive caskets and lavish chapels or meeting rooms. They simply provide the services such as placing the body in the casket and transporting it to a burial site or arranging for cremation. It is up to the family to take care of the rest of the details. These companies may provide help with organizing a funeral or in dealing with the cemetery but these businesses are more often oriented towards selling caskets at competitive prices and providing guidance with the rest of the final arrangements.

In fact some companies only sell caskets as the casket is usually the largest single cost of a funeral. The "funeral rule" requires funeral homes to accept caskets from any source, not just their own. So a family can save money purchasing a casket from a casket dealer and using a mortuary to provide the other services. Caskets can also be ordered over the Internet. There are also many local artisans that will fashion caskets and sell them directly to the public at very reasonable prices. A list of these can be found on the Internet by searching for "caskets".

Alternate providers of funeral items and services can be found in the Yellow Pages under the headings "funeral homes", "funeral information" or "funeral services". Many of these service providers may offer funeral services in the range of $1,500 to $3,000.

In response to what they consider abusive pricing in the funeral industry, some consumers have organized nonprofit memorial societies. There are memorial societies in most states and they can be located in the Yellow Pages under the categories of "funeral homes" or "funeral information". Or they can be located on the Internet. These groups provide consumer counseling and written advice on alternatives to using high cost, funeral home "package" plans.

• They will provide documents and instructions for preplanning funeral arrangements
• They will provide reasons for not embalming.
• They will provide lists of reliable and low cost undertaker services.
• They will give reasons and instructions for cremation.
• They will give advice on where to go for quality caskets or basic funeral plans at a reasonable price.
• They will provide instructions on conducting memorial services instead of funerals.
• They may provide numerous low cost package programs as an alternative to using a funeral director to arrange these options

Social Security will pay $255 to be used towards a burial. It's important to follow up and apply for Social Security burial benefits even though it's not a lot of money. The Veterans Administration will also provide cemetery space for veterans. If the veteran's family can't afford a cemetery plot the VA will provide one in a veteran's cemetery. The VA will also pay for opening and closing the grave, for a standard marker and for the burial itself.

The Cemetery, a Place for Memorialization

In earlier times when our country was mostly rural, loved ones were often buried in a special area reserved for family near the family home or on the family property. And generally people in rural areas can still exercise this option. Today, where most people live within the boundaries of a government community, burying a loved one on one's property would not be allowed. A cemetery is the only option for interment of a body or the secure storage of one's ashes.

A cemetery is a place where one can go to remember loved ones. The grounds and markers are designed to create a memorial to people who have passed on. Larger cemeteries often have well-kept trees and lawns and perhaps even sidewalks or benches. They are typically in neighborhoods that are quiet and if a family member wants to spend some time there the environment is conducive to that.

The concept of providing a memorial to someone who has died is fundamental to humanity. All cultures past and present have some way of identifying a place to remember loved ones by. This is also an important part of providing closure for the grieving process--to have a place to identify our loved ones with. One of the problems with scattering ashes in a public place or over a body of water is that there is often no ability to identify that place and memorialization cannot take place. It may be important to some members of the family to have a special place. Cemeteries make allowances for cremations by providing places where urns can be placed. Some cemeteries also have special garden areas that allow for scattering of ashes. A memorial plaque can also be installed reminding the family where the ashes were scattered.

Wealthy rulers, politicians, people of status and rich people are the most ostentatious in having memorials in their honor. Consider the pyramids as an example. But even in local cemeteries it seems that families compete with each other by trying to erect grave markers or monuments that are better than the ones around them. Some cemeteries recognize this tendency and will restrict the size or design of grave monuments.

Probably the most important thing to remember in picking a cemetery is picking out a location that makes it convenient for the survivors to visit in the future. A cemetery halfway across the country that is picked simply because it was the birthplace of the decedent is not being considerate to the family that may be hundreds of miles away. On the other hand if family are scattered all over the country, location may not be a problem. A second important consideration is also a convenience issue. Many families have parents, grandparents, aunts and uncles and children buried in the same cemetery. This makes it convenient for family members who want to remember more than one loved one to do so by visiting only one location. The cemetery where the rest of the family is buried should be the logical choice. Oftentimes a person will pick his or her cemetery plot based solely on the atmosphere of the place and not take into account the convenience issues expressed above. Being considerate to the surviving family is an important issue in picking a cemetery.

There are presently two types of cemeteries. The first is the traditional cemetery that has been used for perhaps hundreds of years and is filled with upright monuments of stone or above ground mausoleums. The second is a newer concept called a memorial park or memorial garden. This is an effort to equalize everyone who is buried by not allowing any one family to erect monuments different from anyone else. The only markers allowed are ground level tablets of a prescribed size. The Memorial Park is designed to resemble a garden where people can repose or reflect in beautiful surroundings. There may be fountains, sculptures, inviting buildings, water features and so on. Some cemeteries use both concepts.

Here are some issues to consider or issues to generate questions to ask when buying a cemetery plot when preplanning funeral arrangements.

• The plot is not owned, only the usage of the plot for a perpetual interment.
• Prices will vary considerably but generally be more expensive in urban areas with high land values and less expensive in rural areas.
• If a plot is purchased but the family desires another cemetery instead, many cemeteries have exchange programs where the equivalent values can be exchanged between cooperating cemeteries, but many cemeteries do not have exchanges or the exchanges may not work as advertised and the family may be stuck with an unwanted cemetery lot.
• Some cemeteries may be willing to repurchase plots.
• Grave liners or vaults are not required by law but some cemeteries may require them to prevent the ground from sinking.
• Generally plots cannot be resold privately to another individual.
• Most cemeteries that sell memorials place restrictions on the installation of memorials purchased elsewhere. This limits the consumer's choice and drives up the price.
• Most cemeteries will only allow their own personnel to open and close graves.
• Cemeteries may use high-pressure tactics to get people to make a decision on the spot.

Pre-planned Funeral and Burial Arrangements with No Formal Funding

Laws in all states generally hold that funerals benefit the survivors and the person who has died has very little to say in the manner in which services are provided for his or her final interment. In most states a person can express the method of final arrangements in a will but in reality, unless there is a sizable estate and the division is contingent upon probating the will, very few families actually execute a will in probate court. Even if there is a will at death, there is usually no reason to respect it, since most personal assets and savings have been transferred in fact, through beneficiary arrangement or by default to the survivors and the home may pass by joint tenancy, by separate probate or in a trust. Most often wills are never used and remain at home in the drawer or in a safety deposit box.

This does not mean; however, that someone can't plan in advance for his or her funeral. There are reasons that people want to plan in advance.

• They have been through final arrangements with their own loved ones and experienced stress in making decisions dictated by time constraints.
• They have been concerned with what the loved one would have wanted for his or her final arrangements.
• They have been troubled by how much they should spend and not be considered spendthrift's by those who attend the funeral.
• Or they have wondered if the choice of funeral speakers, music and other recognition rituals had been what the loved one would have appreciated.

As a result, many older people want to spare their own family the stress they went through in burying their loved ones. They want to plan in advance for their funeral.

The person planning final arrangements provides a written plan for the family and possibly for a trusted funeral service provider outlining the details of what is to happen. A family meeting is arranged and an agreement is reached that the family will respect these last wishes. However, this is not a legal arrangement. Money can be set aside for this plan or the family may find money from other sources. If there is permanent life insurance, a portion or all of those proceeds can also be used to pay for the services and goods. The funeral services provider agrees to follow through with the plan upon approval of the family after the death. The following issues should be considered when designing a pre-arrangement plan.

• If a funeral service provider is selected in advance, will that provider offer similar services in the future, try to pressure the family to "buy up" to more expensive options or even be in business?
• Will the desired funeral items such as caskets, vaults or liners or grave markers be available in the future? If not, are contingency plans provided?
• About half of the states allow a disposition authorization form to be signed before death choosing cremation or burial as a final disposition. This bypasses approval by the family. If you live in such a state and you want this provision have you checked with your funeral service provider for availability of signing the form now?
• If there is no pre-arrangement with a service provider, will the family know how to properly shop for a funeral?
• In some states, if cremation is desired, all family members must agree. Has this been worked out before hand?
• Where will the money come from to provide for the funeral and burial and if it is to come from savings or insurance, has enough been set aside to allow for inflation with future costs?
• Is the funeral program flexible enough to allow for participants who may not be available at the time of the funeral?
• Do all family members agree on the price range or will one person bolt and insist on spending more?
• If a nonpublic interment with no viewing, no services, no flowers and no fancy caskets is desired will the family respect this request?
• If the person having preplanned, moves to another state is there a contingency plan?

About half of all states recognize the right of the deceased to pick the final disposition of the body -- either burial or cremation. In those states with no disposition laws, courts will likely recognize a written declaration by the decedent on his or her preference for disposition especially if the document came from a state that had a disposition law. Some states allow appointment of a designated agent for body disposition. This is most useful as it provides someone who can represent the interests of the person making the request after death occurs.

One way to informally provide future funds for a prearranged funeral and burial is to buy a life-insurance policy specifically designed for this purpose. And of course anyone who has an existing life-insurance policy that is a permanent contract -- will not lapse at some future date -- can use all or a portion of that death benefit to pay for future funeral costs. Traditional life insurance policies are generally designed for younger people who are in reasonably good health. In addition these policies are usually not available in amounts less than $50,000 in face value. Older people may qualify for these policies, but many elderly who are in good health may not want to buy a policy that large since it could be very expensive. Some life insurance companies specialize in permanent life insurance burial policies for older ages and for people with health problems.

These so-called "final expense" policies are designed to accommodate smaller amounts of death benefit and people who might normally be uninsurable through traditional policies. Available death benefits may range from $2,500 to $25,000. As an example, for a 65-year-old in reasonably good health, a permanent policy with a $10,000 death benefit might cost about $42 to $87 a month depending on the gender and smoking habits of the applicant. The policy will generally have cash value after a certain number of years and may also increase in death benefit value in future years. For those who have cancer or heart disease or life-threatening health problems or in some other way may be uninsurable there are so-called "guaranteed issue" policies. A $10,000 policy like this for a 65 year old might cost $75 to $87 a month depending on gender. In order to protect itself from too many premature death claims with guaranteed issue policies, the insurance company usually has some kind of a waiting period on these policies before a benefit will be paid. One arrangement might pay nothing if death occurs in the first six months, 50% of the death benefit in the second six months, and the full death benefit after the first year. Another policy might simply exclude payment for any death claim in the first two years. This policy would probably be less expensive than the one quoted above.

