Second Half Conversations

Ziegler Estate Law Group

In this episode of Second Half Conversations, we explore one of the most difficult and emotional questions many families face:

How do you know when a loved one needs a different level of care?

Sondra Ziegler is joined by Michelle Pauda, Care Navigator at Ziegler Estate Law Group, to talk through the realities of long-term care planning and the decisions families are often forced to make while already feeling exhausted and overwhelmed.

Together, they discuss the different levels of care—from in-home caregiver support to assisted living, skilled nursing, rehab stays, and hospice—and how families can better understand when each level may become appropriate.

The conversation also breaks down common misunderstandings around home health, assisted living, Medicare rehab coverage, and hospice care, while offering practical insight into what families should watch for as care needs begin to change.

Most importantly, this episode is about planning before a crisis happens.

It’s a thoughtful conversation about caregiving, responsibility, family dynamics, and why having both legal guidance and care support in place can make an incredibly difficult season feel more manageable.

Highlights from this episode:
  • The different levels of care and what they actually provide
  • Signs that in-home care may no longer be enough
  • What families should know about assisted living and skilled nursing care
  • The difference between companion care, home health, rehab, and hospice
  • Why families often wait too long to ask for help
  • The emotional toll caregiving can place on loved ones
  • Why planning early can help avoid rushed decisions during a crisis

🎧 Listen now on Spotify, Apple Podcasts, YouTube.

Creators and Guests

Host
Sondra Ziegler
Executive Director of Ziegler Estate Law Firm

What is Second Half Conversations?

The second half of life can be full of meaningful moments—more time with family, new opportunities, and the freedom to focus on what matters most. At the same time, it often brings important questions about planning, caregiving, relationships, and the future.

So that’s exactly what we talk about.

We'll tackle difficult topics like estate planning and care navigation, strategic aspects of taxes and business succession planning, and the dynamics of relationships and seasons that come with the second half of life.

Because if done right, the second half can be the better half.

Sondra Ziegler:

Welcome to Second Half Conversations. I'm your host, Sondra Ziegler. This is a space to discuss all kinds of topics about the second half of life, from complicated legal topics like wealth protection and business succession planning that we break down in a practical way, to long term care planning and care navigation when you have a loved one on a care journey, to leaning into fully experiencing new seasons of life, of work and relationships. Our team and guests are here to equip you to take full advantage of where you're at. Because if done right, the second half is the better half. Let's get to it.

Sondra Ziegler:

Thank you for joining us again for Second Half Conversations. We are joined today by Michelle Pauda, who is our firm's care navigator. And in our office, a care navigator, is someone who comes alongside our families, when we're doing long term care planning to help them make all the myriad decisions that need to be made when a loved one has a care journey. So often it's the case by the time people are sitting around our conference room table, the caregivers, the decision makers are beyond exhausted a lot of times, and being able to help ease the burden of making the decisions about care is such a blessing.

Sondra Ziegler:

You know, when people think about an estate planner or an elder law firm, they understand we do legal planning. They understand that we're going to help you make sure that your loved one has the right legal documents for a care journey, because they often need to be updated for that reality. We're going to make sure that we're helping apply for benefits if benefits are needed to help pay for care, either Medicaid or Veterans Benefits. We're going to make sure that those two things are coordinated, the estate planning and the benefits planning, that all of that is done in a coordinated way so that there aren't surprises in the future so that, you know, the estate planning doesn't, in the future, the results of that end up disqualifying the person who's already qualified for care once we get them eligible. So, we're going to do all of those things.

Sondra Ziegler:

But what you may not know is that because we have a care navigator on our staff, we can also help with those care decisions. That's a huge and important piece of long term care planning. So, Michelle Pauda is our care navigator. And welcome, Michelle, and thank you for joining us today.

Michelle Pauda:

Hello. Thank you for having me.

Sondra Ziegler:

So this is a topic when I reached out to Michelle and said, what would be good for our listeners to understand about long term care planning? One of the topics that she wanted to talk about was choosing the right level of care. How do you choose the right level of care? That's what we're here to discuss today. So, just to set the stage for people who may not be familiar with really any of this, what is that care continuum? What are the levels of care starting with the least and going to the most? And then let's just dig into each one of them.

