Wednesday, November 27th, 2013
Tuesday, November 12th, 2013
(To view original post: http://chealth.canoe.ca/channel_section_details.asp?text_id=5760&channel_id=2113&relation_id=95973)
Seniors tend to be more prone to getting sick. They are more likely to have medical conditions that increase the risk of flu complications, such as heart disease, lung disease, diabetes, or a weakened immune system. For these reasons, seniors are more prone to flu complications. Seniors have a much higher risk of death from flu complications, and the risk increases with age. One study found that people 85 years or older were 16 times as likely to die of the flu and 32 times as likely to die from flu-related pneumonia as those aged 65 to 69. Seniors in long-term care facilities and nursing homes are at a particularly high risk of getting the flu and developing flu complications.
To reduce your risk of flu complications:
- Take steps to prevent the flu. Your doctor may recommend a flu shot (to reduce your risk of the flu) and a pneumococcal vaccine (to reduce the risk of pneumonia, a common flu complication).
- If you have flu symptoms, see your doctor as soon as possible (find the flu clinic nearest to you). Use the doctor discussion guide to help you prepare for your visit. If you or your loved one are living in a long-term care facility or nursing home and have flu symptoms, tell your resident care provider right away. Keep in mind that flu symptoms may be different for seniors; in particular, seniors may not have the sudden severe fever that is common in younger people. Your doctor may prescribe an antiviral medication, which can reduce the risk of complications, reduce symptoms, and shorten the length of illness if taken within 48 hours of the start of your symptoms.
- If you are diagnosed with the flu, follow your doctor’s instructions for flu treatment. If your doctor prescribes an antiviral medication, have the prescription filled as soon as possible, and keep taking the medication for as long as your doctor recommends to complete the full course of treatment. If you have other health conditions, continue to follow your doctor’s treatment plan for these conditions.
Wednesday, November 6th, 2013
(Original Post: http://www.eldercarematters.com/eldercareanswers/)
Question: Will Medicare pay for ambulance service so that Dad can get to his monthly doctor appointments? Dad does not drive and all the children live out of state.
Answer: No, but there would be special circumstances if he was in an emergency situation. In any emergency situation Medicare or Medicaid would pay the ambulance bill.
- See more at: http://www.eldercarematters.com/eldercareanswers/2013/11/06/leighton-b-deming-jr-esq-answers-familys-question-medicare/#sthash.blMrFeyT.dpuf
Side Note from Steve Davidson, our Regional Manager at Accredited:
The caregivers from Accredited Home Care can transport/escort clients to their medical appointments. They also provide assistance with Activities of Daily Living (ambulation/transfers, bathing/hygiene, dressing, meal preparation, toileting, etc.), so they can help seniors get ready to go to see their physicians, and they can help make them comfortable back at home after returning from the appointment. In addition to our hourly rate, a mileage expense applies (based on current IRS guidelines).
Thursday, October 24th, 2013
Question: What are the qualifications for getting a Reverse Mortgage, what happens to my home after my death, and will my 3 children have any rights to my home after I die?”
Answer: The first qualification is that you, and if you are married, your wife both be above the age of 62. It is also a qualification that you have a minimum of 50% equity in your home.
Allow me to explain further: if you still do have a mortgage on your home the balance should not exceed 50% of the current value of your home. If you have no mortgage currently on your property, then we can lend you a minimum of 50% of the value of your home or more, based on your age.
As far as what happens to your home after you die as well as the rights of your heirs/children: these are two of the largest misconceptions surrounding today’s reverse mortgage.
1 – All rights of the home while you are residing in it and after your death remain with you and/or your estate. After your passing, the home will be conveyed to whomever you wish it to. Securing a reverse mortgage does not diminish your rights as the owner of your home in any way.
2 – What rights will your children have after you die? Exactly as a “normal mortgage” your children will have two choices:
The first being to decide to sell your home, payoff the existing reverse mortgage and retain any profit made by the sale.
The second option is for them to retain your home and in that case they would need to secure a mortgage under their names to pay off the existing mortgage.
It is very important to remember that your rights as the homeowner and your children/heirs have exactly the same rights as they would have with any mortgage.
Hope this helps.
If you have additional questions about elder care matters, you can locate elder care professionals and companies near you by searching ElderCareMatters.com – America’s National Directory of Elder Care / Senior Care Resources for Families.
- See more at: http://www.eldercarematters.com/eldercareanswers/#sthash.8OOaVxt2.dpuf
Tuesday, October 22nd, 2013
(View original post: http://www.bausch.com/en/Vision-and-Age/60s-Eyes/Seniors-Eye-Health)
A regular eye exam is the best way to protect your eyesight – and an easy precaution to take. Another way to safeguard your vision is through proper eye nutrition.
Nutrition is a Key Component of Eye Health?
As part of an eye-healthy diet, choose foods rich in antioxidants, like vitamins A and C, such as leafy, green vegetables and fish. Many foods – especially fish – contain essential omega-3 fatty acids that are important to the health of the macula, the part of the eye responsible for central vision.
An inadequate intake of antioxidants, as well as over consumption of alcohol and saturated fats may create free-radical reactions that can harm the macula. High-fat diets can also cause deposits that constrict blood flow in the arteries. The eyes are especially sensitive to this, given the small size of the blood vessels that feed them.
What If Diet Just Isn’t Enough?
Studies indicate that proper nutrition is important to maintaining eye health. As we age, our eyes may not get enough nutrition through diet alone.
That’s why Bausch & Lomb developed Ocuvite® Adult 50+ Lutein & Omega-3 Formula. This unique formula provides nutritional support for those at risk for AMD (age-related macular degeneration).
These soft gels contain 150 mg of Omega 3 and 6 mg of Lutein, along with anti-oxidant vitamins C and E; nutrients important to the health of the macula, the part of the eye responsible for central vision.
Because the body cannot manufacture Lutein or Omega-3 and ordinary multi-vitamins only contain a fraction of these nutrients, Ocuvite Adult 50+ is important to help maintain eye health.*
Does Smoking Affect The Eyes Too?
Smoking exposes your eyes to high levels of oxidative stress. While the connection has not been clearly identified, it’s a fact that smoking increases your risk of developing a variety of conditions that affect eye health. For help with quitting, visit the American Lung Association’s free online smoking cessation program – Freedom From Smoking® Online – at www.ffsonline.org.