A major problem with final expense policies is that overhead costs, claims, commissions and other costs associated with managing these contracts make premiums much higher in proportion to death benefit than with larger policies of $100,000 or more. Final expense policies are also generally designed to be more lenient in covering the death of policyholders who may have major health problems. And those final expense policies that guarantee coverage regardless of health are obviously going to pay out death claims sooner than a policy that required someone to be in good health when they applied. All of these factors make final expense policies very expensive relative to the death benefit.

Someone in good health buying one of these policies could live a long time. Premiums are generally set up to be paid monthly or yearly as long as the person lives. Some people living a long time and paying into one of these policies could end up paying significantly more in premiums than the policy would pay at death. Such a policy is only a good idea if a person is in poor health and not expected to live very long. For someone in good health, putting money away in a savings account is usually a better option.

Some people use a memorial society to help with preplanning funeral arrangements. One popular group is the Funeral Consumers Alliance which has affiliates in most states. Memorial societies can be found by looking under funerals in the Yellow Pages or local affiliates can be found by going to www.funeral.org.

PreNeed (Pre-Paid) Funeral and Burial Plans

Advantages and Disadvantages of Prepaid Plans
Another way to plan in advance is to sign a formal contract called a "preneed funeral plan", where money is held in a trust, in an escrow account or paid through an insurance policy. Parts of or all of the funeral service and burial are designed in advance and prefunded in advance and the family has little to do but show up. This type of planning has become very popular in recent years. A survey conducted by the AARP in 1999, found that two out of five people over age 50 had been approached to pre-purchase funerals and burial goods and services. An AARP survey in 1998 indicates that 32% of all Americans over age 50, roughly 21 million people have prepaid some or all of their funeral and or burial expenses (but not necessarily through a formal preneed plan). Breaking that down, about 25% of the over age 50 population have prepaid for their burials (cemetery plot, mausoleum or niche), 18% have prepaid for headstones, urns, caskets , grave liners or vaults, opening and closing of graves and so on and 13% have prepaid for goods or services from a funeral home or funeral director. The same article indicates that over $25 billion is being held in pre-need trust funds. Roughly another $25 billion is waiting to be paid out in life insurance benefits. Prepaid or preneed funerals and burials are big business.

Prepaid funerals and burials funded privately by the family, or paid from an individual life insurance policy and arranged informally through a funeral home or funeral director, are generally not subject to state regulation. Any formal arrangement through a second party or involving a contract is subject to regulation in all states. Each state has adopted different rules as to who can sell these plans, what the plans can provide, what contract provisions must be, how the plan is to be funded and what recourse purchasers might have in the event of fraud or default. All states call these regulated plans "preneed" funeral and burial arrangements.

Here are some advantages to why one would want to buy a preneed plan for funeral and burial services and goods.

• It provides peace of mind knowing these arrangements have been made in advance
• It avoids the burden on family members to make decisions when they are most vulnerable to manipulation.
• It allows one to virtually control from the grave by determining in advance the funeral products, funeral services, burial products and burial services that one would prefer having for final arrangements.
• It helps the family to avoid taking loans, arranging finance plans, raiding savings or selling assets to pay for a funeral and burial.
• It guarantees (for many contracts) that if products and services currently purchased are not available in the future, equivalent substitutes will be provided at no additional cost.
• It locks in guaranteed prices (available with some contracts) forever.
• It allows for inflation in future costs (for those contracts that do not guarantee prices) by investing money in an interest-bearing account or buying life insurance that increases in value over time.
• Depending on the contract, it may allow for transfer to another funeral home or for partial or full refund.

Unfortunately, there are also problems with prepaid, preplanned final arrangements.

• With some trust fund and insurance funding options there may be no refund if someone wants to cancel the plan in the future.
• If a purchaser moves to another state there may be no transfer options or there may be different rules governing the funding option.
• In some contracts, interest earnings on investments resulting in excess money not needed for the plan may be retained by the funeral home or funeral director.
• On installment plans interest may be charged but not credited to the account.
• In certain insurance funded contracts, the ownership or death benefit may be irrevocably assigned to the contract holder, preventing the purchaser from enjoying ownership rights in the policy.
• In certain insurance funded contracts, a growth in the death benefit over time that exceeds the cost of the pre-need plan services and goods may be pocketed by the contract holder instead of being refunded.
• If the contract provider goes out of business or fails to secure 100% of the funds for future payment, there may be no recourse to get all of the money back that was put in.
• If certain services or goods that were purchased initially are not available in the future, but more expensive versions might be, the family may be forced to pay extra for those items.
• In certain insurance funded plans, if the insured dies too soon, there may have been a waiting period in which few or no benefits are paid at death, thus forcing the family to pay out of pocket for the funeral.
• Certain unscrupulous providers may have failed to provide an itemized list of services and goods or failed to identify properly, specific services and goods, thus allowing the provider in the future to substitute less expensive items or to leave out services and goods that were originally anticipated in the agreement.

What Services and Goods Can Be Prepaid?
All states allow for prepaid plans for funeral services and merchandise. This would include such things as picking up the body, embalming and restoration, rooms or chapel for viewing and funeral services, casket, vault or grave liner, transportation, permits, death certificates, obituaries and so forth. Almost all states allow for prepaid burial services and merchandise as well. Only about six states do not allow it. Burial services and merchandise might include opening and closing the grave, grave markers, vaults or grave liners, mausoleums or niches. Cemetery plots are excluded from prepaid plans in all states.

Who Can Sell These Plans?
In 16 states, anyone with a special license can sell preneed funeral plans. About the same number of states allow special license sales of preneed burial plans. If the preneed sale involves insurance, all states require an insurance license as well. Most states generally restrict sales of preneed plans to funeral homes, or funeral home directors or their employees or agents. Again if employees or agents of the employer sell insurance funded plans they also need to be insurance licensed

Most states allow for using life insurance for funeral plans and a large number of states allow it for burial plans. In those states that allow insurance, three or four insurance companies have designed policies specifically to fund preneed contracts. The largest of these is a company called Forethought Insurance, which until recently was a subsidiary of the Batesville Casket Company, the world's largest manufacturer of caskets. Forethought agents provide a turnkey operation for the selling of insurance funded contracts through funeral homes or funeral Directors. A standard contract is used with all funeral providers in that state that may or may not guarantee the cost of goods and services and does not require irrevocable assignment of the death benefit to the funeral provider. Where allowed, the contract will include burial services as well.

Persons wanting a preneed contract will sit down with a Forethought agent, go over the various package plans available, choose the desired plan, apply for the insurance and sign the contract. A detailed description of services, merchandise and prices is given to the purchaser. The purchaser also agrees to provide a revocable assignment of death benefit on the policy to the funeral provider. Since the assignment of death benefit is revocable, the purchaser can walk away from the contract at any time and transfer that death benefit to another funeral home if desired. If the contract guarantees prices, however, a new funeral provider may not except those prices and may charge more money.

How Are These Plans Funded?
About six states allow the use of an escrow account to hold money paid into a preneed arrangement. An escrow account is typically a bank trust account funded by the purchaser and managed for the contract provider. Four of these states also allow for at least one other funding option as well. Rhode Island and Connecticut do not.

Most states allow for a specially established trust fund to hold money for preneed arrangements for both funeral and burial plans. A trust fund must be managed by a third-party trustee. Banks often provide this service. The trust fund may be revocable -- meaning the purchaser can remove his money -- or irrevocable -- meaning the purchaser has no claim to the money. These options depend on state rules, on the contract or whether it is a Medicaid spend down trust. The purchaser may put the money in with a series of installment payments or may put the entire amount in within a short time of signing the contract. Most states require that at least 90% of the money destined to pay the preneed plan must remain in the trust. Some states allow the trust to be funded at a lesser percentage. Some states require 100% of the money must remain in the trust.

For those trusts that are partially funded, the money not invested can be spent by the funeral provider with the understanding that the provider will have to replace it when the purchaser dies. What this means for the purchaser is in those states which don't require 100% funding, if the provider has spent the money from this trust account as well as all other trust accounts it is using for prepaid plans, when the time comes to pay for services and goods, the provider may be short of cash and may be unable to pay the balance. A handful of states have recognized this problem and they assess all preneed providers a certain amount of money that goes into a consumer protection fund to reimburse the purchaser if the provider is unable to perform.

Most states allow for using life insurance for funeral plans and burial plans. Estimates are that about 70% of all preneed plans are funded with life insurance. Using Forethought Insurance again as an example, the company offers two kinds of insurance plans starting at an $800 death benefit amount and not exceeding a $25,000 death benefit. The first policy is a guaranteed issue policy -- meaning no health questions are asked -- that is paid up either in one lump sum payment, or with three years of payments, or five years of payments or 10 years of payments. With the single sum payment policy, if the insured dies before six months, the single sum plus interest is returned. After six months the death benefit is paid in full. With the three and five-year payment policies, if the person dies before one year, premiums plus interest are returned. After one year, percentages of the full death benefit are paid based on an increasing scale each year until 100% of the death benefit is reached. With the 10-year paid-up policy the insured must wait two years before the death benefit is paid and the year-to-year increasing scale of benefits also applies. Except for the 10 year paid-up plan, none of this company's insurance plans result in an insured paying in more than the initial death benefit of the policy. The policy death benefit also increases over time to keep pace with inflationary costs of services and items if the preneed contract is not price guaranteed. Increases in death benefit are dependent upon interest earnings and other factors and are not guaranteed.

The major problem with these policies other than the single pay policy is a risk that if a person dies shortly after getting the policy, there is no death benefit to pay for the prearranged funeral plans. On the other hand, the family is not out any money because premiums plus interest are returned. It means the family now must come up with a lump sum of money that would have come instead from an insurance policy death benefit. Since the single sum payment policy will be fairly close to the actual death benefit, the return of that premium will mostly cover the cost of the preneed plan. Forethought estimates that about 70% of its policies are paid with one single sum.

