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  • Guest Writer, Michelle A. Martin, Esq., Robertson Law Group

As we are settling into the time of year where the days become shorter and the time spent with our loved ones becomes longer, your Advance Health Care Directive is probably not on your mind one single bit…but it should be!


The Advance Health Care Directive is one of the most important documents in your entire estate plan. If yours is stuck in a drawer somewhere, maybe with your last property tax bill – well, how is your Agent going to know what to do when it comes time to put your planning into action?


To get the most from your Advance Health Care Directive, you should understand what your Advance Health Care Directive is (and isn’t), what it says, and your Agent should be knowledgeable about your directives.


First Things First – What is an Advance Health Care Directive?

An Advance Health Care Directive is a legal document that is a key component of a complete estate plan. In that document, you accomplish two things: 1) You name a person to make medical decisions on your behalf if you become incapable of making them for yourself (we call this person an “Agent”); and, 2) You provide instructions on your medical care and end-of-life care preferences for your Agent to carry out on your behalf.


If an adult person becomes incapable of making medical decisions and they do not have an Advance Health Care Directive, then their family will likely be faced with establishing a Conservatorship for the long-term management of their care. In some cases, this court oversight may be preferable; however, many people wish to avoid the expense, delay, and public nature of conservatorship proceedings – those people should have an Advance Health Care Directive!


In California, an Advance Health Care Directive is the combination of two types of documents you may have heard of before: A Medical Power of Attorney and a Living Will. A Medical Power of Attorney is a document that simply appoints an Agent to make medical decisions for another person. A Living Will is a document that provides instructions to the Agent on how to make medical decisions on behalf of another. To simplify things, we combine those two components into one document, which we call an Advance Health Care Directive.



Another document that sometimes is confused with an Advance Health Care Directive is a POLST, or Physician’s Orders for Life-Sustaining Treatment. The POLST is a physician’s order that is completed with the patient and signed by the physician on how emergency life-sustaining treatments should be handled for that particular patient. It is not a substitute for an Advance Health Care Directive, because it does not name an Agent to make decisions and it gives no guidance to the Agent on how to make those decisions.


What Does Your Advance Health Care Directive Say – and Is It Up-To-Date?


If you shoved your Advance Health Care Directive in a drawer somewhere in your house and haven’t reviewed it in a while, you’re like a lot of people. Unfortunately, what I find in my practice is that this can mean: 1) It may be difficult to find your Advance Health Care Directive if there is a medical emergency, 2) You may not remember who you named as your Agent – and worse – it may not be who you want it to be, and/or 3) Your instructions may be out of date.


Yikes!


Instead of using the “drawer method” (or equivalent), I recommend that you give a copy of your Advance Health Care Directive to your Agent and to your doctor, to scan into your chart. This way, everyone who needs a copy of the document has it if an emergency arose.


You should also review the Advance Health Care Directive (along with your other documents…) on a regular basis! You may be surprised that your wishes from ten years ago are not the same as your wishes today. A good general rule of thumb is to review your documents every time there is a major life event impacting you and your Agent: 1) births, 2) deaths, 3) marriages, 4) divorces, and 5) physical relocations. In the case of the Advance Health Care Directive, you should also review it before any planned procedures.


Talking With Your Agent


Giving your Agent a copy of your Advance Health Care Directive is a good first step. But if you want to be an A+ student, you really need to have a conversation with your Agent about what the document says. You should explain to them what their responsibilities are and you should explain to them how the document instructs them to handle end-of-life decisions. You should also discuss things like – what quality of life looks like for you, your religious preferences, procedures that you don’t want to have under any circumstances, whether you want to be buried or cremated – you get the point.


Admittedly, these are hard conversations to have! They require a certain level of undivided attention that is hard to find in our increasingly busy world. In addition, there is an undeniable emotional component to these topics that makes these conversations seem unapproachable. I often recommend to clients that they take advantage of the upcoming holidays to have these important discussions. I suggest giving your Agent plenty of advance notice that you intend to have a conversation with them about your medical wishes so that they can prepare themselves for that discussion. I also suggest making a checklist of items you wish to discuss, so that the conversation is efficient. Make sure to leave time for your Agent to ask questions. While these conversations can be difficult, they are so important to have before the need arises!