Exercise is important because it improves blood circulation, which, in turn, improves oxygen levels to the eyes and the removal of toxins.
Being outdoors on a sunny day feels wonderful – but it can be tough on your eyes. The solution? Wear sunglasses that block harmful ultraviolet (UV) rays. Also, a hat with a brim will reduce the amount of UV radiation slipping around the side of your sunglasses.
At the Computer
After two hours of starting at a computer screen, you can end up with the same kind of repetitive stress in your eye muscles that a keyboard causes in your wrists. Here are a few tips to help reduce the impact of computer eyestrain:
- Keep your computer screen within 20″-24″ of your eyes
- Keep the top of your computer screen slightly below eye level
- Minimize the distance between your computer screen and any documents you need to reference while working
- Use drops, such as Bausch + Lomb Advanced Eye Relief Dry Eye Rejuvenation Lubricant Eye Drops, to soothe irritated, dry eyes
- Adjust lighting to minimize glare on the screen
- Take a break every 15 minutes to focus on a distant object
- Blink frequently
If your eye is injured, you should always get immediate, professional medical attention. It’s simply the best way to safeguard your vision. Here are some symptoms that may signal a serious eye injury:
- Obvious pain or vision problems
- Cut or torn eyelid
- One eye that does not move as completely as the other
- One eye that protrudes more than the other
- Abnormal pupil size or shape
- Blood in the white of the eye
- Something imbedded in the eye
- Something under the eyelid that cannot be easily removed
Monday, October 21st, 2013
What Hospice Care Means for Caregivers: Detailed Information (Original Post: http://www.livestrong.org/Get-Help/Learn-About-Cancer/Cancer-Support-Topics/Physical-Effects-of-Cancer/What-Hospice-Care-Means-for-Caregivers)
This information is meant to be a general introduction to this topic. The purpose is to provide a starting point for you to become more informed about important matters that may be affecting your life as a survivor and to provide ideas about steps you can take to learn more. This information is not intended nor should it be interpreted as providing professional medical, legal and financial advice. You should consult a trained professional for more information. Please read the Suggestions and Additional Resources documents for questions to ask and for more resources.
Caregivers who have helped a loved one through the cancer journey understand how cancer changes the lives of everyone it touches. A caregiver goes through the physical and emotional ups and downs of the disease along with their loved one. A caregiver is there to listen, support, encourage, comfort and help in many different ways. As a caregiver, you are vitally important to the one you love.
Hospice care allows a patient with advanced cancer or other life-limiting illness to spend the remainder of his or her life comfortably and peacefully, surrounded by those they love. This is a very important time for everyone involved.
This document provides an overview of hospice care and is meant specifically for caregivers. It describes common concerns and addresses how these services can be helpful to patients, their loved ones, and all of the caregivers during advanced cancer.
The information that follows includes:
- An overview of hospice care
- When hospice services should be considered
- The roles of hospice professionals
- The role of caregivers
- How to get hospice services
- How to pay for hospice care
What is hospice care?
Hospice services are family-centered and are delivered by a team of specially trained and compassionate health care professionals and volunteers. They work with patients, loved ones and the caregivers to help ease the pain and stress that can occur during advanced illness.
The term palliative care is often used to describe the type of care given in hospice programs. Palliative care emphasizes the total well-being of the patient as well as that of loved ones and caregivers. The goal is to prevent, treat or eliminate discomfort whenever and however it appears.
Hospice care gives patients and their loved ones a chance to make meaningful decisions that are respected. Hospice is not about giving up hope. An important goal is to help the patient to be free of pain to give the patient and his or her loved ones, friends and caregivers peace of mind and acceptance of life as it is.
Some people are afraid to ask about hospice care for themselves or for a loved one. They may believe that choosing hospice care means giving up. However, these programs are not about giving up. Rather, they allow the patient and his or her caregivers to focus time and energy on quality of life.
A hospice organization provides care through a team of professionals and volunteers who work closely with the patient and all of the caregivers and loved ones who want to be a part of this experience. Hospice care workers are trained to support the physical, emotional, spiritual and practical needs of all those who are supporting loved ones at the end of life.
Hospice care is often provided in the patient’s home with a loved one, friend and/or hired caregiver managing day-to-day care. The professional hospice team makes regular visits to provide additional services.
Hospice care services may also be provided in other locations such as:
- The home of the caregiver, friend or loved one
- A retirement or board and care home
- An assisted living facility
- A nursing home
- A hospital or an in-patient hospice facility for acute symptom management
When should hospice services be considered?
Hospice care can be discussed at any time. Often, the discussion about hospice services takes place when the patient and his or her loved ones learn that:
- The cancer is no longer treatable and that additional therapies will not provide any benefit
- Live expectancy may be six months or less
- A physical decline and exhaustion are likely to be permanent
- Treatment is no longer desired by the patient
Many health care providerss hesitate to bring up the subject of hospice because they do not want patients to think that they have given up. There may come a time when you think that hospice care should be considered, but are not sure how to start this conversation. If this is the case, a member of the health care team can help you define what options are available. You can also call a hospice agency directly and speak to someone in admissions. They can provide information and if appropriate, contact your health care provider.
Sometimes the patient is ready to consider hospice care before his or her loved ones are. In other cases, the family may want to start services. Often, the decision is made together by the patient and his or her loved ones. If you are struggling with the decision about hospice care, talk to a health care provider, oncology social worker, licensed counselor or member of a faith-based organization about your feelings and concerns.
It is the patient’s right to make this decision unless he or she is unable to communicate. However, if a patient cannot communicate his or her wishes, a spouse or other family member may be asked to decide. The health care team or an oncology social worker can help you find out what hospice care is available in your community and how to arrange for it.
In order to start hospice services, a health care provider must sign a “referring order” that certifies that the patient’s life expectancy is six months or less if the advanced cancer runs its expected course. If a person in hospice care lives longer than six months, hospice benefits can be continued if a health care provider states that the person’s life expectancy is still less than six months.
How does hospice care work?
Hospice care is flexible and can be molded to fit the different needs and lifestyles of patients and their caregivers. Care is primarily focused on making the patient as comfortable as possible when a cure can no longer be expected.
Hospice services can include:
- Medical and physical care for the patient
- Management of the best prescribed pain-control treatments
- Emotional and spiritual support for patients and their loved ones
- Assistance with practical issues for patients and caregivers
The different levels of hospice care include:
- Home care is provided in a private home, nursing home, assisted living facility or other group home. The hospice staff offers hands-on care, assessment of your loved one’s condition and symptom management. They also help you and other caregivers learn how to provide day-to-day care. Hospices services include updates about what is happening and assisting the patient and caregivers to plan for the future.
