Senior Transitions

Everyone has the same concern: What if no-one wants my things?

Every client we work with shares a similar concern – What if nobody wants my things?

The family heirlooms elders have kept safe, polished, and close to their hearts are often not desired by children, grandchildren, or friends, much to the dismay of the elder. A recent article published by The Family Curator (www.thefamilycurator.com) shared a list of the cherished possessions most often asked about:

  1. Photos and Photo Albums
  2. Yearbooks, Wedding Books Scrapbooks
  3. Journals, Diaries, and Letters
  4. Military or Career Memorabilia
  5. Unique and Vintage Treasures

Absent – dining rooms sets, fine china, furniture. The timing of the gift is also suggested – as presents or gifts during the giver’s lifetime.

Matching a gift and heirloom is key.  We recommend investing the time in matching interests with items, selecting the most appropriate platform for the item, and choosing what is a treasure and what is an object.

  • Scan or digitize family pictures, 16-mm films, or videotapes. It is difficult to share pictures. Often, old films or pictures decay. Digitizing your media offers longevity, opportunity to share, and experiences you can share and comment on in real time.
  • Children and grandchildren find old yearbooks as special occasion coffee books, display items, or special items to bring out at family events.
  • Elders and Baby Boomers complain millennial have lost the ability to write a note. Handwritten notes, cards, speeches, academic, business or hobby/interest items creates a living legacy and places thoughts into words for future generations.
  • Medals, service ribbons, uniforms and other pieces that speak to our ancestor’s military service are often welcome heirlooms. Burial flags tell a story and can be displayed.
  • A pin, bracelet, or collectable becomes a treasure because of the story that it tells. Sharing the story of the item – in writing, on video, or face-to-face, makes something small a true treasure.

The dining chest or flat wear purchased and treasured for a lifetime holds special memories for the owner. It brings back a moment in time that is cherished or an investment that became a milestone in a lifetime. We regularly remind our clients (and their families), that what is typically the most meaningful is a story to be shared for generations.

Are You An Elder Hacker?

Are you a hacker? In this case, hacker doesn’t refer to computer programmers. Elder hacking is a phrase coined by Glen Hougan who teaches industrial design. He views an elder hacker as a creative and resourceful repurposer. An elder hacker is able to use common and typically low cost items from office supply or hardware stores to solve everyday problems. A pants hanger holding a cookbook open at eye level or placing a lazy susan in the refrigerator to enable easy reach of everything on the shelf are elder hacker solutions.

Shopping for items that make aging in place simpler are often expensive or employ high-end technology. A fixed income will limit what is purchased. Discomfort with technology may limit an elder adopting a solution. My grandparents lived during the Great Depression. To them, the idea of being resourceful was instilled during childhood and part of their day-to-day lives.

A recent Pew research study found many elders lack digital literacy and comfort with high-end technology. They often see off the shelf solutions as difficult to use, not trustworthy, or they simply don’t address their specific issue. For example, a visit to the Apple App Store finds a number of apps that manage medications. When given to an elder, it may be too difficult to continually enter medications and set up the reminder calendar. A paper option (i.e. calendar on the refrigerator or in the cabinet) is an easier, less expensive, and user-friendly solution.

We all grew up hearing all about generation gaps. The gap between an elder and millennial may feel insurmountable. Elder hacking is an opportunity for the generations to collaborate, be resourceful, and look for solutions to make living longer easier, fun, and a consistent leaning experience.

 

Advocacy: Lose The Throw Rug!

Cold weather, icy walkways, slippery parking lots – stimuli for elder fears of falling and breaking or fracturing a hip increases substantially during the winter months. A recent medical study finds the potential of falling indoors by tripping over an obstacle – power cord, throw rugs, clutter, is far greater than falling in the driveway.

Fear the throw rug!

Author of the study, Dr. Jason Guerico, says, “Given the results of this study, it appears that efforts to decrease fall risk among the elderly living in cold climates should not be preferentially aimed at preventing outdoor fractures in winter…Preventive efforts should focus on conditions present year-round, and especially on indoor risk.” The research was conducted by the North American Partners in Anesthesiology at the Hospital of Central Connecticut in New Britain, Conn.

