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Sunday, December 12, 2010


I apologize for so much time passing between blogs. Between the Thanksgiving holiday, which was complicated by a freak snowstorm, first-of-the-month billings and an exciting event that also required a flurry of time-consuming activity. I just haven't gotten anything written.

My exciting news, though, is that I have been nominated for the Small Business Association's Small Business Person of the Year Award. I am so excited! Of course, these things are never just handed out without some work on the nominee's part. I spent a good portion of last weekend, Monday, Tuesday and Wednesday getting a packet of information together. It had to be at the Seattle SBA office by Friday, December 10th. Evidently, 35 people statewide have been nominated. I was told that I will find out if I've won in early March 2011. If I win for Washington State, I will be invited to the SBA national celebration in Washington, DC in May. Just being nominated is a huge honor!

Building Bridge Builders, Ltd. into a viable business has been the hardest job I have ever had and it has been worth every minute. The services that we provide are so needed and there will be an increasing demand as the baby boomers age. It is a challenging business, though, and it takes a special person with a passion not only to serve our unique clientele but also to have the stamina to hang tough as this type of business is difficult to grow. While there are huge emotional payoffs when successfully helping clients to have an improved quality of life, the down side is that there are those who try to discredit this type of business. A business owner needs the fortitude to withstand those attacks, even though they might be infrequent. If you are considering starting a similar business, here are some suggestions:
  1. Consult a business advisor - The SBA offers assistance for free. The advisor can assist you with the details of the business end because you could have the best idea in the world but if you don't pay attention to the business end of things, you will fail.
  2. Don't believe people who say that all you need to do is hang out a shingle and you'll be swamped with work. This business needs time to establish credibility just like any other business. Bridge Builders, Ltd. is a great idea but we can have quite a challenge convincing prospective clients.
  3. Realize that you need to develop yourself as an expert in the field and this takes time. I am at the end of eight years and only this year have I been receiving comments that indicate that my staff and I are considered experts. Eight years may seem like a long time if you're just starting but, believe me, the years fly by.
  4. Watch your cash flow like a hawk. I only started tracking our cash flow on a weekly basis about two years ago. I wish I had started this at the beginning! I can now look back a couple of years to see if the cash flow is typical, better or worse. Also, if the cash flow is less than my target amount for the month, I tell my staff that they need to focus on tasks that generate billable time and/or it an employee would like to work a little less, now is the time. This can really made a difference at the end of the month.
  5. Be careful with credit. Early on I was seduced by easy credit. When you start a business it seems like everyone wants to give you credit. While most businesses require having a certain amount of debt because cash flow isn't consistent, use credit cautiously and wisely. My brother is growing a business without debt, which is great and I am very proud of him, but it really slows down the growth doing it that way.
  6. Charge what you are worth. That is a very difficult thing to do, especially in a business that provides services to people. But if you don't value your time, your client's or prospective clients won't either. Over the years, we periodically got calls from prospective clients who wanted something for nothing. After spending copious hours over the years trying to convince these people that we are worth what we charge, I just don't bother wasting my time anymore. If someone calls and, after discussing services and rates, says we're to expensive, I'm happy to give them some numbers where they might be able to piece the services together themselves. Sometimes these clients resurface later and sometimes they don't. I don't worry about it anymore.
  7. Hire qualified staff. My business advisor told me once that the staff of an entrepreneurial business need to be pseudo-entrepreneurs. These are people with the experience you need who are willing to work for peanuts because they believe in what you are doing. It will take longer finding these people but it is well worth the wait. My bookkeeper, who has been with me from almost the first, was looking for a part-time job with some challenge that would be flexible and fun. She hasn't been disappointed and I have been the blessed with her knowledge over the years. All of my staff worked uncomplaining for years without raises because there was no money for raises. How did I find these people? Sometimes by networking and sometimes they would hear about my business and come to me. I've learned to be choosy, though. It pays off in the long run.

You need to realize that this is a business that you will be in for the long run. I've had people call me saying that they wanted to start this type of business, run it for ten years and then sell it at a profit. They think that the need is so great that they will be swamped with work out of the starting gate. When I explain that it isn't so easy and why, I don't hear from them again. You need to understand that this business is about serving people. People are not a commodity to be sold at whim. If you are named as Power of Attorney for clients, it is expensive for the clients to change this. Guardianships need to go through expensive court hearings. Your client depend on your to be there for them. That's a heavy responsibility for some people. I find it to be an honor.

Sunday, November 14, 2010

Tips for working the Long-Term Care "System" - Federal Government

Trying to help a friend or loved one navigate through the elder care system can be daunting. Here are some tips so that you can avoid unnecessary aggravation:

Social Security: Did you know that Social Security doesn't recognize Power of Attorney documents? Well, they don't. It has something to do with Social Security being Federal and Powers of Attorney being State. So, if you need to do business with Social Security on behalf of someone else or manage someone's Social Security money. You either have to be their court appointed guardian or you need to apply to become the loved one's Representative Payee. You can find the application online if you look really, really hard. You can also go into the Social Security office and request an application.
  • If you go the the Social Security office do not go at the beginning or end of the month or the beginning of the week. The office is crazy busy during those times. Pick early afternoon on a Wednesday or Thursday.
  • When filling out the Representative Payee application you will need to include the name, address and phone number of your loved one's doctor. It doesn't say this in the instructions and there is no place on the application for it but if you don't have it the application will be handed back to you.
  • I have occasionally run into a situation where the doctor doesn't want to fill out the form. I have found that writing a letter explaining why I need to manage the client's [loved one's] money and why Power of Attorney isn't adequate in a very humble way seems to help.
  • When you receive the letter appointing your Representative Payee, keep it in a safe place because you will need to produce it at the bank and other places from time to time.