- In-home crisis care (also called continuous care) is short-term care that is available in the home when symptoms cannot be managed by the usual caregivers. Under some health insurance plans, between 8 and 24 hours of nursing support for crisis care can be provided in the home each day for a limited number of days. The hospice provider determines when such care is needed and for how long. Depending on the needs of the patient, he or she might remain at home or be hospitalized for pain or symptom management following in-home crisis care.
- Inpatient hospice care is delivered in health care facilities such as a hospital or an in-patient hospice facility. This type of care is used to manage pain or acute symptoms that cannot be addressed at home. The length of stay depends on how long it takes to control the symptoms. If needed after the symptoms have been controlled, hospice can help make arrangements for continued care in another care setting.
- Respite care provides time for home caregivers to rest while the patient is cared for in a nursing facility for up to five days. This is covered by Medicare, Medicaid and some private insurance policies.
In some very advanced cases, the majority of hospice care is provided at home though the patient or loved ones choose that death occur somewhere else. Though this is likely to be a very difficult subject to discuss, it may be best to make a decision like this early enough so that everyone is comfortable with what occurs during the final days and hours.
Who are the professionals that provide hospice services?
Hospice care is a team effort. Caregivers work with trained health care professionals who will assist with the care of the patient as they guide the patient and his or her loved ones through the hospice care. The following table provides an overview of hospice professionals and their roles.
|Hospice Professionals||Roles and Responsibilities|
|Hospice registered nurse||
(Pastoral counselor or other spiritual advisor)
|Grief and bereavement counselor||
Who should consider being a caregiver during advanced cancer?
Becoming a home caregiver for someone who may be dying can come suddenly or after many years of battling cancer. Caregiving can be extremely rewarding, but also very demanding. Take time to look within yourself and think about your personal strengths and limitations.
Caregiving is a 24-hour-a-day, 7-day-a-week job. As a caregiver, asking for and accepting assistance from others may be hard to do—but it will probably be needed. Keep in mind that you will be giving others the opportunity to serve and feel good about themselves for doing so.
Talk with reliable family members, loved ones and friends about specific tasks and when and how they can help. Develop a schedule and contact list of those helpers you trust. Keep track of all the information necessary to stay in touch with these helpers.
Caregiving requires a time commitment. The amount of time and energy needed to provide care for someone is not easy to predict. Sometimes a rotation schedule with other family members and loved ones is helpful. However, caregiving can be very demanding at times, so you may have to take time off from your job at some point.
Serving as a home hospice caregiver is covered by the Family Medical Leave Act (FMLA), which protects an individual’s job standing and benefits during unpaid leave of up to 12 weeks. Not all companies are required to offer this benefit, so discuss the FMLA with your employer.
You can also talk with your employer about caregiving demands and how you can meet them through changes at work such as:
- Flexible hours, schedule changes or working from home
- Vacation and sick leave time you have available
What is the best way for caregivers to work with the hospice staff?
Caregivers and loved ones are a vital part of the hospice team. The hospice staff will be there every step of the way to help provide this care.
Some tips for working well together include:
- Keep a notebook with all caregiving information in one place; have this notebook with you when you talk to the staff.
- When you are describing a new symptom, give as many details as possible. These details help your hospice team find the best solutions.
- Always feel free to ask questions and seek help from the hospice staff.
- If you do not understand something, keep asking questions until you completely understand.
The hospice staff should respectfully listen to you and respond quickly at any hour of the day or night. This includes making home visits at any time to address symptoms or issues that develop. Be sure you keep the 24-hour emergency number for hospice in a visible place for all caregivers and loved ones.
Loved ones and caregivers work with the hospice staff to keep the patient as comfortable as possible. The hospice personnel may help set up a space in the home for ease of care. They arrange for equipment and supplies that are needed to care for the patient such as:
- Hospital bed
- Bedside commode (toilet)
- Over-the-bed table
- Shower chair
- Treatment supplies such as bandages, syringes, sponges, catheters and surgical gloves
A caregiver will usually be responsible for keeping track of many kinds of information. This includes setting up and maintaining a recordkeeping and organizing system that will help to make life as a caregiver easier. Some people are able to organize all of these tasks and schedules by themselves, but many people need help. Hospice staff can help assist to set up an organizational system that will work for you.
Serving as a caregiver during hospice care can be a very loving and fulfilling experience. Many who have worked with hospice programs describe the experience as the most meaningful and rewarding work they could have done.
However, there may also be unexpected challenges that come with this experience.
Caregiving for a loved one who is dying can be very different than caring for someone who has a chronic (ongoing) illness. A patient with advanced cancer usually has a variety of symptoms that caregivers try to manage, and care needs will probably increase slowly over time. Caregivers must take care of themselves or they will not be able to care for the patient when he or she may need the most care.
Some ways to make caregiving easier include:
- Asking for help with anything and everything
- Keeping a baby monitor near your bed to better hear if your loved one needs anything while you are resting
- Appointing one person to keep loved ones and friends informed
- Developing a back-up plan in the event caregiving becomes overwhelming
What are the responsibilities of a caregiver during advanced cancer?
Every caregiving experience is unique. However, caregivers may be required to provide a variety of care tasks including:
Research shows that families find personal care to be the most physically and emotionally challenging aspect of caregiving. For some families this is satisfying and rewarding. For those who are not comfortable providing this care or need extra help, hired private home health aides can help caregivers. Hospice does not pay for such private care, so these are out-of-pocket expenses for the patient and/or family.
If possible, find people to perform different tasks that the patient is comfortable with. Also, talk with family members and friends to determine who is comfortable performing tasks such as:
- Organizing and giving medication
- Monitoring symptoms and discussing treatments with your loved one and hospice staff
- Providing assistance with personal care such as transferring the patient, bathing, feeding and grooming
- Listening, talking, reading or playing music
- Providing kind and loving companionship
- Handling insurance and other legal matters
- Taking care of financial concerns such as paying bills
- Coordinating visits with loved ones, friends and hospice staff
- Discussing and recording the patient’s last wishes
- Ensuring that wishes are carried out if you are also the health care power of attorney
What types of assistance are available from hospice programs?
