The loss of independence can be sudden or gradual. With an accident, fall, stroke, heart attack, or other health crisis, your independence may be swept away in an instant. Even when decline has been gradual, independence frequently ends in a sudden crisis, followed by a hasty scramble to respond.
Both in recognizing decline and taking action in a time of crisis, families typically play a large role. Without family, if you’re suddenly incapacitated, who will step in and see that your home is maintained, bills paid, pets taken care of, appointments cancelled, etc.? Who will huddle with doctors, social workers, and case managers to determine your course of treatment and where it takes place?
What is generally called “advance planning” involves designating surrogates to make medical and financial decisions if you become incapacitated. Of course, you’ll need to be sure these surrogates are findable when needed and understand your wishes. The choice of these surrogates and how they’re empowered is discussed in detail under these headings:
Preparing for the Inevitable – Medical
Preparing for Possible Incompetence (Legal)
Preparing legal paperwork to designate surrogates is essential and should be done well in advance of any actual health crisis. Information about how to contact those surrogates needs to be readily found when the time comes. But when does the time come? The actual transition from independence to assisted living may follow several paths.
An Orderly Transition
If your decline is slow and gradual, the challenge is recognizing and accepting the need for change. You’ll want to get assistance before you become a danger to yourself and others. If you wait too long, your independence may end abruptly when you trigger an auto accident, leave a pot untended and cause a fire, or wander off in your nightgown.
Among the many services spouses and children render is noticing when their aging relatives reach the point where they can no longer take care of themselves. Although this is a primary source of friction between parents and children that people without children are spared, it’s equally problematical NOT to have anyone who’ll notice a downward turn. If you have a neighbor or friend you can speak frankly with, have an honest conversation with them about checking up on you. If you can’t find such a person, a call-alert system might at least provide backup in the case of a health emergency.
The most orderly transition would include selecting in advance a place you trust to care for you in old age and moving there before it’s absolutely necessary. If you decide to stay in your home as long as possible, an orderly transition would involve identifying people to manage your home health service providers and other caregivers. It would also involve a back-up plan for selling your house and moving to a facility if necessary
Without family, it helps to be tough-minded and realistic. This is easy to say in advance. It’s also easy to understand why so many people hide their growing incapacity, even from themselves, and struggle to get along until it’s simply no longer possible.
An Abrupt Transition
Sometimes aging proceeds slowly and steadily, but all too often, changes are precipitated by a crisis. It could be a medical crisis like a stroke, heart attack, or serious fall. It could be that a neighbor notices that you’re looking unkempt and contacts Adult Protective Services
What happens then?
If you’ve planned in advance, your surrogates will spring into action and follow the plans you’ve discussed with them. Your Durable Power of Attorney designates someone to act if you’re mentally incompetent to make legal and financial decisions. If you’re mentally competent, you may choose to have that person act as a financial surrogate under your instructions. You could direct them to sell your home if needed, to arrange short-term care for yourself, your pets, and your possessions. Smoothing your transition in the wake of a health crisis may be more or less complex, and more or less costly, depending on whether there is a house to be sold, sufficient funds to pay a care manager and other variables. No matter the situation, your advance thinking and planning will prove their value.
If you experience a health crisis and haven’t planned in advance, the outcome is far more chancy. If you end up in the hospital and are lucid, a nurse-coordinator or social worker will visit you to assess the situation. Decisions will be based on your finances and the availability of resources in your area. If you live in a small town with only one nursing home, you’re pretty likely to end up in it. If you live in a metropolis with many options within a small radius, your finances will restrict your options. Without surrogates to make and carry out decisions, where you end up will be determined by an overworked social worker looking for available beds in your area. Your fate will hinge on how caring and knowledgeable he/she is, what kind of a day he/she is having, and how willing or able he/she is to make extra efforts on your behalf.
A consideration of the likelihood of your returning home at some future date will be part of the calculus. For many single older people, a health crisis ends with a move to a nursing home or assisted living facility because the support needed to stay at home (care managers, home health aides, home retrofits) is simply too expensive.
Managing the Transition
For all too many people, the move to an assisted living facility or nursing home comes as a sudden, unprepared-for event. As a result, a number of industries have sprung up to facilitate the transition, including geriatric care managers, moving specialists and “referral” specialists – i.e. brokers for nursing homes and assisted living facilities.
Geriatric Care Managers
Dr. Cheryl Woodson describes Geriatric Care Specialists as “rent-a-daughters.” The National Association of Geriatric Care Managers puts it this way: “A professional Geriatric Care Manager (GCM) is a health and human services specialist who helps families who are caring for older relatives.” Actually, a good Geriatric Care Specialist will keep that “older relative” at the center of planning while working with family, coordinating services and working to make sure the elder’s wishes are followed. Though expensive, a good Geriatric Care Manager can be invaluable.
Senior Real Estate Specialists
The National Association of Realtors has a special designation for “agents who specialize in senior real estate services” and a website with a searchable directory of certified agents. Not surprisingly, peddling real estate services to seniors is currently a growth industry. However, most of the senior communities these agents offer are for “active adults” and may be seriously unsuited to older, less mobile people. As far as I can tell, “senior real estate specialists” are likely to be better versed in identifying nearby golf courses than nearby physical therapy facilities (for example). You can learn more about senior real estate agents here and here.
Senior Move Managers
The National Association of Senior Move Managers is a self-described “group of professionals who specialize in facilitating a smooth transition for seniors moving from the home into a senior housing community.”
Senior Referral Specialists
For needier old people, there are “senior referral specialists.” They too have a national association. Here is their mission statement: “The Senior Placement & Referral industry helps families find residential care facilities, assisted living placement, in home care services, and adult group homes for the elderly and those with disabilities.” Although their mission statement bypasses people without family, they’d probably be happy to assist us.
Senior referral specialists are usually “free” because they’re paid by the facilities seeking your dollars. Indeed, for-profit services for seniors are a growth industry and we’re likely to see all kinds of experimentation in this area, for better or worse. A positive example is that agencies are springing up that coordinate custodial and skilled nursing services.
Despite the sales pitches for for-profit facilities, multiple studies show that non-profit facilities do a better job by virtually every metric. You may want to consider them first.
It’s hard to plan for something that’s unpleasant to contemplate, maybe not even going to happen, and whose timing and severity can’t be known in advance. It’s tempting to just leave matters to fate. Yet, if we don’t plan, our fate may rest on an overworked and underpaid individual being pressured by someone else’s children, and a voracious “move manager” seeking the highest payback from the placements he or she makes. Planning ahead seems the better choice.
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