Veteran's Administration: They don't recognize a Power of Attorney, either. If your loved one cannot sign a release of information form allowing you to be their advocate, you have no choice but to initiate a petition to become the loved one's guardian. If you become the court appointed guardian, always keep a copy of your Letters of Guardianship handy so you can wave them in the face of the person who quips, "We only deal with the veteran, not the spouse [family, friend, etc.]. In this day and age of HIPAA Laws, everyone is afraid to say ANYTHING without the appropriate legal document.

  • Try to always have an appointment. The walk-in clinic is a real nightmare. If you can't avoid it, plan on being there an entire day.
  • If your loved one needs to apply for benefits for the first time, contact the local Veteran's center (VFW, DAV, etc.) to learn the best way to submit the application so that it will be processed as quickly as is reasonably possible.
  • If your loved one is a low-income non-service connected veteran, plan on the application taking a year. If they need financial assistance before then, get them signed up with your State's version of Medicaid.
  • You can fill out an application online at but please remember that you still need to print it out, have the veteran sign it and send it in even though you can electronically submit the application.
  • DON'T forget to send the required documentation. Can't find the DD-214? (Discharge papers) You can send to a certified copy on the web site.
  • If you send a copy of the DD-214, you will get a letter stating that you need to send the original or a certified copy withing a certain length of time. Writing them to tell them when you expect to be able to send it will keep the application "live."
  • Give the application a couple months before checking on the status but by all means check. Sometimes these applications seem to fall into a black hole or something. Be especially diligent if the veteran was just in the reserves. We have had more problems with applications going missing for the veterans who were in the reserves as opposed to active duty.
  • Once the veteran is approved for benefits, send updated medical records, bank statements and medical bills (paid) to the VA on a regular basis. You might want to mark your calendar for every three months or so.

If the process seems overwhelming to you, please get help with this. Call your local Area Agency of Aging to find out where you can go to get assistance. While it takes longer, the benefits from the Veteran's Administration come with fewer "strings" than the State Medicaid program.

Sunday, November 7, 2010

Amazing Will to Live - Update 11/7/2010

Amy has started eating, and keeping what she eats down. (She had been having a lot of nausea) Last Monday, she slept through the entire night for the first time since her surgery. She is now joking with the caregivers and recognizing the staff at the facility. She still has a fair amount of agitation but the caregivers and staff are trying to deal with it using exercise instead of medication. The medication makes her sleep during the day and then she is up all night. She is no longer on the oxygen. She actually gave herself a black eye fighting with the tubing! But her oxygen saturation is O.K. now. WOW!

The only real casualty was a cell phone that took a swim in the toilet. Those cell phones just don't swim well at all!

I'm looking forward to taking her to her appointment with the surgeon at the end of the month. I'm sure the surgeon will be amazed, too!

This is what Amy wanted, a chance to live pain free. She wasn't afraid to fight to beat the odds, even with severe dementia. She has taught me so much!

Sunday, October 31, 2010

Amazing Will to Live - Update 10/31/2010

"Amy" is still plugging along. Until this past week she hadn't been eating enough to keep a fly healthy but she is now starting to eat more at meals. [She has never been a big eater and doesn't have much in the way of "reserves", meaning fat.] She has been walking, joking with her caregivers and is recognizing the staff again. Is she out of the woods? Probably not. But she is a daily miracle!

Tuesday, October 26, 2010

Amazing Will to Live - Update 10/26/2010

Amy is still with us, fighting every day to live... almost literally! Her poor caregivers deserve combat pay!

Sunday, October 17, 2010

The Amazing Will To Live

I have a client, I will call her Amy, who has the most amazing will to live. By rights she should have died the Friday before last. Her oxygen saturation was dismal without the O2 being turned up all the way, her kidneys were shutting down and she had an infection. The doctors didn't think she would live through the night but she's still here, fighting every minute to regain strength so that she can continue living.

This is a person with severe dementia, severe osteoporosis and is pushing 90 years old. How did she get to this point?

About a year ago, Amy fell and basically shattered her hip, actually the top part of her femur. The surgeon put in a metal plate and dozens of screws to hold her bone together so it could heal. Because of her dementia, we were unable to keep Amy from walking too early. If she had to use the bathroom she could not understand why she couldn't just walk the few feet to the toilet even though a caregiver was at her elbow to help her into her wheelchair. People with dementia are not able to understand cause and effect anymore. The facility staff did the best they could but she broke the plate and a few screws early on. The amazing thing was that she wasn't having any pain. The doctor decided to just leave it and see it it would still heal.