The other type of Forethought Insurance policy is for people whose health might permit them to buy a cheaper premium in proportion to the death benefit. With this policy the insured gets more death benefit for less money. This policy asks for a person's health history and goes through an "underwriting" process where the company determines if it can accept an immediate risk on the potential death of the applicant. If the applicant is approved, the death benefit is in effect as soon as the policy premium has been paid. All policies provided by Forethought increase in value over time and when the insured dies the excess not used to pay the preneed plan is refunded to the insured's family.

One advantage to the Forethought contract and policy is that preneed costs may in many cases be guaranteed. Another advantage is the policy does not need to be irrevocably assigned to the funeral home. In essence the policyholder can designate whomever he or she wants to receive the death benefit. This in turn makes the contract conditional because nothing has been given to the provider in return for services and goods. This also means the contract holder can walk away from the contract at any time. The problem is the purchaser may end up losing a cost guarantee if he or she tries to use the insurance to set up a new plan with another funeral home. The new funeral home is not required to honor the previous contract but may do so.

How Are Consumers Protected from Fraud or Default?
We've already discussed consumer protection funds in eight states that are designed to repay the purchaser if the funeral provider cannot replace monies used in trust funds. A number of states allow for a full refund upon cancellation, including interest, as long as the preneed contract was revocable and the purchaser followed all provisions for obtaining the refund. A handful of states allow further legal recourse to purchasers either under the state's Unfair and Deceptive Acts and Practices Law, or by allowing consumers who have been injured to file a civil action in state court.

Prepaid Trust Plans for Medicaid Spend Down
Medicaid rules allow someone going through a Medicaid spend down -- in order to have Medicaid pick up all or part of their nursing home bill -- to retain $1,500 for funeral expenses. For many that is not enough. Most states allow potential Medicaid recipients going through spend down to put up to an additional $7,000 or possibly more, with allowances for burial expenses, into an irrevocable funeral and burial plan. Preneed plans are most often used with this spend down provision. Money must be put into a trust arrangement where the trustee will pay for funeral costs and burial costs after the death of the trust owner -- the purchaser. The trust must be irrevocable meaning the purchaser of the preneed plan has no claim on the money or interest earnings. If insurance is used for funding, the ownership of the policy or the death benefit must be irrevocably assigned to the trust. Some states may not allow insurance to be used in this type of trust. Neither cash value nor the death benefit is available to the family. Purchasers who have entered into irrevocable funeral and burial trusts may only use the funds for payment of funeral services and merchandise upon the death of the intended funeral recipient. Any excess in the trust account after payment of funeral expenses might go back to Medicaid or be returned to the local county Social Services Department in which the intended funeral recipient resided, to be earmarked for indigent burials.

Federal law protects the beneficiaries of Medicaid funeral trusts. The law allows the consumer to change funeral homes at any time prior to death without affecting the irrevocability of the arrangements themselves. If such a transfer is desired, a new irrevocable preneed agreement with the newly selected funeral home must be generated. The transfer of irrevocable preneed funds may, however, ONLY be made payable to another funeral home, or another funeral trust program.

Additionally, the law permits the beneficiary's family, at the time of need, to select different goods and services from those originally prearranged. Please note, however, that the funds in the account may only be used for payment of funeral services and merchandise. Any remaining funds in the account after payment of funeral services and merchandise must be remitted by the funeral director to the appropriate trust designated government recipient. The money cannot go back to the family.

 

Dial 211

  The easy to remember phone number "211" was designated by the Federal Communications Commission on July 21, 2000 as a nationwide single source public benefit to help people find resources in their communities. This phone number service is not a business but is a collaboration effort among community nonprofit organizations in each state. Its purpose is to provide information and referral to callers who are seeking help with the ever-growing maze of health and human service providers, government agencies, and community-based service organizations and their associated programs. Information and referral services over the years have been standardized by a group called the Alliance of Information & Referral Systems. This nonprofit group trains both community and corporate information providers in how to handle requests and how to find resources. The AIRS maintains many databases and helps providers design their own database.

In 1999 the United Way of America and the AIRS formed a partnership to promote a national, standardized, information and referral service network. The intent was to have a common phone number and common service procedures that anyone in the country could call from any location. Each state would have its own database of information for local inquiries. The information and subsequent referral from calling the 211 number is designed to offer help in the following areas.

• Basic Human Needs Resource: food banks, clothing closets, shelters, rent assistance, utility assistance.
• Physical and Mental Health Resources: health insurance programs, Medicaid and Medicare, maternal health, Children's Health Insurance Program, medical information lines, crisis intervention services, support groups, counseling, drug and alcohol intervention and rehabilitation.
• Employment Supports: financial assistance, job training, transportation assistance, education programs.
• Support for Older Americans and Persons with Disabilities: adult day care, congregate meals, Meals on Wheels, respite care, home health care, transportation, homemaker services.
• Support for Children, Youth and Families: childcare, after school programs, Head Start, family resource centers, summer camps and recreation programs, mentoring, tutoring, protective services.
• Volunteer Opportunities and Donations.

After the terrorist bombing of September 11, 2001, local communities and states saw how valuable a common source of information could be in helping emergency calling centers coordinate rescue efforts, health services, infrastructure repair, availability of food clothing and shelter and locating loved ones. Dial 211 was an obvious answer to this need. The implementation of 211 has grown dramatically and by the middle of 2005 the system serves approximately 137 million Americans - over 46% of the US population. There are currently 169 active call centers covering all or part of 32 states (including 14 states with 100% coverage) plus Washington , DC and Puerto Rico . The alliance and United Way are currently seeking $150 million from Congress for two years and an additional $100 million for three more years to help expand the system to 100% of the population.

A 211 center is especially useful for long-term care issues because many of the services such as Medicaid and aging network providers don't advertise and community members often don't know where to look for those services. One state coordinator observes that a great number of 211 calls come from caregivers who are looking for services, housing, monetary support and counseling. The drawback of calling 211 is that services are only referred for government or nonprofit organizations. Callers are not given names of private care providers but are typically referred to a government agency that in turn may provide them with lists such as the health Department.

The 211 service is currently funded through local United Ways , other nonprofit organizations and business and government contributors. If the requested federal funding comes through, the $250 million over a five-year period will have to be matched dollar for dollar from local contributions. The federal funding will also place the department of Health and Human Services in charge of coordinating 211 services nationwide. This can provide central direction and administration and make the system more efficient.

 

Elder Mediation Services

What Is Elder Mediation?

It is amazing how quickly formerly cordial relationships between family members will sour when the family has to deal with care of elderly parents or inheritance at their death. Sometimes the consequence of dealing with the final years of elderly parents can break families apart and create long-lasting animosity. Elder mediation is a promising new tool to help families heal broken relations, solve difficult issues arising from dealing with elderly parents or prevent misunderstandings or problems from happening in the first place.

Mediation has been around for a long time but only recently is it being applied to solving problems with elder care. The term "elder mediation" is still not widely used and someone seeking services in this area would most likely contact a "family mediator". Elder mediation is a rapidly growing specialization in the area of family mediation. Family mediators typically handle disagreements and negotiations in divorce, juvenile cases, parenting disputes and the design or settlement of estate plans. As the population ages, as children move further away from their parents and as more traditional caregivers find themselves in the workforce, there is more tension being created among families caring for their elderly loved ones. Mediation can help with problems arising from this tension.

isA mediator is a neutral third party who typically has no relationship with the family members who are in dispute or disagreement. The mediator brings the disputing people together, sits them down in the same room and causes them to talk to each other. The mediator's role is to negotiate a resolution to the problem that is causing the disagreement. The mediator does not dictate or make decisions for the disputing parties but finds ways to facilitate communication between them. The goal of mediation is to produce a written agreement that all parties will abide by.

It is amazing how little some families communicate with each other. Perhaps when they grew up together they were not accustomed to come together as parents and children and work out problems. And now that children are older and taking care of parents they don't have this family council strategy to rely on. It may seem unnatural to them. But that is often exactly what is needed, especially in situations where perhaps one child is caring for the parents and the others are left out of the loop. Children all have a common bond to their parents and as a result a common obligation or responsibility to each other. When disagreements arise suspicions begin to grow. Suspicions or distrust often lead to anger and the anger often leads to severing the channels of communication between family members. This breaking up of ties can occur between parent and child or between siblings or between all of them. It is often at this point that a neutral third party can come in and repair the damage that has been done and help correct the problems that have come about because of the disagreement. A mediator experienced in elder mediation is a perfect choice for solving disagreements due to issues with the elderly.

On the other hand mediation is not always needed when disagreements arise. Some families remain closely connected through frequent visits with each other or on the telephone. Or in today's modern society they may use the Internet as well. It is important that when a member of a closely knit family recognizes a potential relationship problem because of caregiving, inheritance or disturbing behavior from the parents, that person should make sure that the family comes together and resolves the issues before they become disputes.

Advisers to family members such as attorneys, care managers or retirement planners should be aware that potential disagreements can lead to bigger problems with families. These advisers should be quick to recommend to the family member who is their client to get the family together and work out the disagreement before it becomes a major problem. If the client is not willing to do this then the advisor should recommend a competent elder mediator.

The Mediator

Three Different Possibilities for Solving Disputes
The predominant system for solving disputes in this country is the local, state and federal court system. The system is based on Roman Law and English common law and is adversarial -- two parties are pitted against each other in a conflict of words. The parties with disagreements produce evidence of wrongdoing or failure to perform to a judge, or in some cases a jury, and the judge or jury weigh the evidence, typically providing relief to the party with the most convincing evidence. Instead of working out their differences together and reaching a mutual agreement, parties in a court action allow a neutral decision maker, either judge or jury, to dictate the solution to the dispute. Remedies to the dispute are generally determined by common law precedent and the judge decides, based on the situation, the size of the award, the extent of the remedy or the severity of the punishment. If the guilty party or the party ordered to provide a remedy fails to comply with the order of the court, the court can use coercive methods such as fines or jail time to force compliance.

Court actions are often divisive, very expensive and time-consuming. Another alternative is arbitration. Arbitration is a method of rendering a decision for disputing parties that can take less time and cost less money than going through the courts. Arbitration can sometimes result in fewer hard feelings as well. The difference between arbitration and a traditional court proceeding is that the court proceeding is typically involuntary for one of the parties, meaning the disputing parties are forced to come together in a court because of a complaint from one of them. Arbitration is a voluntary alternative although occasionally it can be ordered by a court.

