Life Care Planning at Hook Law Center: Where Sensitivity Meets Solution

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Close to 40 million Americans are aged 65 and older, and about 30% of seniors live alone¹. At the turn of the 20th century, Americans lived to the modest age of 47; today’s average life expectancy exceeds 83 years. While increased life span can mean more time to enjoy the “Golden Years,” it also means more resources are needed to last a lifetime. As we age, the questions and options we face grow more complex and confusing. Managing medical issues, finances, where we will live and how to maintain quality-of-life requires thoughtful planning.

Sometimes, in addition to routine concerns related to the aging process, families face unexpected illness or disease. Those serving as primary caregiver to a disabled loved one may find themselves growing concerned about their continued ability to care for the loved one with age. Across a continuum of circumstances, Life Care Planning is a tool to help individuals and their families face the journey with confidence.


Life Care Planning takes an anticipatory approach to the health, safety, and quality-of-life of individuals and their families to ensure they find the right options, support and services to secure peace of mind. By educating, defining, organizing, prioritizing and mobilizing every aspect of care – including asset preservation, estate planning, public benefits qualification, advocacy, legal representation and care coordination – Life Care Planning offers the support and direction to identify needs and create a detailed roadmap for the future.

Ideally, having a Life Care Plan in place can help seniors address the challenges of aging as they arise. Sometimes, however, an unexpected event – such as incapacity, illness, housing or mobility concerns – results in diminished physical or cognitive capacity. This can create a sense of loss of control for the family, and a strong desire to return life to “normal.” Times like these require immediate action, and restoring a sense of “normalcy” may require a thoughtful combination of action and planning, as well as resources.


Life Care Plans are Designed to Achieve Three Objectives:

  • Ensure that individuals have the information, tools and confidence they need to make informed decisions about their care, including care plans that recognize preferences and maximize autonomy
  • Ensure appropriate care at-home or in a residential facility that will maintain quality-of-life, and identify public and private sources to pay for long-term care while addressing cost-related issues
  • Provide peace of mind that the right choices are made while preserving family resources

“The Perfect Marriage:” Social Work Services and Elder Law

Having a thorough understanding of the issues and concerns facing the individual and his or her caregivers is key to the development of a customized action plan for coordination of care. The Comprehensive Assessment is a classic social work tool used to identify the strengths and needs of the individual and family. Once this has been determined, social work services assist in educating families about all aspects of the continuum of care to help individuals make informed decisions.

Often times, achieving a complete cure is unrealistic, since many conditions affecting elderly and persons with special needs are chronic in nature. In these situations, while major improvements in functional abilities may not be possible, even small changes may significantly improve the individual’s quality of life. For example, regaining the ability to move from the bed to the chair or the chair to the toilet may mean the difference between returning home from a hospital or skilled nursing home, or being institutionalized.

At Hook Law Center, a key component of Life Care Planning includes access to a Life Care Planning Specialist, a licensed professional social worker with training and expertise in serving the unique needs of seniors, disabled and/or seriously ill individuals and their families. Understanding the client’s wishes, the Life Care Planning Specialist works with the Hook Law Center team of Elder Care Attorneys, Public Benefits Specialists and Care Coordinators to develop a plan that maximizes autonomy and honors the client’s wishes to the extent possible.


Working with the individual’s social system, including family, friends, caregivers, and community service providers, the Life Care Planning Specialist provides assessment, care planning, service coordination and referral and monitoring services to ensure the safety, well-being and quality-of-life for loved ones.

Key Activities of the Life Care Planning Specialist:

  • Comprehensive Assessment to Identify Strengths and Needs
  • Develop Plan for Care and Monitor Quality of Care
  • Assist with Location of Care Providers and Provide Referrals
  • Education/Advocacy/Support
  • Assist with Discharge Planning and Conflict Resolution
  • Personal Care Advocacy and Crisis Intervention
  • Ongoing Assessment and Follow-Up


Hook Law Center Offers the Following Social Work Services:

Complete Life Care Plan

The first step toward developing a care plan is the completion of a Comprehensive Professional Assessment. The Assessment is tailored to the individual needs and circumstances of the client, which may include a specific focus on geriatric issues and concerns, psychiatric issues and concerns, or disability-related issues and concerns. Various professional tools are used along with an interview to develop a complete picture of the individual, and his or her social and environmental systems. All Comprehensive Assessments include both psychosocial and functional assessments, including clarification of health issues, functional limitations and goals. Once completed, a professionally developed plan of care is presented to the client, which includes a detailed evaluation, as well as specific care recommendations and referrals.