About six weeks ago, Amy started having pain... a lot of pain. We don't really know why but it could have been that there had been scar tissue holding everything in place and it either got torn loose or might have been just reabsorbed into her body. Amy was sent to the hospital where she spent a couple nights while the doctors tried to decided what to do. The doctors ultimately decided to send her back to the facility where she lives with "palative care." Palative Care means that they are managing pain. It became obvious pretty quickly that this was not a viable option for Amy. Either she couldn't understand why she couldn't move about without a lot of pain or she had to be sedated so much that she was in a stupor.

I talked with the administrator and the director of nursing at the facility, who agreed with me that this was no way for Amy to live the rest of her life. I called the family (who live a long way away) and discussed the situation with them. We came to the agreement that it would be better to take the risk of surgery rather than "sentence" Amy to the current situation. I called the surgeon who had done the original surgery. We discussed options and I decided on the option that wouldn't "fix" her hip but would take the pain away and still allow her a certain amount of mobility. Amy had been using a wheelchair a lot after the first surgery so she wouldn't miss not being able to walk very much. Again, I ran this option past the family, who also agreed. I also talked with Amy about this. Even though she has severe dementia I felt that she could let me know whether she was in agreement or if the thought of surgery was frightening or repellant to her. She fully agreed to have the surgery. She didn't like being in pain and wanted to do what was needed to stop the pain.

The doctor scheduled the surgery for a Thursday and instructed me to have Amy at the hospital by a certain time on Wednesday. Amy was in a good mood and was able to give consent [unofficial but still important] to the doctor after the doctor explained the procedure again. Amy made it through the surgery without a problem. Unfortunately, on Friday the problems started. Amy's kidneys started shutting down and she got an infection on top of needing all the oxygen they could pump into her. The doctors didn't think Amy would live through Friday night but she was still "kicking" on Saturday. Sunday the doctor notified me that Amy needed a blood transfusion. I talked with the family and told the doctor that yes, we wanted Amy to have the blood. [We figured that if she was fighting the least we could do is give her the tools to fight with.] By Tuesday the doctor said she could return to the facility under "comfort care." [Meaning= death is imminent] Well, today is Sunday and she is still with us. Her kidneys have started working again and she is over the infection. She still needs oxygen but that is minor. She is getting up for some meals. She's having trouble keeping food down [probably a leftover from the anasthesia] but she is obviously fighting to live.

Some people might have disagreed about having surgery arguing that someone with such severe dementia has no quality of life left. If you could see her, you would know what determination and quality of life is all about. Amy is one amazing woman and I am honored to know her and be allowed to serve as her Power of Attorney. Life is Precious... no matter what age.

Sunday, October 3, 2010

Starting a Business Like Bridge Builders, Ltd.

What I love about this business is the day-to-day diversity of demands. Each of my clients is their own soap opera, as I suppose each one of our lives is. The difference between my "active" clients [clients who currently need assistance] and the world at large is that my clients cannot manage their lives without assistance. Sometimes they are willing to listen to advice and sometimes they will do things that I know will have unpleasant consequences. It is not my job to tell my clients what to do. It is my job to give my clients the available options, along with the consequences, good and bad, of each option and let my clients make their own decision. It is easy to tell someone what to do. It is far more challenging to respect a person's right to make a bad decision. My job then is to try to be a "safety net" for my client so that the consequences are not as serious as they might have been. I love the challenge.

I "boot strapped" my business. I learned through my journey of developing a business that banks, angel investors, etc., are not interested in bankrolling a social service business. In this business Angel Investors are in the form of friends and family [if they have money to loan]. The bank wants to secure everything you own against a loan for operating money and, in my opinion, are to be avoided.

I started with a somewhat vague business concept of helping the elderly and disabled and have honed it by trial and error through the years. It hasn't been easy but it is the most rewarding venture I have ever experienced. There will always be good times and bad, great cash flow and trickle cash flow, clients I love and clients I could be happier without. There will be the never ending battle to capture receivables [getting the unpaid invoices paid].

If you are afraid of risk, work for someone else.

When my [then] business partner and I started the business, our goal was to "bridge" the gaps between services available for the elderly and disabled. We did not want to duplicate services that were already available. Many people were skeptical when we opened our doors. I finally got someone to explain the skepticism. "Old-timers" could recount numerous businesses that would start up to assist the elderly and disabled, doing a good job. Then, they would disappear leaving all of the people they were helping without any support. It's great having a strong desire to help others, but if you cannot run an efficient business, you will end up closing up the shop.

I have received calls from people saying they want to start a similar business in their area. While talking to them I learn that they expect customers to come flocking them them when they open their doors and that they will build the business for 10-years, then sell it off making a nice, tidy financial profit. WRONG! #1 - Marketing this type of business takes a lot of networking and demonstrating successes. You don't get handed credibility on a platter and credentials only get you so far. #2 - It takes many years to develop a reputation within a community. I am coming to the end of my 8th year and this year we have been hearing that our good reputation extends far beyond the area we serve. It takes about 10 years to develop a reputation as an expert in a particular field. #3 - We are talking about people here, not hardware or some other commodity. You cannot just sell your client contracts to someone else and move on. When my business partner left, I witnessed the concern our clients experienced. Our clients were very worried about whether the business would survive my business partner leaving. I've even noticed how worried some of my clients can get when one of my employees leaves the business. These vulnerable adults depend on us for their quality of life and sometimes for their very lives. Please don't let them down!