The Bottom Line


If you’ve got an Advance Health Care Directive in place, you’ve taken the first step – congratulations! To get the most of your Advance Health Care Directive, make sure that you 1) Review it regularly to ensure that it is accurate, 2) Give copies of the document to your Agent and doctor, and 3) Discuss your wishes with your Agent so that they know how to respond when the time comes to put planning into action.



Michelle and her sister in awe of Half-Dome

Michelle A. Martin is an estate planning and estate administration attorney with Robertson Law Group in Lincoln, California. She is a Certified Specialist in Estate Planning, Trust, and Probate Law, as designated by the California State Bar Board of Legal Specialization.

In her spare time, she enjoys the great outdoors through hiking, backpacking, camping, kayaking, fishing, and everything in between. She can be reached at 916-434-2550.


Dr. Beverly Chang developed a fondness for working with older adults early in her training. She was selected chief resident during her fourth year of residency and was also named a Geriatric Mental Health Foundation Scholar by the American Association of Geriatric Psychiatry.

She went on to pursue advanced training at UC San Diego where she completed a fellowship in Geriatric Psychiatry, which is the field of medicine dedicated to the diagnosis and management of mental health care in older adults. She now practices right here in our backyard, in Rocklin. I asked Dr. Chang for an interview so that I may help educate others. She graciously agreed, allowing me to share this with you.

How is a Psychiatrist different from a Psychotherapist?

A psychiatrist has medical training (MD or DO) and prescribes medications, while a psychotherapist may have a variety of degrees or certifications (Ph.D., LCSW, LMFT, MFT) and focuses on counseling. Therapists and psychiatrists work together to help their mutual patients/clients. Medications alone cannot solve the complex issues that many people face.

Is what you provide different from psychotherapy (talk therapy)?

In my office, appointments are longer to allow time for basic supportive counseling in addition to discussion of medications. However, in many settings, managed care has changed the way mental health is delivered and often the psychiatrist handles strictly medications while a therapist handles psychotherapy. Though I do a combination of both services, there are certain specialized forms of therapy such as EMDR for trauma that require a dedicated therapist with the appropriate certification. In this case, I refer my patients to an appropriate specially trained therapist.

How do you work in conjunction with psychotherapy?

If a patient is already working with a therapist, I update the therapist with any changes in medications or other observations I may make. Likewise, I rely on the therapist to continue reinforcing my recommendations (behavioral/lifestyle changes) since they are typically in weekly or every other week communication with patients. Therapists are also able to communicate to me from an objective standpoint the side effects or benefits of medications.

What common ailments do you treat?

Patients are often seeking ongoing treatment for chronic mental health issues including anxiety, depression, bipolar disorder, and post-traumatic stress. They need medications to be adjusted given the changes in their bodies related to aging. Other patients seek out help for mood symptoms due to neurologic disorders such as dementia or Parkinson's Disease.

What are some reasons why a person would seek out your services?

Patients are often referred for cognitive evaluations since depression can often resemble early dementia. Likewise, dementia onset can be associated with depression, irritability, paranoia, or other personality changes. Geriatric psychiatrists are part of the team of internists and neurologists that make diagnoses.

Behavioral symptoms of dementia can also be difficult to manage and geriatric psychiatrists are specifically trained to weigh the risks and benefits of medications used to manage these behavioral issues.

Lastly, many patients seek out a geriatric psychiatrist due to their difficulties coping with medical complications associated with aging.

Are there some specific signs I should be aware of that might indicate the need for your services?

Day-to-day mood fluctuations are normal. However, mood changes lasting for weeks with the inability to find pleasure in things that previously brought joy, are a reason to seek help for depression. Depression is often associated with sleep or appetite changes, or a withdrawal from support systems. Excessive anxiety causing physical symptoms for which there is no underlying medical cause is also a reason to seek help. Families also seek help on behalf of loved ones who may be experiencing cognitive decline.

Does a patient need to have an existing mental health diagnosis to visit you?

Patients do not need an existing diagnosis. Many patients never struggled with mood issues in their adult lives, but face new-onset anxiety or depression in the context of aging. Others may have never been formally diagnosed since mental health was largely stigmatized in the past.

How are people in the elderly population different from younger folks, when it comes to mental health?

