What is a Medical Neighborhood?


From February 2014 Takacs Newsletter

We Are All Living in a Medical Neighborhood (Part 1)

The Medical Neighborhood is an emerging concept meant to address all the care needs of an individual. The Medical Neighborhood – a group of providers in, literally, the geographic area of the patient and the patient’s family – will identify and coordinate all medical and non medical resources available to manage issues which impact a patient’s health. The aim is to improve clinical outcomes, provide a more satisfying experience of care for both patients and providers, and reduce care costs.
What does the Medical Neighborhood mean for older persons and how will it improve the experience of care they receive from their Medicare providers? Actually, it is part of a larger concept called The Patient-Centered Medical Home that the U.S. Centers for Medicare & Medicaid Services is promoting as a future model for the delivery of care to people on Medicare.
In a Patient-Centered Medical Home, a Primary Care Provider (PCP) is responsible for providing “whole person care.” Under this model, the medical provider is challenged to engage an individual in managing more of his or her own care, to make shared decisions about care with that individual, and integrate with non-medical service providers to support the individual’s efforts. The individual is challenged with knowing how to manage optimum health between office visits and staying out of the hospital.
The Medical Neighborhood includes medical specialists, pharmacies, behavioral health, residential care facilities, non-medical home care providers, and other community resources. Working together, this group will educate and guide the individual in the direction of getting all their care needs met. To ensure that the individual receives optimal care, the Medical Neighborhood strives to meet psychosocial needs, address social and environmental factors that impact the individual’s health and well-being, and address financial and legal aspects that enhance or create barriers to care.
As an essential member of the Medical Neighborhood, the Elder-Centered Law Practice should have a presence early in an individual’s care plan. Within the Medical Neighborhood itself, an Elder-Centered Law Practice is regarded as a specialty: a team of nurses, social workers, licensed therapists, public benefits specialists and attorneys, under one roof, experienced in helping individuals find, get and pay for quality care.
Here is an example of a common situation many older adults and their families face. Frank, 87, is a frail man who has been diagnosed with Alzheimer’s disease. Living by himself at home, Frank is functionally dependent upon his overwhelmed son, Paul, to bring him his groceries, take him to the doctor, pay his bills, and get his medicine.
Is Frank living in a Medical Neighborhood? Where Frank lives – that is, whether or not he lives in a Medical Neighborhood – affects how successfully he and his son Paul will manage his care. That is the subject of our next issue of Elder Law FAX.

We All Live in a Medical Neighborhood (Part 2)

In last week’s Elder Law FAX, we introduced Frank, a frail, 87 year-old man who has been diagnosed with Alzheimer’s disease. Frank lives by himself at home and is functionally dependent upon his overwhelmed son, Paul, to bring him groceries, take him to the doctor, pay his bills, and get his medicine.

How would a traditional elder law practice view of Frank’s situation differ from an elder-centered law practice approach? And, how does the elder-centered practice approach meet the aims and goals of the Medical Neighborhood?

Under the traditional elder law view, Frank currently has or is expected to have a care financing and asset preservation problem. Typically, the elder law practitioner will be retained to put a plan in place to accelerate Frank’s financial eligibility for Medicaid benefits.

For example, the attorney (in another state) of a client of the Elder Law Practice explained in the written plan developed for the client that “the purpose of Elder Care Plans is to protect the assets of persons who have entered into or are about to enter into a skilled nursing facility … The primary way to protect assets is to seek eligibility for Medicaid.”

If Frank doesn’t need immediate nursing home care, Frank will get necessary legal documents in place and counsel on repositioning assets to make them unavailable or inaccessible to the State Medicaid program. If he is a veteran, the elder law practitioner will determine whether Frank is entitled to monthly payments from the U.S. Department of Veterans Affairs (the “VA”) to pay for his care. A plan will be developed that may require Frank to restructure his assets to qualify for a VA benefit.

This may be done by making Frank’s assets legally unavailable to him. If those assets are not available to him, the State Medicaid program and the VA can’t consider them available. The asset repositioning may result in a five-year Medicaid lookback period. Usually, the elder law practitioner will counsel Frank and Paul on the advantages and disadvantages of such restructuring.