If you are not in this business for the long haul, please don't start it. Ten years may seem like a long time when you're starting a business but the time flies amazingly quickly. Of course, you will want to start thinking about how you will phase out of the business as you get closer to retirement. There are ways to do it so that it doesn't traumatize your clients.

Still want to get started? Call your local Small Business Development Council and get a [free] business advisor assigned to you. I didn't start using a business advisor until year four. I would have avoided many problems if I had a business advisor from the beginning.

Sunday, September 19, 2010

Challenging Behaviors, Chapter 2 - Understanding the Resistance

For resistant elderly, the more subtle or indirect the assistance is, the more likely you will have success. Please understand that these elderly are, at their core, terrified. They often have always been fiercely independent and prided themselves as not needing anyone. In reality, we are all interdependent but don't try to reason with someone who has lost the ability to reason. You will lose every time. Elderly folk remember nursing homes and other assisted living facilities [even though the concept of assisted living hadn't been thought of yet] as terrible warehouses of miserable humans who are not cared for properly. While nursing homes and other similar facilities still have their problems, they are nothing like they were in the 50's.

Almost every new client I get insists on staying home and I have to accept this and try to make this happen for them while trying to gently educate them by taking them for "tours" and not putting a lot of pressure on them. Also, natural consequences can be a great motivator.

Many times, family and others trying to help a resistant person help too much. Just how much help is too much help? Well, that differs from person-to-person, which makes it difficult to have a one-size-fits-all answer. If the "helpers" quit helping in certain areas and suggesting an alternate, the resistant person will initially try very hard to coerce, guilt trip or whatever has worked in the past to get the "helper" to continue helping. Once the resistant person realizes that the "helper" will no longer step in, he/she will either a) agree to the alternate solution or b) find another "soft-touch" somewhere to help out. There is nothing you can do if the resistant person chooses "b." Again, you just have to sit back until "b" either shows it works out or the "soft-touch" gets tired and beats a hasty retreat. Playing a rendition of "Good Cop/Bad Cop" can sometimes be helpful. If you can have others [Adult Protective Services, the doctor, etc.] be the "Bad Cop" and set yourself up as the "Good Cop" all the better.

Does it look hopeless? It isn't necessarily hopeless but you have to make a plan and be patient. Talk with Adult Protective Services, especially if the resistant person is being financially exploited or abused. Have a consultation with a Geriatric Care Manager with behavioral experience, who can help you make a plan and give some creative suggestions on how to handle the issue. Contact your local Area Agency on Aging for local resources. The key is to pick your battles and get everyone involved with the resistant person to agree to the plan. One weak link will make positive change almost impossible.

Sunday, September 5, 2010

5 Wishes Advance Directive

I received the following email from Paul Malley, President of Aging with Dignity [not associated with this blog] reminding me about the 5 Wishes:

"We came across your "Aging with Dignity" blog and thought the information contained in it was great. We note in particular you 7/10/10 post on advance directives. I'm not familiar with the laws of Washington, but some states don't automatically recognize the durable power of attorney as the durable power of attorney for health care. Some even require they no be the same person if that person is a beneficiary of the estate or would have some other conflict of interest.

"Moreover, it is not necessary to retain an attorney to complete a durable power of attorney for health care. There are many forms available for that purpose, many of which are provided by the states free. Our own Five Wishes advance directive/durable power of attorney for health care form is easy to understand and use and requires no attorney. It meets the legal requirements of 42 states, including Washington. It also makes provision for empowering the health care agent to apply for Medicaid amount the other powers to be designated. It also satisfies HIPAA requirements.

"I hope you take a moment to familiarize yourself with Five Wishes and what makes it unique among all other advance directives/living wills. A good place to start would be at our website, We have many care manager/consultants like you who are among the 23,0000 Five Wishes partner organizations nationwide."

My organization often deals with legally touchy situations requiring the use of an attorney for estate planning/advance directives but in the past I have used the 5 Wishes form to help me get a clearer understand of the kind of treatment a new client would like in the event that client could not tell me. I highly recommend it. Thank you for the reminder Mr. Malley!

Sunday, August 22, 2010

Unsafe and Resistant to Help, Chapter 1

What constitutes being unsafe? In our country we value our independence and our laws reflect it. Short of a court order, which is extremely difficult to get, a person can live as they chose. As people age they sometimes lose the ability to meet even basic needs. Of course, this doesn't happen all at once. It is typically a slow process. As a caring person, when this becomes obvious you want to set in and "fix" the situation. There are seniors who will welcome help, seniors who will tolerate help and [my typical client] seniors to steadfastly deny that they need help. Here is a list of some of the problem areas:

Financial Exploitation: This happens far more often and any of us want to admit. Financial exploitation has many "faces."
  • A family member always in need of money. Maybe the senior has helped them financially all their lives but there comes a point where the senior my develop dementia and can no longer make a conscious choice.