Michelle Pauda:

Well, the first one is caregiver assistance at home or companion care sometimes it's called. And then you can have assisted living and or memory cares, memory care assisted living. Then there's the skilled nursing level, which is a nursing home type level. And then of course, hospice care.

Sondra Ziegler:

Okay. So, Michelle has experience in the continuum of long term care all the way from home care to assisted living, nursing home care, and even in hospital discharge planning, which is why she's been so valuable to our firm and to our clients. She understands those transitions and what types of care is appropriate or is provided at each of those levels and what care need is appropriate in each of those settings. So when we think about assessing your loved ones, what are you looking for as a social worker? What are the key factors that you're evaluating when you're looking at one of our clients need for care when you go and do that assessment?

Michelle Pauda:

First and foremost, how much care do they need as far as do they need twenty four hour care? Do they need someone there all the time supervision? Because if they don't need the twenty four hour care, that's when maybe the caregivers at home, you know, part time during the day could be a good solution. If they need someone there twenty four hours, then that's when you start looking at assisted living or skilled nursing. And then you would, how much care do they need as far as do they need some heavy medical care?

Michelle Pauda:

Like, are they diabetic or are they twenty four hour, you know, oxygen, wound care, special diets, things like that. That usually is more higher level of care nursing home. If they just need someone to be there with, help them with their meds, make their meals, supervise them, help with incontinent care, then assisted living could be a good choice.

Sondra Ziegler:

Let's talk about ADLs for just a minute. That's jargon in the industry, but it means activities of daily living. What are those main activities of daily living that we hear about? Because I know that's important from an evaluation standpoint, it's also important from a standpoint of what's going to trigger long term care insurance to pay out if they have long term care insurance. I know, correct me if I'm wrong, but it's usually like they need help with two activities of daily living, that that can be a trigger for the long term of course, read your policy. Read your policy, I think that most of them are written. But yeah, just give us kind of the understanding of what those are.

Michelle Pauda:

So most of the time, as you were saying with long term care Medicaid, they require that you need assistance with two or more of the ADLs or activities of daily living, which are dressing, grooming, bathing, feeding, transferring, money management. Those are the biggest ones.

Sondra Ziegler:

Okay, and so in thinking about those, if let's say, what are some of the ADL deficits or the need for help with activities of daily living that could be addressed by in home care and, you know, on a part time basis, but which ones, once they rise to a certain level, what is that level where they would need to move to an assisted living facility or a nursing facility?

Michelle Pauda:

Well, most of the time the caregivers at home can help with the bathing, the dressing, the grooming, but when they are unable to transfer with assistance, what they call a one person assist, when the caregiver can no longer transfer them from the bed to the wheelchair or from the wheelchair to the toilet because they physically cannot do it, then that's the time a lot of times when it's time to look at a different level of care or when they're having frequent falls and, they're having to call the ambulance to help them get up off the floor. That's a sign too that you can no longer safely keep them in the home when they're falling and you're not physically able to help them up.

Sondra Ziegler:

I know we've mentioned this before, but the toll on the caregiver can be great. It really can be a lot, not only physically, but also emotionally. And we'll talk about that a little bit more in a second. But let's talk about in home caregiving and when it works best. So who is a great fit for home care and what are the different types of in home help that you can hire in?

Michelle Pauda:

Probably ideally the person that needs, could benefit from the in home care, somebody again that doesn't need twenty four hour supervision, someone that just needs someone to come in and help, maybe help them get dressed, help them with their grooming, make a small light breakfast, slight housekeeping, and then maybe take them out to run errands, take them to the doctor's office. And most of the time they're mobile or on a walker, usually not wheelchair level. You can have that, but it's not, usually it's walker or independent with mobility. And then of course you can get home health involved, but they are, you know, thirty to sixty days. It's not a long term solution. And they can do some in home therapy and teaching and training for medication management. But the caregivers can't administer the meds, they can just remind them to take them.

Sondra Ziegler:

Okay. Let's dig into that distinction a little bit. So when you talk about, so I know a lot of us, when we think of home health, we think every kind of care that comes into the home is home health, but that's not really true, right?

Michelle Pauda:

No.

Sondra Ziegler:

So, you distinguished between companion care, which is technically nonmedical. Is that correct?

Michelle Pauda:

That's correct. Mhmm.