Analysis of 544 patients with hip fractures concluded greater than 55 percent of the hip fractures occurred during warm months, with the highest rates in May, September and October (around 10 percent each). More than three-quarters of the hip fractures occurred indoors. 60 percent of outdoor fractures occurred from May through October, not in the depths of winter.

The most common cause of both indoor and outdoor hip fracture is tripping over an obstacle. Indoors, throw rugs were the most common obstacle cited; and, falling out of bed was #2.

 

Safety Is Key When Working With Elders

Financial and emotional abuse are the most common forms of elder abuse facing this population today.  In a 2011 report of New York State elder abuse, only 1 in 24 cases of elder abuse were reported to authorities. When working with elders, caregivers, or families during a transition — aging in place, right-sizing, downsizing, or moving & transitioning, our T3 team members often are frontline in identifying cases of elder abuse.  For some elders, a visit to the emergency room is frontline primarily because it may be the only time they leave their home.

The following story recently was published by Kaiser Health News* about an innovative program for protecting elders through intervention in there ER.  We are very proud to say that our team members are trained to identify elder abuse when present.

Abuse often leads to depression and medical problems in older patients — even death within a year of an abusive incident.

Yet, those subjected to emotional, physical or financial abuse too often remain silent. Identifying victims and intervening poses challenges for doctors and nurses.

Because visits to the emergency room may be the only time an older adult leaves the house, staff in the ER can be a first line of defense, said Tony Rosen, founder and lead investigator of the Vulnerable Elder Protection Team (VEPT), a program launched in April at the New York-Presbyterian Hospital/Weill Cornell Medical Center ER.

The most common kinds of elder abuse are emotional and financial, Rosen said, and usually when one form of abuse exists, so do others. According to a New York study, as few as 1 in 24 cases of abuse against residents age 60 and older were reported to authorities.

The VEPT program — initially funded by a small grant from The John A. Hartford Foundation (a Kaiser Health News funder) and now fully funded by the Fan Fox and Leslie R. Samuels Foundation — includes Presbyterian Hospital emergency physicians Tony Rosen, Mary Mulcare and Michael Stern. These three doctors and two social workers take turns being on call to respond to signs of elder abuse. Also available when needed are psychiatrists, legal and ethical advisers, radiologists, geriatricians and security and patient-services personnel.

“We work at making awareness of elder abuse part of the culture in our emergency room by training the entire staff in how to recognize it,” said Rosen. It’s easy for the ER staff to alert the VEPT team and begin an investigation, he said.

A doctor interviews the patient and conducts a head-to-toe physical exam looking for bruises, lacerations, abrasions, areas of pain and tenderness. Additional testing is ordered if the doctor suspects abuse.

“Unlike with child abuse victims, where there is a standard protocol in place for screening, there is no equivalent for the elderly, but we have designed and are evaluating one,” said Rosen.

The team looks for specific injuries. For example, radiographic images show old and new fractures, which suggest a pattern of multiple traumatic events. Specific types of fractures may indicate abuse, such as midshaft fractures in the ulna, a forearm bone that can break when an older adult holds his arm in front of his face to protect himself.

When signs of abuse are found but the elder is not interested in cooperating with finding a safe place or getting help, a psychiatrist is asked to determine if that elder has decision-making capacity. The team offers resources but can do little more if the patient isn’t interested. They would have to allow the patient to return to the potentially unsafe situation.

Patients who are in immediate danger and want help or are found not to have capacity may be admitted to the hospital and placed in the care of a geriatrician until a solution can be found. Unlike with children and Child Protective Services, Adult Protective Services won’t become involved until a patient has been discharged, so hospitalization can play an important role in keeping older adults safe.

During the first three months of the program, more than 35 elders showed signs of abuse, and a large percentage of them were later confirmed to be victims. Changes in housing or living situations were made for several of them.

“It’s difficult to identify and measure appropriate outcomes for elder abuse victims, because each patient may have different care goals,” said Rosen, “but we are working on making a case that detection of elder abuse and intervention in the ER will improve the patients’ lives. We also hope to show that it will save money, because when an elder is in a safe place, expensive, frequent trips to the ER may no longer be needed.

The team’s ultimate goal is to optimize acute care for these vulnerable victims and ensure their safety. They plan to work at continually tweaking VEPT to improve the program and to connect to emergency medical, law enforcement and criminal justice services. Eventually, they hope to help other emergency departments set up similar programs.

* Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

 

 

 

Big Changes to Medicare Plan Finder by CMS

Understanding Medicare can be a full time job.  Medicare Advantage and part D plans can be hard to understand – or compare during open enrollment.  As a reminder, Medicare Part D is the Medicare prescription drug benefit that subsidizes the cost of prescription drugs and prescription drug insurance premiums.  Medicare Advantage plans typically offer additional coverage — vision, hearing, dental, health & wellness.

The following is an excerpt from Medicare Advantage News discussing changes to the medicare Plan Finder.  Changes will enhance the benefit data display that increase transparency and go live 1 October 2017.

CMS unveiled the planned changes in a May 22 memorandum sent to all Medicare Advantage and Part D plan sponsors, saying the enhanced “benefit package data display” will go live on Oct. 1, 2017.

While CMS did not respond to a request from AIS Health for additional commentary on why it is making these specific changes, a top agency official speaking at last month’s Medicare Advantage and Prescription Drug Plan Spring Conference identified enhancing the beneficiary plan selection process as a chief goal of CMS this year. “Our focus is to improve the visibility of the beneficiaries in the Medicare program to identify the best options for them,” stated Demetrios Kouzoukas, principal deputy administrator and director with the Center for Medicare.

According to the memo, the planned MPF enhancements include, but are not limited to:

  • More benefit categories, including preventive care, diagnostic procedures/lab services/imaging, hearing services, preventive and comprehensive dental services, vision services, rehabilitation services, transportation, foot care (podiatry services), wellness programs and Medicare Part B drugs;
  • In-network vs. out-of-network cost share information;
  • Authorization and referral information;
  • Optional supplemental benefits with monthly premium and deductible; and
  • An expanded display for drug costs and coverage.

“If CMS chooses to list of all of these benefits in a co-equal way, it is a big change,” says Michael Adelberg, principal with FaegreBD Consulting and a former top CMS MA official. “Historically, CMS has sought to focus decision-making on a smaller number of core benefits.”

CMS has also historically favored minor adjustments over broad-scale changes, most recently making a series of tweaks highlighting which plans are under an enrollment sanction and adding more information about the sanction itself (MAN 9/15/16, p. 1).

But adding so much new information could be problematic, consumer advocates advise. “The Medicare Plan Finder has always been an extremely important resource for Medicare beneficiaries seeking unbiased information about Medicare health plans,” remarks Jane Sung, senior strategic policy advisory with the AARP Public Policy Institute. “While AARP is pleased to hear that CMS is continuing to improve the Medicare Plan Finder, we remain concerned by the growing breadth and complexity of the information that is being presented. AARP has long argued that the Medicare Plan Finder should be more user-friendly so that it can better assist Medicare beneficiaries as they analyze their plan options.

She continues, “While the new information is certainly relevant given constantly evolving Medicare Advantage and Medicare Part D plans, CMS should ensure that it is presented in a manner that is useful and easily understandable for beneficiaries and their families.”

Consumer Advocates Question Usability

The Medicare Rights Center, which offers a national help line to assist Medicare beneficiaries in navigating the MPF during the Annual Election Period, is cautiously optimistic about the planned changes. “Those are all really good goals and we’re excited to see what CMS does, but I think we’ll have to wait and see a little bit in terms of how usable that information is in the Plan Finder tool. But those are things we think are important to include,” Casey Schwarz, senior counsel for education and federal policy, remarks of the planned enhancements.

Medicare Rights last year issued a series of recommendations to CMS on enhancing the MPF, including providing more “individually tailored information on the summary/comparison results page,” and requested that the tool make it easier for beneficiaries to see if their providers are in selected plans’ networks rather than being redirected to a plan’s website and having to start from scratch. A “searchable provider directory” for each MA plan on the plan finder would streamline the selection process, suggested the nonprofit organization.

Neither a searchable provider directory nor an option for individually tailored information were included in the list of planned changes issued by CMS. “We’re going to continue to push CMS for providing more information that is relevant to a particular person based on any of their claims data or information that they enter into the Plan Finder tool, such as information about the doctors that they use and whether the network includes their doctors,” says Schwarz. But based on CMS’s response to the September 2016 letter from Medicare Rights and other conversations, there are technological and other limitations facing CMS that may keep it from establishing, for example, a searchable provider directory.

