Agi n g i n PLA ACE Act III: Your Plan for Aging in Place www.ageinplace.org NATIONAL AGING IN PLACE COUNCIL Act III: Your Plan for Aging in Place Welcome. This template is designed to help you make your own plan for Aging in Place. Aging in Place is; • A rapidly growing lifestyle option for Americans approaching or beyond retirement age. • It facilitates remaining in the home of your choice for as long as you would like as opposed to relocating to a nursing home or other medical facility. • Offers the services you need to live a secure and safe life in your home. In order to successfully age in place we strongly recommend some planning. This template will make planning easy for you. This will take a chunk of time. We estimate about an hour. But you don’t have to do it all in one sitting. You can save your responses, take a break, and come back. You might want to involve your family or trusted advisors in this process. Make it fun, make it an occasion. Invite them to join you around the dining room table and answer the questions together. At the end of each section, you will find space entitled “My Needs.” Here, you fill in your needs in that area. “My Needs” Evaluation When you complete the questions in all of the areas, you will be given a “My Needs Summary.” This summary will provide you with resources and information on the areas that you may need assistance, based on your answers to the questions. When you complete this template, you should have a clearer picture of your own future. After receiving your “My Needs Summary,” we will provide you with a “My Needs Evaluation.” If you have a local Chapter in your community, a member of the Chapter will assess your “My Needs Summary” to assist you with finding the resources and providers that you will need to age in place. If no local Chapter exists in your community, the NAIPC National staff will assist you with your “My Needs Evaluation.” If an event occurs in your future that alters your circumstances (a change in location, a financial gain or loss, a health issue, etc.), we recommend you revisit your plan to determine if you need to do some rethinking. So now let’s begin to go through the essentials of your lifestyle and evaluate your circumstances. Using This Template We are going to walk you through the essential concerns to sustain a safe and secure lifestyle in your home. We are going to ask a lot of questions you need to ask yourself. The questions are primarily about what you now have and what you might need. The key areas we are going to evaluate are: • Housing • Health and wellness • Personal finance • Transportation • Community and social interaction • Education and entertainment Spousal Evaluation If married you can fill out the template jointly or individually. Certain sections may be more useful if filled out separately. 2 NATIONAL AGING IN PLACE COUNCIL Are you comfortable and safe in your home or do you need another home or modifications to your current home? Please go to page 4. Do you have access to the healthcare you need or do you need advice? Please go to page 8. Do you have sufficient financial resources to fund your retirement? Please go to page 12. Do you have access to the transportation you need? Please go to page 17. Are you part of a community and do you have the Social- interaction and access to entertainment you want? Please go to page 20. 3 NATIONAL AGING IN PLACE COUNCIL Housing Please answer to the following questions: Choice of Residence 1. Describe your current home – size, location, amenities, accessibility.  2. Are you comfortable in your current residence? Yes  No  3. Would you like to remain in your current residence for as long as possible? Yes  No   4. What is it that most makes you want to remain in your current residence? Location Familiarity Size Accessibility to family Accessibility to friends Other. Please explain 5. If you are not comfortable in your present residence, what would you prefer? Downsizing to something smaller Something less expensive Everything you need on one floor A residence more suitable to your physical condition Better accessibility to family Better accessibility to friends A warmer climate Better accessibility to transportation Better accessibility to culture and entertainment Other. Please explain 4  NATIONAL AGING IN PLACE COUNCIL  6. In assessing your living conditions, what are the things you must have? What are the  things you have, but could live without? Must Haves Can Live Without      Affordability 7. Do you own or rent your current home? Own  Rent  8. If you own your home, do you have a mortgage? Yes  No  9. What percentage of your monthly income is your mortgage or rent? (Note: National average is 35%. If you do not have this information at hand, you can calculate it in Personal Finance section.) 