 So the group that we've got here today includes Maureen Kelly, who's a licensed clinical social worker. We've got some representatives from the Jewish family and children's services, which is a great resource. A colleague of mine also, Cynthia Morris, who is a fellow certified financial planner, and Maureen Gibney, who is from Canter, the California Advocates for Nursing Home Reform. The structure of this particular session is going to be that each of us is going to give a shorter or longer presentation. The hope because we've scheduled this for two hours is that at around two o'clock we will have time for a break, a short break for everyone to just go to the bathroom and get a glass of water. And then we will launch into about 20 minutes of questions. I will be monitoring questions beforehand, but I think we probably will not be interrupting due to just the nature of a panel of tremendous speakers. So I wanted to start with, why did I put this particular presentation together? And I did because my mother was failing over the last three years and she passed in January. And as a certified financial planner, I know the resources that are out there and it still was an incredibly difficult journey in which I felt always like I was running behind and never really caught up until my mom passed. So I wanted to just remind everyone of the tremendous resources that are out there, but also to let you know that this is really hard stuff. It's hard for the person whose life is changing as we age. I'm certainly aware of that. It's hard for the family. And I wanted to read something because I think this captures the sense of what changes due to aging can bring up, especially for those of us who are, you know, participating in it, obviously. And this particular short paragraph comes from an opinion from Patty Davis who was Ronald Reagan's, is Ronald Reagan's daughter. And it was in response to some of the criticisms of Diane Feinstein about her working. And it was obviously before she passed. So, you know, how complicated that is. And so I wanted to share that as we start our conversation. So she writes, no matter how many people have traveled ahead of us on the caregiving journey and have shared their experiences, it always feels like a pilgrim's path, lonely and strange. I don't think that summarizes it any better than I possibly can. So I hope you learn a lot. There's going to be a resources page that the library makes available to you after this presentation. Do put your questions in do know that there are one on one sessions with certified financial planners on going right now. And so you can pop into that after the session. Hopefully there will be some space and take the time to learn what you need. All right, so let's let's get started. We're actually on time. Yay. I would like to introduce our first speaker, who is Maureen Kelly, very dear friend of mine walked me through, you know, the changes going on with my dad before he died me through the changes going on with my mom before she died. And just is a tremendous friend and resource. So she recently retired as an elder care counselor for the faculty and staff of UC Berkeley, they were so lucky to have her. And during her 40 year career she worked with elderly people and their families and various nonprofit settings in San Francisco in the Bay Area, as well as in a private practice. She served in as adjunct faculty at us up and she is newly retired as I said at the beginning so Maureen, take it away. Thank you Chris. Hello everybody and I'm, I'm really happy to be part of this panel and to talk with you. So I'm going to talk a little bit about some of the caregiver challenges you may have as a family member providing care to an older person. But I'd like to start by saying kind of piggybacking on what Chris said and I had it in my thoughts as well. Being a caregiver is not an easy job. And I feel like the work is underappreciated undervalued kind of always has been so we're here today to show you our appreciation but also to just kind of teach you a little bit or share a little bit about what we've learned in our various capacities over the years over the years. So, people may not always understand how difficult or frustrating it can be to take care of an elderly person. And by attending this workshop I just want to acknowledge that you're taking care of yourself. And that's a good thing as a caregiver. You're getting informed, you're getting educated, you're taking time out and you're learning and hopefully getting some resources and understanding some ways to really look at what you're going through. So Chris spoke a little bit about some of the challenges she had as a family member and that notion of always running behind. There just aren't enough hours in the day. There usually aren't enough people on the caregiving team to make this a fair sport. So, just want to acknowledge some of that too. It's also confusing I think when family members are providing care. Questions about how much care, how often, what kind of care, it's not always clear. There may have family members or the elder herself or himself who may have a different idea about what they need or they may be resistant and not always accept the care that you're trying to provide. And they probably don't like it when you tell them what they need to do because they even if it's for their own good we tend not to like it when other people tell us what we should or shouldn't be doing. And for those of you who have other family members, whether they're providing care or not, they may disagree and make it difficult for you to provide the care. So the first challenge we're going to look at, excuse me, is the relationships and roles of family members. Many family members don't think of themselves as a caregiver. That's a role we play. They think of themselves in terms of the relationship they have with the elder. So I'm their daughter, I'm their daughter-in-law, their son, their spouse, husband, wife, I'm their partner. I'm the sister, the brother, the grandchild, the niece, the nephew. These are all relationships we've had with the elder. And so caregiver is not a relationship, but it's a role we play as the elder begins to have increasing needs. So their needs become greater. We remain their family member, but we also take on this role. And being an elderly person's family member and their caregiver may get confusing. It does get confusing. Your elder may have expectations of you or other family members may have expectations of you that are different from your expectations of yourself. One example of that is maybe you've started to shop and do a little bit of cooking for your elder and they're considering that part of your job is their daughter. But there's a good chance you didn't shop and cook before they needed your help. So this is really a role you're playing now as the caregiver. This is not something that was inherent in the relationship. So it just might be helpful for you to begin to think about this a little bit differently. And as the elder's care needs increase, you may take on more and more responsibility for their care. So thinking of yourself as the caregiver could be helpful to you. It may also be helpful for family members to think about who is my elder's primary caregiver. So that may be you who's the primary caregiver. It's the person who's providing most of the care. So it could be you could be another family member. It could be the elder's spouse. So we oftentimes have an elderly wife, for example, taking care of their elderly husband or partner. So they may be the primary caregiver. And if you're an only child, so many elderly children said, I wish I had siblings to help. Many, many caregivers with siblings said I wish I was an only child. So there's no, there's no one right position to be in. But if you are an only child or you're a spouse and don't have children or your children are assisting you, you're probably most likely the primary caregiver. So again, this might be important because you want to be sure you're communicating with the primary caregiver. You want to be respectful of their role as caregiver. And you want to see if there's a way that you can provide them some respite, give them a break. So some of the tasks or jobs involved with caring for an elderly family member may include shopping, meal preparation, cooking, cleaning, arranging for healthcare, medical appointments, driving, managing their finances, checking in with them by phone or by Facebook or in person. And not all family members are involved with tasks on a regular basis. We may like them to be, but they're probably not. And they're not all involved in the same way. So perhaps you're in the role of the primary caregiver, but there are other family members who help too. And it might be important for you to ask who's on my elder's caregiving team. It can't be you and the elder or you and two elders. That's not a team. So really to think about who else is there. And if it's only you, please think about identifying other family members, neighbors, services, who may be able to help. This is not something you can do by yourself long term. We want to reduce the amount of work you're doing and most importantly, the amount of stress you're experiencing. So one question you may want to ask yourself is, do I have a backup caregiver in the family? So maybe your mother or your sister is the primary caregiver for your father and you're the backup caregiver that role is an essential and important one to play. It gives the caregiver a much needed break, provides rest fit and allows them some time away from that role. And same for you if you're the primary caregiver, let's figure out who the backup caregiver is or can be for you. Some family members will assist, but it's very narrowly defined. We call these family members circumscribed caregivers and they can be frustrating because they're not available when you need them to be available. They're available when they are available. So what the best way to work with circumscribed caregivers is get them to make a commitment. If they say, I'm going to call or FaceTime, mom and dad, get a date, get a time. This will give your elder something to look forward to and it'll give you a break. So let's make the most of those circumscribed caregivers and other types of caregivers are sporadic. They may help out. You can't rely on them. Don't expect too much from them. You'll drive yourself crazy and it's not worth it. And lastly is dissociated caregivers for whatever reason, these family members have distanced themselves from the family. So you may feel sad about this. You may feel grief. You may be frustrated, but they're not there. So maybe thinking about your family members in this way will help you feel less resentful, less anxious, less stressed. Most importantly, it probably will help you accept who and who will not be involved and in what ways. So the second challenge we're going to look at is expectations. So your family or your culture may have a spoken or maybe an unspoken belief about who provides care for an elder. So you may include the oldest child, the youngest child, the one who lives the closest, the one who lives with the elder females in the family, oldest males, who the person, which person has the most flexibility in their schedule. So it can be very, you know, confusing to know what the expectations are. And they might always not always be accurate around who can provide the care. So you may have expectations of yourself as well. For example, you may believe, I'm the only one that can do the job. I can do it the best. They took care of me. It's my turn to take care of you. All these things might be true, but they're