Alzheimers
More Bad News in Long-Term Care
The numbers of seniors who need personal care help is increasing, says the CDC. The data released last Tuesday by the CDC’s National Center For Health Statistics shows that 7.2% of seniors require help with activities of daily living in 2015, compared to 6.6% in 1997. This includes eating, bathing, dressing and getting around as personal care needs.
Seniors over age 85 were twice as likely as adults between 75 and 84 to require personal care help, and were 5 times a s likely as adults age 65 to 74. The report also found 6.4% of white seniors required personal care help, compared to 9.6% of black and 11.3% of Hispanic seniors.
Not only do we have more seniors, especially those over the critical age of 85, but their rate of needing care is increasing as well. A dangerous combination!
“Nursing Home Evictions Strand The Disabled In Costly Hospitals” was a recent article by Ina Jaffe of National Public Radio.
Quote: “What if you had to go to the hospital, and when it came time to return home, your landlord said you couldn’t move back in? Across the country, thousands of nursing home residents face that situation every year. In most cases, it’s a violation of federal regulations. But those rules are rarely enforced by the states. So, in California, some nursing home residents are suing the state, hoping to force it to take action. … Chicotel [a staff attorney with California Advocates for Nursing Home Reform] says the residents most likely to be refused readmission fit a particular type. First, they’re all on Medicaid, which pays nursing homes less than they get from Medicare or private insurance. Second, he says, these are patients who are behaviorally difficult to manage – for example, ‘residents with mental health issues or significantly advanced dementia, or maybe traumatic brain injury.’ They’re undesirable, says Chicotel, ‘because they might take a disproportionate amount of labor time.’”
State budgets are getting stretched thinner and thinner as seniors continue to accelerate passing through age 65. Most of the newly 65 year olds do not need any Long-Term Care services, but as they continue to age, as you can see from the article above, the incidence of care needs is increasing.
Medicaid picks up much of the cost of Long-Term Care for those who have run through all of their savings, homes, and other assets. Medicaid is half federal money and half state money, so everyone is sharing the pain equally. We are now faced with only 3 workers for every retired person and the ratio continues to get worse. Where will the money come from when you need care?
Just like responsibly planning for the time an automobile accident occurs, I have insurance for Long-Term Care as well as my auto insurance. When I need care someday, I will simply notify my Long-Term Care insurance company. As they receive copies of the bills for my care on a monthly basis they will send me a check each month to reimburse that cost.
I don’t have to worry if the Medicaid reimbursement rate is so low that the facility will be trying to get rid of me. My money will come in each month, in addition to my Social Security check. If I do not like the care I am receiving, I will find a better facility or home care agency and make changes. When you pay for the care you want, you get the care you want.
How will you pay for your care when your health changes? If you want to explore options, contact The Long Term Care Guy at (920) 884-3030 or (800) 219-9203.
More Care At Home Being Paid By LTC Insurance
Many people still think of Long-Term Care insurance as only for nursing homes. For many years, these products have been paying for in-home care, adult day care, and assisted living facilities as well, and we now have figures to back that up.
The people who purchase LTC insurance must be healthy to do so, and thus there is a long tail on this product. Claims may not come in until 15-20-30 years or more after its purchase. Thus it can take quite a while for purchasers to use their coverage.
Reports are now starting to come in that people are paying for care at home with LTC insurance. In fact, up to 10% of home care is being covered by LTC insurance that was purchased some time back.
Most people want to stay at home if at all possible. However, they do not wish to be a burden on their family to provide that care. More home care agencies are opening up every year, it’s actually getting to be quite a competitive market. Having the cash flow to pay for this care is what LTC insurance policies provide.
Family gets worn out trying to provide all the care a loved one may need. A recent report claims that compared to people who do not provide support, caregivers who did were 79% more likely to experience emotional difficulties and more than twice as likely to experience physical problems as well as financial difficulties.
Dementias like Alzheimer’s Disease are the hardest situation for family caregivers. You may have promised to provide the care, but at some point it may simply become impossible. You may remember your promise, but your loved one probably does not. Dementias can entail a host of caregiving concerns, not the least is that the one cared for may not want to get into the water to bathe, resulting in a struggle every time.
Now we hear on the news that people over age 75 who use heartburn medications have a much higher incidence of dementia.
