Planning for the Future:
A Personal View

Reprinted from PN June 2009

Knowing when and where to seek assistance is an important milestone in life.

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Recently, I’ve been thinking more about how I can continue to live independently as I get older. Perhaps it’s because of signals I receive from people I meet when I’m in public. Folks seem to offer help getting my groceries into the car at the supermarket more often, and younger people are extra polite and call me “sir”—and frequently ask if I need assistance. Plus, last week I received an announcement that my high-school class will have its 50-year reunion this summer.

I must admit I find these things somewhat disturbing. Guess I never thought it would happen to me…this “older man” thing.

So, perhaps it’s time to do some serious homework on what services can help keep me in my home and independent as long as possible—and, if necessary, meet my needs when I can’t cut it on my own any longer.

People are generally aware of some of the minor physical and mental changes associated with aging: increased fatigue, weaker vision, compromised hearing, reduced muscle strength, minor memory lapses, and everyday aches and pains. This awareness can come from observing our parents as they grow older or from our own experiences. Most of us have the ability to adapt to these changes without major alterations to our lifestyles until late in life.

However, adapting to aging’s changes can be more difficult for people with chronic conditions such as spinal-cord injury (SCI) or a disease of the spinal cord such as multiple sclerosis (MS). Even minor changes associated with aging seem to appear earlier in life and often have more dramatic consequences. These changes, if not properly managed, can endanger our ability to remain productive and live independently. Managing disability and maintaining daily routines become more difficult as we grow older.

Knowing when and where to seek assistance is an important milestone in our lives. I keep telling myself, Remember—receiving assistance is not relinquishing control; it’s just a means to an end, and that end is remaining at home and independent for as long as possible.

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Accepting assistance with everyday activities can be difficult for anyone, but it’s even more so for those with severe disabilities because of the personal pride we feel from our long struggle to overcome the effects of our injury or disease. From the early days of rehabilitation, we were challenged to “do for ourselves.” Our medical culture pushed us to the limits of our functional ability, and our achievements of self-reliance and independence became the standards by which we valued ourselves.

Growing older and the need for assistance can place those basic values at risk, but we need to get past that and keep moving forward by making reasonable decisions. Pushing our bodies to be self-reliant and remain independent is a laudable goal, but this should be tempered with a strong dose of common sense. The stress and strain of everyday tasks must be routinely measured as we enter our fifties, sixties, and seventies.

During this period of our lives it is wise to have conversations with our families, friends, and certainly with our physicians as we notice life changes. It is important to put aside the pride associated with regained independence and be open to the possibility that assistance and support are positive assets that can prolong our ability to live independently and do the things we enjoy.

VA Long-Term-Care Services

The Department of Veterans Affairs (VA) offers a broad range of services designed to meet the needs of aging veterans. Many are home- and community-based and provide assistance designed to keep older veterans at home and healthy for as long as possible. VA refers to these services as noninstitutional long-term-care programs. They are part of VA’s basic healthcare-benefit package and are available to all veterans enrolled in the VA healthcare system.

VA also provides or helps arrange for nursing-home care for veterans who, because of their advanced age or serious medical condition, can no longer live at home. VA calls these services institutional long-term-care programs. The law limits eligibility for VA nursing-home care to veterans who are service-connected and rated 70% disabled or greater, and for vets whose service-connected condition has been determined to require nursing-home care (VA pays the nursing-home costs for these veterans). VA can also provide nursing-home care to other veterans if resources are available but is not required to do so by law. VA does attempt to meet the nursing-home care needs of veterans with catastrophic disabilities (such as SCI) whenever possible.

VA Non-Institutional (Home- and Community-Based) Long-Term-Care Services

VA Home Based Primary Care (HBPC)

Designed to serve veterans with complex chronic conditions, VA’s HBPC program pro­vides comprehensive medical care in their homes. This care is delivered by a physician-directed interdisciplinary team (most teams include a physician, a registered nurse, a dietitian, and a social worker) over an extended period of time. Because of the medical complexity and functional impairment of these veterans, routine clinic-based care is not effective. This program’s goal is to manage the chronic conditions to maintain health status, retard functional decline, and reduce or delay institutionalization.

HBPC provides medical care, nursing care and education, rehabilitation services, nutrition counseling, social work counseling, clinical pharmacy services, and bereavement support.

Adult Day Health Care (ADHC)

ADHC is a therapeutically oriented outpatient day program that offers health maintenance and rehabilitative services for frail elderly and functionally impaired veterans in a group setting. Individualized programs of care are delivered by an interdisciplinary team of health professionals. The goal is to help participants and their caregivers develop the knowledge and skills necessary to manage care at home. Some VA facilities have this program in-house and others contract ADHC services to community providers.

Community Health Nurse Coordinators (CHNC)

VA CHNCs provide clinical expertise in home and community coordination, continuity of care, and referral of patients to community agencies, VA programs (including skilled home-care health), home hospice, nursing-homes, homemaker health aide, and adult day care. These coordinators also function as liaisons to community agencies and monitor their services to veterans.

Medical Foster Homes (MFH)

MFH is a unique partnership of adult foster home and VA HBPC, operating under Community Residential Care guidelines. This program is designed to meet the needs of veterans who have lived alone and independently for years but who now can no longer do so. It is meant to be an alternative to nursing-home care. The MFH program finds caregivers in the community who are willing to take one or more veterans into their homes and provide 24-hour supervision and personal assistance. Veterans (not VA) pay for room, board, 24-hour supervision, assistance with medications, and personal care. Rates range from $1,200 to $2,500 per month depending on the scope of services required.