10. Does your monthly mortgage payment or rent leave you enough money for your other needs? Yes  No   11. If your home does not leave you enough money for other expenses would you prefer to a) Find a less expensive home b) Find the means to pay off your mortgage and lower your monthly expenses c) Remain in your current home and reduce your other expenses 12. If your monthly home costs are too expensive, have you explored any of the following? a) All benefits available to you (Visit benefitscheckup.com) b) Reverse mortgage (Visit reversemortgage.org) c) If your state has a Property Tax Deferral plan for seniors d) Downsizing e) Home sharing f) Refinancing at a lower interest rate Comfort & Accessibility 13. Can you comfortably move around your home? Yes  No   14. If not, have you considered or researched home modifications? Yes  No  5 NATIONAL AGING IN PLACE COUNCIL   15. If so, which modifications have you considered? a. Rearranging the home so the master bedroom is on the ground floor? Yes  b. Widening the front entrance? Yes  No  No  c. Improving access into the home? Yes  No  d. Putting grab bars in your bath or shower and near your toilet? Yes  No  e. Improving ease of use by adding better storage, such as drawers or pull outs, or lighting?  Yes  No  f. Softening floor covering to help if you fall? Yes  No  g. Eliminating carpet or rugs to prevent falls? Yes  No  h. Other. Please explain 16. What home technology devices have you explored to promote aging in place? S mart pho nes Co mput er s O ther Tablet s Medical alert dev ices 17. Have you considered what home modifications can be done to help address physical changes brought on by any pre-existing medical conditions? Yes  No  Personal Home Assessment Please check one of the following:  My current home is comfortable, safe and affordable for me. My current home is not comfortable enough safe enough affordable enough If your current home is not comfortable, safe, or affordable, what changes should you be considering? 6 NATIONAL AGING IN PLACE COUNCIL  My Housing Needs: 7 NATIONAL AGING IN PLACE COUNCIL Health and Wellness Please choose an answer to the following questions: General 18. On a scale of 1-10, where 10 is “Excellent” and 1 is “Poor,” how would you rate your overall health? 1 2 3 4 5 6 7 8 9 10 19. What concerns do you have in particular about your health?  Medical condition/chronic illness Chronic Pain Limited mobility Costs of medical care Difficulty getting to doctor’s appointments (see Transportation section) 20. Do you feel you have a sufficient understanding of the benefits provided by Medicare or private insurance? Yes  No  21. Do you know where to find this information? Yes  22. Would advice be helpful to you? Yes  No  No  23. Are you aware of the services provided by caregivers? Yes  24. Do you know how to find a caregiver? Yes  No  No  25. Do you avoid seeking caregiving or medical care due to costs? Yes  No  Medicare 26. Are you eligible for Medicare? Yes  No  a. If you answered “no” to Question 17, please skip to the “Private Healthcare Plans” section. b. If you answered “yes” to Question 17, have you enrolled? Yes  No   27. Are your Medicare benefits enough to cover your medical costs? Yes  No  a. If you answered “no” to Question 26, have you reviewed and compared Medicare plans available to you? (It is recommended that recipients compare available plans annually during open enrollment, as plans often change year-to-year.) Yes No  8 NATIONAL AGING IN PLACE COUNCIL b. If you answered “no” to Question 26, have you looked into a Medigap Policy? Yes  No   c. If you answered “no” to Question 26, have you used benefitscheckup.org to determine if you might be eligible for additional medical benefits or programs? Yes  No  Private Healthcare Plans (NOTE: If you are eligible for Medicare, please skip this section) 28. If you are not eligible for Medicare, do you have a private health care plan? Yes  No  a. If you answered “no” to Question 27, can you afford a private plan? This is typically defined as a plan costing 8% or less of your total income. Yes  No   b. If you answered “yes” to Question 27, are your benefits sufficient to cover your medical costs? Yes  No  i. If you answered “no” to Question 27b, have you used benefitscheckup.org to determine if you might be eligible for additional medical benefits or programs? Yes  No  ii. If you answered “no” to Question 27b, have you used healthcare.gov to compare available plans? Yes  No   29. If you have a high-deductible health plan, do you utilize the benefits of a Health Savings Account? Yes  No   30. If you are still employed, does your employer offer Flexible Spending Accounts? Yes  No  c. If you answered “yes” to Question 29, have you enrolled for one? Yes  No   Daily Living/In Home Care 31. Do you have a personal health record? Or do you have a current list of your physicians, health conditions, and medications (including dosages)? Yes  No  a) If you answered no to Question 30 please visit http://www.myphr.com/ to create a personal health record. 