How to care for elderly parents is a major concern of many Foreign Service families. Our concerns mirror those of other American families, but how to ensure good health care, find the right living situation, and handle legal questions is often complicated for Foreign Service families by being posted abroad. The distance involved makes it harder to get information and help so contingency planning is essential.
Often Foreign Service families only have short visits during R & R or on home leave and hate to spend the precious time with their parents talking about serious business or unpleasant possibilities. Or we may be caught up in hectic preparations for an overseas assignment and not want to take the time to do contingency planning with parents. While it is difficult to discuss the issues of aging, the family who has discussed the options and agreed on plans will be better able to handle whatever happens. It will be worth the time taken, if there is an emergency.
The ideal situation is when the parents take control of their own situations and make decisions in advance of an emergency. They should investigate the types of retirement options and decide which is most appropriate, make informed decisions about life-sustaining medical care, and make sure that documents, instructions, and powers of attorney are available to those who must take responsibility in an emergency. The American Association of Retired Persons recommends that elderly people use a document locator list (scroll to bottom of this page) to make sure their papers are in order. This list can then be given to the person(s) who will be responsible for them should an emergency arise. Going through the list with your parents should ensure that their wishes are understood.
Communicating with Elderly Parents
Talking with our elderly parents about their living situations and the possible need for change is not always easy. A successful conversation depends to an extent upon the relationship we have with the parent, as well, of course, as on the parent's mental, emotional and physical condition. While many people put off serious conversations to avoid conflict or awkwardness, both parent and adult child may lose an opportunity for closeness, understanding, access to information that may affect the decision, and optimum peace of mind.
To the extent possible, talk with your elderly parents gently and honestly about their wishes, their abilities and their options. Far more often than not, these conversations are helpful and put the adult child in a better position to make decisions later when the parent may not be able to do so. The following are suggestions for conversations with your elderly parent:
If this kind of conversation seems impossible or the situation and relationship with the elderly parent become overwhelming, professional counseling may be very helpful. You may also consider using the Department of State's resources to approach this delicate issue somewhat indirectly. Filling out FIVE WISHES for yourself and sharing your decisions with your parents may encourage them to open up on the subject. You may also wish to raise the subject of long-term care insurance as a practical matter. (For more information about FIVE WISHES and Long-Term Care Insurance, see below).
When a Lifestyle Change May Be Necessary
Physicians and geriatric social workers warn that there are a number of danger signs that indicate an elderly person needs extra help or a change in living arrangement. Any marked change in personality or behavior should be heeded. However, no change in lifestyle should be made without discussions with the elderly person, other family members, and doctors or other health professionals.
Elder Care Options
If you see danger signals in your parent's behavior, it is important to discuss the changes and do some research. (See IQ: Information Quest below for information about the Department of State's free resource referral service.) There are many housing options available to the elderly. Choosing the best one will depend on the elderly person's preference, age, health, and financial condition.
Aging in Place
Under this option, the elderly person continues to live in his/her own apartment. Many elderly people live in Naturally Occurring Retirement Communities (NORCs), apartment buildings, condominiums, or cooperatives not designed as retirement communities but where at least 50 percent of the residents are 62 years old or older. These buildings often have amenities such as grocery stores, pharmacies, limousine service, or shopping services.
Recent technological advances often make aging in place easier: Velcro fasteners, lightweight wheelchairs, devices to control appliances and dial telephone numbers. There is even a "walk-in bathtub" for people who have difficulty climbing into an ordinary bathtub. Many services are available to help the elderly person stay in his/her home. Information about them can be obtained from contacting IQ: Information Quest (see below) or your local Area Agency on Aging.
Other Housing Options
There are several types of retirement communities that provide living arrangements and services to meet the needs of both independent seniors and those who need assistance. Large hotel corporations are in this field and other facilities are set up for members of a certain organization (retired military, Elks, etc.). It is important when investigating these housing options to understand completely the services provided and the cost.
If the elderly person is not capable of independent living, a nursing home may be the appropriate option. Nursing homes offer two levels of care - skilled nursing and intermediate care - depending on the patient's needs. Most nursing homes offer both levels of care on a single site.