HBPC is an integral component of Medical Foster Home care, and HBPC staff make regular visits to provide patient care, home assessment, and caregiver education. The caregivers must accept that HBPC staff will make unannounced and announced visits.

Respite Care

This program provides short-term services to give primary caregivers a period of relief from the demands of daily care for chronically ill or disabled veterans. Respite care may include a short stay in a VA Community Living Center, VA hospital, or community nursing home; in-home services such as a personal care aide; or services in an adult day health facility in the community. Respite care is also available, as resources permit, in VA’s Spinal Cord Injury Centers.

Hospice and Palliative Care

Hospice is the most intensive form of palliative [relieves or eases without curing] care and is provided to seriously ill veterans who have less than six months to live and agree to enroll in hospice services rather than pursue aggressive cures for their illness. Hospice focuses on comfort for the veteran and loved ones, through comprehensive management of the veteran’s physical, psychological, social, emotional, and spiritual needs. Support for the family includes bereavement.

Palliative care is an interdisciplinary team-oriented approach to expert pain-symptom management and emotional and spiritual support tailored to individual needs and wishes; it is aimed at enhancing comfort and quality of life for veterans with serious, life-limiting, and terminal illnesses.

VA Institutional Long-Term-Care Services

VA’s Community Living Centers (CLCs) program (formerly known as VA Nursing Home Care Units) provides compassionate care to eligible veterans with sufficient functional impairment to require the level of service and skill available in these facilities. Veterans with chronic stable conditions including dementia, those requiring rehabilitation for short-term specialized services such as respite or intravenous therapy, or those who need comfort and care at the end of life are served in these centers.

For admission, veterans must be:

- Enrolled in the VA healthcare system

- Eligible for nursing-home services, or VA may admit them if beds are available and the center is able to provide the services required

- Medically and psychiatrically stable

The reason for admission must be documented, and the center must have the resources to provide the services needed. Documentation also must show the expected length of stay (short- or long-term), as well as the anticipated discharge disposition from the center.

Note: Special populations for whom community placement is difficult will receive special consideration (SCI is one of these special populations).

VA also will coordinate placement in Community Nursing Homes that have contracts with VA and with State Veterans’ Homes. Recent legislation requires VA to pay the full cost of care in State Veterans’ Homes for individuals who meet the eligibility for care in VA CLCs (for eligibility criteria, see section titled “VA Long-Term-Care Services”).

Medicare Long-Term-Care Services

Skilled Nursing Facility Care (SNFC) is provided by Medicare for beneficiaries who have completed a three-day minimum inpatient hospital stay for a related illness or injury for up to 100 days. To get care in a skilled-nursing facility, you must need care such as intravenous injections or physical therapy. Medicare does not cover long-term or custodial care in this setting. (Medicare Part A covers this benefit.)

Medicare Home Health Services

Medicare’s Home Health Services are covered under Medicare Part B. These are available to Part-B beneficiaries who meet the following conditions:

- Your doctor must decide you need medical care at home and make a plan for this care.

- You must need one or more of the following:

      Intermittent skilled nursing care

      Physical therapy

      Speech-language pathology services

      Continued occupational therapy

- Medicare must approve the home health agency caring for you (Medicare-certified).

- You must be homebound or normally unable to leave home unassisted. Homebound means that leaving home takes considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for nonmedical reasons, such as a trip to attend religious services. You can still get home healthcare if you attend adult day care.

Eligibility for Medicare home healthcare is also based on the number of services you need. If you meet the conditions above, Medicare pays for your covered home-health services as long as you are eligible and your doctor says you need them. However, the skilled-nursing care and home-health aide services are only covered on a part-time or “intermittent” basis. This means there are limits on the number of hours per day or days per week you can get skilled nursing or home-health aide services.

Medicaid covers the cost of nursing-home care for eligible individuals. Medicaid is a partnership between individual states and the federal government. Eligibility is based upon income, and criteria (for eligibility) are set by each state. (For information on eligibility in your state, contact your state health insurance assistance program [SHIP]).

To learn more about Medicare and Medicaid services, visit or call 800-633-4227. Request a copy of the publication “Medicare and You” for a comprehensive document that provides information on all the services covered. Medicare sends the free publication to beneficiaries.

Important Legislation

In March 2009, two important pieces of legislation were introduced that, if passed, would significantly improve access to long-term supports and services for people with disabilities.

The Community Choice Act (S.683/H.R. 1670), introduced by Senator Tom Harkin (D–Iowa) and Congressman Danny Davis (D–Ill.), would rebalance long-term supports and services in the Medicaid program by giving people an equal choice of receiving home- and community-based services (in the home) versus in an institutional (nursing-home) setting.

The Community Living Assistance Services and Supports (CLASS) Act (S.697/H.R. 1721), introduced by Senator Ted Kennedy (D–Mass.) and Congressman Frank Pallone (D–N.J.), would establish a new national insurance program financed by voluntary payroll deductions to provide benefits to adults who become severely impaired. This new system will help preserve Medicaid and promote independence by giving participants the right to control and choose what services they receive, how and where they are delivered, and who provides them.

If these issues are important to you, contact your senators and congressmen and ask them to support these two important bills.


Certainly, each of us wants to stay healthy and live independently for as long as possible. But the reality is, aging will take a toll on every one of us, and we will need more and more assistance the older we become.

I needed to be aware of the possible re­sources that exist before a situation that could be properly managed by minimal assistance got out of hand and forced more dramatic alternatives. In my opinion, the old Boy Scout motto, “Be Prepared,” is still good advice!



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Planning for the Future:
A Personal View


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