expectations we have. So we just want to spend some time looking at those. And depending on your expectations of yourself or your family's expectations of you, you may feel like you are unfairly doing most of the work, or maybe you feel like you're not doing enough. So again, just spending a little bit of time around those expectations. It's challenging, but it could be helpful to you. And a third challenge is looking at the history of the caregiver and the care receiver relationship. So as we said earlier, you've had a relationship with this elder long before they were elderly, most of you. And that history may have had a past that's dissimilar or similar to how it is now. So really think about that. Think about, well, how did it used to be? Because sometimes there's a big gap between how it used to be and our expectations of how it should be now. So figure out if it's similar or dissimilar from how it's always been. When I did my research, excuse me, with daughters in the role of caregivers to their elderly mothers, there was often a huge discrepancy between what they sort of fantasized or wished it would be like now and what it had been historically. So maybe just give that a little bit of care if you need to seek some assistance and therapy to sort of work through some of those issues. We don't want stuff coming up as we're providing care to a vulnerable elder. So let's look briefly at a few relationship styles that maybe you had with your elder in the past. One of those relationship styles is hierarchical. So these are relationships where the elder was in control and you didn't have much power in the relationship. And this can even be in the form of not having shared information with you about their history about money and not really treating you like an adult. So this is hard now because we're shifting a little bit and we need you to step up to the plate a bit. So have they always been a dependent person? So this is another style of relationship. And I'm not referring to someone who might be from a different culture or speak a different language. This is somebody who's always emotionally been dependent on you. So they may have been the elder but in fact you were the elder even as a younger person. So I just wanted to make mention of those relationships but also kind of codependent relationships. So some of you may have an elderly family member who and you have a younger brother or sister who is living with them or has always been sort of dependent on them. Those codependent relationships can be very tricky when you're trying to step into the role of caregiver and you may be the one who's responsible. But you're going to have to deal with this other person who's played a very close relationship in that elder's life. Chrissy, how am I doing for time? I just have one more little thing I wanted to end with. You've got one minute. Okay, so I just want to acknowledge that there are many more challenges than the ones we've mentioned today. Memory loss, dementia, mental illness, living geographically distant from the elder, having a difficult relationship history with them. And I know many family caregivers who have felt a tremendous responsibility for caring but who have a little control. So I just want to recognize that by attending this workshop, you're taking control in a way that you can. You're learning resources. Consider a support group if that would help for you. Other caregivers are the ones that understand best what you're going through. So thank you for listening. I'm going to turn it over now to Michelle Javid, who is from Jewish Family Children's Services. And she's going to talk with us about the many senior services that JFCS offers. Thank you, Michelle. Yes. Thank you, Maureen. Good afternoon, everyone. I'm going to share my screen here. I'm excited to be here with all of you this afternoon. Let's see here. So my name is Michelle Javid. I'm the manager of business development for seniors at home. I'm here with my colleague, Rebecca Paul. She's a director of our fiduciary services. Seniors at home is a senior service division of Jewish Family and Children's Services. We're a prominent local nonprofit organization serving most of the San Francisco Bay Area. We serve people of all faiths and backgrounds. And today we're going to talk to you a little about some services that can help you age in place. So I first want to talk about non-medical in-home care because this seems to be kind of the first service that is needed when you're aging. So I'm going to go over some of the different business models that are in the industry as well as when a caregiver is needed. So typically, people hire an in-home caregiver when they're recuperating after an illness like pneumonia or some other debilitating health condition or they're coming out of the hospital. They had a minor surgery. Also, when there's a decline in cognition, they start losing their memory and having trouble managing the household. Also changes in physical appearance. As we age, we lose mobility and we have poor balance, so a caregiver can help us be safe in the home. And the majority of it is around when we start having difficulty with our activities of daily living. So things such as bathing or dressing, transferring in and out of the shower, home-making duties, you know, laundry, housekeeping meals, that's typically when a caregiver comes into the home. And then lastly, respite for a family caregiver. When there's a partner or spouse or adult child who is the main caregiver, a professional caregiver can help provide respite. I do want to kind of differentiate between skilled home health care and non-medical home care because sometimes these are used interchangeably and it can get confusing. So with skilled home health care, this is when a doctor orders a skilled provider, such as a nurse, physical therapist, occupational therapist, speech, social worker. This is typically provided when someone is recovering from a short hospital stay like they had a hip surgery or knee surgery. And this is typically, most likely it is covered by your insurance. Non-medical home care, which is what I'm really focusing on today, these are employees that are professional caregivers. They may have some experience. This is not covered by your insurance. Unfortunately, it's predominantly out of pay. They can do hourly shifts anywhere from four hours to 24 hours a day. They do help with those activities of daily living that I mentioned. They can provide medication reminders. And one kind of key thing is that non-medical home care providers, they're not able to provide a skilled need legally. So they're not able to pre-fill medisets or do dressings or change wounds or injections. That typically has to be done by a skilled provider. And then this here is just a list of the different types of types of home care business models that are in the industry to help you when you are going to hire a caregiver. You know, there is the private caregiver, which is people you hire from Craigslist or maybe a neighbor refers someone to you. And just for you to understand that you are the employer of record with this private caregiver. So you have to kind of take on all those HR responsibilities listed here like the background checks, deal with payroll taxes, workers comp, if there's an accident on your property. Then the middle one is what we call a domestic referral agency. Excuse me. They act as a broker. Excuse me, excuse me. And so they can provide you with an independent contractor. Excuse me. And typically you still are the employer of record. They may do some background checks. They can sometimes replace or reschedule the caregiver, but you're really still kind of doing all those HR responsibilities. And then, lastly, there's the licensed agencies. So like, like seniors at home, we take on all responsibilities where they're employer of record. So we manage all the payroll taxes and workers compensation and we provide ongoing training and we, you know, reschedule caregivers when they call out sick. So one thing just for you to consider is just the kind of the level of risk you want to take on when hiring a caregiver. And then in terms of how you pay for the services, like I said, it's predominantly out of pocket. For those of you who have long term care insurance, that's something that you pay into overtime that could help pay for in home care. If you're a veteran, you know, the veteran house, the VA can also provide some short term home care if you qualify. Some nonprofits organizations offer short term scholarships and grants at Jewish family children services. We do have some depending on the county and eligibility other places like Family Caregiver Alliance and the Alzheimer's Association. They offer respite scholarships for family caregivers caring for people at dementia. Lastly, there is in home supportive services, which is a Medi-Cal eligible program that's run by the state. You have to be Medi-Cal eligible and meet some other criteria and then they will pay for in home care. Now I just want to transfer to care management, which is kind of in lines about what Maureen was talking about when, you know, kind of working with your family caregiver. So one of the ways that care management can help you if you are a family caregiver or you are an elder and you have limited family is that care managers are their professional staff, typically have masters in social work or gerontology or psychology, and they kind of act as a surrogate family member in the sense where they can provide consultation to you or your family caregivers for a long-term planning. They provide comprehensive assessments. They can go in the home, do a safety evaluation, do a, you know, a minor maybe cognitive assessment to see where you are at. They create personalized care plans so that they can identify long-term care goals that you're looking to implement. They provide counseling and ongoing education, and then they can provide ongoing monitoring and coordination, checking in on you once or twice a month. They advocate for people when they're in the hospital, you know, communicating with the doctors, making sure everything's in place, and then long-range planning. So typically, when clients need it, care manager is when there is that limited or no family support. When they're unsafe in their current environment, sometimes, you know, folks are managing lots of different medical and psychological issues. There's confusion about their financial or legal situation, and they're just needing more direction about services and advocacy. And then for families, they need a care manager when they're burnt out, you know, they're managing personal responsibilities. They're confused about care services, which Maureen talked a little bit about. They have limited time or expertise, and they're just needing more communication around and direction around dementia and other aging issues. And then lastly, here's just kind of a quick overview of the services that we offer at seniors at home. Like I mentioned, we provide the in-home care and we also provide care management. We have a full center for dementia care where we help support folks with dementia and family caregivers who are caring for them. We provide counseling and education. We have a concierge care program where folks can hire personal care assistants to help manage household tasks and other organizational projects. So it's really a one-stop shop, and a lot of this will be on that resource list that will be provided to you at the end. But I now want to hand it over to Rebecca Paul, who is our director of fiduciary services, and she's going to talk more about that. Thank you. Are you able to remove, there