  • "Helpers" or "friends." Too many times a senior in denial looks to a neighbor or "nice" stranger for assistance. At first the "helper" assists for little or no compensation but over time they manipulate or demand more from the senior.

  • Solicitation phone calls. Seniors are fodder for a phone solicitor who is friendly and seems to provide a little companionship for those who are lonely and isolated.

  • Mail solicitations. Seniors get deluged with mail requesting financial assistance for anything from sick animals to disabled veterans to third world countries.

  • Charities: Even religious organizations can be pushy about donations.

Personal Safety: There are many personal safety issues but these are some of the highlights.

  • Hoarding. A senior may lose the ability to determine what is trash and what is important so then will not throw anything away. Over time this can build into a health and/or fire hazard. This problem is becoming so prevalent that there are many books written about it.

  • Falls. As a person ages, the possibility of falling increases dramatically. Even when a person realizes he/she needs to use a walker when outside the home, that same person will park the walker in a corner of the house and hang onto furniture and whatever else that is in reach. If a person is going to fall, he/she will fall no matter the location [home/assisted living/nursing home] so the question the becomes, "Just how long do you want to be on the floor before help arrives?"

  • Allowing anyone who comes to the door into the house. This always strikes a certain amount of terror into my heart. Lonesome seniors who welcome anyone into their home yet refuse appropriate assistance.

  • Driving. This is a real hot button for most seniors. When a senior gives up driving, he/she gives up a huge amount of independence and sometimes does not have the ability to problem-solve well enough to figure out alternatives or understand how the alternatives work.

Inability to follow medical instructions

  • Because of short-term memory problems or the inability to comprehend, the senior is unable to follow through with instructions. This may mean medical tests, medication changes or as simple as remembering the next appointment.

  • Inability to manage medication. I have entered many a home that had medication [old and new] everywhere. Other times a senior had a method of tracking medication but due to illness or dementia that method no longer works and the senior is unwilling to change. I've met other seniors who are so afraid of taking too much medication that they take too little.

  • Doctor "hopping." A senior either doesn't like what he/she hears or cannot comprehend the instructions. The senior denies that he/she has a problem, therefore it must be the doctor and changes doctors frequently.

Inability to manage Activities of Daily Living:

  • Personal hygiene becomes poor. The senior doesn't pass the "sniff" test. He/she insists that he/she bathes regularly but it's tough on the nose to be in the car with them for any length of time. Clothing is dirty but the senior insists their clothes are just FINE. [We occasionally have a client that necessitates the use of an air freshener after transporting the client to an appointment]

  • Unexplained weight loss. The senior is losing weight but there is no medical reason. The senior won't let anyone look in the refrigerator or cupboards insisting that he/she has plenty of food. You take that person out to eat and he/she announces their not hungry but eats most or all that is served. If you can look in the refrigerator, food has spoiled and the boxes and cans in the cupboard are past their pull date.

  • Inability to clean house. The house may be fairly tidy but it become increasingly grimy.

What is the answer? There are often no easy answers. What you need is a big bag of "tricks." In the next post I will list some "tricks" that have worked with some of my more challenging clients.

Sunday, August 1, 2010

How Does A Guardian Get Paid?

Anyone who is appointed by the Court to be guardian for an Incapacitated Person (IP) can be paid as long as the Court approves. The guardian [family guardian or professional guardian] needs to make sure that the ability to be paid is in the Order of Guardianship. If the provision for payment is not in the Order of Guardianship, the guardian can petition the Court for an order specifying payment.

Types of Payment:

Private Pay: An IP who has assets [savings and/or investments] would be expected to pay with the client assets. The Court may approve an hourly fee and/or a monthly fee. Some counties require a budget be submitted to pre-approval. It can be very difficult to guess how much time you as the guardian will put in at the time of appointment. The guardian can expect that the first 3-6 months would require much more time and that the required time would drop off after that. If the guardian gets approval for a budgeted amount and then realizes that much more time is required, the guardian can petition the Court to approve an amended budget.

Medicaid [Welfare]: For IPs who are on Medicaid, the State of Washington allows a base rate flat fee of $175.00 per month payment for a guardian. I have found that most of the time this is adequate, especially if the IP lives in a facility. Sometimes an IP will require more time. The guardian can provide documentation at the reporting period of the addition amount of time and request the Court approve the additional amount. The wording has to be specific to how the law is written. The Department of Social and Health Services (DSHS) will need to be notified within their required period [usually 20-days] and they can send an attorney to contest the additional fees. If the Judge approves the fees, DSHS is obligated to adjust the participation to pay the guardian.

Public Guardianship Program: This program is for those who are not on Medicaid but are indigent or very low income. In Washinton State, the Program pays the professional guardians who are contracted to be a part of the program a monthly flat fee.

