Eleanor Feldman Barbera, Ph.D.

It was noon at the nursing home and the staff was busy wheeling residents into the dining room. “Are you going to buy me lunch today?” an aide joked as she unlocked the brakes on Mr. Romano’s wheelchair. He smiled, but I could tell he was pained. He’d just spent his last psychotherapy session discussing his now-meager funds after a lifetime of earning and saving.

In my conversations with hundreds of long-term care residents over the years, I’ve found money to be an almost universally sore subject among them. Since money is a primary concern for most of us throughout our adult lives, it should come as no surprise that financial concerns continue to be a stressor for our residents even though they’re living in the mostly money-free society of LTC. The reasons for this financial tension vary, and with some adjustments we can reduce aspects of our residents’ financial distress.

Money stress sources and remedies

Spending down: Residents who saved money during their lives and are now spending their savings to qualify for Medicaid are particularly sensitive to, shall we say, variations in care.

“This is what I’m paying for?” they’ll ask with incredulity at an unpalatable meal or an unpleasant interaction with a staff member. It’s a bitter pill to scrimp all one’s life and have to pay out of pocket for healthcare with savings, particularly when the lifelong free spender in the next bed is getting exactly the same care paid for by Medicare and Medicaid.

Remedy: While we can’t change the fact of the spend down (and it should go without saying that we provide the best service possible to every resident at all times regardless of their funding source), we as experts can offer suggestions for spending down that allow residents to make the most of this period.

  • For example, elders might want to buy a television set, some extra clothes and other belongings they’ll be able to enjoy once they’ve qualified for Medicaid and don’t have as many funds to access. Perhaps they’d like to buy themselves flowers or fruit that arrives monthly for the next year so that they have some luxury in their lives when things get tight. New residents and families have never spent down before and they need our advice about what’s permissible and likely to make them happy in the years to come.
  • Residents may be legally allowed a financial gift to a family member who can then use that money for them at a later point.
  • Encourage seniors to put aside money for a burial fund, if needed, so that they don’t have to worry about this later in life. Money for burial isn’t counted toward the maximum amount residents are allowed to hold in their personal accounts.

Personal Needs Allowance (PNA): Residents are entitled to a monthly PNA that allows them to buy things such as clothing, haircuts, special trips and other items not provided for by the facility. Unfortunately, when this amount — which varies by state — was determined back in 1980, no provision was made for inflation. In New York, the $50 PNA from 1980 is now worth $17.32. If the PNA had been adjusted for inflation, the resident would be getting $144.36 each month, which is a reasonable allotment that would permit people to buy the aforementioned goods and services, plus some takeout food or an occasional gift for their grandchildren. Managing personal needs on $50 a month in 2014 is beyond challenging. (For more on this, see the Money Issues anecdotes at My Better Nursing Home and the “Your Money” chapter of The Savvy Resident’s Guide.)

Remedy: Clearly, PNA levels should be adjusted for inflation, but for now we can help residents living on a very tight budget in several ways.

  • If they’re smokers, assist them in quitting this expensive habit.
  • Provide as much secondhand clothing as possible and encourage donations from the community so that PNA funds can be used for other items.
  • Create events that raise money for activities such as off-campus concerts, thereby reducing the need for residents to spend personal funds for special trips.
  • Offer ways for residents to make or purchase low-cost items for family members for the holidays so that they can continue to give within their means.
  • Train staff not to joke around about money or to take “tips” for doing favors like keeping the change from the purchase of an egg roll on lunch break. This very small transaction might not be what staff members have in mind when they’re told that tips are prohibited but can make an impact on the residents’ bottom line.
  • If clothing is lost in the laundry, acknowledge to the resident that this is a major hardship and quickly replace the item. It may just be an old shirt to us, but the purchase of a $20 shirt can be 40% or more of their monthly allotment.

Not being able to use their money for purchases: Elders may have access to their facility bank accounts through the social worker, a family member, or the ability to get to the banking office on their own, but it’s often difficult for them to buy anything except what’s in the onsite vending machine. This is a huge source of frustration.

Remedy: While most facilities allow a traveling store to come on campus a couple of times a year, we can provide additional ways for residents to shop for items and increase their sense of control over their lives.

  • Make it easy for residents to access their funds through debit cards connected to their accounts. A debit card can be used like a credit card but it prevents people from spending more than they have in their accounts.
  • Provide off-campus shopping trips so that elders can make their own purchases with assistance from staff.
  • Hold a regular activity where staff members are available to help residents buy things online using the debit cards linked to their accounts.
  • Assign someone to make regular off-campus purchases for residents.
  • Develop an on-campus store (or roving cart) that takes orders.
  • Offer computer access with adaptive equipment such as enlarged print so that residents can shop independently.
  • Helping our residents feel less stressed around money will ease their general anxiety about life in LTC — and we can all take that to the (good karma) bank.

For a humorous take on one resident’s efforts to manage her money, click on “Aunt Sylvia Spends Down.”

Eleanor Feldman Barbera, PhD, is a 2014 Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is the author of The Savvy Resident’s Guide, and an accomplished speaker and consultant with nearly 20 years of experience as a psychologist in long-term care. This blog complements her award-winning website, MyBetterNursingHome.com, which has more on how to create long-term care where EVERYBODY thrives.