we go. Yes. Great. Thank you. So thank you, Michelle. My name is Rebecca Paul, and I'm the director of fiduciary services at Jewish Family and Children's Services. And what I'm going to talk to you a little bit about today is the fiduciary side, more of the financial and the business side, which is complimented by what Michelle was talking about in terms of the home care needs and the physical needs. This is more of the business side. And many people meet with an attorney and create an estate plan for the future, which we highly encourage because what we're trying to do and trying to have others create for themselves is a plan and not be reacting in crisis when something untoward occurs. There are a number of different things that occur as we age, and one of them often is that there is a challenge with our capacity to manage our lives. And fiduciaries are individuals who are assigned to act on behalf of us when we can no longer manage our health care or financial decisions. And a fiduciary is someone who has the highest level of duty and trust and responsibility. They are asked to implement the decisions you've made ahead of time in the estate plan that you've created with your attorney to make sure that your life continues to run both while you're alive, but you are determined by a physician not to have capacity to manage your health care or your finances. And then after you pass away to carry out your estate plan and to capture all your assets, collect them and distribute them according to your plan. So again, the goal is planning. We are trying to prevent individuals from having a crisis situation and not having individuals and legal documents in place ahead of times. So most people are going at some point in their life to need an agent or a surrogate decision maker. And as I said, this is both while you're alive and then after you pass away to implement what you've decided. This is to empower you now at this point in your life to take control over what happens later in your life. So you're making plans currently for future events. Now, individuals are required in these legal documents to name an agent or a surrogate that's going to step into their shoes and keep their lives running while they're no longer able to do so. Historically, that's been your family, your children, your brothers and sisters. But today there's other options. And this is a good thing because sometimes in some families, it's not appropriate to have a family member or it's just inconvenient to have a family member or there isn't a family member or friend that can or should take on this responsibility. So sometimes it's a gift not to name your family and friends to avoid burdening them and asking them to take on a fairly significant level of responsibility. There are also a number of family and sibling dynamics that come into play in most family situations where it just may not be the best fit. Also, you have to think about the fact that your siblings and your friends are often aging at the same time that you are. Your children might live across country. They may have their own children. They've got busy lives and a lot of responsibilities themselves. So this can be a lot of work to take on and it's always something to really think about when you're naming somebody in your legal documents. Is this really going to be the right fit at a later point in life? I recommend that people when they're working with their attorneys name more than one person for every role. And that's because you want to make sure that if the first person either isn't available or for whatever reason cannot take on the responsibility that you have someone following them and it's like a ladder. The first person that you've selected is asked to take on this responsibility and if they can't or choose not to, it immediately reverts to the second in line and thereafter. So the different options that individuals have in naming an agent are as I just indicated family or friends. Also, there are financial institutions such as banks and trust companies. However, they typically will really only take on the role of a trustee. Sometimes they'll act as a power of attorney for finance, but most of them will not act as any type of health care agent. So there is positives and negatives. There's also private professional fiduciaries who can be named. And since I believe 2007, there's a licensure that's required for any individual that is going to become a private professional fiduciary in the state of California. And this requires them taking a course load, maintaining a license, sitting for their license, continuing education courses. It's overseen by the Department of Consumer Affairs. And there's a wonderful organization that many belong to called PFAT, professional, I just blank on what PFAT stands for. It'll come to me. The other option is that there are agencies or social services organizations, which is somewhat of a hybrid between an individual and say a bank or a financial institution. And in this situation, you're naming the agency, but not an individual to become your agent or surrogate for later in life when you can no longer make decisions and implement them for yourselves and keep your life running. And there are some positives to this because there's continuities business. There's a business model. This is one of those type of organizations and we're a nonprofit social services agency. It's been in existence for over 170 years. And as Michelle indicated, there are numerous services that are all fall under one umbrella, which is a really good thing because you have a lot of different individuals that can be within an email communication with one another to coordinate the services, pay for the services, maintain the services, and basically help to keep an individual's life running both from a healthcare perspective and a financial perspective. There's also a board of directors. So it's a nonprofit corporation, a 501C3. There's oversight, transparency and accountability. The fiduciary department at JFCS is currently comprised of licensed fiduciaries, myself as an attorney. There are other professionals who work in tax and business and come with a variety of different skill sets to comprise a department. So when working with an individual or an organization as a fiduciary, they're going to work with a financial advisor, a tax professional, a lawyer, a property manager, all of the other professional services to keep your life running. And the fiduciary is going to coordinate all of it and make sure that everything that needs to be managed is taken care of. So it's very comprehensive. And it's really important that a lot of thought is given to who you're naming as your agent, be it an individual or an organization or a bank or a trust company. So typically when most people meet with their attorney, they're going to create at least four legal documents. They're going to create some form of healthcare directive. And this is either called an advanced healthcare directive or a power of attorney for healthcare. And it helps so that ahead of time, you as an individual can create a document which states what your wishes are while you're alive but don't have capacity and your end of life decisions. This document typically commences when there is an incapacity determination made by a professional, typically a physician. And it springs into effect. It's called a springing document. It terminates upon your passing, other than some very small decisions which have to do with end of life funeral burial cremation, things of that nature. And this is the individual who is going to make decisions about all the interpersonal details in your life while you're incapacitated, where you live, working with your medical providers, if you're going to have a medical procedure, any social issues, things of that nature. Most importantly, you have to remember that they're going to step into your shoes and do all the things that you do for yourself right now but you don't really think about. And so this is the time when you're working with your lawyer to really think about what you want to have happen in your life when you could no longer make your decisions through the end of your life and who is the right fit for you. What is going to work in a comfortable way. And a lot of what both Maureen and Michelle talked about fall into this legal appointment that you're making. If you don't have any type of health care directive and you get to a point in your life where you could no longer make decisions, then the court will take over and if indicated a conservatorship of the person will occur. And this is something that we'd like to try and avoid and you'd like to try and avoid for yourself. So the other thing I'd like to say about health care directives is many people have a post a physician order for life sustaining treatment. And that is something you want to make sure is consistent with your health care directive and your post you work with your physician on your health care directive you work with your lawyer. The second document that most people create when they meet with their attorney is a power of attorney for finance or a durable power of attorney and again you're naming an agent. It commences again at incapacity it springs into action when you can no longer make your decisions on all of your finance and business side for any non trust owned asset. It terminates again upon your passing. You're naming an agent to manage your legal financial insurance benefits and all your day to day financial matters keeping you know PG&E bill paid making sure that somebody can talk to Social Security and Medicare and your health insurance company things of that nature. Any non trust asset falls into this area also so if you don't have a trust and some people do and some people don't depending on their circumstances. This is the individual who is going to work with the banks the for it with any investments your personal property make sure your taxes get paid and your bills get paid things like that. Again, if not, and you don't have someone in this role, the court will come into play and a conservatorship of a state will be appointed by the court. Some people have a financial situation, especially if you own real property in the state of California where a trust is really indicated and you can speak with your attorney about whether your circumstances would benefit by having a trust. And in that trust you need to need to name a successor trustee. This again is a role that is is taken on. When you get to a point where you can no longer manage your trust owned and trust titled assets. And this person also distributes your estate after you've passed away in accordance with your legal trust document and who you've named as your beneficiaries. It's a private relationship, it helps to avoid probate which is something that is beneficial for most people that have assets that indicate this. There are there's asset protection because any trust asset is retitled into the name of the trust as opposed to titled to you as an individual. It helps for tax planning purposes. There are different types of trusts and you can speak with your lawyer about that there can be a revocable or irrevocable trust. There can be a testamentary trust in your if you have a will. And it also can help with special needs planning if you have an individual in your family or a friend who is has disabilities which would indicate that a special needs trust or some other type of protective trust would allow them to hold assets. Not in their name but in the trust name but also qualify for public benefits. The other document is a will and over time. Most people used to have a will. People still have a will