Both sides in the dispute sign an agreement that they will use arbitration instead of the court system and that the decision of the arbitrator will be final. There can be no appeal. But like the court system, an arbitration agreement signed in advance of any current dispute will also result in one of the parties being forced to appear for arbitration if a dispute occurs. Decisions from arbitration can also be enforced legally. The arbitration process is similar to a court process where witnesses and evidence are produced but it is generally much simplified and more straightforward than the court system. The arbitrator weighs the evidence and renders a decision in favor of one of the parties.

Mediation is a non-adversarial approach to solving disputes. Mediation is a process of bringing two or more disputing parties together and having them mutually negotiate a solution to their disagreement. The mediator is not a judge and does not render a decision but is there to make sure that communication flows freely between the disputing parties. Mediators are trained in the art of negotiating resolutions. Unlike the court system or arbitration, parties to a mediation generally cannot be forced involuntarily to meet. They must mutually agree to come together. Arbitration and mediation are often called "alternative dispute resolution" because both methods avoid using the court system.

Types of Providers, Fees, Training and Licensing

Community mediation services are generally provided free of charge to socially needy or poor families. Or they may charge a small fee ranging from $20-$50. Their funding may come from a variety of sources such as state legal service programs, nonprofit community service organizations, grants and foundations and local and state government. Services are typically provided for solving disagreements or disputes in the following areas.

•  landlord tenant disputes

•  neighbor to neighbor disputes

•  employer/employee disputes

•  disputes between service providers and their customers

•  parents having conflicts with their teenage children

Community mediation services may also become involved in elder disputes. A family or an adviser to a family may want to see if a local community mediation service can provide help before hiring a private mediator.

Companies specializing in dispute resolution can also provide elder mediation services if a member of the firm specializes in this area. These companies, however, are more likely to serve deep-pocketed corporate clients and their fees might be prohibitive. Such firms may charge an upfront administrative fee of $500 or more before they will even get to a session. Then they may charge $200 or more in hour for their services in a formal mediation. And finally they will charge an additional fee for writing up a final agreement.

Independent mediators may be individuals who have training in mediation and who specialize in specific areas of mediation. These are the people most likely to be of help to families needing elder mediation. Some of these people may actually specialize in elder mediation and they are likely to have a background as a care manager, a social worker, a gerontologist or a psychologist. Those who specialize in elder mediation are most likely to have a background dealing with issues with the elderly. Others of these providers may be able to help with elder mediation but their specialty may be more broad and they will typically present themselves as being family mediators. Depending on their reputation and their effectiveness, independent mediators may charge anywhere from $50 per hour to $150 per hour. Typically they do not charge any additional fees other than their hourly rate.

Attorneys and court-connected mediators are most likely to be associated with mediation in the court system. For instance attorneys who also act as mediators may be providing an additional source of revenue for themselves in states which require mediation in certain legal proceedings. A court connected mediator may be a free service of a court ordered procedure. Mediators with a legal background are less likely to specialize in elder mediation but that may not always be the case. For instance some elder law attorneys may have found as a necessity of their practice a need to provide elder mediation. They must however avoid a conflict of interest with their own clients unless the family is willing to agree to a mediator who has a connection to one of the complaining parties. This is usually not an acceptable position to the other family members since having an attorney as a mediator who represents a member of their family is going to make the rest of them highly defensive. An elder law attorney is most likely to become a mediator on recommendation from a professional adviser such as a retirement planner or a tax adviser. Attorneys specializing in elder mediation are going to charge about the same hourly rate that they would charge for their legal services.

 

Because they provide no legal services or render judgments and because they provide no other services other than facilitating communication, mediators currently have no licensing requirements in any states. And there are no definite training requirements as well. Theoretically anyone wanting to be a mediator could simply hang out a shingle and start providing services. But the majority of mediators have been through a training program either offered through a local college or university or from a school specifically organized to offer mediation training. Since it is a rapidly growing field, states will likely require specific training, licensing and continuing education for mediation services in the future. Or mediators through their professional societies may require some sort of a certification based on training or experience. This is not currently the case.

Since there are currently no standards for mediators, it is difficult for someone requiring these services to know whether a particular provider is qualified or not. But qualification based on training or licensing may not be the only determinant whether a mediator is effective. Some people regardless of training have a natural talent for getting opposing parties to agree with each other. And the person with a knack for mediating might not have the most elegant technical qualifications. So how can families find the right person who will "get the job done"? We will discuss in more detail at the end of this section how to find a qualified mediator.

Arranging a Mediation

The Value of Using Mediation
As people age the relationships with their families sometimes change. Impaired mental and/or physical abilities often cause a child to view the parent in a different light. Relationships created by caregiving can often cause tensions among siblings. And sometimes greed, generated by the anticipation of obtaining their assets when the parents are gone, can have a surprisingly huge negative impact on the behavior of siblings and parents. Below are some of the changes that can occur in family relationships.

• Roles can reverse and the child becomes the parent and the parent becomes the child.
• There may be a loss of respect from children due to the unsavory appearance, errant behavior and disability issues of parents.
• Because of the change in the environment or the perception of the change there may be behavioral changes in a parent receiving care and reactive behavior changes in the caregiver.
• Other siblings may display jealousies, lack of respect or distrust of a sibling caring for parents.
• Aging loved ones may display the same lack of respect or regard for a child or a spouse caregiver.
• The childlike dependence of a care recipient may allow a spouse or child caregiver to take advantage and engage in physical or financial elder abuse.
• There may be a disagreement with family members over how to handle a loved ones lack of mental capacity
• The disposition of parents' assets can create greed, resentment, heated discussions and even physical attack between squabbling siblings.

For unexplained reasons a family may disregard a change in relationship and instead of finding a solution resort to name-calling and isolation of the perceived troublemakers. Perhaps families don't have the skills to solve their own disputes. Perhaps they think disputes are a normal consequence of caring for aging loved ones. Perhaps there is a lack of respect for a sibling due to divorce and failure to maintain a job and this attitude blocks any dialogue between family members. Maybe the behavior changes have occurred over a period of time and the family has not recognized what has happened. Whatever the reasons for not dealing with the problem, it may be impossible for the family to find a resolution internally. Without knowing it the family needs help from a professional.

Family problems have always existed but in the past we were rarely exposed to a family's dirty laundry. Perhaps this generation of the elderly is different from the one preceding or the generation of baby boomers currently moving into their elder years. The current cohort of Depression and World War II era elders may be creating more tension in their families by refusing to discuss financial issues and showing an unwillingness to share their feelings, intentions or wishes.

Or there may be other reasons for the apparent modern dysfunction of families dealing with the elderly. Modern families are often living further apart and it is more difficult to communicate. Or because of the parent-child relationship, parents may not respect their children's views but be more willing to respect the views of a neutral expert. Perhaps it is the openness of today's society that is allowing us a glimpse into what has always existed. Or maybe more is coming to light because traditional caregivers are working and parents are being exposed more to services of professionals who are being hired to come into the home. Professionals may recognize the problems with the family relationship where the family hasn't. Whatever the reason for an apparent increase in elder related disputes, families and advisers should know that professionals are available to solve problems the family is probably not capable of solving itself.

Mediation can achieve results that the family by itself may not be capable of realizing or have the expertise of achieving. Here are some reasons that make mediation so valuable.

Mediation:

• Allows for a trained expert on communication to give the family a perspective it could not gain by meeting together on its own;
• Allows all involved to meet and prevent problems from arising by anticipating situations that may cause disputes;
• Allows for a meeting in a relaxed atmosphere where people are more likely to share their feelings;
• Allows for the mediator to invite experts such as care managers or other care providers into the meeting to educate the family and give them a new perspective;
• Allows individuals to discuss undisclosed or undiscovered issues that may be causing the dispute;
• Allows parents to focus on their abilities rather than their limitations;
• Allows children to come up with and consider options not thought of previously;
• Allows those sheltering feelings to express themselves in complete confidentiality;
• Allows the family to come closer together instead of drifting further apart;
• Allows uninvolved family members to become involved;
• Allows parents to maintain their dignity by being involved in making decisions for themselves;
• Allows parents to express wishes and desires that had previously gone unuttered;
• Allows everyone to agree on the disposition of parents' assets;
• Allows for a neutral third party to challenge family members and make them take responsibility for their actions;
• Allows for participants to feel personally empowered with their ability to handle problems themselves;
• Allows for consensus of all involved which in turn creates a much higher rate of compliance with the plan than with any other process; (the success rate for compliance with elder mediation is estimated to be about 80% to 85%)
• Allows for and requires a written plan with specific responsibilities which makes compliance feasible.

Disagreements Suitable for Elder Mediation

Elder mediation is a brand-new field and is still finding its roots, but those active in this area have identified the following issues with older people that can lead to disagreement, conflict or dispute.

•  parental living arrangements,

•  health and personal care (such as driving ability),

•  provisions in the case of terminal illness,

•  home upkeep and repair,

•  financial concerns,

•  nursing home care,

•  trust and estate issues,

•  guardianship,

•  power of attorney,

•  relationships between parents, grandparents and grandchildren.

Court Ordered Mediation
It is becoming more common in some states for the court system to order mediation because of state laws that require it with certain civil cases. Some states require mediation in divorce property settlements, custody of minor children, with certain employer/employee and company/customer disputes and sometimes with small claim commercial disputes. At least one state requires mediation as the first step in a contested divorce process. And it is becoming more common for judges, at their discretion and when court jurisdiction allows it, to order mediation in any civil case where the judge thinks it might be appropriate. They do this because realistically only about 2% of all civil cases result in a verdict. About 98% of disputing parties negotiate a settlement before a verdict is passed, usually before the trial even starts. In order to save the court time and effort, or at the request of the complaining party, a judge may require the disputing parties to come together before a trial and attempt a solution through mediation first. If mediation does not work then the trial can proceed.

Although it is rare for disagreements concerning the elderly to end up in court, there might be two or three situations where this might occur. The family may go to court to contest a will, there may be a civil action brought by family members against a member of the family suspected of stealing assets or one or more members of the family may press the court for a guardianship or conservatorship for an elderly family member. In all these cases it is possible the court could order a mediation. A court ordered mediation would be most likely in a contested guardianship situation where some members of the family want the judge to declare a parent incompetent and others of the family do not want this.