Hospice staff can be called 24 hours a day to answer questions. They are also available to make in-home visits at any time of the day or night to address pain or other issues that might develop. The hospice team will work with the patient and family to create a care plan that is based on specific needs. The care plan includes a schedule of visits from the hospice team members, and it will be changed as needs change. Many memories are created during the hospice journey. Keep this in mind as plans are made for end-of-life care.
The following is a typical example of scheduled home hospice visits:
- Registered nurse: 1–2 times per week or more often as needed
- Social worker: 1–2 times per month or more often as needed
- Chaplain: 1–2 times per month or more often as needed
- Hospice aide: 1–3 times a week or more often depending on needs
- Volunteers: A few hours per week as needed by patient or caregivers
Some hospice organizations provide light housekeeping as part of their covered services
The hospice staff will provide information about things to do to keep the patient comfortable. Needs will change over time, and hospice will help you understand and watch for these changes. If you have any questions, you can contact a member of the hospice staff at any time.
A hospice social worker can help with many practical concerns such as:
- Explaining and helping to complete advance directives, if requested
- Explaining what services hospice benefits pay for
- Help schedule and participate in patient/family conferences with the care team
- Setting up a system for staying organized
- Linking caregivers and family to community resources
- Setting up services with a licensed counselor or support group
- Assist with the arranging for respite care to give caregivers time off
- Contacting friends and relatives
- Assisting with funeral arrangements
Caregivers also need breaks (respite) to avoid physical and emotional exhaustion. Respite care services can provide this type of relief for caregivers for up to five days. Hospice benefits may pay for the patient to be cared for outside the home in a nursing facility for five days. During this time, the caregiver can visit the patient. Talk with the hospice staff as soon as possible about arranging for this type of break because respite care may not be available immediately.
Why are advance directives important for hospice patients?
Advance directives can be provided to family and health care providerss to advise them of a patient’s care preferences. Ask the health care team or hospice staff to talk with you about the benefits and risks of each type of directive. They include:
- Directive to Physicians and Family or Surrogates (sometimes referred to as a Living Will),
- Medical Power of Attorney, and
- Out-of-Hospital Do-Not-Resuscitate Order which protects your wishes outside the hospital setting (similar to a DNR order a health care provider might write in the chart at the hospital).
Hospice programs do not require these directives. However, they support the right of patients to make their own decisions about care. Advance directives give patients the control and legal ability to state how they want to be cared for and who they want to make decisions for them if they ever become unable to communicate their wishes. These directives specify the types of medical support wanted by the patient including the use of feeding tubes, breathing machines, and provision of cardiopulmonary resuscitation (CPR).
Advance directives are prepared at the patient’s request and must be signed by him or her and two witnesses before they are given to the health care team. The Out-of-Hospital DNR Order must also be signed by the patient’s health care provider. . The patient decides what will be included in each document. If he or she becomes unable to clearly communicate his or her wishes for care, the Medical Power of Attorney, or if there is no MPOA, certain family members can make decisions on the patient’s behalf.
If advance directives have not been completed at the time of hospice admission, and the patient would like to complete them, the staff can help to arrange for and finalize these documents. Each option will be clearly explained so that the patient can make informed decisions. Advance directives and DNR orders can be changed or cancelled by the patient at any time.
Advance directive forms that are approved for your State can be downloaded at www.caringinfo.org
How can hospice staff and caregivers help manage pain?
As a loved one’s illness progresses, caregivers may spend a lot of time and energy trying to manage symptoms that keep changing. People living with advanced cancer may experience many different symptoms. The hospice staff will tell you what changes or symptoms you need to watch for. Most symptoms can be alleviated, so be sure to ask your hospice team for help.
Different medications are often given around the clock to relieve symptoms. Sometimes, treating one symptom can cause others to appear. Caregivers will be observing and discussing changes with the hospice staff while working to relieve physical discomfort the patient may have.
Some people experience little or no pain at the end of life. For others, pain may be constant and intense. Pain that cannot be relieved at least a little bit is rare. Hospice physicians and nurses are experts in using the most advanced pain control methods available.
The hospice nurse will advise about what symptoms to track and discuss with the hospice staff. Use a notebook to write down and describe in detail such things as symptom changes, including different levels of pain, new symptoms, responses to treatments and other changes as instructed by hospice staff. Pain medications are generally taken by mouth, usually on an around-the-clock basis to control the pain and prevent new pain from appearing.
If swallowing becomes difficult, medicines may be given in various other ways including in small amounts of concentrated medicine under the tongue or inside the cheek, by suppository, by skin patch, or through a feeding tube (if there is one). Breathing and relaxation exercises may also be used when appropriate
What types of emotional and spiritual support are available to caregivers?
Being a caregiver can affect you both physically and emotionally. You may have trouble sleeping, which can lead to fatigue. The fatigue, in turn, can make negative feelings worse and even result in your own depression. Caregivers or loved ones who become emotionally overwhelmed may be helped by the hospice social worker or by a referral to a therapist.
Patients and their loved ones are welcome to talk about how you are feeling with the hospice nurse, social worker and chaplain. Because caregiving is such a big job, caregivers need to take care of themselves to avoid becoming exhausted.
In some cases, home care may not be possible. Try to be clear in your own mind what loved ones and caregivers want to do and are realistically able to do. Then work with the hospice staff to develop a plan for what is best for everyone involved. Take care of yourself during this time, and try to avoid worrying about what you think you should do–or what other people might expect you to do.
What emotions are common for loved ones and caregivers?
When hospice care is started, many caregivers and loved ones feel overwhelmed by the fact that the end of life may be near for someone they love. There may be many types of emotions, both expected and unexpected, that come and go unexpectedly. Over time, there may be a realization that the patient is not going to get better despite your best care. This may bring feelings of frustration, anger, sadness, grief and loss.
During advanced cancer, the final months, weeks and days are likely to be very emotional for everyone. Some people are able to use their remaining time together to grow closer. They celebrate the life they have shared by talking, laughing, telling stories and being open about their feelings–perhaps as never before. Everyone deals with dying and death differently. There is no wrong or right way.
As you deal with advanced cancer, it is important to allow yourself to express your sadness, grief and acceptance with your loved ones and others you trust. These types of symptoms are common and part of the process that both the patient and caregivers go through.