even if they have a trust but if you don't have a trust you definitely would benefit by a will. But in that document you're naming an executor and if you haven't named someone then the court appoints an administrator. This only comes into play after you pass for your assets but for anyone with minor children it's also really important to think about a guardian for your minor children and naming it in the legal documents. There are various different ways that one can create the will and you can work with your attorney on it. If you have a trust typically it will be a poor over will and the will transfers the assets into the living trust upon your passing. And there are benefits also because if you have a small estate which changes in value from year to year you could still have somebody that you've appointed and they will take care of the small estate even if probate is not indicated. There are also some banks and financial institutions where you can create other types of documents that would pay upon your passing, pay upon death type of documents. And those can be bank accounts if you've made that arrangement, life insurance policies, annuities, IRAs and various different types of retirement accounts all of which you name a beneficiary which is connected to that financial instrument. You can name your trust or your estate as the beneficiary or you can name other individuals or charitable institutions as your beneficiaries and you really want to think about that. This can be a stronger designation than just passing with a will because it's a legal transfer of asset upon your death. So I mentioned conservatorship, which is something that we do want to hope to avoid for individuals if possible because it's a, it's a lot of work, it's, it's can be expensive. The information, some of the information about your life can become public, but it is the last resort for court oversight if there's not a valid estate plan document that covers your finances and your healthcare when you can no longer make your own decisions at that point in life. There are a lot of practical problems that we encounter as fiduciaries. Sometimes the banks and financial institutions have a lot of hoops to jump through. And it can be very challenging and confusing for individuals who don't do this day in and day out. My staff and myself do this day in day out. This is part of our business model. And we have a lot of experience. It can be very hard for an individual to jump in and deal with all the complexities of what's required to be able to help and assist your family member or friend. Sometimes when we find when we take over a case is that there's been improper funding or titling of assets. So somebody intended something to be a trust asset, but they didn't title it properly. So when you're creating your estate plan, many attorneys you work with will really help walk you through that to make sure that what you're trying to achieve is achieved in terms of the titling of assets. Also, can I just ask that maybe we save some of the detail maybe for the question and answer section. Sure. Sure. My final would be having a state plan check up every few years or upon any changed circumstances in your life. Thanks. Okay. I'm going to now introduce Cynthia. It's my pleasure to introduce Cynthia. Cynthia Morris is a certified financial planner, a daughter and a daughter-in-law. She adored her grandparents, has volunteered for Lighthouse for the blind helping visually impaired seniors, and has also served as a Marin County ombudsman advocating for seniors and small living facilities. Her attention now is focused on her own mother-in-law. Thanks, Rebecca. And hi, everybody. In our short time today together, I will, I want to give you just a little insight into my own journey and share some suggestions on how we can all add value to our elders, our seniors, and other loved ones. I'm going to use those terms interchangeably. I'm going to share my screen. Chris, can you give me a thumbs up if it is the right page? So Chris, are we good? Okay. Great. Thank you. I'm always worried about sharing. I boiled this down to two schools of thought in the, in, you know, as a, as a daughter and a daughter-in-law. Some people approach it. Using the rule if it ain't broke, don't fix it, you know, and, and others come at it with, well, there might be a potential issue. Let's try to get ahead of it. As a financial planner, you probably can guess my, my perspective. Unknowingly or knowingly, our elders and our parents often will tell us that everything is okay when maybe it isn't. So, and, you know, and that's, it's easy to take it at face value and say, okay, everything's fine. But I think paying attention is, is important to recognize potential issues perhaps sooner rather than later. And dealing with them early can make them sometimes easier, less dramatic and potentially less costly. My first kind of bullet point is be curious. I think I heard this earlier. I can't remember who said it, but be curious. Don't, don't sweep this stuff under the rug. You know, ask questions and, and ask to be led into a conversation. You can see on, on your screen, there's a book cover there. There isn't really a manual to carrying a caregiving or taking care of loved ones as a family member, but there are a lot of resources at the library. This book, Can't We Talk About Something More Pleasant was one of my favorites. There is one of my favorites and has a lot of stories with which I could relate and humor. Don't forget the humor as you go through this. As a first child, this picture could have just been me, my parents. I was really apt to, you know, try to tell them how to run their life. But with my mother-in-law, I didn't have that same sort of relationship. I didn't really feel like I could tell her what to do. My husband is the only remaining child and her only relative, and she lived in LA. Well, we lived up here. That's what, 300-something miles. So, you know, and I don't know if you've ever gotten a call like this, but we would get calls from her neighbor who said, hi, this is, you know, your neighbor, your mom's neighbor. Everything is okay, but you know it really isn't. So, we kind of saw trouble ahead in terms of her living situation and the fact that we were so far away. And also, she's very isolated, and that can make somebody really vulnerable and lead to, you know, other problems, some of which can be financial. So, we had been watching because she had been chid, fallen prey to some high-priced subscription services, like, you know, really exorbitant phone and cable that she wasn't using. And also, she had a visit from a very nice window salesman. The windows turned out to be fine. But, and we didn't, you know, we didn't have to return those, but we did have to return the car that she bought on credit thinking she had rented it. So, she thought she had rented it or has taken it for a test drive for a couple of days. And anyway, we couldn't tell her what to do, but we were watching and feeling like we were in the back and kind of a backstop position from 300 miles away. It was very difficult. And, I mean, I think Maureen mentioned that we just felt responsible, but we had no control. So, the next point, or the kind of my next lesson, or that brings up the next lesson, which is establishing boundaries. We go to bad. It was kind of simple for us because there were no, there are no remaining siblings. So, we really just had to coordinate amongst ourselves. My husband and I, and we had to decide, hey, when are we going to get involved? When are we not going to let her do her own thing? And we decided that our boundaries were if she needed a wheelchair or if she lost her driving privileges. A wheelchair would have involved, you know, extensive homely modeling and maybe a caregiver hired down there. Or if she lost driving privileges and in LA being so spread out, we just didn't think that would work. But we really didn't want to force that issue, you know, didn't, didn't feel like it was our place to do that. And a very good friend of mine who works in this senior in a senior living facility said, you know, let, let her make her own decision if you can. There will be an event. Something will happen either with her or someone in a circle of friends that will precipitate the decision, some decision to change. And lo and behold, we didn't have to force the issue. It came really close. But in the end, she got a diagnosis of macular degeneration and made a decision that I must humbly admit was much better than, than anything we had come up with. So she ended up moving to an independent living facility or an apartment. And it's doing just great. Whatever the living situation is, or whatever the change that happens in, in to art with our seniors and elders. I think it's really important as children or caregivers to identify your team. And I think that was mentioned earlier too. This is not a solo sport. It is a team sport that can provide additional help. You should now see like a list of stuff that I just put down on paper ideas and areas we thought about with the complexity of a move from a house of 50 something years and waning eyesight. You know, we, we needed to take, you know, we had to take over administrative duties for my mother-in-law. It was gradual, probably wasn't as efficient as it could have been. But we didn't, we wanted her to be able to establish trust in what we were doing and also to retain her own dignity. So you can see from our, our team over here, the check marks or the items that we handle ourselves and the little green arrows are those things that we outsource. And I will let you know kind of dovetailing on some of Rebecca's comments that having an attorney in this process for us was that attorney put together some power of attorney. Some power of attorneys, durable power of attorneys for finance and healthcare and my husband is successor trustee. We handle all of the administrative duties, all of her bills, her insurance, her taxes. And also before I leave this slide, I want to remind you that the lower, lower half of the last item is an ice cream buddy. There's a lot of logistics that go into helping a senior, you know, physical logistics, don't lose sight of the social and the emotional. As people age, their friends, you know, to pass away or move away and my mother's mother-in-law's case, she moved away and had to start a whole new social network. So this kind of brings some joy, being a ice cream buddy is a really a good break for everyone. I mentioned durable power of attorney. I think it's really important to know a little bit about the medical side of things. The picture will change over the years for your loved one. And it's really important in my opinion to know how Medicare works and as someone who hadn't yet had a lot of exposure to that. When we first started down this path, it wasn't, it wasn't real natural, but with the help of ICAP and that's in your resource packet. We did some classes and learn a little bit about how Medicare works and that was really helpful. And what I have in my wallet, some of you might want it on your phone, but I keep a list of all of her doctors, my mother-in-law's doctors and her meds for easy reference. You know, you never know when you're going to end up in the ER. So in closing, here are, I hope you guys can see my, the number one there, but basically I've got a couple of words, you know, a couple of list of my to-dos. Be curious. Don't sweep this under the rug and, you know, do be interested in what's going on with your senior. If change needs to be, if change is coming, coming down the way and you see it, try not to force it, but do recognize that you have your own