Sondra Ziegler:

Okay. So they would be doing things like helping with those activities of daily living as far as transferring, helping you transfer from a chair to the bed or from the bed to the bathroom, helping prepare the meal, doing the things that you just described. They would not be, like you say, they could remind you to take medication, but they can't administer it because they're not licensed providers, right? They're not nurses themselves.

Michelle Pauda:

Correct.

Sondra Ziegler:

Okay.

Michelle Pauda:

Right. They're not, yeah.

Sondra Ziegler:

So when we talk about home health that is licensed nursing care, is the majority of the time that that sort of care is coming into the home, is that prescribed by a doctor, Medicare paid care? And is that why there's the limit to the amount of, to the, timeframe, to the amount and the number of days that that can happen? Is that why there's a limit on it?

Michelle Pauda:

Correct.

Sondra Ziegler:

Okay.

Michelle Pauda:

Correct. Yes. It's Medicare. And then of course you have to still meet eligibility. So at thirty days they'll say, does this individual still require this type of care? It's usually therapy and nursing care. And if so, then they'll restart it for another thirty days, but it just usually doesn't extend beyond that.

Sondra Ziegler:

So is that prescription, I'm going to use that word loosely, is that doctor's order to allow that or for Medicare to pay for that home health care for that limited period of time, does that usually come after a certain health event, you know, something has happened and so we're helping that person transition, you know, because they've had some sort of health event that they now need this care for a defined period of time, but it's not designed for just on and on and on long term health.

Michelle Pauda:

Correct. It's usually prescribed after say you had a surgery or you've been in the hospital or you're discharging from skilled nursing rehab, or you've been to the doctor for a visit and he or she noticed that you've had a decline. Physically, they can order some therapy for you at home. Yes, it's not designed for long term, it's just to, like you said, to extend, to kind of get you transitioned at home.

Sondra Ziegler:

Okay. Yes. To kind of get over a hurdle understand your new limitations or help you figure out how you're going to do this going forward or what you need to do now.

Michelle Pauda:

Yeah. And in your home, the occupational and physical therapists, yeah, assess you at home kind of teach and train what would be best for you to be successful at home.

Sondra Ziegler:

Right. Okay. So, yeah, so when we're talking about ongoing long term help to be able to stay in your own home, that really is that companion care that is non medical, that's going to be ongoing, you know, if it will allow you to stay at home. So, let's talk about assisted living for a moment. So, what is assisted living?

Sondra Ziegler:

And what isn't it? What types of services do they provide in assisted living? What can they not provide? And what do families, I guess I'm going to ask you, what do families often assume is included but isn't?

Michelle Pauda:

Assisted living is, of course they offer the twenty four hour support. There's somebody there with you twenty four hours a day. They don't have the amount of staff that a skilled nursing has. So they can help with the activities of daily living. They can help with meals, housekeeping, there's activities.

Michelle Pauda:

But if you need a higher level of care, as far as, like I was saying earlier, you need, someone monitor your diabetes, every two hours, transfer or what they call a Hoyer lift, then that's not something that they can do in assisted living. And one, they're not licensed for that type of care. But, two, sometimes they just don't have the staff to do that. If you have, special diets sometimes like a diabetic diet or you have puree diets, some, those are managed in long term care, skilled nursing, not assisted living, usually.

Sondra Ziegler:

If I am looking at assisted living for my loved one, what are some of the best questions that I should be asking about that facility when we tour?

Michelle Pauda:

I think that the best questions are, again, about the staffing. How many people are here during the day? How many people are here at night? Because I've seen some assisted livings where there's just one person at night. And for some people that may be concerning or that would be difficult, for one staff person.

Michelle Pauda:

And, of course that also depends on the census or how many people are living in that community. Do they have activities? Do they have transportation? Because that's another big thing of transportation to doctor's appointments or other things they may need or want to go to. Those are important for their quality of life.

Sondra Ziegler:

And what are the biggest signs that someone is beyond assisted living in terms of their needs?

Michelle Pauda:

I think the biggest signs are if they, if they are more hospice level appropriate, they're maybe towards the end of life or not getting out of bed or, you know, bed bound. Again, you know, needing a lot of help with transfers, needing regular medical care, a doctor, to come see them regularly, a nurse to check their vitals, to check on their oxygen levels, a nurse to, you know, their wound care. They need therapy to be able to assist them, those kinds of things.