How will Frank’s needs for personal care be addressed? Or his values, or safety, or the risk that Paul will suffer caregiver burnout? The traditional elder law practitioner will make referrals to personal care agencies or geriatric care managers, but typically does not align the practitioner’s asset protection plan with the client’s personal care needs.

An elder-centered law practice aims for whole-person care, assisting Frank and his son Paul with attaining their goals of addressing issues that impact health or that enhance or create barriers to care. What level of care does Frank need and what kind of care does Frank want? A plan will be developed and implemented to help Frank find, get and pay for the care that most closely aligns with his values and his needs today. Frank will get legal documents and asset restructuring advice, but care financing—albeit critical—is only one aspect of the representation.

The elder-centered law practice will employ a team of health professionals who will coordinate care and advocate for Frank and for Paul. The practice will have a working relationship with community resources including residential and in-home care providers. The practice will offer Frank options. It is the aim of the elder-centered law practice to support older clients and their families in the day-to-day self-management of their chronic illnesses.

Elder Law Practice of Timothy L. Takacs
201 Walton Ferry Road
Hendersonville, Tennessee 37075
Voice: (615) 824-2571
Fax: (615) 824-8772

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One thought on “What is a Medical Neighborhood?

  1. Hi Pete,
    I am dealing with this now with my Father. In a nutshell, this is what we have done for him, as advised by an elder care attorney in North Carolina. I’m sure Tennessee laws are a little different.
    My advice is this is complicated and to please get expert legal advice for your situation!

    My Father will need to be in an assisted living home soon and could transition to a full time nursing home in the near future. He has worked so hard all his life and wants to leave his things (home, stocks, etc) to his children and grandchildren. My Mother died 20 years ago, so currently, my older sister lives with my Father and is his caretaker.

    This is what we were advised:
    1. Medicare will only take care of you up to a point (so many days of in-home care, hospital care, rehab care etc.) It is then up to my Father, his family etc to pay for these extra costs out of pocket. A nursing home can cost around $5500.oo to $7000.00 a MONTH. That is for room and board only in most cases. The average person depletes his assets and savings within a year or so at this rate.

    2. Once you have run out of money and exhausted EVERYTHING you own to sell, you then are eligible for Medicaid. Once you sign up with Medicaid, they make sure you don’t have any assets. If you do, they seize them and sell them. Once you are penniless, they take over providing for you.

    3. What if I have a will? Doesn’t that override Medicaid and leave things to my heirs? The answer is NO. Medicaid will override your Will and seize your assests.

    WHAT? WHAT DO I DO?

    A. Draw up and transfer you will, house, stocks, car, checking and savings accounts – virtually ALL you own into an:
    “Irrevocable Trust” A “Revocable Trust”, which is what most trusts are, can be changed at any time, and be overriden by court judgements, say in a Medicaid case!

    Once drawn up and signed, an Irrevocable Trust can NEVER be changed – not by YOU, your children or the Government – anybody! And, it is NOT applicable to the 5 or 7 year “look back” law.

    B. This kind of trust was drawn up with MY FATHER as the recipient, guardian, executor during his lifetime. Therefore, it’s his home to do with as he pleases (he can sell it, for example), he lives in it, still owes property taxes; he still gets his stock dividends, social security, writes checks out of his accounts etc. etc.

    C. In essence, his things are still his things and work the same way they always have, but ON PAPER, NO ONE can touch or revoke what he has done – not him or Medicaid.

    D. So when the time comes for him to go into a home, he goes on Medicaid IMMEDIATELY because he is considered penniless. Because everything is in an IRREVOKABLE TRUST, they cannot touch it. He continues to receive his stock dividends, etc. which my sister puts in his savings account etc.

    E. She is his “Power of Attorney” so she can write checks for him etc.

    F. When he passes, his Will takes over and things are distributed as he wished because THEY ARE STILL THERE!!

    I don’t know if this information will help anyone or not but it is sure something to get some LEGAL advice about!

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