What does all this mean to you? If you are healthy yet, do not delay – investigate LTC insurance for yourself so you do not end up putting family in such situations. I got mine at 52 and I am thankful I did. Even though I am very active with work and travel, I could never qualify to purchase the coverage I have today at 66.
If you are in Wisconsin, give us a call at TheLongTermCareGuy.com and lets schedule a time to investigate. Dial (800) 219-9203 or of in Green Bay dial 884-3030. We will be glad to sit down and offer idea so you can decide what to do.
Long Term Care In The News
Yesterday’s Wall Street Journal had some interesting statistics on labor growth predicted for the next decade. The article stated that 95% of new jobs would be in the service sector.
Previous articles have noted that the fastest growing service profession is caregiving. Earlier this year the New York Times estimated that by 2020 (four years from now) there will be more people working in caregiving than work in retail.
Where are all those low wage workers going to come from? And speaking of low wages, the minimum wage is increasing, in many locales doubling to $15 per hour. Since most Long Term Care (LTC) is minimum wage labor, what will this do to the cost of such care?
Currently $3000 a month is the base cost at many assisted living facilities, assuming you really do not need any help. A median cost is $4500 a month and dementia often goes for $6000 a month. Nursing homes often are $10,000 a month. Costs have been increasing at a rate of over 5% per year (the past 8 years of recession excepted). Now with interest rates having risen, inflation will increase, and minimum wage earners will be demanding higher wages.
How many of you can afford to pay for LTC for very long out of your current savings when your health changes? Many people tell me they plan to die in their sleep, a noble hope, but not likely to work out for you. Can your children leave their jobs, children, homes to come care for you? I doubt it.
The baby boomers continue to pass through age 65 at 10,000 a day. Some of them (like myself) have LTC insurance. The facilities want people like me as they lose money on the low Medicaid reimbursement levels. When there are enough people who can pay for their LTC because they purchased LTC insurance (or the few who are rich), the facilities will start declining to accept people on Medicaid.
I don’t want to think about the day when I can no longer properly care for myself either, but I know I will not become a burden on my children and will have ready access to the care I want, in a nice place I can afford. I no longer stay at Motel 6, even if they do leave the light on for me. I have become accustomed to nice surroundings and have little interest in changing. If home care can work, my policy will pay for that too.
You know the day is coming, are you going to investigate what you can do for yourself, or ignore it until it happens? You don’t need a lot of money to get LTC insurance. Since the fall back option is to sell everything, including the house and your life insurance to go on Medicaid, you might use some of that house equity to get coverage so you can stay home if you want, to or stay in a nice place (not your children’s basement).
For more information visit www.TheLongTermCareGuy.com You can email me questions at [email protected]
How To Care For Two Parents at Once Without Going Broke
“The biggest challenge of all is holding onto your patience.”
Reprinted from Money Magazine
For years, Madeleine Smithberg has been at the forefront of American comedy as co-creator of “The Daily Show” and a talent coordinator for “Late Show with David Letterman.”
That sense of humor was especially handy during the last few years. That is because Smithberg had to cope with not one, but two elderly parents in rapid decline.
“It’s heartbreaking,” says Smithberg, 56, who heads a production company in Los Angeles. “And yet it’s invisible, because nobody talks about it.”
“It’s like having toddlers,” says Smithberg, whose father passed away in 2014 after she moved her parents to Los Angeles. “They’re hot, they’re cold, they’re hungry, they ask repetitive questions, and their needs become the most important thing in the world at that second… The biggest challenge of all is holding onto your patience.”
According to a new study by Northwestern Mutual, the childrearing comparison is apt: 59% of Americans feel that taking care of two parents between ages 85 and 90 would be even harder than handling two kids between ages 3 and 5.
Caregivers may also have kids of their own. In that case, it’s not just the “Sandwich Generation” – it’s a Triple-Decker.
The Northwestern Mutual report found that 38% of those surveyed have not planned at all for handling the financial burdens of caring for elderly parents.
The costs can be gigantic: National median costs for an assisted-living facility are now $43,200 annually, according to insurer Genworth Financial in its annual Cost of Care study. A private room in a nursing home? $91,250.
That is more than enough to blow up any financial plan. The following is advice on how to care for your parents without going bankrupt yourself.