Service Includes:

  • Comprehensive Professional Interview and Assessment (Approximately 2 hours)
  • Research to determine the best care options, including home health and residential facilities and specialists
  • Presentation of care recommendations
  • Professionally written plan of care

Home and Personal Safety Evaluation

An estimated 30% of seniors live alone; balance and gait disorders affect up to 15% of seniors, who suffer an increased risk of falls. Safety in the home is an important factor in determining if the living environment can support an individual’s needs. Performance of basic Activities of Daily Living (ADLs) depend on one’s ability to maneuver safely and effectively in the living environment. A direct assessment can identify problems with balance; maneuverability (one’s ability to move safely throughout the environment), and safety hazards in the home. Clutter and hoarding issues are commonly associated with Alzheimer’s Disease and other forms of dementia, and can impose barriers to mobility that lead to confinement, falls, and social isolation. A comprehensive Home and Personal Safety Assessment can determine level of independence and provide concrete solutions designed to maximize safety and independence in the home, or provide recommendations for increased levels of care as needed.

Service Includes:

  • Comprehensive Professional Home and Personal Safety Evaluation (Approximately 2 hours)
  • Written Assessment (Includes modifications, interventions and referrals)

Ongoing Care Coordination

Ongoing Care Coordination can provide peace of mind for busy families members who may find it difficult to navigate the many individual service providers involved in a loved one’s care plan. The Life Care Planning Specialist serves as a central point-of-contact for implementation and coordination of a loved one’s care plan, and can offer urgent care support in times of crisis.

Service Includes:

  • Coordination of recommended care plans. (Includes: screening, arranging and monitoring of home care, coordinating relocation and transition plans for respite/long-term care)
  • Routine or urgent visits as needed

Insurance and Benefits Services

Approximately 70% of Americans over age 65 will require some type of long-term care services during their lifetime; more than 40% will require nursing home care². In Virginia, the average cost to someone in need of assisted living is $45,0000 per year; nursing home care averages $200 per day; and home health care services average $17 per hour². Understanding long-term care services and the possible need for services, as well as the benefits and costs of long-term care insurance, can enable peace of mind, knowing that independence and functioning will be maximized in the event of a sudden illness, chronic condition or accident. Under the guidance of Hook Law Center’s team of experienced Elder Law Attorneys and with the assistance of the Public Benefits Specialists, the Life Care Planning Specialist can review and provide recommendations for coverage and changes to coverage. For those with existing policies who may be facing the need to initiate a claim for benefit, the Life Care Planning Specialist can initiate and manage the claims process.

Service Includes:

  • Evaluation of health and long-term care insurance coverage, as well as other public and private benefits
  • Recommendations for changes to coverage and advocacy with claims
  • Management of initiation of claim, including coordination of required application components, communication with insurance policy carrier and service providers Management of ongoing claims and appeals

Medical Advocacy

Service Includes:

  • Personal care advocacy, crisis intervention and where necessary, nursing home advocacy and discharge planning
  • Accompanying a client and/or family to a medical appointment, or a meeting at the hospital when the client is inpatient, to provide support, guidance and advocacy.

Ongoing Coaching and Guidance

Service Includes:

  • Ongoing telephone and email access (frequency as determined in advance) to get quick answers, guidance and coaching related to all care issues, behavior management strategies, and general caregiver support.

Facilitated Family Meeting

Service Includes:

  • Presentation and collaborative session to discuss a new life care plan, or modifications to an existing plan, focusing on helping a family or group of caregivers better understand and reach a consensus about care options.


This guide is provided as a courtesy to help you recognize potential estate planning issues. It is not intended as a substitute for legal advice. It is distributed with the understanding that if you need legal advice, you will seek the services of a competent elder law attorney. While every precaution has been taken to make this explanation accurate, we assume no responsibility for errors or omissions, or for damages resulting from the use of the information in this explanation.