Nevertheless, Medicare Rights has observed that CMS is “willing to make improvements” to the tool and that prior changes, such as increased accuracy and more frequent updating to address problems experienced during open enrollment, have made it more usable over time, adds Schwarz.Meanwhile, whether the expansion of core benefits on display will drive plans to incorporate more low cost “extras” (e.g., dental and vision benefits, wellness programs) into their bids remains to be seen. Shelly Brandel and Pat Dunks, both principals and consulting actuaries with Milliman, say there was no immediate reaction from plans to change up their 2018 bids (see story, p. 1). But the revisions may have more of an impact next year, if there appears to be a trend of seniors gravitating toward plans that include more of those benefits in their plan benefit packages, they suggest.

Source: https://aishealth.com/archive/nman06081702utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115672897

 

Elder Friendly Smartphones: Essential for Safety, Security, & Support

Comedians – professional and others trying to get a laugh, love to share stories of introducing technology to parents and grandparents. Chief among them is the smartphone. The reality of the situation is that smartphones are essential not a luxury. For an elder, the smartphone is a source of safety, support, and security.

I still don’t understand why my cellphone should have amazing photography capability!

Urgent-care aps to visual communication with adult children and grandchildren (i.e. FaceTime) is why a smartphone is an essential component of creating a safe elder environment. Selecting a smartphone easily accessed and comfortable for an elder to use is the key.

www.maketecheasier.com and www.gottabemobile.com recently published their recommendations for top smartphones for elders – and why. We provide a quick overview of each device and a couple key specifications important in making the product elder-friendly.

Jitterbug Smart The Jitterbug Smart features an interface that is easy to see and navigate with a simple list interface. The phone boasts a large 5.5-inch display, which may present a problem for some elders. However, with a larger screen, everything on the screen is much easier to see. The device has a number of urgent care apps pre-installed. The Jitterbug Smart is also hearing aid compatible and comes with 4G LTE connectivity.

Specifications: 5-inch display with HD resolution; 4G LTE; Hearing aid compatible – M4/T4 rating

PowerTel M9500 This 5″ smartphone is made by Amplicomms whose motto is “Loud and Clear.” The PowerTel M9500 is super loud. The phone’s ringtone can go as high as 90 dB, which is similar to a train whistle or an oncoming subway train.  The phone features a volume boost key that enhances the speaker volume by an additional 40 dB. You won’t have to ask “do you hear me now?” with this device. PowerTel M9500 has a retooled user interface with clearly labeled large buttons.

   Specifications: 5-inch display; Android 5.1; 4G LTE;  Hearing-aid compatible – M4/T4 rating

Emporia Smart The Emporia Smart features a unique blend of old and new. The Android smartphone has a touchscreen that can be overlaid with a keypad cover. The user will have a more tactile experience dialing; and, text with a physical keypad. If at a later date the user warms up to the touchscreen, the keypad cover can be completely removed.  The Emporia Smart’s user interface has large buttons and a simple menu for easy navigation. The device comes with a stylus for those uncomfortable with touch-based navigation. Despite some interesting features not normally associated with other smartphones on the market, the Emporia Smart doesn’t have the best specs.

Specifications: 5-inch display with a 960 x 540 resolution; Android 4.4.2 Kitkat;  Hearing aid    compatible – M4/T4 rating.

Doro Liberto 825 The Doro Liberto 825is easy to use. It has large icons and clear text. The device offers a tutorial for first-time users. There are interactive tips guiding users through the process of sending text messages, emails, etc. A great feature is an online help center featuring videos that walk him through step by step.  Users can nominate trusted contacts that can remotely control the Liberto 825. This remote access is a great help for elders who need a little bit more. THE LIBERTO 825 IS NOT AVAILABLE IN THE US; DOUBLE CHECK BRANDS YOUR PROVIDER SUPPORTS BEFORE PURCHASING.