boundaries and need to have your own boundaries. Don't forget about your team. Think about that ahead of time. How can you, how can you offload some of the responsibility that might be coming your way? Don't underestimate the power of understanding Medicare. And don't forget that list of medicines that I've used that I think twice now. And lastly, don't expect perfection and do expect frustration that both of those will be coming down the, down the way and give everybody a break. You know, we're all, it's a journey and none of us have been down this road before. So that's, those are my remarks. And I am going to now introduce Maura Gibney, who is the Executive Director of the California Advocates for Nursing Home Reform. C-A-N-H-R is an acronym you'll see often. She's going to talk about MediCal eligibility and updates in that area. Her organization, Panner, is a statewide nonprofit organization that really is dedicated to improving the quality and availability of many long-term care options in California. She has previously worked in other organizations serving developmentally disabled people and families of children with developmental delays. She is a graduate of USC and has a master's in social work. Maura? Thank you so much, Cynthia. I am going to share my screen if that's okay. And thank you for being here today. And I want to follow in everybody else's kind of footsteps who talked about some of the caregiving responsibilities and follow up with some additional resources. So I'm here today to talk about MediCal for long-term care and available home and community-based services. And I think, Cynthia, for the introduction, Canner is a statewide organization. So the goal of my presentation today is to maybe raise some interest for some of you, but just know it's a lot of information. This is a difficult process. There's so many options and information. You won't walk away an expert and no one expects you to. The great thing is that there are resources that you can follow up with later. So if you hear something today that sounds like it might apply to you, just know that you can always reach out to Canner after the presentation today. So my goal is not to overwhelm you. You're probably already overwhelmed enough. So I'm going to be talking a little bit about what is the long-term care landscape look like? So what are the payment options? So you've heard about Medicare. I'm going to be talking about MediCal. Some people have long-term care insurance, though, to be honest. That industry has really dried up over the last decade or so. There aren't a lot of great policies. And for older adults who already have some type of a medical condition, it's either impossible or practically impossible to get. Veterans Aid in Attendance is a program that is for veterans or their spouses who serve during wartime. That might be something that could be an option for some people. And then Supplemental Security Income, or SSI. And this is different from SSA, Retirement Benefits. It's a special program that's only available for very low-income individuals who are over 65 or disabled. So a little bit about Medicare, the myth versus the reality. We get calls from across California through our 1-800 hotline and we provide over-the-phone information. A lot of people call us. They're very confused about what their options are and how they're going to pay for them. So Medicare is a federal health insurance program. It's based on work history. It's not based on income or assets. It's for people who are 65 or older or who have been disabled for two years. It's important to know that Medicare offers very limited coverage if you're very high-need. So for hospitals, it's only up to 150 days with deductibles and copays. Nursing homes, Medicare will only cover up to 100 days and that includes about 80 days that have a copay that's rather high. They don't offer rent and room and board for assisted living facilities. They can offer some limited home health and hospice services. And as far as in-home services, there's some very intermittent skilled nursing therapy if someone is truly homebound. So you can see that Medicare for someone who has short-term needs, definitely an option. But if somebody's care needs have increased to the point where they're going to need services for quite a long time or for the rest of their lives, Medicare is not going to provide that coverage, unfortunately. So what does MediCal offer? MediCal is California's Medicaid program. So you may have come from other states. You may hear the term Medicaid used on the news. MediCal is California's program. It is health insurance for individuals with limited income and assets. So that part is changing and I'm going to talk about that in a moment. MediCal does cover long-term care in hospitals, nursing homes, and offers home and community-based services. In a hospital, in a nursing home, and at home, these services are of unlimited duration. There's no limit. It truly depends on what the need of the person is. And if they continue to have a need, then the service can continue to be provided. There's some home care options that I'm going to be talking about. Daycare options, case management, and a program called the Assisted Living Waiver. So I'll go into detail about each of those programs after we look a little bit more at eligibility. One thing to note, we get a lot of calls for people who want to know about MediCal because they're considering payment for an assisted living facility. Assisted living facilities, sometimes known as RCFEs or residential care facilities for the elderly or boarding care facilities, are licensed differently than a nursing home and are not traditionally covered or paid for by MediCal. So that's often a huge disappointment for people who are trying to plan for their loved one who maybe needs some care and supervision but might not meet the need for skilled nursing yet and might not be at the point where they're ready to go into a higher level of care in a nursing home. There are some exceptions including the ALW program that I'm going to talk about. And there are some limited services for very high-risk individuals available through new managed care plan benefits called CalAIM. In San Francisco, those services are just getting started now, so we won't really see the impact on what those services will look like, at least for another couple of years. MediCal may cover some health and hospice services in an assisted living, but it's not going to pay for the $5,000, $7,000, $8,000 a month that a lot of private assisted living facilities charge, especially in the Bay Area. So what are the reasons to enroll in MediCal? We get a ton of phone calls again from across the state. People say, well, MediCal, no, there's no way that I'm going to be eligible for MediCal. There's no way that my mom will be eligible for MediCal. Someone two years ago told me that she wasn't eligible, and it's just important to know that the rules are always changing. So what I'm going to talk about today, today's MediCal eligibility is very different from 2024, and some new things on the horizon, eligibility may be different in 2025 and beyond. So it's good just to stay up to date about what the options are. So what are some reasons why people end up on MediCal? They don't have Medicare coverage. Some people don't have work credits. MediCal also covers the 20% Medicare gap. MediCal is a pair of last resort. It's the safety net. So if all the other insurances have paid or won't pay, MediCal is the safety net that ensures that everything, all the bills get paid. It covers some medications, which Part D coverage does not cover, and it covers medical supplies, incontinence pads, diapers, all the kinds of things that people need, those kind of daily supplies, diabetic strips. It offers in-home personal care and health care, adult day health care, and very important, one of the most expensive services, nursing home care. So could you or your loved one be eligible for MediCal? It's important to know that there's a lot of different MediCal programs, and when applying, MediCal is supposed to match you with the program that best meets your needs. But I'm going to be going over some of the income and asset guidelines because with any large agency, particularly bureaucratic organizations, accidents and sometimes not accidents happen. So it's good for us as consumers to be informed about what our options are so that we can ensure that we're matched with the program that meets that person's needs. So these are some common MediCal programs. There are a lot of different ones, but I'm going to be talking primarily about these ones that are for older adults, people with disabilities. Magi is the most common program, and it is the one that ends up causing the most confusion for people who are trying to apply to the other ones, because it's pretty simple. Magi is for people in 1964. It's truly based on income. You're either eligible or you're not. There's no asset criteria, so it doesn't matter what you own. An income limit changes slightly every year with the federal poverty level. So for this year, it's 1677. The thing is, this is the largest program. A lot of the MediCal eligibility workers are very familiar with this program and not so familiar with the other ones. And that's where some of the confusion ends up happening when people try to get these other types of MediCal eligibility programs. So for older adults, people with disabilities, they're not typically on Magi, especially you can't be on Magi once you turn 65. The next program is Age Blind Disabled Federal Poverty Level Program. It also has an income limit of 1677. However, there are some allowable deductions. You can use supplemental health insurance policies that you're paying for like Medicare, like drug plans, like your Medicare Advantage plan to reduce your accountable income and reach that income limit. Asset limits apply, though that is also changing, and you must be 65 or older, blind or disabled. Maura, I'm going to ask you a quick question. It's Chris here. The 1677 is a monthly income. That's a monthly income, yes. And it's also a figure that changes. So you see this as for 2023. That number will typically it increases every year with the federal poverty level. So yes, you'd want to take a look at your income possibly over the year and then divide by 12. There are some people that maybe get a distribution once a year from their IRA or their 401K. You could divide that by 12 as well, kind of figure out what your average monthly income is. But generally, this is the type of thing that my organization does every day. People call us, they go through their scenario, we look at the numbers together, and then we figure out what program could you possibly be eligible for. So that's a great question, Chris. Thank you. For the medically needy program, it is similar. There is an income limit, but it's a program that exists for people who are over the income limit. And they end up paying what's known as a share of costs, which I'll explain a little bit more in a moment. And then finally, long term care medical, this is the type of medical that is provided for people who are in a nursing home. And that's when I get phone calls from people who say, well, I need, you know, my mom is in a nursing home. She needs medical. I know she's not going to be eligible. And I go, well, why do you think that? Well, she makes too much money. The thing about long term care medical is there really isn't an income limit. If your income is less than what that nursing home would be charging you. And I'll be honest, the average private pay rate in the state is $11,000. In the Bay Area, it's much higher. So