Paying for Long-Term Care
It is important to understand the different types of insurance that are available to older people. Many people believe that Medicare will cover long-term care needs. It will not.
Medicare is a Federal health insurance program which helps defray many of the medical expenses of most Americans over the age of 65. Medicare has two parts:
(Part A) Hospital Insurance helps pay the cost of inpatient hospital care. The number of days in the hospital paid for by Medicare is governed by a system based upon patient diagnosis and medical necessity for hospital care. Once it is no longer medically necessary for the person to remain in the hospital, the physician will begin the discharge process. If the person or the family disagrees with this decision, they may appeal to the state's Peer Review Organization.
Medicare does not pay for custodial care or nursing home care. It will, however, cover up to 60 days in a nursing home as part of convalescence after hospitalization.
(Part B) Medical Insurance pays for many medically necessary doctors' services, outpatient services, and some other medical services. Enrollees pay a monthly premium.
Medicaid is a joint federal-state health care program for people with a low income. The program is administered by each state and the type of services covered differs. There are strict income requirements so it is necessary for the person to "spend down" all income and assets to poverty levels before becoming eligible. Medicaid is the major payer of nursing home care.
The Medicaid requirement to "spend down" all income and assets created a great hardship for the spouse of a person needing nursing home care. Changes in the Medicaid rules now allow the spouse to keep a monthly income and some assets, including the primary residence. The amounts allowed change, so you must check for current levels.
Why buy other insurance? The purchase of additional insurance gives the policy holder access to a greater choice of facilities without dipping into additional financial resources. Medigap is the name given to privately-purchased supplemental health insurance. It is designed to help cover some of the gaps in Medicare coverage but does not cover long-term care. Study Medigap policies carefully to be sure they provide the protection needed and do not duplicate other health insurance.
Long-Term Care Insurance is a private insurance that is usually either an indemnity policy or part of an individual life insurance policy. An indemnity policy pays a set amount per day for nursing home or home health care. Under the life insurance policy, a certain percentage of the death benefit is paid for each month the policyholder requires long-term care. Policies are priced differently depending on the age of the policyholder, the deductible periods chosen, and indemnity value or duration of benefits.
Information about other long-term insurance policies are available from:
American Foreign Service Protective Association (AFSPA)
1716 N Street, NW
Washington, DC 20036
As with Medigap health insurance, it is important to read the policy carefully and understand its restrictions before purchasing.
Who Can Help?
IQ: Information Quest (formerly LifeCare�)
IQ: Information Quest is a free 24-hour/ 7 days per week counseling, education and referral service that can help Department of State employees find the programs, providers, information, and resources they need to manage personal and professional responsibilities. IQ: Information Quest makes referrals, not recommendations. IQ: Information Quest counselors will help determine what services are needed and available in any U.S. locality and refer to appropriate providers. In addition to other services, they provide referrals in the area of adult care services (anywhere in the U.S.), including case management, emergency and respite care, home health care, long-distance care giving and legal and financial issues. Their web site features information on caring for an aging loved one, discussing caregiving options with your loved one, adult care information worksheet, caregivers of older adults, managing work while caring for your loved one, and geriatric care management services.
IQ: Information Quest will also provide an "Eldercare Kit" upon request which features caregiving guidance, checklists, and resources information, as well as a few useful practical items such as a pill sorter, night light and jar opener.
Permanent employees of the Department of State, The U.S. Agency for International Development, the Department of Justice, the Department of Labor, and FMAs overseas are eligible to use IQ: Information Quest. For the Department of State, this includes both Civil Service and Foreign Service employees serving at any Department assignment location nationwide and worldwide. Other employees working for the Department are not covered at this time (contractors, Foreign Service Nationals, PITs, PSCs). Spouses, children or others who are members of the employee's immediate household may use IQ: Information Quest. They verify eligibility by providing the name and date of birth (month and day) of the eligible employee. Employees of agencies other than the Department of State should check with their headquarters for guidance in how to contact and use IQ: Information Quest services.
IQ: Information Quest
Tel: 1-800-222-0364 or 1-888-222-0364 for the hearing impaired
For access to the passworded area of the site, contact your agency's HR Bureau.