9 NATIONAL AGING IN PLACE COUNCIL 32. Are you able to independently perform daily activities? Check all that you are still able to perform: Bathing and showering Personal hygiene and grooming (including washing hair) Dressing Eating/feeding Functional mobility (moving from one place to another while performing activities) Personal device care Toilet hygiene (completing the act of relieving oneself) a. If you did not check off any item(s) listed in Question 31, do you have a family member or friend who can serve as your caregiver and assist you with that activity(s)? Yes  No  b. If you answered “yes” to Question 31a, what role would family/friends/volunteers play in a situation where you needed help with daily living activities? c. If you answered “no” to Question 31a, do you have the financial resources to hire a caregiver to assist you with your daily activities? (See Financial section) Yes  No   33. Do you have a chronic medical condition that requires daily monitoring and/or treatment? Yes  No  a. If you answered “yes” to Question 32, are you able to manage your medical condition on a daily basis (taking medications exactly as prescribed, using medical equipment, etc.)? Yes  No  i. If you answered “no” to Question 32a, do you have a caregiver (family member, friend, or hired employee) who can assist you with managing your medical condition? Yes  No  1. If you answered “no” to Question 32a(i), have you consulted with a geriatric care manager who can advise you on how to better manage your condition? Yes  No   34. Have you considered what home modifications can be done to help you address physical changes brought about by your condition? What modifications? 35. Have you researched technology products that might assist you with managing your condition? Yes  No What products?   36. Is there technology you’d like to know more about? If so, what technology?   10 NATIONAL AGING IN PLACE COUNCIL  37. Do you have the means for traveling to medical appointments? Yes  No   38. If you were to experience a major health problem (surgery, diagnosis with chronic illness, etc.), do you have a plan for how you will pay for your medical expenses? (See Finance section) Yes  No   39. Have you completed the appropriate legal medical documents, including a healthcare power of attorney, a living will, and an advanced directive? Yes  No  a. If no, do you need information on how to complete these documents? Yes  No   40. What plans have you put in place in the event you are no longer able to make decisions about your health care?  41. What plans do you have in place in the event you become terminally ill?   42. Have you made funeral arrangements? Yes    My Health & Wellness Needs: 11 No  NATIONAL AGING IN PLACE COUNCIL Personal Finance 43. Do you currently have sufficient income and/or savings to cover your monthly expenses? Yes  No  a) If you answered no to Question 40, do your monthly expenses exceed your monthly income? Yes  No By how much?  b) Do you have a plan to fill the gap in income? Yes  No  c) Do you need to trim your monthly expenses? Yes  No   44. Do you feel comfortable that you have enough money to get you through retirement? Yes  No  45. Are you delaying retirement because you fear you don’t have enough money? Yes  No  46. Have you prepared a list of your income, assets, and your expenses? Yes  No  a. If your answer to Question 42 is no and you would like to prepare a list, use the following grid:    INCOME Current Retirement Wages, salary, tips Cash dividends Interest received Social Security Pension income Rents, royalties Other income Adjustments Federal income taxes State income taxes FICA - SSA Other taxes Total Income Total Taxes Total Adjusted Income $ $ $ $ $ $  12 M/Y NATIONAL AGING IN PLACE COUNCIL  Current Retirement Mortgage payment or rent 2nd home mortgage Real estate taxes Automobile note Personal loans Life insurance Disability insurance Medical insurance Long-term