there are nursing homes in San Francisco that charge $17,000 a month. So if you're making less than that, medical is probably going to be beneficial because it's very unlikely that you're going to be able to afford that amount of money long term. There is currently an asset limit for a single person of $130,000. That doesn't include homes and, you know, your car and I'm going to go through some of those in a moment. And again, no one is supposed to memorize these figures. This is just out here for guidance so that you can kind of think about could this be a possibility when it's time, you know, to make some important decisions. Does MediCal count all of my assets? So what are assets? Assets are things that we own. It could be money in the bank, stocks, bonds or bank accounts. It could be our retirement accounts. No, MediCal doesn't count all of these things. There's either your assets are grouped into things that are either exempt, which are not counted or non-exempt, which are counted. And it's important to know that we're in October and we're only a few months away from a massive change to non-Magi MediCal programs, which is there will no longer be an asset limit as of January 2024. This means that MediCal will no longer ask you any questions about what you own when you apply. If you're on MediCal now, you do not have to provide MediCal with any information about your assets during renewal. Income guidelines will stay the same. So you'll still have to report information about any income that you receive and any income that you receive from your asset. So for example, if you owned a rental property and you're getting rent from that property, that counts as income. So that's what the program is really going to focus on now. Unfortunately, the asset limit increases only for MediCal. This was a California-only change. SSI is a federal program and the asset limits will remain the same. Benefits here is have to stay under 2,000 for an individual or 3,000 for a couple. This is just a couple of the exempt assets for right now. If you really wanted to apply for MediCal today, it's important to know that your home would not be counted. Your primary residence does not count. Everything that's in your home is not counted. It doesn't have to be in your home realistically. It could be in your storage unit or whatever, but they're not going to go through your things and try to figure out how much things are worth. You can own a car. You can have work and retirement income pension accounts. There's several other things that are here. You can have $130,000 cash reserve right now. This was a big change that happened in 2022. And if you have a spouse or registered domestic partner, that person can have up to $148,000. Again, this is only going to matter and my presentation is going to become a lot more streamlined in 2024. This is only for people who apply in the next couple of months. In January, there's no longer an asset limit. It really just comes down to income. So now we'll switch to the income side. What does MediCal do with the income information that it receives for these programs? So first we'll start with what is a share of cost? If someone has countable income that's over $16.77 a month for a single person or $22.69 for a couple, and again, these figures change every year, they will likely have a share of cost. And this is the amount of money that someone must pay each month towards medical related services, supplies, equipment, in-home caregiving before MediCal starts to pay. So you can think of it kind of like a monthly deductible. MediCal figures out the share of cost based on your total countable monthly income and people may be able to purchase supplemental medical insurance to bring down their countable income. So let's take a look at Sylvia. She receives $1,900 a month in Social Security retirement benefits. We take away a $20 any income deduction. It's not worth explaining why that is. It's just one of the MediCal rules. And so she's left with $1,880. Right now the maintenance need or what the state has determined that you need to live in the community, and this is a number that hasn't changed in more than two decades, is $600. And Sylvia's share of cost is $1,280. So I don't know anywhere in California that someone can realistically live on $600 a month and pay $1,280 for medical needs. Sometimes where this works out is if Sylvia lives with her family members, so she doesn't really have any other bills, but for someone who's living on their own, this is really unrealistic. So it is something that we're working on advocates from across the state are working on increasing the maintenance need. We're waiting to see what the legislature does in 2025. So how can we help Sylvia get rid of her share of cost supplemental insurance policy payments can help Sylvia lower her countable income. If she can purchase $203 in insurance is to lower her countable income to 1697, then she would be eligible for age one disabled she will not have a share of cost she'll have free MediCal. Different types of insurance that can be used or health dental vision drugs long term care insurance there's a long list of others. Oops, let me go back. Other options for people whose income is too high just there's a limit to how much insurance people can purchase. So we take Louis he has an income of $2,700 a month he cannot lower his countable income it's just too much insurance to purchase. And he would have a share of costs of about $2,080. So what can he do to meet his share of cost. He must have out of pocket expenses that are equal to that share of costs every month before MediCal will kick in. So he can use that money to purchase medical equipment pay for prescription drugs. Other things that MediCal does not provide or medical procedures or treatments that have been denied by MediCal. He can pay his IHSS caregivers and that's a way of meeting his share of costs. And he can also get additional home care services prescribed by a doctor in addition to his IHSS hours. So how does nursing home share of costs work it's important to know that it is very different from community based share of costs. So we'll go back to Sylvia, she has Medicare MediCal, she ends up meeting to remain in her nursing home beyond the Medicare days. So she's now going to transition to long term care MediCal. In a nursing home people share of costs is all of their monthly countable income, they keep $35 for personal expenses, another figure that hasn't changed in decades. Everything else is paid to the nursing home as a share of costs. So when you hear people say things like oh I heard that the nursing home is going to take my social security. That's not quite how it works. People owe a share of costs like a deductible before MediCal pays for the rest of their nursing home coverage. Residents who are MBA attendance can keep $90 an additional $90 and SSI eligible residents can keep $50. I just want to mention that there are some complicated but very important special rules for people who are married or have a registered domestic partner. And if only one of those people, one of the persons in the couple needs to be in a nursing home, or is able to access a home and community based service. They get different income and asset guidelines that are much more generous. So the spouse who's not on MediCal can keep all of their income it doesn't matter what their income is. And the person who is on MediCal can also allocate some money to them as well. This can often reduce or remove a share of costs completely for a married couple by rebalancing their income. Couples can have a higher amount of combined assets right now and again in 2024 that will change. So MediCal if you're married, registered domestic partner and one of the persons is very high need, please reach out to Canner. These are rules that sometimes the eligibility workers don't even know about. We spend a lot of our time helping people navigate these rules. So, again, it's just important to know that this resource is here. So spend a little bit of time talking about what are some of the home and community based services that are available for MediCal, Medicare or private pay. And these are, this is not an exhaustive list. These are just some of the most common. These are programs that offer an alternative to nursing home placement for people who want to remain in the community. They can include in home caregiving, case management, home modifications. Not all services are available in all counties, though I will say if you're from San Francisco and most of the Bay Area, these are, you know, all available. I would say when you start getting into rural counties is where you find that some of these are not available. Unfortunately, you have to apply to each program individually and it can be really confusing. So we have a lot of resources in the resource list that Chris provided as offered what's called the home and community based services quick guide. It's a really brief overview of each program so that you can kind of figure out how much more time do I want to spend learning about this program. Again, participation in these programs that I'm about to talk to can allow a high need married person or registered domestic partner to receive extra income and asset allowances when they're on MediCal. The first is MSSP. I'm going to use the acronyms because that's what's used. So there's a link to the slide but the multi-purpose senior services program it's a lot easier to call it the MSSP program and that's generally how it's known. This is a case management program that helps people over 65 to remain in their homes and communities. Services can include some kind of light equipment, medical systems, medication dispensers. They can do adaptive equipment, nutrition services. You have to be 65 or older and have kind of some high needs though on each of these slides you'll see skilled nursing level of care is needed. That is a varying kind of degree in each program does its own assessment. Applicants for this program may not have a share of cost. So you could be eligible for MediCal with a share of cost and be meeting it through paying other things and then participate in this program. This program does exist in San Francisco, but this would kind of be HCBS light. This is probably the least intensive of all of the programs. Next is a very common one. Everybody, a lot of people are very familiar with this program but maybe not exactly sure what it is or what it does. IHSS provides home and community based attendance services and support. This is a program that pays for a worker, a family, a spouse, a friend to help with household chores, personal care services, paramedical services, and protective supervision for people who have cognitive disabilities, then that includes Alzheimer's and dementia. So this is the type of program that based on assessment people are given a certain number of hours. So there's no age restriction and hours are based on a needs assessment. There's no waiting list. Truly one of the biggest barriers is identifying your own worker. So this can be a really great program for somebody who has a family member or friend who's ready to provide the care is maybe already providing the care. And now this program can pay that person to be the provider. IHSS pays your provider directly and wages vary by county, though I will say these are not high wage, you know, jobs, and which is why there's such a worker shortage. How to apply you must be eligible for Medi-Cal and you contact your local IHSS office to begin the application process. If someone has a share of cost, I mentioned that IHSS payments or payments to a caregiver can help that person meet their