Long-Term Care
“Long-term care, long-term care, long-term care.” That’s the simple advice from Smithberg. Her father had taken out coverage for himself and his wife, which she calls “the best thing he ever did.”
Long-term care insurance covers expenses for nursing home or home care if you become incapacitated – most of which is not covered by Medicare. The coverage, like the care, can be extremely expensive, and to be sure, it did not cover all of Smithberg’s parents’ assisted-living costs. But, combined with their own life savings, the policy has meant that she has not yet had to dip into her own savings to pay for their care.
Have the Talk
With the holidays right around the corner, it is one of the few times of year when far-flung families tend to gather in one place. Don’t let the opportunity slip by to discuss your parents’ expectations, should illness arrive. Find out if they have advance directives – documents that spell out what treatment they would and would not want during a life-threatening health crisis. Make sure you establish who has power of attorney, should they need someone to make important decisions.
“It’s the perfect time to have this kind of conversation,” says Kamilah Williams-Kemp, Northwestern Mutual’s vice president of long-term care. Her spouse’s grandmother lived to 102, and her mother-in-law has been diagnosed with Parkinson’s.
Consider a Reverse Mortgage
Reverse mortgages allow homeowners aged 62 and above to borrow against their home equity and to receive either a lump sum, a series of monthly checks or a line of credit that can be tapped as needed. The upside of a reverse mortgage? With the bank paying you every month, instead of the other way around, that check can help cover costs for in-home caregivers.
Tom Davison, a financial planner in Columbus, Ohio, is working with a 90-year-old woman whose daughter moved in with her as a caregiver. “A reverse mortgage could help (the daughter) pay her the wages she has given up,” Davison said.
Be sure to have proper documentation that the child is actually employed by the parent. If not, and later Medicaid is needed, Medicaid will count each payment to the child for care as a gift, disqualifying the parent from Medicaid. rraabe
The downside, of course: The family home will eventually become property of the bank.
The proceeds from the reverse mortgage can also be converted to an income for life – but NOT like an ordinary annuity which uses your average life expectancy. When health is not good and life expectancy is less than “average” then a company that takes that poor health, and “shorter than average” life expectancy into account gives a much larger monthly payment. rraabe
Get Help
Your first instinct as a child may be to drop everything and handle all your parents’ needs yourself. But if it comes at the cost of your own career, think about the ripple effects – on your retirement savings, on the needs of your own kids, even on your own sanity.
With Americans extending their lifespan – 76.4 years for men, 81.2 years for women, according to the National Center for Health Statistics – this is a family challenge that won’t be going away anytime soon.
Denver financial planner Kristi Sullivan recommends hiring a case manager to do the heavy lifting.
“For an hourly fee, these people can handle tasks quickly that it might take you hours to do – scheduling doctor’s appointments, handling medical payments and dealing with insurance, helping find a good nursing home or in-home care,” Sullivan says. “Spending this money may seem expensive, but it’s less than putting someone’s career on hold to become a full-time caregiver.”
For more strategies, financing options, or ways to deal with the costs of Long Term Care even if not planned for in advance, contact www.TheLongTermCareGuy.com
Private Industry Has Solutions For Funding Care At Home That ADRC’s Do Not
I attended a dementia hearing recently. Eight Wisconsin legislators were listening to ideas and problems in dealing with dementia in Wisconsin. Many of those testifying spoke of how people will not accept home care because they think they cannot afford it.
People rely on family for help and care because they cannot afford home care. The most common advice these people receive from social workers and ADRC’s is to spend down to impoverishment and end up on Medicaid. In many cases, this means selling the home and moving to a facility with absolutely nothing left at death to pass on. No wonder people are terrified of needing Long Term Care someday.
Private industry has solutions as well, and often times they are completely overlooked. I am not speaking of LTC insurance here, once care is needed it is way too late to be trying to buy insurance. Let me give you an example.
Imagine you are an older American, living in your home (the only real asset you have) with very little money in savings and trying to get by on Social Security. You know you cannot afford to pay $1000 to $2500 a month for home care and so you just try to get along by yourself or with the help of family or friends.
Someone in this position often does not realize they can utilize the one remaining account they still have – Bank of House. A reverse mortgage is not something to go into frivolously, but as a last resort, it can keep you in your home.