The following emotions are common to those dealing with advanced cancer:
- Denial about death
- Fear and anxiety about the separation and the unknown future
- Anger about the cancer
- Grief and tremendous sadness
- Relief that the pain and suffering have been eased
- Peace and acceptance
It is very difficult to determine what another person is thinking or feeling. However, most emotional changes are accompanied by physical changes that should be watched for and discussed with the hospice staff, including the following:
|Emotional Challenges||Physical Symptoms to Watch For|
|Confusion or delirium||
Keep in mind that pain problems can lead to or worsen emotional issues for patients. Certain medications can sometimes cause emotional symptoms to occur. The hospice nurse will help you understand what to do to keep the patient as comfortable as possible
Ignoring feelings can be harmful. Expressing and sharing them can be freeing. Find someone to talk with and cry with–someone who will just listen and not judge you for how you are feeling. Do what is right for you, and trust yourself to know what you need. You may find comfort in talking with the hospice chaplain, your own spiritual advisor, or an oncology social worker or other counselor.
Caring for a loved one who is nearing death can be an important time of growth for caregivers. It may also help with the grieving process after death. The experience can bring a deep sense of joy and satisfaction in having helped to make a loved one’s last days happier and more peaceful.
The final phase of your loved one’s cancer journey may be the most intense experience of your life. As a caregiver, you have provided a very loving gift by making sure that the person you love dies with peace and dignity.
Hospice provides families and loved ones with bereavement support free of charge for one year after a death. During this time, the program may stay in touch through letters and phone calls on a regular basis. Many hospices offer grief support groups and some offer individual counseling. Some hospice programs offer special memorial services for those who have lost loved ones.
How are hospice care services paid for?
Most health insurers have a hospice benefit that pays for all or most of the costs associated with the types of hospice care listed below. This means that families usually pay very little, and often nothing, for this end-of-life care. Some costs are not covered by insurers when hospice care is given in a retirement or nursing facility such as rent, meals and routine care services provided by the facility.
Hospice benefits typically pay for:
- Health care provider services
- Nursing care
- Social work services
- Chaplain care
- Medical equipment (like wheelchairs and walkers)
- Medical supplies (like bandages and syringes)
- Medications for symptom control and pain relief
- Short-term care in the hospital (including respite and inpatient care for pain and symptom management)
- In-home crisis care (as determined by staff) for short-term 24-hour nursing care to manage difficult symptoms
- Hospice aide and homemaker (housekeeping) services
- Physical and occupational therapy
- Speech therapy
- Dietary counseling
- Grief support to help you, your family and other loved ones
Insurers that provide a hospice benefit include:
- Medicare – The Medicare Hospice Benefit
- Medicaid (in most states) – The Medicaid Hospice Benefit
- TRICARE (military health system)
- Most private health insurance companies
If the patient does not have or qualify for any form of health insurance, some hospices may still be able to provide services at little or no cost. Talk with several hospice organizations to find out what is available.
If outside help is hired, such as home health aides, prepare a list of duties so the workers will know exactly what you expect of each of them. Hospice does not pay for the services of private professionals that you hire.
This doument was produced in collaboration with: Betty R. Ferrell, PhD, RN, FAAN, Cancer Survivorship Consultant Caroline Huffman, LCSW, MEd, Survivorship Program Manager, Lance Armstrong Foundation Jennifer Zieger, MPH, Pancreatic Cancer Action Network
American Cancer Society. When the Focus Is on Care: Palliative Care and Cancer. Eds. Kathleen M. Foley, MD et. al. Atlanta American Cancer Society Promotions, 2005.
National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. May 2004. www.nationalconsensusproject.org
“Choosing a Hospice.” NHPCO.org. 2005. National Hospice and Palliative Care Organization Caring Connections Program. www.caringinfo.org
“All About Hospice: A Consumer’s Guide.” Hospice-america.org. 2005. Hospice Association of America. www.hospice-america.org
“Hospice Care.” PLWC.org. 2005. People Living With Cancer.www.plwc.org
“What Does Someone Dying Need?” Hospicenet.org. 2005. Hospice Net. www.hospicenet.org
“The Hospice Choice” MMHospital.org. 2005. Marietta Memorial Hospital. www.mmhospital.org
“Knowing What to Expect Helps You Help Your Care Recipient” Caregiving.com. 2005. Caregiving.com. www.caregiving.com
Byock, Ira R. “Hospice and Palliative Care: A Parting of the Ways or a Path to the Future?” Journal of Palliative Medicine 2 (1998): 165-176. www.dyingwell.org
The suggestions that follow are based on the information presented in the Detailed Information document. They are meant to help you take what you learn and apply the information to your own needs. This information is not intended nor should it be interpreted as providing professional medical, legal and financial advice. You should consult a trained professional for more information. Please read the Additional Resources document for links to more resources.
- Things to consider before becoming a caregiver:The hospice staff visits the home only several hours a week. You will be responsible for your loved one’s care for the rest of the time. Be sure you are able and willing to provide this care.
Ask yourself the following questions:
- Are you physically strong enough to lift and move your loved one?
- Do you have any health issues that may limit you?
- Can you take care of your personal and family needs at the same time?
- Can you afford to take time off from work if it is necessary?
- Do you want to provide end-of-life care at home?
- Can you handle being a caregiver for several months?
- Do you and your loved one want death to occur at home or somewhere else?
- Does everyone involved in caregiving understand how decisions will be carried out?
- Do you have family members and loved ones who are willing to help you?
- How to find a hospice provider:
- Ask your health care team to refer you to hospice providers. Also talk with family members, friends and neighbors for recommendations about hospice agencies to consider.
- The National Hospice and Palliative Care Organization (NHPCO) has a state-by-state directory of hospice providers on its website, www.nhpco.org. You may also receive assistance by calling the NCPCO “HelpLine” toll-free at (800) 658-8898.
- Good hospice organizations listen and help you make decisions that work best for you and your family. Call those providers you want to interview, and ask to meet with the admissions representative.
- Questions to ask prospective hospice providers:
- About the Hospice Program
- How long has the hospice organization been established in the community?
- Who owns the hospice? Is it owned by an individual, a partnership or a corporation? Is it a for-profit corporation or a nonprofit corporation?
- Is this hospice organization licensed by the state and certified by Medicare?
- What other accreditation does the organization have?
- What industry quality standards does the organization meet?
- About the Staff
- Who is the medical director and what are his or her credentials? Is he or she certified in hospice and palliative care?
- What are the credentials of the other staff members?
- How many of the nursing staff are certified in hospice and palliative care?