care insurance Homeowner’s insurance Automobile insurance Umbrella liability insurance Savings (regularly) Investments (regularly) Retirement plan contributions Other Total Fixed Expenses $ $        13 M/Y NATIONAL AGING IN PLACE COUNCIL   VARIABLE EXPENSES Current Electricity Gas/Fuel Telephone Water Cable TV Home repairs/Maintenance Landscape Credit cards -- total. Food/Dining Clothing/Laundry Camp/Child care Personal care Other family care expenses Automobile gas & oil Automobile repairs, etc. Other transportation Education expenses Entertainment Recreation/Travel Club/Association dues Hobbies Gifts/Donations Unreimbursed medical/Dental Miscellaneous Other Total Variable Expenses $ Retirement M/Y Retirement M/Y $   NET CASH FLOW Current Total adjusted income Total fixed expenses Total variable expenses Discretionary Income (Income - Expenses) $ $ 14 NATIONAL AGING IN PLACE COUNCIL 47. Are you currently collecting Social Security benefits? Yes  No  If your answer to Question 44 is no, please answer these questions: a. Have you decided when you will collect your Social Security benefits? Yes  No  i. If your answer to Question 44a is no, do you need help figuring out what is best for you? Yes  No   48. Do you have savings or pensions? Yes  No  a. If you answered yes to Question 45, where are your savings/pensions located?  401 K Account  IRA account  Bank savings account  Investments  Annuities  Other 49. Do you get advice on how to utilize your savings or pension? Yes  No  a. If you answered yes to Question 46, whom do you depend on for advice?  Professional financial advisor  Family  Friends  Banker 50. Have you researched all the other benefits that may be available to you? Yes  No  Medicare Yes  No  Medicaid Yes  No  The Savers’ Credit Yes  No  Medicare Part D Yes  No  Veterans Administration programs including Healthcare benefits Yes  No  National Council on Aging (NCOA) BenefitsCheckup Yes  No  Other  51. Have you considered Long Term Care Insurance? Yes  No  a. b. c. d. e. f. g. a. Would you like more information about Long Term Care Insurance? Yes   52. Have you considered using your home equity to supplement your income? Yes  No  a. If you answered yes to Question 49 , have you considered:  Home Equity Line of Credit  Reverse Mortgage 15 No  NATIONAL AGING IN PLACE COUNCIL  53. Have you completed the appropriate legal documents, including a financial power of attorney and a will for the disposition of assets? Yes  No  a. If no, do you need information on how to complete these documents? 54. What measures/ legal documents do you have in place?    55. If married, do both spouses know how to access important documents and accounts? Do you both have account access? Yes  No  56. Have you made arrangements for your funeral? Yes  No  a) If you answered yes to Question 52, what arrangements have you made?    57. Do you need the assistance of an Elder Law attorney or estate planner to help you? Yes  No  a) If you answered yes to Question 53, which preparations?       My Personal Finance Needs:    16 NATIONAL AGING IN PLACE COUNCIL   Transportation Please choose an answer to the following questions: General 58. Do you live in a(n): Urban Community Suburban Community Rural Community 59. What is the most common form of transportation in your community? Car  Uber Walking Lyft Bus Train Taxi 60. If driving a car is the most common form of transportation in your community, are you still able to safely and comfortably drive a car? Yes  No  a. If you answered “yes” to Question 56, do you have a plan in place for your future transportation needs if your ability to drive changes? Yes  No  b. If you answered “no” to Question 56, do you have family or friends who can assist you with your transportation needs? Yes  No  i. If you answered “no” to Question 56b, do you have access to public transportation? Yes  No  ii. If you answered “no” to Question 56b, do you have access to taxis or car services? Yes  No  iii. If you answered “no” to Question 56b, do you have access to programs through local non-profits like the Village to Village network, volunteer services, or ride share programs? Yes  No  61. Will you continue driving longer than you think you should because there is no alternative? Yes  No  17 NATIONAL AGING IN PLACE COUNCIL Transportation Needs 62. Do you need transportation most frequently for: (Select all that apply) Doctor Visits Grocery store trips Social Events Errands 63. How do you most frequently find transportation for these needs? Drive self Friends/Family members Walking Public transportation Taxis or car services  