Sondra Ziegler:

So that takes us right into my next questions, which are about skilled nursing when it's appropriate. So, you mentioned wound care, oxygen. What are some other common reasons that somebody truly needs skilled nursing? You mentioned mobility, like if they're a two person lift or they need a Hoyer lift, what are some other ones we might be missing?

Michelle Pauda:

If they have trachs or feeding tubes, those are of course skilled nursing level. If they need IV antibiotics regularly, there's some, you know, a lot of patients that sometimes have to have those pretty regularly for different medical conditions. If again, special diets, puree diets, because they're no longer able to swallow a lot. That happens a lot with advanced dementia patients. Their body no longer tells them to use that muscle. And so they need puree diets or IV feedings, those types of things.

Sondra Ziegler:

How do rehab stays fit into this picture? Because, you know, if you fall and break your hip, a lot of times you'll be in a long term care facility for a rehab stay. And so what should families know about the difference between short term rehab and a long term nursing care stay?

Michelle Pauda:

Well, short term rehab will usually be ordered after you've been in the hospital for the three midnights and you have a diagnosis that requires you to go to rehab for therapy, but also medical management. Depending on what kind of insurance or Medicare supplement you have, it will often depend on how long you get to stay in that facility. Advantage, Medicare Advantage plans typically don't give you as much time as if you had traditional Medicare with a supplement. But, you know, we've all heard you have the up to a hundred days in the facility. The first twenty days are usually covered at a 100%. The average length of stay, I know it changes, but is originally around thirty days, unless you've had something significant like a stroke and sometimes you'll get more time.

Sondra Ziegler:

Wow. So, 20 days

Michelle Pauda:

Yeah, unfortunately.

Sondra Ziegler:

Or thirty days. Yeah, that's a lot less than you would think.

Michelle Pauda:

A hundred. A lot of people believe that the hundred days is guaranteed and you have to qualify for those days based on your progress on your diagnosis and your, unfortunately your insurance.

Sondra Ziegler:

So, what is the best way? Well, before I get to that, I wanted to ask you about hospice care. So, tell us a little bit about what hospice care is, when it's typically used, and where you can receive hospice care.

Michelle Pauda:

Well, I'll start by saying people have misconceptions about what hospice is. And when you bring that up, oftentimes family members feel like it's a death sentence type situation. And hospice is now a much more, supportive. They're there to support for pain management. They have volunteers, they have respite care, and it's just more eyes and ears for someone who is needing more care.

Michelle Pauda:

And so additional, so say they're in the nursing home and they'll have another nurse come check on them, another nurse's aid come and help with baths and checking on them, volunteers to come and spend time with them. It's just a very supportive and pain management is real important too, but it's just a very supportive program that Medicare covers based on, of course, if you have the appropriate diagnosis. But it's always good to have your loved one evaluated if you feel like hospice could be helpful.

Sondra Ziegler:

So is that care that they could receive at home, in assisted living, in a nursing home, like basically regardless of where they reside?

Michelle Pauda:

Yes.

Sondra Ziegler:

Okay.

Michelle Pauda:

And there aren't, there are certain facilities that don't allow it in their home, in their facility. And so it's always, of course, something you might want to ask if you're interested in getting hospice involved at some point. Do you allow hospice to come in and spend time or care for patients-

Sondra Ziegler:

That would be an important question.

Michelle Pauda:

iIn your facility. I haven't found too many that don't, but there are some that do not allow hospice in their facility.

Sondra Ziegler:

How do you recommend that families plan for, if they know, obviously if you don't know that a need for care is coming, and it just happens suddenly, that's different. Know, if your loved one has a stroke, that's a different situation than a loved one who's diagnosed with dementia, perhaps, or some other chronic debilitating illness where they know they have a care journey ahead of them, where it's likely that the need for progressively more care is coming, just so they aren't forced into a rush decision. I mean, how do you recommend that families think about that progression and, you know, where do they start?

Michelle Pauda:

I would suggest first and foremost to get, like we were saying, or we were talking about in another podcast that they need to get their legal documents in order first, while the loved one can still sign. And if you know that this care journey is coming because oftentimes the journey is long and can be expensive. And so those are things that need to be in place first. And then I would say secondly, to make sure that they receive the proper diagnosis from a physician or neurologist. That's important.