The Employee Consultation Service (ECS)
The Employee Consultation Service (ECS) at the Department of State should be the first stop for Foreign Service members with eldercare concerns. The clinical social workers offer brief counseling and help in coordinating an evaluation and assessment anywhere in the United States. ECS social workers act as a liaison in providing appropriate and necessary services for the elderly. All services are free and confidential. In Washington, make an appointment for a personal consultation; from overseas write or cable for advice.
ECS also conducts support groups for employees and their families who are responsible for an aging relative. The groups meet at the State Department to share issues, resources, and approaches to the problems that arise as an elderly person declines, including the issue of emotional stress that occurs for family members watching such decline.
Employee Consultation Service (M/MED/ECS)
Columbia Plaza, Room H246
Washington, DC 20520
The Administration on Aging (AoA)
The Administration on Aging (AoA) is part of the U.S. Department of Health and Human Services. It was set up to "remove barriers to the economic and personal independence of older persons and to assure the availability of a range of appropriate community and family based services for older persons in social or economic need." AoA supports a network of the state and Area Agencies on Aging that reinforce and supplement the daily support that the elderly receive from family, friends, and neighbors.
Administration on Aging
Department of Health and Human Services
330 Independence Avenue, SW
Washington, DC 20201
To get information on eldercare services in a particular community, contact the Area Agency on Aging. One can locate a specific state agency on aging through the Eldercare Locator Service via telephone (1-800-677-1116) or the website at http://www.eldercare.gov. The Eldercare Locator Service is sponsored by the AoA and operated by the National Association of Area Agencies on Aging.
National Association of Area Agencies on Aging
927 15th Street, NW
Washington, DC 20005
Services provided by Area Agencies on Aging include information and referral, homemaker/home health aides, transportation, congregate and home delivered meals, chore and other supportive services. Types of services available vary in each community based upon needs and resources.
Private Geriatric Care Managers
Private geriatric care managers are professional social workers and nurses who assist the elderly and their families by assessing need, coordinating services, and monitoring care for a fee. They are particularly helpful when long-distance care giving is necessary. Fees vary and are sometimes covered by Medicare or private insurance. The Department of State's Employee Consultation Service or IQ: Information Quest, the local Area Agency on Aging, and community agencies can provide referrals nationwide. If the older person has been hospitalized, hospital discharge planners can also provide information and referrals for after-care.
Services Offered by the Private Sector
Some private companies have set up programs to help their employees with eldercare. Foreign Service spouses who work in the private sector should investigate any eldercare options offered by their employers. These programs can include seed money for eldercare services, flexible work schedules for caregivers, subsidies for eldercare expenses, unpaid leave for up to a year, referral services, inter-generational day care centers (for both the elderly and children), geriatric assessment and case management, and group rates for long-term care insurance.
Unfortunately, many of the services provided by companies require that the elderly person meet the tax-law definition of a dependent. This increases the burden for families whose elderly relatives are not financially dependent or who are not living with the employee.
Eldercare in the Foreign Service
Putting Parents on Your Orders
Foreign Service employees may request that their elderly relative(s) (including step parents and legally adopted parents) be approved as an eligible family member and added to their Post Assignment Travel Orders for an overseas assignment. The employee must complete an OF-126 Foreign Service Residence and Dependency Report. This form can be found on the Department of State Infoforms with instructions on completion. Each new OF-126 replaces the old OF-126, therefore all blocks must be filled out each time a new OF-126 is done. The new OF-126 must be forwarded to the employee's personnel technician in HR/CDA/ASD, Room 2419, Truman Building (Main State). Travel orders can not be authorized for newly-acquired eligible family members until the personnel technician receives the OF-126 form.
Along with a completed OF-126 form, the officer must prove that the relative is at least 51 percent dependent for support (subject to review and approval per 6 FAM 117; USAID employees should also see Supplement 1B to HB 32, Chapter 1). The officer must quantify that he/she has provided more than 51% of support by submitting an affidavit or notarized statement testifying to that fact. This is termed passing the "financial support test." An explanation regarding the parent's residency is also required, with an explanation as to why the application is being made to add the parent to the travel orders. Other documentary evidence may be required by the employee's agency. These documents are attached to the completed OF-126 form and sent to the officer's agency as specified on the forms. Requests are reviewed for approval by a Personnel OF-126 Committee.