You could take out the available money from a reverse mortgage and spend it for care until it is gone, but wouldn’t it be much better if the money lasted as long as you did? There is a way to convert the equity in your home into an income for life – a monthly check to use for home care that continues until the day you die, no matter how long that is.
If you used the proceeds from a reverse mortgage to buy a regular life income annuity, that would probably be a very bad idea. A life income annuity is based on how long the annuity company thinks you will live – based on age and gender. Remember, your health is not the best, you need care, and may not have as long a life span as others of your chronological age who are healthy.
There is one company that takes your poor health, and thus your shorter than average life expectancy into account, and will require far less money in return for that income for life -based on your shorter than average life expectancy – than a regular annuity would. Many times I have been able to convert the equity from the reverse mortgage into enough monthly income to pay for home care and keep people in their homes for the rest of their life.
So, often it comes down to this choice: Sell the house, spend down the money until impoverished, apply for Medicaid, and end up in a LTC facility with nothing left over. Or, take the equity in the home out through a reverse mortgage, and convert it into a life income, paid monthly, for as long as you live. By taking into consideration that your life expectancy is less than other healthy people of your chronological age, you get a bigger income and can pay for the home care you thought you never could afford.
For more information visit www.TheLongTermCareGuy.com or call me at (920) 884-3030 or (800) 219-9203
Being Stuck In Sandwich Generation Is No Baloney
Reblogged from CNBC
One-time real estate agent Evelyn Rehg was showing a house to a prospective buyer four years ago when an alarming phone call came from the retirement facility where her mother lived.
“They told me I either had to get my mother immediately into a mental hospital or she would be evicted,” said Rehg, 48, of Crestwood, Missouri. “I panicked,” she added. “I didn’t know how to handle it insurance-wise, what hospital to take her to or anything like that.”
Rehg’s mother, 80, suffers from mild dementia, severe anxiety and manic behaviors that now are treated properly. But prior to the phone call, her mom’s anxiety had become so debilitating that she began calling Rehg’s cell phone upward of 200 times a day.
In desperation, Rehg, then still working in real estate, changed her number because she needed her phone for work. So instead, her mother started incessantly calling the front desk at the retirement facility. “They put up with it for about a day and a half,” Rehg said. “Then they called me.”
Rehg also has two children, who were then 12 and 9 and needed supervision and care. That meant that her husband, Jon, had to adjust his work schedule to tend to their needs.
Financial advisors say that in addition to the emotional drain, “sandwichers” may also face a financial burden if they haven’t taken an interest in the steps parents have put in place to ensure they receive proper care.
“It’s important to talk about financial things, but allow your parents some space,” said Rita Cheng, a certified financial planner and chief executive of Blue Ocean Global Wealth.
“You don’t need to be completely involved in their business, because they still want to be independent and in charge,” she said. “But ultimately, if they want to be in charge of how they are cared for, they need to be proactive and plan for it.”
After the call that made it clear that her mom’s condition had deteriorated, Rehg checked her into a mental health facility. It was the first of a handful that Rehg had researched before her mother received a diagnosis and effective medication.
But then her mom fell and broke her arm and spent several months in a rehab center. She then lived in Rehg’s house for about six months, until the situation became too challenging for the whole family.
Rehg, who by then had given up her real estate license, eventually found a suitable assisted-living facility and moved her mother there.
Gregory W. Edwards, a CFP and partner at Lawless Edwards & Warren Wealth Management, is also in the sandwich generation. His father, who had lived next door to him since 2001, died in 2011 after losing his battle with Alzheimer’s disease.
His dad was financially well-equipped to pay for his care, but Edwards organized it—and it was complicated, because his father’s wishes stated that he never wanted to be put in a nursing home.
During the last two years of his dad’s life, the cost to care for him in his own home was $7,000 to $8,000 monthly.
Additionally, Edwards and a brother each now give their mother, who was divorced from his father years ago, about $1,800 a month toward her various expenses, medical and otherwise. “People have no idea of what’s coming down the pike when it comes to the cost of care in the last months of life,” he said.
For many sandwichers, the pressures from the parent side outweigh those from the child side.
“The hardest part is feeling overwhelmed and overworked. Sometimes you have to make hard choices and you have to be patient with yourself.”
Rehg said that without her husband, she doesn’t know how she could have managed the situation.