I love working with the older adult population, as they have a wide range of experiences and resilience. They are susceptible to social isolation and loneliness, so the simple act of meeting in a "medical setting" that is not a hospital or outpatient clinic is therapeutic. They often do not want to take additional medications, which I appreciate due to the tendency for older adults to be at risk for polypharmacy.

Do you provide prescriptions for medications you recommend?

If I will be scheduling ongoing meetings with a patient, I will prescribe medications as needed/indicated by mood symptoms. If I meet and assess that a one-time consultation is appropriate, I make recommendations on medications (and behavioral measures) to the primary team.

Do you work with medical doctors if necessary?

It is absolutely essential to work with the medical team. Older adults have medical issues that can often contribute to depression or anxiety such as underlying cardiac or respiratory illnesses. A new patient visit is never complete until I have made contact with the other team members.

What other treatments do you typically offer as an adjunct to, or instead of medications?

I offer supportive therapy for mental and physical adjustments to aging, grief, and bereavement, and psychoeducation on the benefits of mindfulness techniques. If it is agreed that a patient requires more intense counseling, I work with them to find an appropriate referral. I often work with families on coping with their loved ones' cognitive and physical changes by directing them to partners in care (Caregiver resource centers, Parkinson's Association of Northern CA, Alzheimer's Association... to name a few).

Are your services covered by Medicare and my insurance plan?

Medicare and medicare advantage plans and private insurances cover these visits. Medicare is now permitting telemedicine and phone appointments as well due to COVID19 and other mobility and transportation issues.

How are you handling COVID?

I am currently doing a mix of in-person and telemedicine visits. Video or phone visits are not as ideal as an in-person face-to-face visit, but they are still a point of contact and a chance to assess an older adult's mood and cognition.

Thank you, Dr. Chang! You can find Dr. Beverly Chang at Geriatric Psychiatry Direct, a unique psychiatry practice in Rocklin, where care is individualized and your questions are fully addressed.

Schedule a consultation by contacting Geriatric Psychiatry Direct at: 5701 Lonetree Blvd, Suite 323 Rocklin, CA 95765

Call them at 916-303-4353

Or send an email to info@geropsychdirect.com


  • Lori Cochrane, Principal Fiduciary

By Lori Cochrane, Principal Professional Fiduciary, Cochrane Support Services

When it comes to Medicare plans, long term care plans, and knowing the ins and outs, the information is overwhelming and confusing. Only professionals know what the heck they're talking about. When I need information for my clients, I get first-hand information directly from the pros.


Turning 65 brings about questions about health insurance and what to do about Medicare. As we decline and enter a phase where our long term care insurance may kick-in, we need to know how to maximize benefits.


These two insurance topics are not as straightforward as they should be. The rules are complicated. I asked Katie Fernandez from All Types Insurance to help me understand Medicare. I also asked Susan Feldman from BrightStar Care to help me understand long term care insurance. Read on to learn more...


Medicare


I recently asked Katie Fernandez about the opportunities to change Medicare plans mid-stream. I was surprised at the available options. With Katie’s permission, here are snippets from our conversation along with information obtained directly from Medicare.gov. It always helps to get a better understanding of what might be available.


Meet Katie --


“My name is Katie and I have specialized in the senior health insurance market for 18 years. I’m locally available to help people navigate Medicare and answer any questions they may have. I specialize in services related to Medicare insurance products, such as Medicare Supplements, Medicare Advantage plans, and Part D (prescription drug plans). Regardless of a client’s current plan, it is always a good thing to understand and know all of your Medicare options.”


Q. When are we supposed to enroll in Medicare?

There is an Initial Enrollment Period that lasts seven months for individuals turning 65 to enroll in Medicare.


Katie says, “Anyone turning 65 years old has 3 months before, the month of, and 3 months after their 65th birthday to make their plan choice."


Q. What are our plan choices? There are three types of plans to choose from, each with a variety of enrollment periods. They include:

  • Straight Medicare Part A & Part B (plan D for drugs sold separately)

  • Supplemental, aka “Medi-gap” (plan D for drugs sold separately), and

  • Medicare Advantage (Includes a drug plan)

Q. When can we change plans?


You can change Medicare plans during the Annual Enrollment Period which is each year from October 15th through December 7th. This is an annual opportunity for ALL Medicare recipients to change plans of ANY KIND. This is also the allowed time frame to change prescription drug plans or enroll in one to avoid further penalties.