Employees of the Department of State can obtain advice on how to put your parents on your orders through the Career Development and Assignments (CDA) division of the Bureau of Human Resources. Ask for an Assignments Support (CDA/AS) officer. Employees of other agencies should contact their HR representative.
See section below, Taking an Elderly Relative to Post, for details regarding official government support.
Bringing Parents to Post Who Are Not on Your Orders
If your relatives are not financially dependent on you, they may come to post as members of the employee's household, but will receive no official support from the U.S. Government. No official support translates into no access to the U.S. embassy health unit, no airfare or allowance payments in the case of evacuation from post, and no diplomatic status with the host country. Parents who come to live overseas for an extended period of time should consider having additional medical insurance (Medicare does not cover costs related to care overseas). In addition, parents should also maintain Air Medical Evacuation Insurance. A list of companies that provide this insurance can be found on the Department of State Consular Affairs web site.
Family Medical Leave Act and Family-Friendly Leave
If you think you may need to care for an elderly relative, be sure to check the provisions of the 1993 Family Leave Act on taking leave for this purpose and contact the a leave specialist in your agency. Department of State employees can contact a Department leave specialist in the Office of Employee Relations (HR/ER/WLP) about paid and unpaid leave at 202-261-8180.
Eldercare Emergency Visitation Travel (Eldercare EVT)
In January 2001, the Eldercare Emergency Visitation Travel (Eldercare EVT) provision was implemented, permitting travel at government expense for employees and eligible spouses serving at an overseas post who need to assist parents in declining health. Eldercare EVT allows an employee two trips over a career to visit his or her parents. It is meant to support one mother and one father of the employee and of the eligible spouse. It does not mean a couple may pool their four eldercare visits to assist the parent(s) of only one member of the married couple. For more information, email the Family Liaison Office (email@example.com) for a copy of "Questions and Answers on Eldercare Emergency Visitation Travel."
Taking an Elderly Relative to Post
If elderly relatives are classified as eligible family members, they travel on diplomatic passports and have the same diplomatic immunity as a spouse or child. If not classified as such, elderly parents use tourist passports and do not have diplomatic status.
Housing assignments are based on the number of official eligible family members the employee brings to post. Travel to and from post (with the exception of medical travel) is also available to all elderly parents designated as eligible family members.
Elderly parents, regardless of their status, are not covered by the Foreign Service medical insurance program and do not have access to the health unit. Employees may, however, ask the Health Unit for names of local physicians who can provide medical services for their elderly parent. This kind of assistance from the Health Unit may also be requested during the bidding process, to determine if a post has adequate local health care providers to meet the medical needs of a parent.
Because elderly parents are not covered under the Foreign Service medical insurance program, they also do not have access to embassy medical evacuation (medevac) services. Therefore, all parents coming to post for either a short or an extended period of time should purchase (and maintain) Air Medical Evacuation Insurance. A list of companies that provide this insurance can be found on the Department of State Consular Affairs website.
It is essential that a parent going overseas, either officially or unofficially, have adequate medical insurance. Medicare only pays medical expenses in the United States, and in Canada and Mexico under certain very limited circumstances.
The insurance companies listed below provide a variety of coverage and can be contacted for more information. Pay special attention to "age limit" noted in the policy.
Clements and Company
Under its GlobalCare Plus program, Clements and Company provides overseas major medical insurance, including full world-wide evacuation services. Coverage is offered for individuals as well as families. Substantial coverage is available at a reasonable cost. GlobalCare Plus is for policies lasting 6 months to one year. Clements also write policies for shorter-term travel (15 days to 4 months) through Patriot Travel Medical Insurance.
Clements and Company
1660 L Street NW, 9th Floor
Washington, DC 20036
Tel: 1-800-872-0067 or 202-872-0600
Blue Cross/Blue Shield
Provides coverage to Americans living abroad only through the local offices where the clients have residence. Insurance may be purchased while the client is overseas.
CareFirst BlueCrossBlueShield (Washington, DC Area)
550 12th Street, NW
Washington, DC 20065
Available to U.S. residents only. A policy may be purchased only while client is in the United States, but coverage is good worldwide.