Getting the Parties Together
There are number of key problems encountered in getting a family together for a mediation session. The first of these would obviously be a denial that mediation is needed or can help. If a family member is initiating an invitation to other members of the family to attend mediation, and there has been little communication to this point with the others, an invitation would likely be rejected. A member of the family who has recognized the need for mediation would have to find some way to convince the others that it is needed. Generally the acknowledged leader of the family such as the eldest or the person who has the most respect is going to succeed if that person is also requesting the meeting.

If a non-leader is initiating the request, that person must win over the family leader in order to be successful. Or another approach might be the parents requesting such a meeting if one or both of the parents are capable of doing that. Another approach might be using a trusted family adviser such as an attorney or a church leader to initiate the request. Yet another approach may be to hand the responsibility for invitation over to the mediator who would then contact each person, explain what is going on and invite everyone to an initial meeting to outline the concept of mediation. A number of mediators provide a 30 or 40 minute video dramatizing a mediation meeting. The purpose is to allow those who are skeptical to see a live example of how it works.

Another key objection to mediation is the cost and who is going to pay for it. The mediation process could cost $200 to $1000 based on the hourly fee and the amount of time needed. If a community mediator is used there may be no cost or at the most $50. If a family member is initiating the request, that person may be willing to shoulder the cost entirely. Or if the family comes together for an initial meeting to be convinced of the need for continued mediation perhaps the family member could cover that initial meeting cost and then if other members of the family agree, they might all consent to put in their share of the remaining cost. Knowing that participants must be convinced of the process first, many mediators will offer a no cost initial consultation. If an adviser is recommending mediation to one or more family members, that advisor will have to justify the cost. Even though people are willing to pay $200-$1000 to repair their cars, make repairs to their homes or to take a trip, the same money put towards mediation might seem to them a waste. They would have to be convinced of the value.

Another deal breaker is that in order to be successful all parties to the disagreement or dispute must be involved. If one or more of them refuses it would be impossible to go on. Or another issue related to this is that perhaps one or more people are willing to participate but they live a great distance away and it is difficult for them to come together with the others. In this case, the mediator can arrange for them to participate through voice conferencing. Or the initial face-to-face meeting might be arranged but subsequent meetings, if necessary, might be conducted over the phone or even on the Internet.

Choosing where to meet can sometimes be a challenge as well. If family are scattered over a great distance it may be more convenient not to hold the mediation in a mediator's office but perhaps in a place convenient to all but where no interruptions can occur. Sometimes, meeting around a conference table can be confrontational. A better setting might be in someone's living room or around someone's dining room table.

A family lawyer may attend as well as religious advisers but these people are there only as support or for informational input and are not part of the negotiated process. Everyone would have to agree to allowing outsiders to come in since everything discussed in a mediation process is confidential and everyone agrees that all written notes or other things discussed only stay in the meeting. The mediator may also get permission from the participants to invite experts such as a care manager or a home care provider. In many cases the mediator may likely already be a care manager.

How a Mediation Works

Preliminary Procedures
Prior to the first formal session, participants will receive a written copy of rules and procedures. This may include a description of how a session is conducted and the rules that everyone agrees to abide by. The most important of these is confidentiality. The parties will agree to not divulge or talk about anything discussed during the mediation. Any notes, including those of the mediator will be destroyed. Keeping information confidential is a key element of achieving success in the mediation process. Unless it has been ordered by a court, the outcome of mediation cannot be used in any court proceeding. Each participant may also be asked to fill out a form giving the mediator some background on that person. The document will also discuss the fees and how they are to be paid and finally the participants will be asked to sign a statement that they will not hold the mediator legally responsible for any problems that may result from mediation.

The Meeting
Mediation is not just an informal get-together but a structured process guided by the mediator. After everyone has come together and the meeting officially convenes the mediator will make introductions, then describe the rules that the meeting will follow and then urge all who attend to be open-minded and to cooperate.

The next step would be an invitation to those who are in disagreement to describe their side of the issue, how they have been affected and the outcome they would like to see. This is not a discussion and others are not allowed to argue or interrupt. Everyone has his or her turn. After everyone has spoken, the meeting may be opened to comments from the group to attempt to draw out additional issues or to clarify the issues already expressed. Argument is not allowed and it is up to the mediator to make sure that the purpose of the meeting is to communicate and not to fight. At some point the mediator restates or translates the essence of the disagreement and continues to restate if necessary until all participants agree to accept a common definition of what the dispute entails. Once common ground has been reached the next step is to come up with a solution that is acceptable to all.

The mediator might use several different methods to facilitate communication, to recognize the issues and to come up with strategies that will be acceptable to all. If participants are unwilling to share their thoughts, the mediator may have to pick a side and become confrontational in order to draw out information. But it is not the job of the mediator to predetermine which side of the dispute is the right one and a confrontational technique would soon be abandoned after the intended outcome is achieved. Another favorite technique is to encourage brainstorming to come up potential solutions to the problem. According to Elisabeth Seaman, the founder of Conflict Prevention & Resolution Services,

"My aim is to help people get a better understanding of each other,"..."The point is to get people listening to each other and in such a way that they understand another's point of view," she continues, "They don't necessarily have to agree with each other, but solutions are only possible when each party respects the integrity of the other."

The next step in the process is to come up with a solution that is acceptable by all. It is up to the mediator to keep the momentum going towards this common goal. The mediator will never suggest a solution but will allow the parties involved to design their own. Once all have agreed to a resolution, the final step is for the mediator to produce a written agreement based on this mutually accepted solution that all parties will sign. The agreement is not a legal document, but the process used to produce it generally results in a very high compliance with its provisions. The parties can agree to make it a legal contract and enforceable in court but in most elder mediation cases there would probably be no need to do this.

If communications break down and no immediate solution is found, this is not necessarily the end. Family members may agree to go home and think about it and come together at a subsequent meeting. Or the process of mediation may have opened doors to communication that were not previously there and possibly over time an informal solution may evolve with family members more willing to talk to each other.

Finding An Elder Mediator

There are a number of different areas of mediation and it is important to find someone who specializes in family or elder mediation. We have already mentioned above that a family is likely to find someone specializing in this area either through a community mediation service or by contacting an independent mediator. Lawyers who are mediators are probably less likely to specialize in the family area.

Most mediators have training and experience in the area that they are working. Most can produce evidence of certification. As we mentioned before they are no licensing requirements to be a mediator. The number of cases processed and the background of the person offering this service is an important consideration in the selection. Here are some suggestions for finding this service.

• Yellow Pages, look under "mediation services"

Internet search, try some of the following web sites:

• http://www.searchamediator.com/
• http://www.mediate.com/
• The Association for Conflict Resolution http://www.acrnet.org/
• National Association for Community Mediation http://www.nafcm.org/
• The Association of Attorney Mediators http://www.attorney-mediators.org/
• or type in a search engine "family mediators (state)"

other contacts

• Contact the local area agency on aging
• Contact your state bar association
• Contact a local university or college and asked to speak to the department that provides mediation training and ask for a referral.
• Contact a care manager, many care managers may also be mediators or may know an elder mediator. Find a care manager under "senior services" in the Yellow Pages.

 

eHealth Services For the Elderly

Ehealth is a nebulous word to describe a trend to use computer technology in the delivery of medical care. We will use the word in the context of our discussion below to describe technology initiatives that promise better health care for elderly Americans. Some of these initiatives are already in use but not yet widely supported through payments from Medicare. Others are in the process of formation and will bring future benefits. The most effective tool available to all today is the use of the Internet for healthcare information and to some extent interactive health-care treatment.

Using the Internet
A recent survey reveals that 19% of all Internet users "often" use the Internet for healthcare information and another 31% "sometimes" search for information related to health care. The Internet is a major new source of information for the public to research health care issues. Here some are ways in which people are using the Internet:

• People are able to educate themselves in medical vocabulary.
• Thousands of sites allow users to research and understand medical conditions and how they're treated.
• New information being posted daily helps people to research new treatment options that their health provider may not be aware of.
• Hours of research and study empower individuals and allow them to confidently discuss medical issues with their doctors.
• About 7% of Internet users actually interact with their health care provider on the Internet to manage their care. We expect this number to grow in coming years.

Electronic Health Records
A major impediment to quality care is the current paper system for medical records. Elderly patients often generate a large number of office visits, hospital visits and prescriptions. An older person's file could end up being an inch thick or more. No doctor can remember all the details of every patient and in many cases must spend a great deal of time reviewing records. Former treatments and medications can be missed, previous consultations are not easily tracked and referrals to other specialists may be difficult to pinpoint.

Complete information is critical in the treatment of patients who have large medical files. A computerized medical records system tied to a database allows the doctor or nurse to pull up selective information such as a list of drugs, the dates of previous consultations, a history of lab results, potential drug reactions and treatment outcomes or referrals to other doctors. The computer also allows staff to follow up on treatment, to electronically submit prescriptions to pharmacies, to schedule appointments and to provide proper treatment codes and automatic billing.

One witness in a recent Senate subcommittee hearing points out the power of using electronic health records. According to Dr. Robert Kolodner, chief health informatics officer at the U.S. Veterans Health Administration,

"As U.S. health-care costs rose dramatically, the U.S. Department of Veterans Affairs (VA) doubled the number of patients served in the past 10 years, while increasing its health-care budget by only 50 percent."

Kolodner attributed the VA's ability to hold down costs directly to its use of electronic health records. He states, "I have used VA's electronic health record system for years. As a doctor and as a patient I am very enthusiastic about the benefits of this technology."

Kolodner continues, "Recent Hurricanes Katrina and Rita showed the need for electronic health records that follow patients. The VA began rolling out an electronic health records system in the mid-1990s, and today, all 1,300 VA medical facilities use electronic records. Katrina had a "significant impact" on the operation of a dozen VA facilities, destroying one and forcing another to be evacuated, and the two recent hurricanes scattered Gulf Coast evacuees across the country," he continued. "But the VA was able to get access to basic medical data such as medication information for patients treated at those facilities a day after Katrina hit, with full medical records available in about a week," Kolodner added.

But converting the current paper system to computers may end up being a very difficult task to accomplish. For small clinics or individual doctors' offices the cost and effort of switching from a paper system to a computer system can be overwhelming. Procedures must be redesigned, doctors spend considerable time retyping previous histories and existing paper records must be transcribed into the system. The implementation often represents a major increased commitment in time sometimes over a period of a year to get the system implemented. Personnel and workflow procedures must be completely reorganized and the consequence is usually longer patient waiting times and a high frequency of mistakes made during the changeover. There is also a need to hire or contract with a technology expert to handle equipment failure, virus attacks, system failures and software glitches.