“It was the hardest thing I’ve ever been through in my life,” she said. “At the height of it, I was probably spending 40 hours a week on my mom—paying bills, talking to doctors, visiting her, medicines—and trying to work 30 to 40 hours a week and take care of the house and two kids.”
Cheng at Blue Ocean Global Wealth said that it is a difficult balancing act.
“The hardest part is feeling overwhelmed and overworked,” she said. “I have to give myself permission that I’m only one person and this is stressful. Sometimes you have to make hard choices and you have to be patient with yourself,” Cheng added.
There are strategies that can help no matter what your current situation dealing with LTC. In some cases, even if someone is on Medicaid already there may be ways to help improve the financial situation. Of course, owning a good LTC insurance policy is the best way to have the cash flow to pay for the help you need. For more information visit www.TheLongTermCareGuy.com
Giving An Engagement Ring for Christmas? Be Aware Of This!
Christmas is a common time to get engaged. A ring doubles as both a wedding proposal and solves the what to give her for Christmas question. Then you can dream in front of the fire this winter, planning a spring wedding.
Financial planners will offer many pieces of advice to new engaged couples, but typically not this piece of advice:
Once you are married, you are one – financially. If you have more assets and your spouse suffers a stroke dancing at the reception (yes it happens, not all newly engaged couples are in their 20’s) you will spend your nest egg paying for the other’s long term care (LTC).
Even many attorneys are not aware of the fact that a prenuptial agreement is not honored by Medicaid, the welfare program that will pay for LTC once you are impoverished. I was called in on a case where an older gentleman, who owned a very valuable farm that his son was farming, married a sweet gal his age. The attorney told him the prenuptial agreement would protect him. When his wife needed LTC, he found out that was not true, and now must sell the farm out from under his son to pay for her care.
While I do have several options to help pay for care once the care has already started, the least expensive strategy is to own LTC insurance. Most people cannot handle a bill of over $100,000 that comes every year. If your funds to pay this come from an IRA, the IRS will be involved as well.
LTC insurance is available up through age 84. I have had many a mature couple in my office to purchase a LTC insurance policy on the one who does not have it yet. When the cost ends up being substantial, the one with the wealth typically says that this must be obtained before the marriage license or all the life’s savings could be spent paying for care and the risk is too great to ignore.
The ideal time to address this is when you are still healthy enough to get LTC insurance. Every year it gets tougher as medical issues that were acceptable years ago, are not anymore. Diabetes leads to an increased risk of Alzheimer’s. Bone density loss leads to loss of mobility when the doctors cannot repair the broken hip. Any use of steroid drugs can cause a decline. This is not like the affordable care act where anyone can get the insurance. By 60, a fourth of us can no longer purchase it. On the other hand, cholesterol medication or blood pressure that is controlled is not a concern.
So, if you are in your 40’s or 50’s and healthy, this is the time to investigate. Do it now as a Christmas present for your children. They won’t have to make room for you to move in with them when your health changes. They won’t have to retire early or go part time to care for you. With care provided, they can come visit, versus bathe and dress you. For more information visit www.TheLongTermCareGuy.com
Thanksgiving is Coming, How is Your Family Doing?
Thanksgiving comes around every year about this time. Families get together, hopefully getting along. Sometimes it is the one time a year everyone sees how the older members of the family are doing since last year.
For some families, it will be a difficult time when they realize that grandma or grandpa are not as sharp as they used to be. Perhaps it is difficulty in getting around, or driving, or perhaps it is in confusion that seems to be getting worse and frustrating the person no end.
Well, the family is all together, so let’s discuss what to do. Perhaps nobody is willing to start the discussion, ignoring the elephant in the room. Or perhaps someone attempts to make suggestions and is quickly shot down.
Talking about losing independence is never easy. Help may be offered and declined since “I can do it myself”! In any case, some family members can see that a problem is evident and wonder what to do about it.
A big part of searching for solutions is learning what options are available. All sorts of support services exist, to help people in their homes, day care several times a week, or even an assisted living facility. Many of these have pools or hot tubs, and most now offer happy hour one afternoon a week to help with socialization. However, who will bring up the topic and risk the wrath of the loved one you all care about?
All of the options can be expensive. The good news is that only about 15% to 20% of LTC is done in nursing homes now. Home care and assisted living facilities cost half or less than a traditional nursing home. However, $1500 to $4500 per month will strain most budgets or put a large dent in the family funds rather quickly. Perhaps it might be prudent to learn what financing arrangements for LTC services are available.