Non-profit programs/volunteer services/rideshare programs a. If you selected “Drive self” in Question 59, do you have a plan in place for your future transportation needs if your ability to drive changes Yes  No  b. If you selected “Public Transportation” in Question 59, do you have a plan in place if you become unable to utilize public transportation? Yes  No   64. How do you access transportation? Landline Cellphone Computer 65. Have you set aside money for your potential future transportation needs? Yes  No   66. Can you contact/dispatch the type of transportation that you need, or do you need assistance from someone else? Yes  No   67. If you do not have access to the transportation that you need, would you consider relocating to a community where it is available? Yes  No   68. What are things you would like to do but do not do because of lack of transportation? (Select all that apply) Social events Buy groceries Doctor visits Visit family/friends Attend church/synagogue or other religious services 18 NATIONAL AGING IN PLACE COUNCIL My Transportation Needs: 19 NATIONAL AGING IN PLACE COUNCIL Community & Social Interaction Please choose an answer to the following questions: General 69. Do you feel that you have enough social interaction with other people? Yes  No  a. If you answered “no” to Question 65, what are the reasons? (Select all that apply)  Transportation  Home is isolated  Children/family no longer live in the area 70. Do you feel that you are a part of your local community? Yes   71. Do you want more access to entertainment? Yes  No  No  a. If you answered “yes” to Question 67, what kind of entertainment do you prefer?  Theatre  Dance  Music  Movies  Reading  Speakers 72. Is the entertainment that you prefer available in your community? Yes  No   73. Would you like more information on volunteer opportunities in your community? Yes  No   74. Do you participate in events at senior centers? Yes  No  a. If not, would you like to? Yes  No   75. Are you interested in local adult educational programs? Yes  No   76. Are you a member of or do you belong to any religious institutions, clubs, local groups, alumni associations, etc.? Yes  No   77. Are you familiar with the following kinds of communities? (Select all that apply) The Village to Village Network NORCs Senior Housing Complexes/Developments 20 NATIONAL AGING IN PLACE COUNCIL 78. If you are not as involved in your community as you would like to be, is there a reason? (Select all that apply) Do not have access Do not have mobility Have not made the effort Other 79. How comfortable are you using technologies (smartphones, tablets, computers)? Not comfortable at all Moderate comfort Very comfortable 80. Do you use any of these technologies to “stay connected”? If so, which ones? Yes  No  (Select all that apply) Smartphone Tablet Computer 81. Have you considered a course on using these technologies? Which ones? Yes  No  (Select all that apply) Smartphone Tablet Computer 82. Do you have enough activity in your life to keep you occupied? Yes  No  a. If you answered “no” to Question 78, what are you missing? (Select all that apply)  Adult education  Exercise  Entertainment  Parties and social events  Other 83. Do you enjoy traveling either internationally or domestically? Yes  84.Would you like to travel more? Yes  No  No  a. If you answered “yes” to Question 80, what is preventing you? Mobility Finances Lack of information on available travel options Other 85. What concerns do you have regarding social and community connections? 86.Do you feel you are isolated? Yes  87. Do you feel depressed? Yes  No  No  21 NATIONAL AGING IN PLACE COUNCIL My Community & Social Interaction Needs: 22 NATIONAL AGING IN PLACE COUNCIL My Needs Summary Recap from end of each section above. My Housing Needs: My Health & Wellness Needs: My Personal Finance Needs: My Transportation Needs: My Community & Social Interaction Needs: 23 NATIONAL AGING IN PLACE COUNCIL My Priority List Your last steps: From the list of My Needs above, list your priorities in order. Things I can accomplish myself: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Things for which I need help and support: 1. 2. 3. 4. 5. 6. Now you have your own plan for Aging in Place. If you wish to receive additional assistance, please submit your plan to our national office with your contact information and location included: NAIPC 1400 16th Street NW Suite 420 Washington, DC 20036 Telephone: (202) 939-1770 Fax: (202) 465-4435 Email: NAIPC@ a g e i n p l a c e . o r g 24
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