Once accomplished, the results are outstanding. Prescriptions and renewals are handled more efficiently and safely, appointments and checkups are handled automatically, lab results from cooperating ewired labs are immediately added to electronic files, prescriptions are data based and potential interactions avoided, patient questions are answered on the spot and expensive duplication in testing and treatment is avoided. In the end there is also a cost savings to the clinic or office due to improved efficiency.

But very few small practices or small clinics are willing to change over because no one reimburses them for the cost or time. And no one is giving them an incentive to change the current system. Insurance companies still pay the same regardless of the system used to deliver the care. And many of the savings in the cost of care are passed on to the insurance company and are not realized by the health-care providers.

The message to the public desiring better care from ehealth initiatives is to use larger clinics or hospitals that have the resources to implement this new technology.

Telemedicine Services
The use of computers and the Internet in a hospital setting is also improving the efficiency and quality of care. Here are some examples.

Preventive telemedicine services allow nurses at a central station to monitor patient vital signs. But these records are also automatically added to the patient's database and a history of input is available to the treating staff which might be the personal physician, a medical specialist or someone else in the hospital. Instead of a bed chart and an in-room visit from the medical provider, all information can be accessed on the computer and any changes in condition can be dealt with immediately. The data accumulated from the patient's daily monitoring and interactive healthcare sessions can be used for early diagnosis of general deterioration in the patient's health. This feature allows for preventive actions to be taken before the patient develops a major health crisis, which can save the patient unnecessary suffering, the necessity of drastic and expensive medical intervention and prolonged hospitalization. All of this early intervention due to electronic monitoring and data storage results in lower costs and better quality care.

Interactive Consulting is proving beneficial in some settings. Using a mobile computer monitor and a video camera, a specialist can make a "virtual" visit to any patient anywhere in the world. With the help of an assistant, the specialist can observe any physical problems; query the patient about symptoms and at the same time access online records from the patient's file. Any simple tests can be done and immediately transmitted. This allows specialists or professors in teaching hospitals to see more patients and to effectively use their time better. Considerably more patients can be consulted from the specialist's office as opposed to the specialist driving to various locations or consulting on the phone. This service would probably not currently be used by hospital staff or the personal physician visiting his patients in the hospital. But it may not preclude these providers using such a service in the future

Videoconferencing is about connecting surgeons and other medical professionals with the information they need. Systems can link operating rooms with facilities around the world. These systems exchange MRI's, X-rays, live pictures and other kinds of information between operating rooms, doctors' offices and teaching institutions everywhere. The goal is making telemedicine a reality, in real time, with worldwide access.

Telehomecare or Home Telehealth
Telehomecare is a more effective way to deliver home care under certain circumstances. Since it is a rapidly developing field, it's difficult to define all telehomecare applications. It usually involves two-way electronic communication between the patient and the formal caregiver such as a nurse or doctor. Communication can occur with two-way radio, telephone or as is usually the case, two-way interactive video using a computer and phone lines, cable Internet, wireless Internet or satellite Internet downlink. This electronic face-to-face home visit also requires some means for the care provider--who might be hundreds of miles away-- to access patient vital signs and receive patient-initiated medical tests. The patient or her in-home informal caregiver has been trained to use electronic monitoring or test equipment that sends the relevant video snapshots or numeric data via phone line, or radio wave to the formal caregiver.

Telehomecare is often more cost-effective in rural areas. And in many cases it provides a higher quality of care. Here are some of the ways telehomecare is proving to be beneficial:

• reducing number of visits to the emergency rooms
• reducing unnecessary visits to physician's offices
• avoiding unnecessary costly visits by health providers
• providing education of the patient in early symptom management
• monitoring vital signs on a 24-hour basis, therefore providing a potential for early intervention and/or prevention of repeat hospitalization

 

A Typical Day In The Life Of A Home Telehealth Patient
(A Composite Case Drawn From Many Examples)

63-year-old Mary Smith of Gatesville , Kansas has lived with diabetes for 15 years and has had many complications during that time. Travel to hospitals and specialists has been difficult and the visits expensive. On her last discharge from hospital to home, her doctor approved home telehealth service and monitoring.

It's 6:30 AM in Mary's rural farmhouse. A house where she has lived most of her life. Mary is awakened by her alarm going off reminding her to measure her blood glucose and blood pressure and to check her weight and to send those readings through her telephone to her telenurse, Susan Brown, who works 200 miles away in Wichita. Susan will receive the information and contact Mary if there is a change of health status or if help appears to be needed.

Mary sends her first report at 8:00 AM but she doesn't do it with a regular phone call. She does it by using three telemonitoring devices-a blood pressure cuff with a telecommunications plug-in, a similar device to monitor blood glucose and a body weight sensor. These devices are all attached to a telehealth, computer workstation. The telehealth work station is connected to Mary's phone line and is linked through the line to Susan's computer in Wichita . After Mary's computer sends its data, Susan receives the information on her own computer and can instantly interpret the state of Mary's health. In addition, an inexpensive camera perched on top of Mary's telemonitor can take snapshots of Mary as she measures her insulin, inserts her syringe, and rotates injection sites, and will send the pictures along to her nurse so that Susan can actually see Mary and how she is doing. If she needs to, the nurse can give her patient a phone call and coach her along. Using her telemonitoring machine and a telephone, Mary can be connected with a nurse, ask a question, or be reminded of a routine on a 24/7/365 basis.

Mary, who lives alone, also suffers from hypertension and has had some bouts of depression related to living with multiple chronic diseases. Until now, her children had felt that sending her to live in a nursing home was a good choice, but, with telehealth, Mary can monitor herself regularly and learn lifelong self management routines. Currently, nursing home placement is not necessary; she can get the assistance she needs at home. And the challenge of monitoring and managing her own health on a daily basis has given Mary focus and helped her with her depression. In addition, with the regular counseling she receives from her nurse and careful management of exercise routines, she has already reduced her number of medications and has not made any emergency room visits in a long while.

Mary also notes: "I'm able to stay at home with my books, my music, and my birds."

Here is how Medicare currently treats the payment of home Telehealth.

"201.13 Telehealth.--An HHA (home health agency) may adopt telehealth technologies that it believes promote efficiencies or improve quality of care. Telehomecare encounters do not meet the definition of a visit set forth in regulations at 42 CFR 409.48(c) and the telehealth services may not be counted as Medicare covered home health visits or used as qualifying services for home health eligibility. An HHA may not substitute telehealth services for Medicare-covered services ordered by a physician. However, if an HHA has telehealth services available to its clients, a doctor may take their availability into account when he or she prepares a plan of treatment (i.e., may write requirements for telehealth services into the POT). Medicare eligibility and payment would be determined based on the patient's characteristics and the need for and receipt of the Medicare covered services ordered by the physician. If a physician intends that telehealth services be furnished while a patient is under a home health plan of care, the services should be recorded in the plan of care along with the Medicare covered home health services to be furnished."

Telehospice Care
The delivery of hospice care requires the coordinated effort of a team of skilled medical personnel, spiritual counselors, volunteers and family. Telehospice is a promising new approach to helping the hospice team better do their job. By using a high-tech means of communication and monitoring, telehospice allows busy care providers to use their time more efficiently and to respond to patient needs more quickly.

Due to a burgeoning elderly population, government funding and available skilled care providers for the elderly are becoming more scarce. Telehospice can help support this growing lack of resources.

Tele hospice and home Telehealth are quite similar in the fact that they monitor health conditions in the home and Telehospice may use similar remote monitoring equipment as a Telehealth workstation, but the emphasis with hospice is on comfort and support. Currently, Telehospice is being tried on a limited basis mostly in rural communities where it is difficult for the providers to make regular visits.

This new concept is designed primarily to augment and not replace the services of the hospice team. For instance if a crisis occurs in the middle of the night and the nurse on duty is a long drive away, a consultation over the phone and using computer video could probably substitute for a personal visit. Or perhaps the doctor needs to see how his patient is doing but is busy on a particular day or his practice is a long distance away. A Telehospice visit using computer video may be adequate to helping him assess the situation. Or another use might be in remotely monitoring and controlling IV pumps for pain management. Uses of Telehospice are only limited by imagination and we suspect as more uses are identified it will become a common part of all hospice treatment.

National Health Information Network
In 2004 the Bush administration created the Office of the National Coordinator for Health Information Technology (ONC) a part of the Department of Health and Human Services. The purpose of this agency is to create the National Health Information Network. The network is to be a national Internet database of all medical records in the United States . In order to achieve this, all health-care providers will have to convert from paper records to electronic records. There will also have to be a national standard for all records to be shared across providers using the Internet database. It is estimated this initiative will cost the private health-care sector $150 billion over the next five years. This may seem a formidable task but HHS awarded its first six contracts for networks in October 2005. Even without the initiative some 100 or so local network projects have already been started by hospitals and large clinics across the country. But so far there is no standardization for linking these networks together.

Initial estimates are a national network could save $120 billion a year by eliminating duplicate tests, shortening hospital stays and improving care for chronically ill patients. Total savings estimates for all sectors of health care run as high as $600 billion a year or about a third of the current $1.9 trillion being spent on health care in this country. The government, particularly Congress, is solidly behind this initiative because it could be a major factor in saving Medicare from running out of money. Here are the goals the network plans to achieve by the year 2014.

Eliminate Medical Errors According to Business Week, dated October 31, 2005, "Medical errors, which cause as many as 195,500 deaths a year, are an unmitigated epidemic. The doctors and medical technology that go into American medicine may be the best in the world, but the care that comes out the other side is beset by woeful inefficiency, dizzying bureaucracy, and enough mistakes to make medical care the third leading cause of death, behind heart disease and cancer." Eliminating medical errors will be a primary goal of this database.

Eliminate Duplication There is a great deal of duplication in medical tests. Sometimes previous tests are not available in time for a doctor to make a decision or the care provider may not even be aware of tests that were done previously. As a result duplicate or even triplicate tests are often ordered. The network would prevent this problem and allow instant access to any tests that have been performed.