Pro Bono: A guardian who agrees to accept a client who does not fit into any of the above categories would need to be willing to provide the service for free. Those who are professional guardians are encouraged to accept some Pro Bono guardianships but it is often difficult to find a professional guardian willing to take a guardianship without getting paid. Being a professional guardian is a business just like any other business and it is necessary to limit the amount of pro bono cases or the business as a whole will suffer. Sometimes a professional guardian will agree to take a client pro bono but is able to find assets later on. The guardian can then return to court to request an order allowing payment.

Saturday, July 31, 2010

What is a Guardianship?

The word "guardianship" often strikes terror into the heart of the person who hears the word. The media prints many horror stories and individuals pass more personal horrors stories to friends. Unfortunately, guardianships have given a bad rap but some of it is earned. Let me tell you how guardianships work in Washington State:

  1. Any concerned person can initiate a petition of guardianship.

  2. The person initiating the guardianship does not have to be the guardian. You may recommend yourself or even someone else but the final decision is that of the Judge.

  3. You may or may not have to pay for the cost of initiating the petition. Talk with an attorney who is familiar with guardianships. If the AIP [Alleged Incapacitated Person] has assets [investments], chances are that the AIP's estate will pay all the costs of establishing the guardianship. If the AIP is low-income, the County may pay for all or part of the fees but at a reduced rate.

  4. Adult Protective Services can initiate a petition of guardianship under very strict guidelines. Typically, the process takes quite a long time. If you have a pressing concern about a loved one or friend and the APS worker agrees that a guardianship is needed, I would recommend initiating the guardianship yourself.

The Process:

  • The first thing that the judge does after reviewing the petition for guardianship is appoint a GAL [Guardian Ad Litem]. This is a specially trained "third party" who talks with the AIP and all who are concerned about the AIP. The GAL reviews the petition with the AIP and asks if the AIP would like to be represented by an attorney. If so, the GAL will return to Court and ask the Judge to appoint an attorney to represent the AIP. The GAL then investigates whether there is financial exploitation, self-neglect, medical and safety issues. Then the GAL puts together a report for the Judge and will state 1) whether or not a guardianship is necessary or if there might be a less restrictive alternative 2) does the AIP need a full or limited guardianship and 3) whether the recommended guardian is appropriate or recommend a different guardian. The GAL has 45-days in which to complete the report and submit it to the Court.

  • The GAL could recommend a full or limited guardianship. A limited guardianship is anything that isn't a full guardianship. The limitations will be laid out in the Order of Guardianship.

  • If the AIP doesn't contest the guardianship, you can expect the process to take a minimum of 90-days from start to finish.

  • If the AIP contests [fights] the guardianship the process can take much longer. The attorney representing the AIP is required by law to represent what the AIP wants. It doesn't matter that the AIP might be unreasonable. The AIP has the right to take the guardianship all the way to a trial, either before a Judge or with a Jury.

After the Guardian is Appointed:

  • Within 90-days of appointment, a guardian [professional or family] needs to file a report. If it is a full guardianship, this will mean an inventory of the IP's [incapacitated person's] possessions and finances and a care plan explaining how the IP will be cared for.

  • After the 90-day report, a yearly report is required within 90-days of the anniversary of the Order of Guardianship. If the IP is on Medicaid or is a DDD [Development of Developmental Disabilities] client, the report time is typically three years.

  • The guardian still needs to notify the Court whenever there are substantial changes to a client's care or the client is moved to a different location. Moving the client out of the county the guardianship was originated in requires a Court Order.

Next: How Does a Guardian Get Paid?

Saturday, July 24, 2010

Mom/Dad Seem to Make Sense... But...

Sometimes Dementia can be very difficult to pin down. It can actually be a "moving target." It can be worse one day a much better the next. If the loved one was highly intelligent before developing dementia, they can finesse it [or cover up] for quite some time. Also, no matter how severe a person's dementia is, that person can pull themselves together and behave perfectly normal for a short period of time. That's why it is sometimes so difficult to convince the doctor or other medical professionals that there is a problem.

Please remember: Anyone who is developing dementia is terrified. One of the unique features of the brain is that while it can immediately tell you of pain elsewhere in your body, it only has a vague awareness that something might be wrong with the brain itself. Most people who have dementia are either totally unaware or only have only a vague awareness that something is wrong.

What does dementia do? In the mild to moderate stages it starts stripping away at social skills. Your loved one may occasionally do or say something totally [seamingly] out of character. What had been personality "quirks" become magnified.

If they were very structured in their routine throughout their life, you might find that they become even more structured. Someone who might have been a detailed person may lose their ability to organize or recognize what are important papers, garbage, etc., so they throw away nothing and will not allow anyone else to throw it away. Sometimes they might spend copious amounts of time going through papers trying to make sense out of them. Even if they ask someone else to tell them what the paper(s) is about, they don't really believe it.

Frequently, the ability to write checks and track money is one of the first signs that the dementia is becoming problematic. Bills may start being paid late or not at all. When you try to discuss a possible solution you are met with agitation and defensiveness.

Over time, your loved one may lose the ability to plan and prepare even simple meals; forget how to use the washer and dryer; lose the ability to clean their home; wear the same clothes for weeks on end; be unable to manage their medication or quit taking their medication altogether.