Specifications:  5-inch display with a HD resolution; Android 5.1.1 Lollipop; Hearing-aid compatible

Samsung Smartphones – Various Models All modern Samsung phones from budget to top of the line offer an “Easy Mode.” This enlarges the icons and puts all the important stuff within easy reach. If you already own a Samsung or simply want to have a more popular phone, Easy Mode is ideal. Easy Mode isn’t enabled out of the box for obvious reasons, but turning it on is a snap.

iPhone 6s and 6s Plus  The most significant aspect of this device is that it easily can be linked with other Apple products; thereby expanding its universe and accessibility. The 6s Plus has a 5” screen for easier reading and, overall, fewer options and controls to avoid overwhelming the use. What is also nice is the fingerprint reader. The iPhone 6s has many of the same features of the 6s Plus on a smaller 4.7” screen and at a lower cost.

Moving to Assisted Living IS Traumatic

Moving to an assisted living community can be is traumatic.

We are often asked to provide project management services for elders transitioning from their independent residence to an assisted living community. Recently, the request has been to provide professional services for elders moving from one assisted living community to another. Our first message to the elder, caregiver, or family member is to anticipate an adjustment period in the new residence.

We have discussed issues associated with the decision to move in previous conversations. Transition Trauma, also known as relocation stress syndrome (RSS) is manifested in anxiety, confusion, and hopelessness. When combined with the physical issues of moving, the recovery can take months. Keep in mind; the notion of transitioning to an assisted living community is most often viewed as helplessness and the loss of empowerment.

Our task is to lift the weight of the move off the shoulders of the elder, caregiver(s), and family. Success requires a team approach. This begins with selecting the assisted living community that meets the elder’s needs today and during the next five-year period. Taking the time to discover the best community will pay off in a year or two.

Once the community has been selected, there are a number of things elders and family can do to enhance the adjustment.

  • Stay positive about the move. Understand what is happening and prepare.
  • Search for answers. Ask questions of everyone. Keep a list of questions with you so you don’t forget.
  • Meet people. Don’t sit in your apartment or residence all day.
  • Remember WHY you/your elder is moving. The new community offers the services, privacy, care level, and safety that is necessary for quality of life.
  • Make a home. The move to assisted living requires right sizing. Determine what household inventory is the most meaningful and take it with you. Photo albums can be digitized, wall hangings can be rehung, a favorite chair can be moved,
  • Remember going to summer camp or sending a child to college? You want to keep in touch but not hover. The same holds true with the move to assisted living.

Our transition team is adept at asking questions and uncovering what is important to the elder, caregiver, or family member at this moment in time. If we all are successful, the transition will go relatively smoothly and the elder will discover a new community and home.

Creating Order Out of Chaos Following the Death of an Elder

The days and months following a death are filled with high emotion, chaos, and a laundry list of ‘to do’s.’ There is little time for family, friends, or caregivers to grieve.  The weight of these to-s on the survivor’s shoulders is significant.  At this moment in time, the most immediate need is creating order out of chaos.

It begins with listening – understand what’s important and necessary. It begins by listening and understanding what is necessary to be accomplished. This includes, but not limited to:

  • Declutter, sort, and liquidate a residence.
  • Search for specific legal documents, treasures, and memories.
  • Household inventory with financial or personal value – value family may not be aware of or value family is mistaken about.
  • Referral and coordination of property liquidation, sale, distribution.

Handling assets, inventory, and meeting  the needs of a surviving spouse, caregivers, 0r family members during the days and weeks following a death requires empowering decision makers and engaging family and caregivers.

Recognizing limitations and assessing the real needs of a situation are also essential.  If there are health issuers of a serving spouse, those needs must be met.  Sorting and liquidating physical assets easily can become a full time job for a family  member or caregiver.  If someone does assume the role, what happens to their work in the interim?  Assessing time required and the best way to efficiently invest that time cannot be done within a climate of emotion, grief, and chaos.

The team supporting the surviving spouse or family typically includes an attorney, CPA, financial consultant, and others.  The inclusion of an elder project manager who assumes the responsibility of project manager and coordinator of physical assets will enable family to concentrate on what is important at this moment in time; and, ensure family wealth and assets are preserved through an efficient liquidation process.

The single greatest error made by family, caregivers, or untrained professionals is quickly discarding all contents of the residence.  Elders who have been housebound or have had any physical or behavioral illness hide money, documents, and other important items within the residence. Knowing how and where to uncover hidden treasures is a primary task – not to be taken lightly.

Each family manages death in their own unique way.  Common among all cultures, faiths, and communities is the need to grieve.  Asking for help with the tasks at hand when a death occurs is a strength.  It is recognition that life continues to move forward concurrent with the need to grieve.