Track Prescription Drugs We have mentioned in a previous section that many health-care providers are unaware of the number of prescription drugs and over-the-counter drugs their elderly patients are taking. A central database would identify these drugs and also automatically raise a warning flag if there is a potential for drug interaction.

Online Medical Records Currently everyone is entitled to a copy of his or her medical records but actually obtaining those records is a difficult and cumbersome task. The network would allow anyone to access his records on the Internet. The projection is to make this available nationwide by 2014.

Sort out Best Treatments This is one of the key elements of the database and one of the key sources of cost savings. The idea is that a national database would allow the health-care system and insurers to track the effectiveness of various treatments and discard those that were ineffective and promote those that work the best. It would also help standardize treatments across the country where there currently appears to be a great disparity in the amount of care provided individually in various sections of the country. In some sections the elderly receive twice as much care for the same types of conditions as they do in other parts of the country but yet there seems to be little difference in the outcome or the death rate.

Allow for Performance-Based Health Care A central data base would make it possible to track the cost/benefit outcome of hospitals, clinics and doctors offices. This would result in a long-sought innovation in the health-care system to reward those providers who achieve the best medical outcome for the least money and penalize those providers who cost the system a great deal of money.

Manage Chronic Diseases Chronic diseases such as diabetes, congestive heart failure and asthma, consume a third of all medical spending in this country. Home monitoring systems would feed vital sign health readings into the central database. A nurse or doctor could periodically check the vital sign readings of their patients and if it appeared that the condition was worsening, the providers could intervene with treatment before more costly care was necessary.

Three major obstacles may stop this initiative in its tracks.

1. Cash-strapped hospitals, small doctor's offices and small clinics won't foot the cost to convert since most of the savings go to insurance companies and not to the providers themselves.
2. Medical records privacy advocate groups are very concerned about the security of online records and without adequate assurance or even with it they may seek to stop the initiative.
3. Advocacy groups and most Americans in general are concerned that a central database could be used by the government or by large corporations to spy on people or to gain control over this country's citizens.

 

Assistive Technology and Monitoring and Alarm Systems

Assistive Technology

Assistive technology is a broad term and may mean different things to different people but for our purposes we will define it as the following:

1. Devices or systems to help people who have no skilled medical needs manage their disabilities
2. Devices or systems that may also support disabilities with people who are receiving Medicare home care
3. Personal items or devices that make life easier for people with disabilities
4. Living environments that accommodate disability
5. Consultants, books and other advice
6. Home Modification

 

1. Devices or systems to help people who have no skilled medical needs manage their disabilities

Many assistive technology devices and systems that support disabilities may serve as well a disability caused by a medical condition, but we have chosen in this article to differentiate between a medical or a non-medical use because we are talking about the elderly. As a general rule Medicare will reimburse 80% of the cost for rental or purchase of devices or systems that support disabilities due to a medical problem. Some items on the list we provide below of these devices or systems may also be included in Medicare's list of allowable durable medical equipment. Here is our list of devices in this category

• Lifts
• Oxygen equipment
• Sensory Augmentation Devices
• Computer Usage Arrangements for the Disabled
• Wheelchairs and Scooters
• Other mobility related devices

2. Devices or systems that may also support disabilities with people who are receiving Medicare home care

• Lifts
• Oxygen equipment
• Sensory Augmentation Devices
• Wheelchairs and Scooters
• Other mobility related devices

If there is a medical need and if the device or system meets Medicare's definition of durable medical equipment (DME) below, then Medicare will pay for 80% of the cost and the Medicare recipient pays for the other 20%. In addition if the care recipient has a Medicare supplement policy, that policy usually covers the other 20% of the cost.

The term DME is defined as equipment which

• Can withstand repeated use; i.e., could normally be rented, and used by successive patients;
• Is primarily and customarily used to serve a medical purpose;
• Generally is not useful to a person in the absence of illness or injury; and
• Is appropriate for use in a patient's home.

3. Personal items or devices that make life easier for people with disabilities

This could include some of the following exclusive items for disabled persons or for those going through rehab at home.

Therapy Equipment
Hydrotherapy, Paraffin & Fluidotherapy, Iontophoresis, Biofeedback, Hot & Cold Therapy, Wellness & Massage Therapy and Electrotherapy & Ultrasound

Supports
Arthritis Supports, Wrist Supports, Elbow Supports, Cervical Collars, Back Supports, Ankle, Foot, & Heel Supports, Foot Management, Bed Positioning & Safety Products, Compression Products, Edema Garments, Thumb Supports, Contracture Management Splints, Upper Extremity Positioning/Supports, Thoracic & Pelvic Support, Knee Immobilizers, Knee Straps, Knee Supports, Thigh Supports, Ankle / Foot Orthoses, Heel & Elbow Protectors, Lower Extremity Positioning, Wound Care Products, Scar Management & Gel Products, Lymphedema Products and Taping Products

Dining
Knives, SupergripT Utensils, Sure Hand Utensils, Tapes & Tubing (for enlarging the diameter of an object), Utensil Holders, Acute Care Tables, Clothing Protectors, Dycem® Nonslip Plastic Food Catchers, Home Care / Long Term Care Tables, Non-Slip Matting & Trays, Cups, Mugs & Nursers, Drinking Aids & Straws, Nosey Cups, Self Feeders & Arm Supports, Feeders, Arm Supports & Overbed Tables, JAECO / Rancho Mobile Arm Supports, Mobile Arm Support Accessories, Dinnerware, Feeding Evaluation Kits, Food Guards, Scoop Dishes, Suction Bowls & Plates, Tableware, Jar & Bottle Openers, Kitchen Supplies And Cooking Utensils

Bath , Toileting and Hygiene
Bath & Shower Chairs, Bath & Shower Seats, Bath Boards, Bath Transfer Benches, Bathing Systems, Beluga Bathlift, Folding Shower Seats, Hydraulic Bathlift, Reclining Shower / Commode Chairs, Shower Stools, Bath lifts, Commodes, Folding Commodes, Grab Bars, Lifting & Wooden Commodes, Raised Toilet Seats, Raised Toilet Seats & Splash Guards, Raised Toilet Seats with Armrests, Safety Rails, Toilet Frames, Toilet Supports & Reducer Rings, Bathing & Shower Cushions, Bathing & Shower Mats, Bathtub Grab Bars & Rails, Diabetic Foot Accessories, Grooming & Accessories, Hand-Held Showers, Scrub Sponges & Brushes, Incontinence Products, Mirrors, Catheterization Accessories, Urinals and Mattress Covers

Aids of Daily Living
Reachers, Door Knobs & Grip Assists, Furniture Risers, Home Accessories, Household Helpers, Trolley & Carts, Respiratory Care, Low Vision aids such as magnifying glasses and reading screens, Mouth Sticks & Headpointers, Speech & Communication aids, Language & Cognition aids and activities, Dressing Aids (button hooks, hooks, etc.), Dressing Education, Fasteners & Shoe Laces, Shoehorns, Slippers & Fasteners, Socks & Slippers, Leisure Activities and Helpers, Environmental Controls, Activity Tables, Book Holders, Page Turners & Reading Aids, Scissors, Writing Aids, Dysphagia Resources, Oral Motor aids

Special Clothing
Outer garments, underwear, leisure wear, footwear and other specialized clothing for elderly people with Alzheimer's, arthritis, mobility issues, foot problems, incontinence, scoliosis or obese individuals.

4. Living environments that accommodate disability

There are a growing number of companies that will make the home into a safe environment for a fee. Here is a list of what one company called Safe Living Solutions, at http://www.safelivingsolutions.com/ will do.

What We Do
Reflecting on our mission statement, we are committed to improving the lifestyles of the older aged and the disabled. The many services we offer are based on an extensive and diligent focus on enhancing the lives of those that have a need of our services and will benefit from them.

SafeLiving SolutionsT (SLST) is a non-profit. community-focused service provider with a commitment to improving the lifestyles of the older aged and the physically impaired that reside in the Yakima Valley and surrounding areas. The many services we offer are based on an extensive and diligent focus on the enhancing the lives of those that have a need of our services and those who will benefit from them.

SLS Tdiffers from many other service agencies because we are consumer-directed. People with disabilities are significantly involved in SLST, not just as clients but as Founder and representative on the Board of Directors and our employment goal is for staff members as well. We are funded through federal, state, and local grants, contracts and private donations.

Our goal is to expand opportunities for people with disabilities to achieve their highest potential in independent living and community life. We provide individualized and group services for people with disabilities, and also are actively involved in community outreach and advocacy. These services are available to all persons with disabilities in the Yakima Valley and outlying areas. Individuals and families can receive assistance through services provided in-office, in-home.

By learning to make independent choices and by taking control of their own decisions, clients, with our support and assistance, move away from unnecessary and costly dependency. SLST itself, through community education and advocacy, works to encourage removal of institutional barriers to full inclusion of people with disabilities in community life allowing Independent Living and remaining in the home.

5. Consultants, books and other advice

There are numberless books available from bookstores and from online sources that give advice to caregivers in all areas of disability support. These sources often go beyond the issue of devices and equipment and deal with such things as meal preparation, menus, activities, music and other social issues important to the disabled. Private and government consulting are also available. Check online or dial 211 or call the local area agency on aging.

6. Home Modification

Many people with disabilities want to remain in their home as long as possible. Such things as narrow doorways that cannot accommodate wheelchairs, more than one living level and inconvenient layout of the home may prevent a person from living there. In addition disabled people often require rails, special bathroom facilities and special dining facilities as well. There are three options to modifying the home.

• Research can be done and materials procured to make the home more livable and the family friend or relative can pitch in and do the remodel.
• A contractor can be employed to do the necessary modifications.
• An attempt can be made to find a local company that specializes in the home modification for the disabled. These providers may be readily available in larger population areas.

In addition help can be sought from the following community service providers.

• Local area agency on aging
• State department on aging
• State housing finance agency
• Department of public welfare
• Department of housing and community development
• Senior center Independent living center

The national Association of home builders and the AARP have teamed together to form the Certified Aging-in-Place Specialist (CAPS) program. These people have been trained in the unique needs of the older adult population, aging in place home modifications, common remodeling projects, and solutions to common barriers. It may be possible to find a person in the desired area by going to http://www.nahb.org/or by calling the local home builders Association and asking for someone certified in this area.