The worst part is when your loved ones deny they need assistance.

What you can do:
  1. Keep a journal. This can be very helpful to the medical professionals whether your loved one is seeing a doctor or not. It will also help you to identify patterns of behavior.

  2. Encourage your loved ones to get their estate planning papers done if they have not already done so. These include Powers of Attorney (Durable Financial and Healthcare), Healthcare Directive and Will. A Power of Attorney document will allow the designated person to intervene, indirectly if necessary, to ensure important bills and other paperwork continued to be addressed in a timely manner.

  3. Avoid pointing out the problem areas. Nobody likes to be reminded of their shortcomings, especially by their children. Humbly suggest solutions and try to let all but the most concerning problems slide.

  4. Introduce caregivers as "friends" and not "caregivers." This allows your loved one to save face and keep their dignity at a time when their dignity is feeling pretty shredded. This is easier to do when the person designated as power of attorney can set up the caregivers without the loved one's knowledge.

  5. Get the billing addresses changed to the designated power of attorney. This is especially effective if the loved one also has memory problems. What is out of sight is truly out of mind. Do it in slow increments. Have the bank statement addresses changed first and see what happens. If the loved one doesn't miss them, then the designated power of attorney can access the loved one's money to pay the bills. If the loved one does miss the bank statement, then feign an "oops" and change the address back.

  6. Emphasize that you want your loved one(s) to stay as independent as they want for as long as they want. Point out what they are still doing well. Minimize [to your loved one] the problem areas. Ask what they would like you to do to assist and how they would like you to do it.

  7. If you keep running into resistance from your loved one, get a professional consultation from a care manager or someone who specializes in behavior modification.

  8. Remember: You cannot force your loved one out of their home without a court order. If your loved one continues to stay at home and is unsafe, you might need to use some "tough love." That means not rescuing them when they get themselves in a bind and call you for assistance. You will want to plan your "tough love" strategy. Part of this strategy could be calling local law enforcement to do a "wellness check" on your loved one and/or calling Adult Protective Services for their intervention. As a last resort, if nothing seems to work and there are safety issues or extreme self-neglect, you may need to discuss initiating a petition of guardianship for your loved one with an attorney.

Saturday, July 17, 2010

Identifying Signs of Problems

It is easy for friends and family to be unaware that their parent, friend or other loved one is in crisis. Family and friends fall into what I call "conversational patterns" meaning that basically the same things are discussed all the time. An elderly person with dementia knows the socially acceptable answers to these types of questions.

It is impossible to have a clear understanding of what is happening with your elderly friend without spending a substantial amount of time with him/her/them.

Signs of problems:

1. Weight Loss for no apparant medical reason. Even bringing prepared food to the elderly person doesn't seem to help. The food goes bad in the refrigerator. Basically, the elderly person "grazes" or eat bits and pieces.

2. Gets medication mixed up or quits taking medication. The helper finds all kinds of medication in drawers, on the cupboard, etc., but often it isn't what the elderly person should be currently taking.

3. The elderly person starts falling. Now, I often hear family or friends immediately want to put the elderly person in assisted living or a nursing home when they've had a fall or two. If someone is going to fall, he/she will fall there, too. The thing to do is work with the doctor to try to determine the cause. It is not uncommon that an elderly person who falls for no apparant reason has a urinary tract infection (bladder infection) and once it's cleared up the falling stops.

4. Not allow anyone in or allowing everyone into the home. This is a safety issue.

5. Wears the same clothes for weeks on end.

6. Unable to pay their bills on time or at all. This can lead to financial exploitation.

I've been called in to assist an elderly person because a friend or family member, who has been helping out, can no longer assist due to the decline in their own health. The helpers will tell me that the prospective client only needs a limited amount of assistance but when I see the home and talk with the client it is obvious to me that the client is in crisis. Sometimes the prospective client is no longer safe to stay alone at home.

When I run into this situation, I try to find out if there is a Power of Attorney document and contact the person designated so that I can work with the person responsible for the client to make the home a safe place for the client. Sometimes that means hiring caregivers to come in for a few hours a week or daily (depending on the need), accompanying the client to medical appointments and sitting in on the appointments to get a clear view of the medical issues.

If there is no Power of Attorney, the next step is to get Adult Protective Services involved. The 800 number for your State is in the State section of your local phone book. If you still cannot find the number, call your local law enforcement and they will give you the phone number. Adult Protective Services can help get resources in but they work under strict guidelines and cannot remove anyone from the home without a court order.

Sometimes a client needs to move into a facility. Typically, approaching the topic as a temporary situation is more easily accepted by the client than talking about the move as a permanent arrangement.

I realize that this is a simplistic way to resolve a crisis but each crisis is so varied that I will illustrate some in future posts.

Saturday, July 10, 2010

What are they???

With the HIPAA Laws (Privacy Laws), every adult should have a Durable Power of Attorney and a Power of Attorney for Healthcare. If an adult is in an accident or becomes extremely ill and is incapacitated, sometimes even a spouse, adult child or parent is unable to get information from the medical community in order to advocate for the incapacitated person without these documents.