- What are the credentials of the social workers and chaplains?
- How are home caregivers trained?
- About the Services
- What services are provided by the hospice?
- What services are provided in nursing homes or other residential care facilities?
- At which facilities (hospitals, nursing facilities and other health care settings) does the hospice provide care?
- Does the organization have its own facility for inpatient care? If not, where does the hospice provide inpatient hospice care?
- Is there 24-hour access to the hospice staff?
- What services are available after hours?
- How often will the hospice staff visit the patient and caregiver at home?
- What hospice services are not paid for by insurance, Medicare or Medicaid?
- About Medical Care
- How is the patient’s personal health care provider involved in hospice care?
- What is the role of the hospice physician?
- Which cancer-fighting treatments can be continued and which must be stopped?
- Is there an RN (registered nurse) on-call 24 hours a day? Are the on-call RNs certified in hospice and palliative care?
- About Volunteers
- Are volunteers available to help the family?
- What type of training do volunteers receive?
- What sorts of help do volunteers provide?
- About Family Support
- How does the hospice organization support the family?
- Are housekeeping services offered?
- How and where is respite care provided?
- How are the emotional and spiritual needs of the patient and family addressed?
- Describe the bereavement support provided.
- About the Hospice Program
- Recordkeeping and Organization Tips for Caregivers Caregivers need to keep track of many types of information. Hospice staff will help you develop an organization system that works for you. Here are some ideas that may help you get started.
- Have a notebook or 3-ring binder with pockets to keep everything in one place including:
- Medication journal – dosages, times to give, their effects
- Instructions from hospice staff
- Phone numbers and other contact information
- Medical records
- Keep this notebook in one convenient place so anyone who comes into the home has easy access to it.
- Make notes about symptom changes, including dates and times.
- Reserve a section for questions that you write down as they occur to you.
- When you talk with the hospice staff, take notes so you can refer to the information you receive later.
- Use a calendar for keeping track of visits from the hospice staff, volunteers, helpers, family and friends.
- Keep all medicines in one place and out of reach of children and pets.
- Keep supplies within easy reach of where you will be using them.
- If there is a Do Not Resuscitate (DNR) order, put it in a visible place that anyone in the house can easily see.
- Make a list of the important phone numbers you will call often and keep this list in a convenient location such as on the refrigerator. Include the names and contact information for the following:
- Hospice staff, including day and night numbers
- Caregivers’ cell phone numbers, work number and other emergency information
- Family members and friends who can help
- Individuals who can make medical decisions
- Have a notebook or 3-ring binder with pockets to keep everything in one place including:
- End-of-Life Comfort CareThe following are some things you can do to keep your loved one comfortable during end-of-life care. The hospice staff can provide more information to you about providing physical care and emotional support.
- Let your loved one make decisions about food, activities and visitors.
- Ask what kind of lighting he or she prefers.
- Ask what music your loved one likes.
- Ask if you can read aloud books that your loved one enjoys.
- Sit in silence together.
- Make sure your hands are warm before giving a bath.
- Gently massage your loved one’s hands and feet.
- Let your loved one know you will listen to anything he or she wants to talk about, even if those topics are difficult for you.
- Ask your loved one what he or she prefers to eat.
- Ask about preferences for having family meals together.
- During times of frustration or high emotion, leave the room for a moment to calm yourself.
When your loved one is no longer able to communicate:
- Keep the light low with blinds or soft lighting.
- Play soothing music that your loved one likes.
- Read aloud books that your loved one enjoys.
- Sit in silence together.
- Make sure your hands are warm before giving a bath.
- Gently massage your loved one’s hands and feet.
- Provide excellent mouth care for your loved one.
- Remember that your loved one will probably be able to hear until the end, so talk to, not about, your loved one.
- Caring for the Caregiver While you are taking care of your loved one, you will need to take care of yourself as well. If you become physically or emotionally exhausted, you will be less able to help your loved one. Do things to take care of yourself in the different areas of your life such as:
- Physical wellness
- Get enough rest. Fatigue is the number one enemy of caregivers.
- Arrange for someone to stay with your loved one while you nap or sleep.
- Maintain a healthy, balanced diet.
- Continue to take your own medications and visit your own health care providers.
- Emotional and spiritual wellness
- Talk to the hospice staff, friends and your own spiritual advisors about how you are feeling and what this experience is like for you.
- Find and take advantage of opportunities to share, laugh and remember.
- Express your feelings.
- Let your loved one have time alone, if requested.
- Talk to your social worker or a counselor if you start to feel overwhelmed or depressed.
- Participate in online support groups to learn how others have handled caregiving.
- Participate in spiritual activities that are meaningful to you.
- Be as patient and compassionate with yourself as you are with your loved one.
- Balanced living
- Try to balance your caregiving with the rest of your life, including work and social activities.
- Do not isolate yourself. Stay in touch with people and try to get out of the house at least once a day to be around others.
- Let some things go–such as housework.
- Set aside some time for yourself everyday to read, take a walk, have lunch with friends or just relax.
- Save time and energy by asking someone to keep friends and family up-to-date on your loved one’s condition.
- Schedule respite care.
- Physical wellness
Thursday, October 10th, 2013
by Meghan Foley
October 9, 2013
The state of California announced Tuesday that 28,699 residents completed the eligibility determination process via its online insurance exchange, Covered California.
“We’ve started strong,” exchange director Peter Lee said of the first week’s numbers in a press release. “With almost three months to enroll for coverage effective Jan. 1, the fact that thousands of Californians and hundreds of our small businesses are stepping forward in our first week is a testament to the need for the Affordable Care Act.”
Covered California also received 987,440 unique visitors during the first week of the enrollment period. “Looking back at this one week, the response has been nothing short of phenomenal,” Lee said. “We anticipated we’d have very low enrollment in the first week.”
Lee estimated that between 500,000 and 700,000 Californians would purchase health insurance policies with the help of a federal tax subsidy by the enrollment period ends on March 31. In total, about 5.3 million state residents will have access to the marketplace’s policies by next year, with about half that number eligible for financial assistance. Plus, approximately 1.4 million people will be newly eligible for Medicaid.
Covered California’s numbers exceeded expectations and proved that the concept of online exchanges can be a success at a technical level. With the glitches that marred the opening week of the cornerstone provision of the Affordable Care Act, California’s example is an important success to record, even if it says little about the long-term viability of the individual mandate.
