Long-Term Care Planning Checklist

Comprehensive Long-Term Care Planning Checklist

Purpose

This checklist guides individuals and families through the essential elements of long-term care planning. Proactive planning helps ensure that care preferences are honored, finances are protected, and family members understand their roles in the event that long-term care becomes necessary.

CLIENT INFORMATION

Client Name: _______________________________________________

Spouse Name (if applicable): _______________________________________________

Date of Birth: _______________

Spouse Date of Birth: _______________

Planning Date: _______________

Planner/Attorney: _______________________________________________

SECTION 1: ASSESS CURRENT SITUATION

1.1 Health Assessment

Current Health Status:

☐ Review current medical conditions
☐ List all current medications
☐ Identify any chronic conditions requiring ongoing management
☐ Assess cognitive health
☐ Document functional abilities (ADLs and IADLs)

Conditions to Monitor:

Family Health History:

☐ Document family history of dementia/Alzheimer's
☐ Document family history of stroke
☐ Document family history of Parkinson's or other conditions affecting long-term care needs

1.2 Current Living Situation Assessment

Current Residence:
☐ Own home - single story
☐ Own home - multi-story
☐ Condo/Townhouse
☐ Apartment (rent)
☐ With family member
☐ Independent living community
☐ Other: _______________

Home Safety Evaluation:

☐ Stairs and step hazards assessed
☐ Bathroom safety (grab bars, non-slip surfaces)
☐ Lighting adequacy
☐ Emergency response system in place
☐ Accessibility for mobility aids
☐ Home maintenance manageable

Modifications Needed:

1.3 Support System Assessment

Family/Social Support:

☐ Identify primary caregiver candidate(s)
☐ Assess availability and willingness of family members
☐ Evaluate geographic proximity of family
☐ Consider family dynamics and potential conflicts
☐ Identify backup support persons

Support Network:

SECTION 2: LEGAL DOCUMENTS

2.1 Essential Legal Documents Checklist

Durable Power of Attorney (Financial):
☐ Document exists: ☐ Yes ☐ No
☐ Date executed: _______________
☐ Agent named: _______________________________________________
☐ Successor agent named: _______________________________________________
☐ Document is "durable" (remains effective upon incapacity)
☐ Document grants Medicaid planning powers
☐ Document grants gift-making powers
☐ Document reviewed by elder law attorney
☐ Copies provided to agents and financial institutions

Healthcare Power of Attorney/Healthcare Proxy:
☐ Document exists: ☐ Yes ☐ No
☐ Date executed: _______________
☐ Agent named: _______________________________________________
☐ Successor agent named: _______________________________________________
☐ HIPAA authorization included
☐ Agent knows client's wishes regarding life-sustaining treatment
☐ Copies provided to agents and healthcare providers

Living Will/Advance Directive:
☐ Document exists: ☐ Yes ☐ No
☐ Date executed: _______________
☐ End-of-life preferences documented
☐ Guidance on life-sustaining treatment
☐ Organ donation preferences
☐ Registered with state registry (if available)

POLST/MOLST Form (if appropriate):
☐ Completed: ☐ Yes ☐ No ☐ Not yet appropriate
☐ Signed by physician: ☐ Yes ☐ No
☐ Posted in visible location in home

Last Will and Testament:
☐ Document exists: ☐ Yes ☐ No
☐ Date executed: _______________
☐ Executor named: _______________________________________________
☐ Successor executor named: _______________________________________________
☐ Document coordinated with beneficiary designations
☐ Document reviewed after major life changes

Revocable Living Trust (if applicable):
☐ Trust exists: ☐ Yes ☐ No
☐ Date executed: _______________
☐ Trustee named: _______________________________________________
☐ Successor trustee named: _______________________________________________
☐ Trust properly funded
☐ Pour-over will in place

2.2 Additional Documents to Consider

☐ Medicaid Asset Protection Trust (MAPT)

• Appropriate if planning 5+ years ahead
• Assets protected from long-term care costs after lookback period
• Discussed with elder law attorney: ☐ Yes ☐ No

☐ Caregiver Agreement/Personal Care Agreement

• In place with family caregiver: ☐ Yes ☐ No ☐ N/A
• Services and compensation documented
• Medicaid-compliant

☐ Special Needs Trust

• If disabled family member: ☐ Yes ☐ No ☐ N/A

☐ HIPAA Authorization Forms

• Authorizing release of health information to family
• Distributed to healthcare providers

SECTION 3: FINANCIAL PLANNING

3.1 Income Analysis

Monthly Income Sources:

3.2 Asset Inventory

Countable Assets:

Non-Countable/Exempt Assets:

3.3 Long-Term Care Cost Projections

Current Costs in Your Area (Research and Update):

Self-Insurance Calculation:

If long-term care needed for 3 years at $____________/month:
Total Cost: $____________

Assets available for LTC: $____________
Gap (or excess): $____________

3.4 Long-Term Care Insurance Review

Existing Long-Term Care Insurance:

☐ Policy in force: ☐ Yes ☐ No ☐ Never purchased

If yes:
Company: _______________________________________________
Policy Number: _______________________________________________
Daily/Monthly Benefit: $_______________
Benefit Period: _______________
Elimination Period: _______________ days
Inflation Protection: ☐ Yes ☐ No Type: _______________
Home Care Coverage: ☐ Yes ☐ No
Assisted Living Coverage: ☐ Yes ☐ No
Annual Premium: $_______________

☐ Policy reviewed within past year
☐ Understand benefit triggers
☐ Know how to file a claim

Consider Purchasing LTC Insurance:

☐ Obtained quotes
☐ Compared policies
☐ Evaluated hybrid life/LTC policies
☐ Decision made: ☐ Purchase ☐ Not purchasing

SECTION 4: CARE PREFERENCES

4.1 Care Setting Preferences

Preferred Care Locations (Rank 1-5, 1 being most preferred):

___ Remain at home with in-home care
___ Move in with family member
___ Independent living with services
___ Assisted living facility
___ Nursing home

If specific facilities preferred, list here:

1. _______________________________________________
2. _______________________________________________
3. _______________________________________________

Factors Important in Selecting Care Setting:

☐ Close to family/friends
☐ Religious/cultural considerations
☐ Private room
☐ Specific amenities: _______________________________________________
☐ Quality ratings
☐ Cost considerations
☐ Accepts Medicaid (if needed in future)
☐ Other: _______________________________________________

4.2 Care Provider Preferences

☐ Preference for same-gender caregiver
☐ Language preferences: _______________________________________________
☐ Cultural/religious requirements: _______________________________________________
☐ Other preferences: _______________________________________________

4.3 Daily Life Preferences

Document preferences for:

☐ Daily routine (wake time, bedtime)
☐ Meal preferences and dietary restrictions
☐ Religious/spiritual practices
☐ Social activities
☐ Television, music, reading preferences
☐ Pet preferences
☐ Visitor preferences

SECTION 5: MEDICAID PLANNING

5.1 Pre-Planning Assessment

☐ Review current assets vs. Medicaid asset limits
☐ Calculate potential excess assets
☐ Understand 5-year (60-month) lookback period
☐ Review any prior transfers that may trigger penalties
☐ Consult with elder law attorney

5.2 Planning Strategies to Consider

Asset Protection Strategies:

☐ Medicaid Asset Protection Trust (if 5+ years before need)
☐ Spend-down on exempt assets (funeral, home, vehicle)
☐ Caregiver Agreement with family member
☐ Medicaid-compliant annuity (spousal cases)
☐ Promissory note strategies
☐ Spousal protections (CSRA, MMMNA)

5.3 Crisis Planning (If Care Needed Soon)

☐ Gather 60 months of financial records
☐ Identify any lookback period violations
☐ Calculate potential penalty period
☐ Develop spend-down plan
☐ Consider half-a-loaf strategy (if appropriate)
☐ Apply for Medicaid at appropriate time

5.4 Key Medicaid Dates

☐ Lookback period begins (60 months before application): _______________
☐ Earliest application date (if planning ahead): _______________
☐ Last date for pre-planning transfers: _______________

SECTION 6: VETERANS BENEFITS

6.1 Veteran Status

Is Client or Spouse a Veteran?

☐ Client is a veteran
☐ Spouse is a veteran
☐ Client is surviving spouse of veteran
☐ Neither

If Veteran:

Branch: _______________________________________________
Dates of Service: _______________________________________________
Discharge Status: ☐ Honorable ☐ Other: _______________
Wartime Service: ☐ Yes ☐ No
War Period(s): _______________________________________________

6.2 VA Benefits to Explore

☐ VA Aid and Attendance Pension

• Eligibility reviewed
• Application filed: ☐ Yes ☐ No ☐ N/A
• Status: _______________________________________________

☐ VA Health Care

• Enrolled: ☐ Yes ☐ No
• Priority Group: _______________

☐ Service-Connected Disability

• Rating: _______________%
• Receiving benefits: ☐ Yes ☐ No

☐ Dependency and Indemnity Compensation (Surviving Spouse)

• Eligible: ☐ Yes ☐ No ☐ N/A

SECTION 7: ACTION ITEMS

7.1 Immediate Actions (Next 30 Days)

7.2 Short-Term Actions (1-6 Months)

7.3 Long-Term Actions (6+ Months)

SECTION 8: PROFESSIONAL TEAM

8.1 Key Contacts

8.2 Family Contacts

SECTION 9: DOCUMENT LOCATION

9.1 Important Documents Location

9.2 Account Information Location

☐ Master list of accounts created
☐ Usernames/passwords secured
☐ Family member knows location of information

SECTION 10: REVIEW SCHEDULE

10.1 Annual Review Items

☐ Review and update legal documents as needed
☐ Review beneficiary designations
☐ Update asset inventory
☐ Review insurance coverage
☐ Assess health changes
☐ Reassess care preferences
☐ Update professional team contacts
☐ Hold family meeting (if appropriate)

10.2 Review Triggers

Review plan immediately if:
☐ Significant health change
☐ Loss of spouse
☐ Change in financial situation
☐ Change in family dynamics
☐ Move to new residence
☐ Change in applicable laws

10.3 Review Log

SECTION 11: FAMILY COMMUNICATION

11.1 Family Meeting Checklist

☐ Schedule family meeting to discuss care preferences
☐ Share location of important documents
☐ Discuss roles and responsibilities
☐ Address financial aspects of care
☐ Discuss contingency plans
☐ Document decisions and understandings

11.2 Difficult Conversations

Topics to address:
☐ End-of-life wishes
☐ Living situation if care needed
☐ Financial expectations
☐ Family member roles
☐ Potential conflicts and resolution

SIGNATURES

Client:

Signature: _________________________________

Date: _______________

Spouse (if applicable):

Signature: _________________________________

Date: _______________

Planner/Attorney:

Signature: _________________________________

Date: _______________

This checklist is provided for planning purposes and does not constitute legal, financial, or medical advice. Long-term care planning is complex and benefits from professional guidance. Consult with an elder law attorney, financial advisor, and healthcare professionals as appropriate.