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People live longer into infirmity now more than ever before. According to the US Census Bureau only the dependency ratio for older adults was 11 percent in 1940. In 2010 that ratio was 21 percent. By 2020 the dependency ratio is expected to reach 28 percent and 37 percent in 2040. Someone has to take care of this dependent population.

Families are not able to accommodate all of the older persons who are dependent. This is where nursing homes, assisted living centers and independent living centers come in. Nursing homes are the place where people who need the most help live.

There are two different kinds of residents in most nursing homes: people needing long term care, and persons needing skilled care. People needing long term care are unable to take care of their activities of daily living: eating, bathing, dressing, toileting, transferring and continence. This population may be paying for their care entirely out of pocket, have some assistance from the Veterans Administration, or be receiving long term care benefits from TennCare. By law, each resident is required to receive the same level of care, no matter what the payment source might be.

People needing skilled care are generally getting physical therapy, occupational therapy, or IV therapy. Medicare, or other types of insurance, generally pay for rehabilitative care. This kind of care pays the most per bed per day in a nursing home.

According to a 2015 Genworth survey of private pay costs for long term care the average across Tennessee was $192 per day, or $70,080 per year. In Nashville and surrounding are that rate is an average $200 per day, or $73,000 per year. The average TennCare reimbursement rate for long term care in Tennessee is $182.42 per day, or $66,583.30 per year.

The average length of stay in a nursing home for long term are is somewhere around 835 days. Around Nashville that means an average of $167,000 in nursing home cost per person. So, clients either have to have enough money to pay for the cost on their own, or must have few enough countable assets to qualify for TennCare benefits. What does this mean for an attorney trying to help clients qualify for the potential of nursing home care for their clients? It means is it a good idea to help your clients prepare. In the case of nursing home care, the sooner the better. Keep in mind that most transfers of assets that occur within five years of an attempt to qualify for TennCare assistance create significant problems.

Revocable living trusts are not the answer. Because they can be revoked the entirety of the assets of a revocable living trust can be counted. Annuities may be part of the answer, but could easily be dangerous. Long term care insurance products, especially partnership plan qualifying products, are a good idea in many circumstances. Irrevocable trusts are a good option, but you had better know what you are doing when you draft one. Tax issues, trustee issues, allowable distribution issues, and allowing for change as the clients have varying needs should all be considered when drafting the trust. What might seem to be a minor issue can create major problems when your client applies for benefits.

Selection of the right nursing home is important. Good management at a facility can make the difference between a decent experience and a horrible experience. Proximity is also important. It is easier for family to visit a close facility. The more family visits, the better the care. If staff believe a family member may show up at any time, the resident is more likely to be in good shape at all times.

There are a number of companies which help families find appropriate placement in all levels of eldercare facilities. Walking around the facility a day or more before the meeting with the marketing person is a must. If the hallways smell in more than one or two places, care is lacking. If the afternoon “entertainment” for the residents is lining up in front of the nursing desk, care is lacking. Look in at the therapy area. If one therapist is attending too many people at once, it is likely no one is getting adequate care. It doesn’t matter if the hallways are festooned with fresh carpet and lovely paintings when care of the human residents is lacking.

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