A Durable Power of Attorney gives a designated person the authority to manage a person's finances, for example pay their bills, until the incapacitated person regains capacity [gets better].

A Power of Attorney for Healthcare gives a designated person the authority to advocate for the incapacitated person's medical care.

SOMETIMES they are two separate documents and sometimes they are combined into one document.

These are powerful legal documents. When chosing someone to designate, much consideration needs to be taken to try to ensure that the person designated will make decisions about your medical care and finances that are in your best interests.

There are fill-in-the-blank forms on the Internet but I strongly encourage each reader to invest some money in having an attorney write the documents. If there is a reasonable chance that you or your parent may have to apply for Medicaid [or your State's equivalent], there will need to be special language put into the document to allow the designated person to do Medicaid planning. There is also a need for special HIPAA (Privacy law) language. The fill-in-the-blank forms often do not have these pieces. An attorney would most likely also encourage you to fill out a Healthcare Directive (Living Will) as well to help guide your designated person in making healthcare decisions on your behalf.

Call around to Elder Law Attorneys to find out what they charge. The charges vary. If you are very low income, call your local Area Agency on Aging. They have a program where attorneys donate their time.

If you have these documents but they are over five (5) years old or you have moved to another State, you need to have an attorney review them to make sure that the language is not outdated. Powers of Attorney are somewhat different from State to State. Also, you may realize that the person you designated is no longer the appropriate person or they have died or they have become incapacitated themselves.

Once you have your Powers of Attorney in hand, you need to make sure key people know where to find the originals. PLEASE DO NOT put the originals in a Safe Deposit Box without a key person as a signer on that box. If you are the only person who is signer on your safe deposit box, the designated person or person trying to help will have to get a court order in order to get into the box.

Sunday, July 4, 2010

I Can Pay My Own Bills!

How many of you are dealing with a loved one who is unable to pay bills or even figure out what is a bill and what is trash mail? This is a common problem, especially when the loved one has mild or moderate dementia. One of my more challenging clients is a good example:

Jane [not her real name] was referred to me by her family who lived a very long way away. Jane's daughter, Mary [not real], called explaining that Mom was having difficulty paying her bills but that she had always been very independent and proud. And by the way, Mom had some memory problems. I arranged for a date to visit Jane with Mary who assured me that she would talk with Jane shortly before I arrived to prime her for my visit.

When I arrived Jane let me in but was definitely reserved although polite. It was immediately evident to me that Jane had more than "some" memory problems. Her short term memory was very poor. We chatted a bit and when I brought up the subject of assisting her with paying her bills, I was politely but summarily excused.

This short visit told me several things: 1) Jane had moderate to severe short-term memory lose, 2) I could not approach Jane regarding her bills directly and 3) I was not going to be able to fix this problem quickly.

After thinking about the situation and talking with my other care manager, I decided on the following game plan: 1) I needed to visit Jane daily in order to get into her long-term memory (short-term memory becomes long-term memory with repetition) and 2) I needed to be patient and wait until she allows me to help with something "safe" [not related to bill paying]. In other words, I needed to build some trust with Jane.

It took several weeks of stopping in daily and shooting-the-breeze with Jane before she took that important step of trust and allowed me to purchase something at the store for her. Over time I was able to learn when her bills came and would show up. Our conversation would go something like this:

Me: Hi Jane! How are you doing today? I see that you're working on your bills. Could I write your checks out for you?

Jane: Thanks but no. I can take care of my bills.

[We would chat for a bit]

Me: Are you sure I couldn't help write out your bills? It would only take a moment.

Jane: No thank you. I know you want to help but this is my job and I can handle it.

[We would chat a bit more]

Me: Well, it's time for me to leave.

Jane: Before you go, would you write these checks out for me?

Me: Sure! Let's see, which one shall we do first?

Because of Jane's dementia, it took her a while to process the information [my offer of assistance] and develop a face-saving response. A little patience can really help.

You'll hear more about Jane. She was one of my first clients. She has since lost her resistance "gene" but I still delight in visiting her and seeing what a wonderful quality of life she still has despite severe dementia.

Welcome to this Blog!

I am founder of Bridge Builders, Ltd., a Care Mangement and Guardianship agency. We provide many services in our community but our primary goal is to help our clients preserve their dignity while living as independently as they wish. Sometimes this is as simple as just being a local emergency contact and sometimes we are trying to figure out creative ways of keeping a client safe until they realize they need something different. We work on an as-needed basis and are on-call for our clients 24-hours a day as crises do not happen within the hours of 9 AM to 5 PM. We act as Durable Power of Attorney for those who do not have family or friends that are able to act in this capacity. I and one of my staff are Certified Professional Guardians in the State of Washington, qualifying us as a Certified Professional Guardian Agency. We also provide support services to family and friends who are acting in the capacity of Durable Power of Attorney or Guardian as these jobs can be extremely time consuming and daunting to the "lay" person. We are willing to work with the more challenging behaviors and have a fair amount of success with clients with whom others refuse to work.

My hope for this Blog is to assist those of you who are struggling with issues pertaining to parents and other loved ones in trying to find that balance between safety and independence.