6600 W Broad Street
Richmond, VA 23230
Tel: 1-866-807-3982 or 202-822-3948
If Your Elderly Relative was a Foreign Service Employee or Spouse
The Senior Living Foundation of the American Foreign Service, sponsored by the American Foreign Service Protective Association (AFSPA), provides information and assistance to retired Foreign Service personnel and their surviving or divorced spouses and, on the basis of need, helps to defray the costs of home health care, senior housing facilities, long-term care insurance, or other services that contribute to their health and security. The Foundation is especially concerned with the 14 percent of the 11,000 retired members whose small pensions keep their income at or below the poverty line.
The Foundation's Resource Center provides information about and assistance in obtaining community, State, and Federal resources. A licensed clinical social worker with Foreign Service experience reviews each case to determine the best resources available for the individual. Help ranges from volunteer visits to long-term care planning to advice on the legal maze of Medicaid. For more information contact them at:
Senior Living Foundation
1716 N Street NW
Washington, DC 20036-2902
If an elderly relative becomes mentally incapacitated, it is necessary that someone step in to take care of affairs. Advance planning on the part of both the elderly person and those who care about him/her will facilitate this process. You should consult an attorney before taking any of the following steps.
The Document Locator (scroll to bottom of page) is a useful tool for the elderly person and his/her relatives to make contingency plans for future care. Other factors to consider include setting up joint bank or property accounts and signing a durable power of attorney.
Joint property or bank accounts are the simplest way to ensure that someone will be able to handle the elderly person's affairs if s/he becomes incompetent. There are, however, serious financial and tax consequences to such an arrangement. For example, when applying for Medicaid assistance, the assets of both owners are taken into account to determine eligibility. No one should enter into such an arrangement without checking all the legal implications.
A durable power of attorney is important because an ordinary power of attorney is not valid if the principal becomes incapacitated. This can create serious problems for the person handling the affairs and arranging care. A durable power of attorney is designed to survive disability or incompetence and is an important alternative to guardianship, conservatorship, or trusteeship. Laws vary from state to state so it is important that a durable power of attorney be drawn up by an attorney licensed to practice in the state in which the client resides.
Guardianship or conservatorship is the legal mechanism by which a court declares a person incompetent and appoints a guardian. The court transfers the responsibility for managing financial affairs, living arrangements, and medical decisions to the guardian. This procedure can take some time, usually when time is of the essence.
Making Life and Death Decisions
Because of the amazing advances in health technology, people are living longer. Newspapers are filled with stories of families asking the courts to allow terminally ill family members to be removed from life support systems. Adult children are often asked to make these kinds of decisions for their terminally ill parents. Courts are increasingly asking what preferences about medical care the patient may have expressed. Ideally, everyone should make his/her own wishes known by preparing and signing a medical directive, a health care power of attorney, a durable power of attorney, and/or a living will.
Some definitions are in order:
Power of Attorney - Ordinary powers of attorney allow an individual ("the principal") to give legal authority to another ("the agent") to handle business or property transactions for the principal. The power of attorney may be general or limited, for a definite or indefinite period of time. As long as the principal remains competent s/he may change or end the power of attorney at any time. These powers of attorney are effective only as long as the principal is competent.
Living Will - This is a written statement of wishes regarding the use of specified medical treatments. It is provided to the doctor, hospital, or medical provider and becomes part of the official medical record. Each state requires the use of its own form for a living will and many states have other limitations. In some states, living wills apply only to those with Alzheimer's Disease, strokes, degenerative disorders, or those in a coma or persistent vegetative state.
Health Care Power of Attorney (also called a medical power of attorney or health care proxy) - This durable power of attorney is for health care (as opposed to financial) issues. It authorizes the agent to make health care decisions for the principal in the event s/he is unable to make such decisions. Without such a document, many health care providers and institutions will make critical decisions for the patient, not necessarily based on what s/he would want. The health care power of attorney can also include a statement of wishes and preferences in specific situations (for example, a person may want to forego respirators but continue nourishment). A statement of wishes concerning organ donation should also be included. Health care powers of attorney can be used by individuals who want life-sustaining treatments continued as well as those who want to forego such treatments. An increasing number of states are enacting statutes that recognize health care powers of attorney and many states provide forms and procedures for creating the document.