Medicare does not pay for LTC. Medicaid will, but only once the person has spent-down to impoverishment and cashed in any life insurance. There are other, better options available. LTC insurance, if purchased while still healthy is the least expensive way to address this, but even after the need arises, there are other strategies. In a worst case, there is still the option to move some money to family without Medicaid penalties. You simply need to consult an expert in this area and learn what options can work for you.
More information is available at www.TheLongTermCareGuy.com
More Bad News For The Sandwich Generation – Filial Responsibility Laws
The sandwich generation are the folks who are currently raising teens, paying for school, and taking care of their parents as well. This causes much missed work, missed work opportunities, missed events with children, and general exhaustion. How could you possibly accept a promotion requiring a move when you are taking care of an aged loved one here?
Now there is another worry to consider, Filial Responsibility Laws. 30 states have them and they state that adult children have a duty to provide necessities for parents who cannot do so for themselves. This includes long term care (LTC)!
Here is a list of the states that have such laws: Alaska, Arkansas, California, Connecticut, Delaware, Georgia, Idaho, Indiana, Iowa, Kentucky, Louisiana, Maryland, Massachusetts, Mississippi, Montana, Nevada, New Hampshire, New Jersey, North Carolina, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, South Dakota, Tennessee, Utah, Vermont, Virginia, and West Virginia. If your state is not listed here you are NOT out of the woods. If you have parents living in one of those states, you could become responsible for their bills including the cost of home care, assisted living or a nursing home.
Judges use a number of factors when determining the adult child’s responsibility to cover the indigent parent’s bills. I personally thought I would never see these laws enforced, but California, New York, and Pennsylvania have each had a number of cases.
You may have heard the various rumors of shortfalls in government budgets. You may also be aware that the baby boomers are turning 65 at a rate of 10,000 a day and will for the next 18 years. Where do you think the money will come from to pay for the LTC these people will need, if they do not have the funds, or insurance to pay their own bills?
You might view this as a way to get even with your kids, like the bumper sticker that says we are spending our children’s inheritance. But do you really want to bankrupt them from their financial security? Perhaps you should investigate LTC insurance for yourselves, if you are still able to qualify for it. for more information, visit www.TheLongTermCareGuy.com
Protect Mom’s Money
Here is a not untypical situation where Mom needs care and even though Medicaid will soon be needed, some funds can be moved to family.
In our example, Mom is 83 years old and suffering from dementia. She has 2 daughters, one of which is married, the other divorced. The daughters have finally convinced Mom that she will be happier, safer, and better cared for in an assisted living facility. Mom agrees to move in.
The daughters now need to liquidate Mom’s modest house and her car. An estate sale ensues to dispose of the unneeded contents of the house. When all is liquidated, and Mom’s first month is paid for, she retains about $110,000 in her bank account.
If Mom spends down to Medicaid impoverishment, and is left with just $2000 of assets, the daughters will end up paying for Mom’s funeral at death. This is due to the requirement that any life insurance paying more than $1500 at death be “cashed in” and spent to qualify for Medicaid.
However, Mom can put up to $15,000 (varies by state) into an irrevocable burial trust (IBT). These accounts are allowed by Medicaid, there is no 5 year look-back on transfers to an IBT, and the money earns interest until the date of Mom’s death. At that time, the funds are available, by wire transfer, to pay for funeral costs immediately, even before the death certificate has been printed. By comparison, life insurance proceeds are usually not received until 5 weeks or more after death, commonly causing someone to put up a credit card at the funeral home for at least partial payment.
In addition, in many states, Mom can also fund irrevocable funeral spaces trusts for up to $15,000 for each of her children and spouses thereof. The funds will be immediately available for their funeral costs at death, and in the meantime are protected from any creditors, nursing facilities, lawsuits, etc., as they are outside the estate of the beneficiary of such trust. The money is truly protected.
For those of you who thought that all Mom’s money would be spent on her Long Term Care costs, now you know that some funds can be left to family. Of course, preparing for LTC while healthy with a LTC insurance policy is the least expensive way to deal with the care that the Health and Human Services government agency says will be needed by 70% of us. But for those who did not prepare, options exist. For more information visit www.TheLongTermCareGuy.com