share of costs. We go back to that example of Louis. He has a very large share of cost. He has $2,080 share of cost. He's awarded $200 of IHSS after he does or 200 hours of IHSS after assessment. So his provider gets paid $3,300 a month based on what that county pays. So he has to pay his provider the share of costs, the 2,080, and IHSS pays for the rest. So you can pay your share of cost each month or and use private caregiver payments to meet the share of cost. So I provided some resources here. It's very important. I strongly urge people are thinking about applying for IHSS to complete a self assessment. This is a grid that really helps outline for the IHSS worker how much care and services this person needs to be safe at home. Next is the CBAS program. So this used to be called adult day health programs. These are center based programs where people can go for part of the day. Usually it's something like 9am to 2pm. They do really specialize in people with cognitive disabilities including dementia. And it's available both through Medi-Cal but also as a private pay benefit. There are several centers in San Francisco. I had a woman that I spoke with last year, her father's income per month. They lived in the south part of San Francisco Bayview and he had $4,000 a month in retirement. He had had a great job. And now she needed a lot of care for him at home. We did the share of cost. It was just too high for what he needed. But we found a CBAS program where the cost per day was about $120 a day. And that was exactly right for them. He could afford it. It was going to alleviate some of her caregiving needs. But it is one of the few programs that's also available as a private pay option and it's quite reasonable. PACE provides a combination of in-home care services in addition to adult day health centers. In San Francisco I believe there's a couple of providers. I'm familiar with On-Loc for example. You may see their vans around town. And people can go to these centers to receive medical care meals, rehabilitation therapy, social services. People have to be 55 and older and be a little bit high need. And it's only available as a managed care plan. So people have to switch from their managed care plan to a PACE plan because it is supposed to be all-encompassing. The PACE plan will provide all the care and services that that person needs both at the center-based program where they provide the transportation to and from and also in the home as well. It is available as a Medicare plan option with a private pay, but I've heard that it's quite expensive. So I'll put it out there. You don't just have to be eligible for medical, but it can be quite pricey if you're paying privately. CCT is a program that helps transition people who are currently in a nursing home or a hospital for more than 60 days back to the community. So a lot of times people will become institutionalized and maybe they lost their apartment or their home and they want to, you know, they've either improved a bit or maybe they think they can go home with appropriate support. So this program helps people prepare for that transition and supports that transition for over, you know, for close to a year. This includes everything from home and vehicle adaptation. They purchase medical equipment that's needed so that the person can live at home. It could be a Hoyer lift, for example, or a special bed. And then they arrange for the type of in-home care that the person needs through other types of home and community-based services programs. They can also help with finding and setting up a new home, including deposit assistance. Realistically to be, you know, for San Francisco, it's challenging, right? San Francisco and the Bay Area, it's hard to find housing. So they're not magicians, I will say that, but they can be, you know, a great option for someone who maybe is ready to return back to the community and need support with that. HCBA is a program for very tiny individuals who need care at home or who want to transition out of a facility. Right now, the waitlist is completely closed and advocates are trying to work with the state to see how we can fix this issue. But people should know about the program. It works on top of IHSS hours. So there are people who are able to have close to 24-hour-a-day services in home when they combine IHSS and the HCBA program. So it supplements IHSS caregiver hours with doctors, nurses, other types of respite hours. The assisted living waiver program, this is one of those exceptions that I talked about earlier. This is a program where MediCal pays for people who are over 21 to live in an assisted living or public subsidized housing is only an option in LA County for some reason. And it's meant to be an alternative to nursing home placement. So MediCal helps people find contracted assisted living facilities. The individuals are only responsible for paying their room and board, which is a pretty low rate, 1324 to 1344 a month. And then MediCal supplements the care and services that person needs based on the tier system, which is based on their assessment. So high-need individuals who are in a nursing home or a hospital are prioritized for placement. It is a waitlist, but it's definitely worth getting on the waitlist, particularly if maybe the person that you're caring for is maybe not high needs now, but could be in the future. If they have, you know, maybe a degenerative condition that's likely to get worse, it would be worth exploring now. People must be eligible for MediCal with no share of cost. And this can be possible if people have income that is below 1677 up to about, I've seen people successfully get down to, you know, by purchasing supplemental insurance who are in maybe the $2,300 range per month. It is available in San Francisco. People can also opt to move to other counties that are listed here as well. They aren't limited to just San Francisco County. And so again, must be enrolled in MediCal with no share of cost and you apply through what's known as a care coordination agency who does the assessments and helps with finding a placement. I just want to briefly mention MediCal recovery. We get these calls for the time. Can MediCal take my home after I die? I don't want to use any of these services because I heard they'll come and take my home or they'll, you know, take my money. The state can only secret payment from your estate after death only if you were in a nursing home on MediCal or if you use some specific services. And if what was left in your name is going to go through probate. So earlier one of the other speakers talked about how you can avoid probate through some simple estate planning procedures. So recovery is limited to those people who were over the age of 55 and use specific services. But if there's nothing left in the person's name, then there can be no MediCal recovery. They don't go after your children's estates. If you pass away and you have very little income, earlier one of the speakers mentioned a small estate with a value of $184,500 or less in personal property or $61,000 in real property. There's a small estate affidavit, so there's no recovery. Property that won't go to probate. So if you set up a living trust, if the property is held in joint tenancy, if you did one of the payable onto death accounts that the speaker mentioned, a life estate, or if you own a mobile home, there can be no MediCal recovery. Those items will not go to probate, so there is no MediCal recovery. And if there's a surviving spouse or registered domestic partner, and I forgot to put on here, a disabled child of any age. They don't actually have to be a minor. A surviving spouse, registered domestic partner, disabled child of any age, there is no MediCal recovery. It's forever barred. So it's important for people not to be scared to access these services and that there are things that people can do to avoid MediCal recovery. So I want to keep us closer to time. Canner's website. I'll put it in the chat again. I believe Chris already put it there. We have a 1-800 number. And so please give us a call or email us or go on our website. We have a lot of good information and great fact sheets. And I will stop sharing now. Mara, thank you so much. And thank you to our entire panel. I really appreciate just all of this information. I hope that everyone that's on this presentation has gotten a lot out of it. And I know from personal experience, it's hard to take all of this in. It's sort of drinking from the fire hose. I had hoped to have a short little break, but I also am very well aware that we have a hard stop at 220. There are no questions in the chat box. Mind blown. There are no questions in the chat box right now. But I'd like to give our panelists an opportunity, just in a loose form, and I've got a couple of things written up too, to maybe throw out something that you'd like to add or to ask a question of another panelist. There's not so many of us that we can't work this out, but I will keep us on track for time. So I have a question. Go Jenny. All right. So this is a question for Maureen or anyone else. So for singles, I know that there was a question did come up about resources for singles. So we were talking about some of the kind of illegal and the financial so I'm just curious from any one of you. What are other things that singles can do, perhaps in their community to kind of build up their, their, their connection base. I'll just speak to it a little bit and maybe somebody from Jewish Family Children Services can add on more specifically but you know I think it's, it's thought that if one has children one is has a safety net and that is not true. I think it's thought if one has a partner one is a safety net and that is not true. So in some ways we're all here single. I appreciate your question which is, you know, I think looking at kind of who is my support now, like who do I engage with who do I have intimate relationships with who can I rely on. And I think, beginning to have some conversations with people. I know I worked in the tender line for many, many years as a new social worker, I was new for a long time. I was really struck by how some of those folks who were living by themselves who seem to be very isolated had connections in the neighborhood and many, many people knew their comings and going so I think figuring out who your support system is currently. Are there ways you can build it up a little bit for example if you take a class through Wrecking Park is there someone there that you can extend yourself to a little bit more. So, I think, you know, especially in a big city like San Francisco I don't know what the numbers are but we have many, many singles who live here and take advantage of your neighbors neighbors are really happy to put in as long as it's something very specific but. So that's just off the top of my head in response. Anyone else have thoughts on that one. I would add the San Francisco village are is a really great nonprofit organization for those of you who are not familiar with the village movement. It started off in Boston and really it just became a community of older adults to help support each other as they age share resources volunteer. I think for for a single elder the San Francisco village is a great resource and within the within their village services they actually have a kind of single elder group that meets. It's a membership fee it's quite nominal and I think they have scholarships for folks who can't afford the fee, but I would recommend that as a resource to. Thanks Michelle. Thank you. I wanted to add something. I know more you had said that long term care insurance is, you know, getting less and less. I that