Through that mandate, every American who can afford to buy health care insurance is required to do so or pay a penalty of $95 or 1 percent of income — whichever amount is greater. But 44 million Americans are expected to remain uninsured next year, according to the Congressional Budget Office, and those who hold out longer are more likely to be the individuals needed to ensure the success of the individual mandate: the young, healthy, and cheap to insure. To function as intended, the marketplaces need a broad, healthy risk pool to keep staggering rate increases from occurring.
The premiums of healthy, cheap-to-insure people cover the big bills for the relatively small number of sick people. So if the exchanges don’t enroll enough young, healthy people, insurers will have to raise everyone’s premiums. What Covered California’s numbers do not show is how many policies have been purchased and who has enrolled thus far. Before October 1, the day the exchanges opened, health policy experts predicted that the first to enroll would likely be those with pre-existing conditions, people who tend to use their benefits more often.
Being that California is the most populous state in the country — with more uninsured individuals than any other state, amounting to 7 million, or 15 percent, of the United States’s total — the long-term success of its exchange will be a vital indication of the viability of health care reform as a whole.
But due to the fact that California has so many uninsured residents and a quarter of its population lives below the poverty line, the fact that enrollment numbers show higher-than-expected demand may just be a sign that those who would most benefit from the reform are already taking advantage of the new marketplaces, which fits into the framework set out by health policy experts: The majority of early enrollees to the exchanges will likely be proportionally older and sicker, as well as more likely to have been without insurance for some time.
Still, the small number of glitches is a good sign. The Healthcare.gov Web portal, which links customers to the online marketplaces for the 36 states with federally facilitated exchanges, was riddled with glitches since the first day enrollment was open. The hours of waiting, backlog of potential enrollees, problems calculating subsidies, and numerous error messages that characterized the first week of enrollment was an indication for Obamacare opponents that health care reform was the proverbial train wreck that many lawmakers had promised.
Of course, California was one of 14 states that chose to set up and operate its own exchange, rather than default to a federally facilitated or partnership exchange, and its system fared better. The fact that fewer technical problems with Covered California were reported could also have helped enrollment numbers.
The California exchange could owe part of its success to the fact that its officials and lawmakers have done more to embrace health care reform than any other state. “California decided early on to go all in,” Larry Levitt, senior vice president at the Kaiser Family Foundation, told the Washington Post. “There has been lots and lots of investment, and a lot of smart people have really been working hard on this. It really set up a best-test-case scenario.” The state also received almost $1 billion in grants to help set up the exchange from the Obama administration.
Thursday, September 26th, 2013
By Bill Bischoff
If you or a loved one turns out to need long-term care, you don’t want to see a big chunk of hard-earned savings go down the drain to pay for it. Long-term care (LTC) insurance can help. As a bonus, qualified LTC policies deliver some tax breaks. Before getting to the tax angles, let’s first cover the basics on LTC insurance.
Long-Term Care Insurance Basics
Benefits paid under a long-term care insurance policy are usually stated as daily maximums ranging from $50 to $300. While lower benefits translate into lower premiums, don’t get carried away. According to a recent MetLife survey, the national average cost for a semi-private nursing home room in 2012 was $222 a day, which translates to about $81,000 over a full year. The average base rate for a year in an assisted living facility was about $44,000, and additional services cost extra. Most LTC policies also cover at least a portion of home health-care costs, which came to about $21 per hour last year. While these national numbers are interesting, the costs where you live are what really matter, and they can be significantly higher or lower.
You can buy a LTC policy with or without automatic annual inflation adjustments to your benefit maximums. Usually, the annual inflation adjustment rate is 3% to 5%, and that rate can be compounded annually or not. Choosing a 5% compounded inflation adjustment feature is more expensive, but it could be money well spent.
Finally, you can usually choose benefit periods ranging from two years to lifetime coverage. Most policies have benefit periods of three, four, or five years. The average length of a nursing home stay is about two and a half years, but this statistic doesn’t account for periods of home health care.
When you sign up for LTC insurance, the hope is that you’ll pay fixed monthly premiums. The premiums are based on your age and health factors at the time you enroll. Enrolling at age 65 could cost twice as much or more than enrolling at age 55. Your overall health status needs to be good when you apply for coverage or you won’t be accepted at any age. After you obtain coverage, it will remain in force—regardless of changes in health and advancing age—as long as you pay the premiums. Beware: while the insurance company can’t raise your LTC premiums due to changes in your personal age or health, it can raise premiums for broad classes of policyholders when financial results go south. This has turned out to be an all-too-often occurrence. So be sure to check the overall reputation and premium-raising history of any insurance company you’re considering for LTC coverage.
Tax Breaks for Qualified Policies
Qualified LTC policies are eligible for federal income tax breaks (and maybe state income tax breaks too depending on where you live). Qualified policies must be guaranteed renewable, and they cannot have any cash value. Most policies sold these days are qualified policies, but make certain before signing up if you want to collect the tax breaks I’m about to explain.
Tax-Free Benefits: Benefits received under a qualified LTC policy are generally federal-income-tax-free (and usually state-income-tax-free too) because they are considered insurance reimbursements for medical expenses. For 2013, this tax-free treatment automatically applies to benefits of up to $320 per day. (The tax-free cap is adjusted annually for inflation.) Even if you receive benefits above the cap, they are still tax-free as long as they don’t exceed your actual LTC costs. If you collect LTC insurance benefits during the year, the total amount will be reported to you on Form 1099-LTC, which you should receive early in the following year. You then calculate the taxable amount of benefits (probably zero) on Form 8853, which is attached to your Form 1040.
Tax Deductions for Premiums: Because a qualified LTC policy is considered health insurance for federal income tax purposes, the premiums are treated as medical expenses for itemized medical expense deduction purposes. However, if your premiums exceed the age-based caps listed below, you can only count the capped amount as a medical expense. Don’t forget to count premiums paid for coverage on your spouse as well as premiums paid for any other dependent relative (for this purpose, a dependent relative is someone for whom you pay over half the cost of support during the year).
|Age on Dec. 31, 2013||Amount you can treat as medical expense|
|40 or under||$360|
|41 to 50||$680|
|51 to 60||$1,360|
|61 to 70||$3,640|
Take your qualified LTC insurance premium amount (limited to the age-based cap if applicable) and combine that figure with your other medical expenses (health and dental insurance premiums, insurance co-payments, out-of-pocket prescription costs, and all your other unreimbursed medical outlays). If the resulting total exceeds 10% of your adjusted gross income (AGI), you can write off the excess as an itemized medical expense deduction. If you or your spouse will be age 65 or older as of Dec. 31, 2013, you can write off medical expenses to the extent they exceed 7.5% of AGI. (AGI is the number at the bottom of Page 1 of your Form 1040; it includes all taxable income items and is reduced by certain write-offs such as deductible IRA contributions and alimony payments to an ex-spouse.)