Michelle Pauda:

So that way they can get on the correct medications, to help, so they can be successful in as long as possible in the environment that they're in. If their medications are regulated and they're on what's most beneficial for them, then they can thrive in that environment longer, I've seen if their care

Sondra Ziegler:

That's an important note there about the correct medication. So, what I've learned is that dementia, you know, a lot of people think we're just talking about Alzheimer's, you know, whereas dementia is a big umbrella of different conditions and getting that diagnosis from a neurologist when it's dementia, what type of dementia is so important to getting the right medication. And I'm sure that's true in other conditions as well. What can you tell us about some common mistakes you see in choosing care? What are some common mistakes that families make or are some common misunderstandings that families have in choosing care?

Michelle Pauda:

I think that oftentimes I've seen where I feel like the patient probably needs long term care, nursing home type care. And people feel like the nursing home is, nursing homes are really bad places or places where people go to die. And so they end up trying to manage manage their care in an assisted living type setting. Oftentimes that's just not, it's not always the best place for them to be simply because they're not getting the level of care that they need. Because they feel like the nursing home has a stigma, you know, of being a really bad place. Or you told me you would never put me in a nursing home kind of situation.

Sondra Ziegler:

Oh, absolutely. Yeah. What can you, on that point, in fact, what would you tell the caregivers who might be listening to this about why it is not a bad thing to be seeking, help with the caregiving and advice on next steps and where their loved one is and what kind of care they might be needing next on why that's a good conversation to be having sooner rather than later?

Michelle Pauda:

Well, in my experience, especially working in discharge planning for so long, people put off that conversation just because it's a really hard conversation to have and to visit about, or it's overwhelming to them. So they just don't push it or do it until they're in a crisis situation. Someone fell and loved one fell, broke a hip, or had, you know, stroke or isn't in the hospital. And then they have to make that decision at that point. Require, you know, they don't have a choice and it can be very overwhelming for them and they didn't make plans.

Michelle Pauda:

And so it can be really stressful on everyone and the discharge planner can help as much as they can. But if the appropriate things weren't put in place, like again, like directives, medical power of attorneys, financial power of attorneys, those kinds of things, it can all just kind of come at once. And it can be very overwhelming when you're forced to make those decisions. And a lot of times with Medicare, when you're in the, they don't give you a whole lot of time, maybe a couple of days, they'll say, okay, you're gonna be discharged in forty eight hours. The families are under a lot of stress to try to figure that out in a couple of days.

Michelle Pauda:

And again, the discharge planner can help, but a lot of times he or she has other patients too. And so it can be really hard on the families trying to make plans in a hurry. And the financial piece too, you know, Medicare will pay for some of that, but what are we going to do after that?

Sondra Ziegler:

Right. Yes, in fact. So, just to wrap up, if you're listening to this and you have a loved one who needs care, whether that's because of a sudden illness or health event, such as a stroke or a car accident, or if you have a loved one who has been diagnosed with dementia or some other chronic debilitating illness, and you need to find out what your next step should be, call our office here in Lubbock or go online to zieglerestatelaw.com. You can fill out a form to request a consultation on there. We'll gather some information, and it'll be a free consultation.

Sondra Ziegler:

That will be an opportunity for you to meet with our attorney, with Michelle Pauda, and give us a chance to understand your situation, your family dynamics, your loved ones, assets that they have to protect from the cost of care, what legal documents they already have in place, what they may need to redo since that's usually appropriate when there's a long term care journey ahead that we need new powers of attorney. We may need a new will, we may need a new trust. Whatever the needs are for the legal documents, we're going to make sure that those coordinate with an application for benefits if that's needed, so that it all works together as a plan and coordinated very importantly with help making care decisions from Michelle. So, take the first step, as I think what we're saying is if you have a loved one who needs care, start today so that if there are new documents that need to be signed, your loved one still has capacity to do that. And we'd be happy to put that plan in place and help walk it out with you.

Sondra Ziegler:

Thank you, Michelle Pauda, for joining us today on Second Half Conversations and for all of the great information and all of the things you do for our clients and their families every day. And just a quick reminder to our listeners, today's podcast information is for educational purposes only. This is not legal advice as we would have to meet with you and know all about your specific situation to give you legal advice. Thanks again for joining us.