is true. I'm interested in what the other certified financial planners have to say. We've certainly seen a lot of insurance companies, you know, sort of extract themselves from the long term care insurance set of plans available in California. But we're also starting to see some others coming in. And this is a really complicated issue I you know if I was to touch I am touching on it but I won't be able to give it all of the information that that anyone interested in this service, but there are long term care insurance specialists who can walk you through some of the options. And as with any financial product, you know, it's kind of our job to take it slow listen to what the resources say not feel forced into any sort of a purchase, but there are options out there. There was something. I, there's something that's called a hybrid plan that is kind of a combination with a life insurance plan. Once again very complicated but it can be explained and you can take a look at that maybe the underwriting in other words your physical health issues may not play as big of a role. There's also some religious organizations that that offer lower cost long term care insurance. I'm not going to give you any specifics on any companies because I think that that would be narrowing the field too much but Jenny and Cynthia what are you seeing out there for long term care insurance. I agree that there, it's, there's more out there than is commonly perceived. You know because a lot of people just say oh no, it's going to be too expensive. I won't qualify. So that it absolutely there's, it is difficult and it can be expensive but don't, you know, use that to not even investigate it I would encourage most everyone to investigate what is out there. Be sure to involve the next gen or whoever is going to be helping you if you need to spring that long term care insurance. You will need somebody else that knows what's going on. If you're if you're in need of it you probably won't be able to help people work. I just want to mention as well that long term care insurance can be amazing for in home care. My grandmother, we, she was not we were able to have an aunt to really figured out the policy and again to Cynthia's point it took my aunt reading through the policy going through all the paperwork to keep my grandmother at home for a very long time without with no out of pocket costs really for their family. What we're seeing a lot of is that it when it's a very limited benefit that is often tied to someone's Medicare eligibility for skilled nursing so long term care at a nursing home is where a lot of the policies drop off. And so I think it's just important for people to understand what they're getting into that. The long term care that calls we get really helpful at home but may not be for someone who ends up needing to be in a nursing home, you know, for a very long time. It could be vice versa that it just covers homes and not in home care so that goes back to earlier comments about having someone like your aunt that can read through the policy and continue to push because like any insurance policy they're often denial denial denial, and a lot of people just drop off and they don't follow up. But you know if you pursue and really get somebody who understands the policy and read it in specific detail. I've seen a number of people who have been able to prevail. I love what everybody's saying here the keep read the policy read whatever information you have, and then go and ask the subject matter experts whether it's an estate planning attorney whether it is canner, giving you information about Medicare Medicare, whether it's the seniors at home people. There is help out there and I just want to say I personally experienced how hard it is to reach out for help so you're not unusual if you're struggling with that at all. The other thing as a financial planner is all insurance you need to read all of your documents to understand what you have so this is very similar. Does anybody have any other questions I'm looking at the chat I don't see anything there any other comments that you wanted to make in our final eight minutes. There was a question about Medicare recovery. It says where the rules California specific or Medicaid in general. I thought you needed an irrevocable trust to avoid. So these are California specific rules that canner actually helped write and it took 20 years to get them passed. So the medical recovery or medical or Medicaid recovery rules that are specific to California are unfortunately specific to California alone we've been trying to work at the federal level to get medical recovery eliminated. But so far that has not passed through Congress. So we're very fortunate that we live in California with these rules and I definitely would would caution people to do their homework on an irrevocable trust you do not need an irrevocable trust to avoid medical recovery. Any trust will do there's also other options for people who can't afford trust. But an irrevocable trust means you cannot change it versus you know a living trust and there's other types of revocable trust options so no. Those are kind of myths that persisted from the old medical recovery rules. But in order to avoid medical recovery trusts living trust. There's a lot of different options and there's some resources. I will share there's an organization called Hera housing and economic rights advocates I want to say they're based in the Bay Area and for low income individuals they provide estate planning services on a sliding scale. So you know I think it's great to talk about attorneys and and have an attorney but for people who can't afford them there are also some options. I see a raised hand that would be my raised hand. I just wanted to I wanted to point out and I want to acknowledge that many people who have an elder who doesn't live in the San Francisco or in the Bay Area so on the research. I'm sorry on the resource sheet. The elder care locator that is an opportunity to see what's available in the community where elder lives so you just go in there it's very easy. You just put in the zip code and they will provide you resources or a contact number to find out what with information referral for that county. Okay see a raised hand for Emily. And I asked her to type her question into the box, because I think she's not going to be unmuted. Okay, yeah. Okay so we have a question. Okay, if a senior comes from a different state into California and already receives Medicaid from another state. How does that transfer to California. You can answer that unfortunately there is no interstate transfer process. People need to come to California and be able to establish residency and I'm using that term kind of it, how you establish that residency it can vary and there's this long list available from medical about the type of documents that can be used to establish residency so it's easier said than done right you know somebody comes they're not going to have a utility bill necessarily. It's not always a state ID but there's different ways of establishing residency. One of the things that is allowed to establish residency under medical is physically being in a hospital or a nursing home. So, unfortunately, that's a difficult process there is no, you know, kind of federal system Medicare doesn't have a way of helping people transition from state to state so families often have to navigate that on their own, or you know that's one of the times I think when people seek the services of a geriatric social worker, or case management program because it's there really is no benefit program that's going to help you with that. Okay, so I guess, along with that, that would be the same case if someone immigrated, because I often talk to you know younger people that talk about bringing their parents over from another country so that would be the same. Yes. And last year, California also changed the rules for residency so it does not matter what someone's immigration status is they can access Medi-Cal for ages 50 and older and starting next year, any age starting next year Californians people who are in California, regardless of their residency status regardless of their immigration status can apply for Medi-Cal. The rules don't change the income limits are still the same. So, and I will mention that for older adults who need nursing home services and some of those very high need HCBS programs like the HCBA program. They could create what's known as a public charge issue so they they would definitely if there's want Medi-Cal to go to the doctor get some IHS services and home, really not a problem. So when they're higher need that depending on what their, you know their status of maybe their immigration issues are in they may want to talk with an immigration attorney first before using those services. Okay, all right, that's very useful information. Okay, we've got to see. I am muted. Yes. This is overwhelming. I must say, I'm a single I don't have close by family. This is a huge amount of information. Where can I follow up on what we've been presented today. The agencies that presented here. Yes, you are going to be able to reach out to Jewish family and children services directly, you're going to be able to reach out to canner directly. There is a resource page that the library will send out to anyone that reach that fills in the survey of this particular program. And it's just a two pager so there's a lot of information on there that is going to be available. It's also in the chat, but I know some people may have some difficulties in getting that. And I am a part of villages of San Mateo County, similar to the village of San Francisco. We probably would like to arrange for someone to do a presentation here. Each of you could be contacted for that kind of thing too. Yeah, so that should go offline. You can certainly reach out to the library I've given all of the contacts here the certified financial planners are independent. But reaching out to canner and to, and to Jewish family and children services that they're just, they're incredible. It is time to be wrapping up someone just asked about the slides. The library does have the slides so it's really important for you to reach out via email the email is in the chat so copy chat is a good way to go or just snag that email before we go off this call which will be in one minute. And there's a survey that this library has that you can fill out and you can get the resources page that we put together as well as more slides. I want to just say a huge thank you to all of our presenters today and to Jenny as well. You're amazing people, all of you. And this was just, it was such a calming discussion for me. Also, and I hope that everyone loved it. It is recorded, and that is the most important piece is that I, it will be available as a recording in the future, and anyone who attended can steer others to this discussion. So, thank you, thank you to all and also thank you to the library. Incredible group of people. Yeah. It's, it's such a pleasure to work with all of you so thank you for so much information that we're going to have to read and reread the slides. And that tax update coming up next it starts in 10 minutes. Please check that out Larry pond is going to be presenting there he's incredible with tax it's going to be a lot of information again I'm sorry we didn't get the break in there. Also there are one on ones, still going on I didn't get an update on how crowded that was at this point, but please check it out. You can go to the right link or through Bay Area financial planning days, be as in Bay, a area financial FP planning days DBAFPD.org. All right, have a good one everybody.