Also, consider taking these steps:

• Get recommendations from friends who have had similar projects completed.
• Hire a licensed and bonded contractor. Be specific about modifications in advance.
• Ask for a written agreement with only a small down payment. Make the final payment only after the project is completed.
• Check with the local better business Bureau regarding the contractor's or program's reliability and performance record.

Alarm, Tracking and Prevention Devices

This area of assistance focuses more on the use of devices that warn of problems with homebound people who are often without caregivers for certain periods of the day. This may include

•  24-hour vital sign monitoring,

•  video surveillance,

•  emergency signaling systems or

•  GPS locator devices for wandering care recipients.

These services are very popular and can be found in the Yellow Pages or by going online.

 

Government and Community Elder Care Services

We cover these services in more detail in the other chapters. The purpose of this section is to summarize government services and provide contact information.

Administration on Aging

The Older Americans Act of 1965 created a program to provide community aging services to Americans 60 years of age and older. Over the years, with numerous amendments, the focus of the act has been changing to provide more long-term care services and caregiver support to help individuals remain independent in their homes and avoid going into long-term care institutions. Programs created by the Older Americans Act are managed by the Department of Health and Human Services, Administration on Aging.

The Administration on Aging, as an agency of Health and Human Services, has guided the development of the national aging services network that today consists of 56 State units on aging, 655 area agencies on aging, almost 250 Tribal organizations, 29,000 community-based provider organizations, over 500,000 volunteers, and a wide variety of national non-profit organizations. This nationwide infrastructure currently provides a wide array of home and community-based services to over 8 million elderly individuals each year, which is 17 percent of all people aged 60 and older, including 3 million individuals who require intensive services and meet the functional requirements for nursing home care. It also provides direct services to over 600,000 informal caregivers each year, who are struggling to keep their loved ones at home. The national aging network is the largest long-term care provider network in the country.

Eldercare Locator

The Eldercare Locator, a public service of the Administration on Aging , U.S. Department of Health and Human Services, is a nationwide service that connects older Americans and their caregivers with information on senior services. The Eldercare Locator is designed to help older adults and their families and caregivers find their way through the maze of services for seniors by identifying trustworthy local support resources. The goal is to provide users with the information and resources they need that will help older persons live independently and safely in their homes and communities for as long as possible.

Established in 1991, the Eldercare Locator links those who need assistance with state and local area agencies on aging and community-based organizations that serve older adults and their caregivers. Whether an older person needs help with services such as meals, home care or transportation, or a caregiver needs training and education or a well-deserved break from caregiving responsibilities, the Eldercare Locator is there to point that person in the right direction.

The Eldercare Locator is administered in partnership with the National Association of Area Agencies on Aging and the National Association of State Units on Aging. The locator is available online at www.eldercare.gov/or by calling 1-800-677-1116.

State Aging Services

State aging departments or units as they are referred to under the Older Americans Act coordinate and distribute funding from the administration on aging to local area agencies on aging in the state. Some programs of the older Americans act are coordinated at a state level but may be administered at the local level through an area agency. Here is a list of services typically coordinated at a state level.

Long Term Care Ombudsman
A long-term care ombudsman is a sounding board for residents of long-term care facilities such as nursing homes, assisted living or board and care facilities. Residents or families of residents can contact an ombudsman if there is concern about services or treatment from staff in a facility. The ombudsman investigates and if necessary resolves the problems.

Each state, under the older Americans act, is required to have a state long-term care ombudsman program that is managed at the state level. About 38 states include the office of ombudsman under the state aging unit and 15 other states or territories manage the office under a different state agency or use a private contractor. The state office manages a corps of local volunteers who respond to complaints or, time allowing, visit with residents of long-term care facilities to gain feedback. In 2002 more than 261,000 complaints were handled by about 8,000 volunteer ombudsmen nationwide.

Adult Protective Services
The term commonly used by most states to describe the department responsible for adult abuse is "adult protective services". But not all states use this term. A few states have put adult protective services under their social service, health or human service or children and family services departments. But most states have put protective services under the state aging units described above. This is because the Older Americans Act already requires services for elder abuse and also some funding. In addition, local area agencies on aging are in a good position to report abuse and help with abuse problems. Many states that have elder abuse laws combine legislative funding and other federal funding with OAA funding and give the responsibility for elder and vulnerable adult abuse to the state unit on aging.

Health Insurance Counseling
Many elderly have difficulty understanding their Medicare coverage and many unscrupulous health care providers may be preying on the system by charging for services not actually provided. The elderly may also have questions about whether to buy Medicare supplement policies or buy into Medicare advantage plans. In the fall of 2005 Medicare is introducing part D, the new drug prescription program. The aging network has been given responsibility by the Centers for Medicare and Medicaid services to counsel the elderly about this program. The health insurance counseling services, typically coordinated at the state level, are designed to deal with these issues.

State Legal Services
The Older Americans Act requires state aging units and area agencies on aging to provide legal services for older Americans. There is also a requirement for the state to appoint a person known as a "legal assistance developer" to coordinate legal services in the state. The administration on aging has also formed coalitions with various national groups to help states and local agencies implement legal services. Not only is there concern for the elderly about dealing with issues relating to estate planning, income and long-term care planning but there is a great deal of concern that the elderly may be vulnerable to exploitation by con artists and unscrupulous businesses. The OAA specifically directs legal services for the following issues: income, health care, long-term care, nutrition, housing, utilities, protective services, defense of guardianship, abuse, neglect, and age discrimination.

There may only be enough money for most states to hire a legal assistance developer and other staff attorneys may only be possible for larger states. States and local area agencies on aging must rely on the volunteer services of the legal community. Some states and federal government agencies may also provide money for this program. Licensed attorneys may donate some of their time for assessments and law students may be used to help identify problems and offer solutions. Extensive legal help is only available without recipient out-of-pocket cost in a few cases.

The services can be obtained by calling a local area agency on aging.

Area Agencies on Aging

There are 655 area agencies on aging in every state and territory of the United States . Area agency services are also available to over 240 Indian tribes and native Hawaiians. Area agencies on aging represent the largest single aging services network in the United States , with over 29,000 participating service providers and over 500,000 volunteers. Services are numerous but concentrate primarily on helping elderly people remain independent in the community, delaying the possibility that they will need help in a facility. But area agencies also support caregivers and coordinate government paid services for nursing homes, assisted living and board and care homes. Agencies also support caregivers and grandparents caring for their grandchildren. Here is a list of common services.

• Access Services , such as transportation, outreach, information and assistance, case management and so on
• In-Home Services , including homemaker and home health aides, home repair, snow removal, chore and maintenance, supportive services for families of older individuals who have Alzheimer's disease and so on
• Community Services such as adult day care, senior centers, legal assistance, recreation and so on
• Community served meals and meals on wheels

A local area agency on aging can be reached by dialing 211.

Community Aging Services

There are many private, religious and government organizations across the country that provide supportive services for older people. Many of these services center around helping people stay in their homes and avoid having to go to live in an institution or perhaps move in with family. Other community services may provide socialization or training opportunities. Many community programs are coordinated by a local area agency on aging or many community programs may overlap services with the local AAA. Community aging programs might include:

• Meals served in community centers or delivered to the home
• Community Senior Center activities and training
• Transportation and shopping services for people who can't drive or leave their homes
• Home repairs, snow shoveling, telephone support, caregiver support, care management, legal services, energy and weatherization services, housing subsidies, home health care, counseling and much more
• Adult day care
• Protection from abuse
• Help with health insurance and government entitlement programs

Senior centers are often the focal point for all aging services in a community. Experts or contact people are housed in senior centers and can provide many services in the center itself or refer out to other organizations that can help. The community served meals or congregate meals in senior centers are a means for attracting older people into the centers. Seniors can then be exposed to the many services that are available. A call to 211 will help in locating these services.

Single Source Resource Centers

This concept is fairly new and is probably going to be the most helpful source of information and referral available to the public. Currently the administration on aging is funding pilot programs in 24 states to test the idea of a single point source of all elder care services in a community. Not only will the center be a source for government programs but it will coordinate local church and nonprofit and charity programs as well. The state of Florida was so enthusiastic about this program that the Legislature provided funding for resource centers in all areas of the state not only just for a test area. Within the next three years, testing should be complete and results fully evaluated and states should start implementing their programs statewide.

In most states the single resource centers will be called Aging and Disability Resource Centers (ADRC) but states may choose to call them something differently. These resource centers are most likely to be incorporated into the services of a local area agency on aging. The boundaries of an ADRC will most likely correspond with the area served by the sponsoring area agency on aging. The fastest way to locate a resource center is to dial 211.

Veteran's Administration

The Veterans Administration provides aging services to veterans of war who qualify. The veteran must be receiving health care benefits through a local VA hospital and generally be at least 70% service related disabled. But disability rules are often relaxed in areas where funding is available to provide care for non-disabled veterans. Veterans receiving benefits must have a medical need and a staff at the local hospital decides the type of care the patient will receive. This may include nursing care, home care, adult day care or domiciliary as it is called and assisted living. Unlike Medicare, the VA has no time limit on how long a patient can receive long-term care services. Some VA hospitals have nursing units in-house but those facilities that do not have nursing care will contract with a local nursing home. Contracts are also arranged for home care, assisted living and domiciliary. To receive this care call the local VA hospital service area number.

The VA also supports another system of long-term care called State Veterans Nursing Homes. There are about 115 of these homes in all states, but a number of them are in rural areas far from major cities. State nursing homes are constructed by the state with participating funds from the Veterans Administration. States will either operate the homes themselves or more typically contract with a management company to operate the nursing home. Eligibility is determined by each state but as a general rule anyone who is a veteran is eligible.

The Veterans Administration also provides a subsidy for operating these homes called a per diem. The per diem for 2005 is $59 a day. As a general rule the per diem has not been keeping pace with inflation. If it costs the state $130 a day per patient to operate the home and the VA chips in $59 a day, typically the veteran will pay the difference of $71. But there also may be state subsidies for low income veterans. The VA itself also has a subsidy for very low income veterans that will pay about $800 a month of the nursing home cost if the veteran is can't cover it. Some veterans' nursing homes in urban areas have waiting lists depending on the time of year. One urban home as an example has a waiting list of two years for its Alzheimer's wing. The local veterans contact phone number may be able to provide a referral to the closest VA State home.