Note: Department of State employees may request a free copy of FIVE WISHES from the Office of Employee Relations, Work/Life Programs (by email to HR-ER-WLP on the global address list or call 202-261-8180), one copy per person. FIVE WISHES is a planning tool and legal document in most U.S. states that combines the features of a living will and a health care power of attorney.
Questions to Consider
The most important considerations when preparing a durable health care power of attorney are whether or not to permit life-sustaining procedures and whether or not life-sustaining procedures include nutrition and hydration (food and fluid provided by a nasogastric tube or tube into the stomach, intestines, or veins).
The health care power of attorney should state clearly one of the following:
Another important decision is the agent who will make the health care decisions. Remember that this person is the one to make health care decisions, not manage the money. Choose a trustworthy person who is good under stress and good at talking to doctors.
Other Points to Consider
Getting a Lawyer's Help
It is recommended that a lawyer draw up any durable power of attorney and/or health care power of attorney so that the document meets your special needs and will be acceptable in your state. This is especially important in any state which does not have a statutory form. The Society for the Right to Die provides free information on your state's current laws on both living wills and powers of attorney for health care. The National Academy of Elder Law Attorneys can provide information on how to chose an attorney specializing in elder law. Other referral sources include the local Office on Aging or the local Alzheimer's Association. See Eldercare Resources below for the addresses and telephone numbers of these organizations.
Useful Eldercare Resources
AARP Webplace - This advertisement-free site provides information and encourages elder advocacy.
Aging Parents: The Family Survival Guide
Consisting of a booklet and two videotapes, this guide is designed to help family members respond to eldercare crises and to plan ahead for long-term care giving. To order, call 1-888-777-5585 or order online at http://www.agingparents.com/
Aging Parents and Elder Care - Articles, comprehensive checklists, and links to key resources. The site is designed to make it easier for family caregivers to quickly find the information they need. http://www.aging-parents-and-elder-care.com/
Travel Tips for Older Americans from the Department of State Bureau of Consular Affairs http://travel.state.gov/travel/tips/tips_1232.html (see Special Planning Considerations / Senior Travelers).
Academy of Elder Law Attorneys
1604 North Country Club Road
Tucson, AZ 85716
Alzheimer's Association, Inc.
919 North Michigan Avenue, Suite 1000
Chicago IL 60611
American Association of Homes for the Aging
901 E Street NW
Washington, DC 20004
American Association of Retired Persons
601 E Street NW
Washington, DC 20049
Provides the following free pamphlets: Miles Away and Still Caring (D-12748); A Handbook About Care in the Home (D-955); A Path For Caregivers (D-12957)
Choice in Dying/Partnership for Caring
1035 30th Street NW
Washington, DC 20007
Tel: 202-338-9790 or 800-989-9455
Free medical directives and living will samples.
Guide to Retirement Living
Douglas Publishing Company, Inc.
9302 Lee Highway, Suite 750
Fairfax, VA 22031
Tel: 703-536-5150 or 1-800-394-9990
Call for a free single copy of this magazine.
Health Insurance Association of America
555 13th Street NW, Suite 600 East
Washington, DC 20004
Publishes A Consumer's Guide to Long-Term Care.
National Association of Private Geriatric Care Managers
1604 North Country Club Road
Tucson, AZ 85715
Provides free referrals nationwide and sells a directory of members and managers.
National Council on the Aging, Inc.
409 3rd Street SW
Washington, DC 20061-5087
Publishes Perspective on Aging, a bimonthly magazine, and Family Home Caring Guides.
National Institute on Aging
9000 Rockville Pike
Bethesda, MD 20892
National Guardianship Association
1604 N. Country Club Rd
Tucson, AZ 85716
Long-Term Care Link
A comprehensive web site with links to eldercare services and insurance information. Updated web site addresses for all State Agencies on Aging:
For general resource information: http://www.longtermcarelink.net/
State Agencies on Aging
A listing of web sites is available at: http://www.eldercare.gov/Eldercare.NET/Public/Index.aspx
Document Locator List
Updated July 2007
Information provided by the Family Liaison Office
Contact the Family Liaison Office