Growing Old is Mandatory. Growing up is Seasonal.

Growing old is mandatory, but growing up is optional. — Walt Disney

imagesWalt Disney was literally Peter Pan. Growing old could be a state of mind if not for the state of our bodies. During these final weeks in December, there are some families who are able to come together to consider memories of roads travelle
d while creating new memories of journey yet to be discovered.

There are some whose ays are filled with eyes closed. Their minds taking them into a world of imagination. A world in which their bodies are controlled by their brain, their surroundings are directed by their desire, and their engagements are filled with those who love them and they love.   By keeping their eyes dimmed, the world of their dreams is able to lighten their heart and lift the spirit.

This is the time of year in which the reality of our world rings louder than do those dressed in Santa hats at street corners. Heath, body, and finances are magnified in the eyes of those who care for elders. Plans are expedited, empowerment is endangered, and decisions are hastened in the name of love, safety, and family.

As the new year’s resolutions are made and the realization last year’s resolutions were not reached, many realized their hope are fading and the potential for a new chapter in the book of life is less likely. Others look forward to this chapter with anticipation and hope. We simply sit back and come to the understanding the final chapter is elusive to the author and how the story will end is still unknown – even to the greatest of all authors.

We gather to watch balls drop, corks fly, lights illumine, and children gaze in wonder as spectrums of colors pass before their eyes wrapped around boxes of all shapes and sizes. We are told it is a time to look back and bask in out accomplishments; yet, amazed at how baffled we are how the easy tasks still aren’t accomplished.

You go over the river and through the woods, down the runway and through the jet way. Step through the clutter or around the nurse’s station. Past the childlike arts and crafts or across the faux wood floor.

To grandmother’s house we go.

Once there, what will you do? What will you say?   Will you be honest with your thoughts or imagine this is like it was fifty –years ago? Growing old is mandatory. Growing up?

Perhaps, growing up is seasonal.

Happy holidays and a healthy new year.

Talk To Your Parents About Aging Now. What Are You Waiting For?

My mother was ill for several weeks and hospitalized. The pulmonologist said she would require rehab before coming home. This meant a rehab facility. AKA nusing home.

We told mom. She looked directly at me and said “I wouldn’t do this to you.” There were no words to be said at that moment. All these years, my eyes still well up and a sinking feeling grows in the put of my stomach thinking about that moment.

The days and nights she spent in rehab were some of the worse either of us spent up to that moment in time. I had lived for years with the belief she would never leave home and the disbelief life would never change. In reality, aging is like any other stage of life; it is a series of changes concluding with death in the same way life begins with birth and then a series of changes occur.

I advocate with all clients to prepare and plan. Once a plan is in place, have not one, but two or three alternatives. Underlying the plans is simplicity and transparency.

This includes rightsizingpossessions, finances, passwords, clothing, and more. It also includes rightsizing plans.

January is the time it is customary to make New Year’s resolutions. This December when the family comes together, you have an opportunity to create your family resolution early. This year’s resolution is to plan and have a conversation about aging.

It applies to everyone in the family – not just grandpa or grandma. The college family members soon have to think about life after college. Single family members need to make decisions – remain single or consider a family so that everyone will stop asking! Family members who will retire in the next year are planning what to do with their time.

Elders need to plan as well. If not, others will make decisions when elders are unable to speak for themselves. Some plans and decisions are easier than others. For instance, at 90, is an inheritance as important as it was at 60? Do 70-year old children have the same needs as 30-year olds? Do elders need access to greater of healthcare providers? Is it important for adult children to know an elders wishes concerning hospice?

Other issues are emotionally difficult at this moment in time because they require the elder to make decisions requiring giving up independence, a sense of who they are, and perhaps accepting the realization of their own mortality. Is it time to downsize? Am I ready to move into a senior community? Is it not safe to live alone any longer? Is my health failing?

Thinking through these questions independently or with family members, developing a plan of action, and carrying out the plan is the best way to start the New Year. It is an act of empowerment for the elder and family.

Engaging a third party to help with this conversation can often encourage honest dialogue. Our transition team often will mediate conversations, assist with planning, or carry-out plans for rightsizing, moving, or transitioning to senior living.