Supplemental is a Medicare Primary plan with a Supplement “medi-gap” (does not include a drug plan):

Open Enrollment coincides with the Annual Enrollment Period which is October 15th through December 7th, each year.

Birthday Open Enrollment -- This period lasts 30 days before and after your birthday.


Katie says, “I can shop Medicare Supplement Medi-gap plans each year, enrolling you 30 days before and up to 30 days after your birthday, to help you receive identical benefits for a lower monthly premium.”


She goes on to say, “For those who choose a Medicare Supplement, overpaying and constantly increasing costs can get frustrating. I focus on shifting my clients to the same plan for less money with no health questions asked.”


Medicare Advantage plan (includes a drug plan):

Annual Enrollment Period is October 15th through December 7th.

Open Enrollment is January 1st through March 31st, each year.


Katie adds, “I make sure you have the best advantage plan that works with your network of doctors and hospitals. Some Medicare Advantage plans I offer include dental, vision, transportation to and from doctors’ appointments, free gym, and classes as well as a monthly allowance to purchase over-the-counter supplies!”


Q. What is Special Enrollment?


Katie says, “Special enrollment periods are when you can change your plan outside of these open enrollment periods, which you may not be aware of. During this time, you can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life. Some of the qualifying events may include:

  • A move in or out of a service area

  • Moving into or out of a Long-Term Care facility

  • Losing an employer plan

  • Involuntarily losing creditable prescription drug coverage

  • Being affected by a weather-related disaster or a natural disaster

  • A change in “extra help”, for example to Medi-Cal assistance, or loss of a special needs plan

With so much more to know we recommend you ask a professional for advice about Medicare options and enrollment. The more you know, the more you save!


Katie offers a free consultation to help clients choose the right Medicare insurance policy, make policy changes and sort out claims. You can call Katie at 916-408-7665. You can find her at: All Types Insurance Agency, 805 Twelve Bridges Drive, #15, Lincoln, CA 95648.



Long Term Care Insurance: Use it or lose it!

By Guest Contributor, Susan Feldman Community Liaison, BrightStar Care


If you’ve been paying premiums on a long term care insurance policy for years and wondering “What does this policy cover?”, “When do I use it?” and “How do I use it?”, read on.


Given the choice, most people wish to age in their own home, in familiar surroundings with family, neighbors and pets. If you had the foresight to purchase a long term care policy with an “In Home Care” benefit, you’re in luck.


Locate the Policy: If you have your hands on the policy, that’s great. If you can’t find it, call the insurance company and request a copy. Make sure your adult children and/or power of attorney know you have a policy and where it is. Nothing is worse than paying into a policy and not remembering to use it.


Schedule of Benefit: This summary page states the coverage of the policy. For example, how much will the policy pay for in-home care, assisted living or nursing home care? Some even have a benefit for home modifications and fall alert devices.


Elimination or Deductible Period: This is the portion the policy holder is expected to pay before the insurance company pays. It can be 0, 30, 60, 90 or up to 100 days. How those days are defined can vary. Some are individual days of care while others are calendar days. This may be waived in certain situations.


Qualifying Need: The critical “trigger” to use the policy hinges on needing either stand-by or hands-on assistance with at least 2 of these Activities of Daily Living (ADLs); transferring, toileting, incontinence care, bathing, dressing and feeding (not meal prep).


Qualified Caregiver: While some LTCi companies allow family members to be the caregiver, most require a licensed home care agency to provide the care.


Use it or Lose it: Tapping into your LTCi policy when there is adequate need yet not waiting too long (investment wasted) simply takes evaluation. If qualified assistance is needed to help a senior stay home safely, possibly relieving a spouse or adult child of the tasks, why not investigate starting a claim. After all, that’s why you purchased the policy in the first place.


If you’d like assistance in navigating the waters of your LTCi policy, I’d be happy to meet with you, review the policy, discuss care needs and do a home safety assessment. Just email or call to set up this complimentary service.


Susan Feldman has been with BrightStar Care for over 10 years helping those with long term care insurance understand and utilize them well. She can be reached at susan.feldman@brightstarcare.com or 916-919-0063.