If you’re self employed, you can generally deduct premiums for qualified LTC insurance on page 1 of Form 1040 whether you itemize or not. However, the age-based deduction cap applies to you too.
Tuesday, September 24th, 2013
By Brian O’Connell | TheStreet.com – Wed, Jul 31, 2013 3:10 PM EDT
(view original post: http://finance.yahoo.com/news/5-crucial-questions-ask-retirement-191000066.html)
About 49% of U.S. adults express serious reservations about saving enough for their post-career years, according to a study by the Employee Benefits Research Institute.
What’s more, 46% of Americans are so disenchanted about their lack of long-term savings that they haven’t bothered to calculate how much they’ll need to live on in retirement.
That’s like taking your car on a long vacation and not bothering to check the fuel gauge before you pull out — and you don’t know how much money you have in your pocket for gas along the way.
John Bucsek, CFP and managing director at MetLife Solutions Group, has an interesting take on the retirement anxiety dilemma — particularly on how the financial journey toward your golden years changes, and how your retirement savings strategy should change, too.
Bucsek urges Americans to ask (and answer) five key questions about their retirements:
1: Do your accumulated savings and other sources of income replace about 80% of your pre-retirement income?
Bucsek: When determining sources of income you want to look at Social Security and pension funds in addition to 401(k) and IA funds you may have in place. For example, if your pre-retirement income is $100,000, your goal is to have $80,000 of retirement income per year. This number assumes retirees may be able to maintain their standard of living with less income because their taxes could be lower, there would be no need for retirement salary deferrals, their mortgages would be paid off before or soon after they retire and they would no longer have work-related expenses.
2: Will you be in a high Social Security bracket?
Bucsek: Social Security may replace a lower proportion of your pre-retirement income if you had high earnings over your career. From the example above, one should subtract Social Security, which would be $21,600 — leaving $58,400 to come from other sources. For those with lifetime “high” annual earnings, Social Security will replace a lower percentage as compared with someone who had a lifetime of “medium” earnings, in which case they will get a higher percentage.
3: What is the degree of risk in your portfolio?
Bucsek: Market fluctuations, interest rate changes and inflation can have a significant impact on retirement, especially if there are substantial losses before and at retirement. It might be a good idea to use a moderate return rate for your long-term projections, which involves a lower degree of risk and helps prevent your retirement funds taking a big hit while you’re in or close to retirement. Work with your financial adviser and recalculate every year to be sure you are on track.
4: What age did you begin saving?
Bucsek: There is no better time to save for retirement than today. The longer your money has to work and grow for you, the easier it is to reach the desired level of retirement income. If you started to save early in life, you may need to save less out of each paycheck because compounding should enhance your overall savings. If, on the other hand, you started later in life, you may need to take out more from each paycheck to reach your desired retirement income.
5: What age do you want to retire?
Bucsek: Nowadays, people are having children later in life, the cost of college is on the rise and the burden of saving for retirement has been shifted to the employee. The good news is that people are living longer, healthier lives. Folks may need to work a couple of additional years to provide their desired retirement fund level; but by keeping an open dialogue with their adviser, they will be better prepared for this outcome
Monday, September 16th, 2013
More older Americans are living alone in their homes, but a startling number of those seniors are experiencing social isolation and dementia symptoms. The results of a decades long study from the University College London on the impact of loneliness and isolation has shown that both loneliness and infrequent contact with friends and family can, independently, shorten a person’s life. Living alone may be more dangerous than we thought.
It may not come as much of a surprise that nearly 90% of people over age 65 want to stay at home for as long as possible, according to a 2011 survey by the AARP. Living at home and staying in a familiar community may offer benefits to seniors’ emotional well-being—but research indicates that a staggering number of seniors who should be receiving assisted living care services are still living at home—in many cases, alone. To some of us, the answer may seem obvious: make the move to an assisted living facility where social activity, health monitoring and medication management is all included. However, moving to a senior care facility can be an emotional and difficult decision, particularly if your loved one is not keen on moving. For more information on the topic, read our guide to assisted living vs. in-home care.
More Seniors At Risk of Living in Social Isolation
The Administration on Aging reports that about 29%, or 11.3 million older adults lived alone in 2010. The percentage gets even higher for those over 75: almost half (47% ) of women aged 75 and older lived alone. For the oldest old—centenarians, who have lived to age 100 or older—about a third live alone, according to U.S. Census data.
At the same time, it’s estimated that over 12% of seniors 65 and older—more than 5 million—need assistance with long-term care to perform activities of daily life (Kaiser Family Foundation). Some estimates are even higher. Those seniors who are low-income or live in poverty are even more likely to live at home rather than in a facility, even if they require more care. The numbers for individuals with Alzheimer’s or dementia are, quite frankly, startling: of the 60-to-70% of seniors with dementia living in the community, 25% live alone, reports theAlzheimer’s Association. Andrew Steptoe, a professor of psychology at University College London, says he was surprised by the results of the social isolation study. “Both social isolation and loneliness appeared initially to be associated with a greater risk of dying,” he says. “But it was really the isolation which was more important.”
When Living Alone is Unsafe for Seniors
If we want our loved ones to remain safe and healthy, it’s important to make sure their environment is appropriate to their physical needs—particularly if they’re showing early signs of cognitive impairment. If you notice that your loved one needs help with daily activities such as eating, bathing and dressing, they may have decreased cognitive functioning associated with early or middle stage dementia. Even in their own home, the combination of poor eyesight and minor safety hazards can put seniors at risk for falls, broken hips and even death. Keeping track of physical symptoms, mental health, and senior nutrition is of critical importance. Warning signs that living alone is no longer safe for an older adult:
- Medication management issues
- Poor eyesight
- Social isolation
- Forgetting appointments
- Unable to keep up with daily chores and housekeeping
- Poor nutrition or malnutrition
- Home safety hazards such as poor lighting and loose carpeting
- Unable to pay bills on time