How can I find the best housing and care for my loved ones?
By Amy Goyer
Depending on your loved ones’ physical, cognitive, and financial situation, there may be many different places they can live, and various levels of care associated with them. As the amount of care provided increases, the cost goes up. Wherever your loved ones live, make sure you get a realistic picture of the type/level of care and supervision/monitoring needed versus what is actually provided. If they live in facilities, review the facilities’ detailed policies. Never assume your concept of care is the reality. And remember that quality of life is paramount.
Start by talking with your loved ones about where they want to live and how they want to receive care. Ask them what makes them happiest and brings them the highest quality of life. Then review the options in their area and determine the best fit currently, keeping in mind their needs may change in the future. You can obtain the services of a geriatric care manager, aging life care expert, eldercare consultant, social worker, case manager, assisted living locator service, or the area agency on aging to help make this decision.
As you review the options:
- Get recommendations from residents and their families – this usually gives you the most accurate information about what it’s like.
- Visit facilities, without an appointment, so you get a realistic perspective. Eat a meal, observe the happiness of residents and staff, notice bad odors, note the real staff-to-patient ratio (not just what they tell you it is), etc.
- Always check to make sure that facilities are up to date on licensing, and check with the Better Business Bureau, the state long-term care ombudsman, and Medicare Care Compare to see how they are rated and if there are complaints against them.
Here’s an overview of what to expect with various types of care: (Be aware that there are varying names for these types/levels of care in different states as well as varied state regulations and monitoring systems.)
- Care at Home – The vast majority of care in the U.S. is provided at home – either in a care recipient’s home or in the family caregiver’s home. Any level of care can now be provided at home with the help of medical equipment, in-home care, and appropriate home modifications (if needed). Depending on the type of care needed and the hours of care required, you may need to supplement your care with paid caregivers.
- Adult day services centers – Adult day services centers (sometimes known as adult day health centers or adult day care centers) are places your loved ones who are living at home can go during the day. They provide meals, socialization, and activities, and some provide additional services on-site like speech therapy, physical therapy, occupational therapy, bathing, medication administration, and more. They usually charge a flat fee for the day which is generally much less than the cost of one-to-one care at home.
- Independent Living – Independent living may be an apartment, rowhouse, duplex, or detached single-family home in a community designed for older adults, sometimes called a senior community or 55+ community. In “independent living,” apartments or homes are designed to be safer for aging in place, and may offer some basic optional services such as meals, activities, housecleaning, and perhaps transportation. Some have security and may include medical alert devices. Others offer some personalized services a la carte (you pay for each additional service on top of the base fees) such as medication reminders, or help with bathing, laundry, etc. There is usually very little or no supervision or tracking of residents because residents are indeed able to live independently. Many residents still drive and go out on their own. Independent living should provide a somewhat safer environment and socialization than living alone at home.
- Group Homes – Sometimes called board and care homes, residential assisted living, or residential care homes, these are homes in a residential neighborhood that are set up to take in several people to be cared for by the owner (who may live in the home) and additional paid staff. They offer meals and usually help with bathing, dressing, toileting, and medications. Most do not offer a skilled nursing level of care. They should offer some planned activities. Because they are smaller, they should provide more personal one-to-one connections and possibly quicker response times. These homes are licensed by the state and have certain requirements for the home, the care, and the staffing, so be sure to monitor that they are adhering to those parameters. A group home should offer similar services as assisted living but in a smaller, home-like environment.
- Assisted Living Facility – Residents have small apartments, usually with a kitchenette, and receive some supportive services in a facility designed to be safer for older adults. Services offered can vary greatly in an assisted living facility and may be included in a flat fee, but often you pay for them a la carte (which can add up if more support is needed). Generally, the facility provides assistance and not much more. It is not round-the-clock, one-to-one, hands-on care with someone checking on your loved ones constantly all day. They may help with medication management, bathing, dressing, meals, and activities. And there is at least some level of supervision and monitoring, generally with a front desk and staff on each floor. Your loved ones may have to wait 30 minutes or more when they ring their call button. For most assisted living facilities, residents can still come and go as they please, so consider a GPS tracker or other device if you are concerned your loved ones will leave and get lost (or check out memory care). Assisted living should be a place where people who can’t be fully independent, but don’t need constant care, can get assistance when they need it – along with some socialization.
- Skilled Nursing Facility (SNF) – Often referred to as “nursing homes,” residents in these facilities require a higher level of medical care. These facilities offer meals and activities like other levels of care but should provide more supervision/monitoring, and they will do things like feed someone who is unable to handle eating alone. Residents’ abilities may vary quite widely, with some up, dressed, and moving about the facility during the day and others who remain in bed all day. Residents have call buttons but may have to wait quite a while before someone responds. Nursing homes also don’t have one-to-one staffing, but their staff-to-patient ratio is much lower than in assisted living. Some skilled nursing facilities provide rehabilitation care, so your loved ones may be there for a short time to get stronger and recover from an illness or surgery, returning to their previous situation once they are stronger. (Note that there are also rehabilitation facilities that only focus on short-term rehabilitation and do not offer long-term care.) Those in rehabilitation generally get more frequent physical, occupational, and speech therapy (make sure these are offered in-house and on-site). Other residents may live there on an ongoing basis. A skilled nursing facility should provide quality medical care as well as socialization activities. It should be clean and free of bad odors, and staff should interact kindly with residents. Your loved ones should receive the medical care they need, as well as timely incontinence care.
- Memory Care – These facilities are designed specifically for people living with dementia and should have safety features in place to prevent any residents from leaving and getting lost. Generally, memory care facilities help with bathing, dressing, meals, activities, and medications like assisted living. Some also offer a higher level of skilled nursing care (but you will also find people living with dementia who are no longer very mobile living in skilled nursing facilities that are not memory care-focused). In memory care, there should be a higher staff-to-resident ratio and more supervision and monitoring than in an assisted living facility. Activities should be targeted specifically for those living with cognitive challenges, and the best facilities have outdoor areas that are designed to be safe for your loved ones to walk about and enjoy nature without getting lost.
- Continuing Care Retirement Communities (CCRC) – A CCRC includes several levels of care, generally including independent living, assisted living, and skilled nursing. Some include memory care. Many are rent-based, and others require a very large down payment (like the cost of a home). Additional monthly fees may be charged. The advantage is that residents can move between levels of care as needed. For example, if your loved ones live in a CCRC independent living apartment and break a hip, requiring rehabilitation after a hospital stay, they could go to the on-site skilled nursing facility for a few months and then move back into their apartment. Or if their abilities have declined because of the injury and rehab, they could instead go to assisted living. A CCRC should provide a safe “campus” and it should be easy to go between the levels of care as needed. Be sure to ask about waiting lists if your loved ones experience a crisis and need a higher level of care immediately, as well as increased costs.
- Palliative Care programs – Palliative care is for anyone living with a serious health condition, and its purpose is to ease your loved ones’ pain and increase their quality of life. You can receive palliative care in any location (home, hospital, nursing home, etc.) while also receiving treatment for the health condition. There is no limit on the length of time palliative care is provided, and it may be covered by Medicare, Medicaid, or Veterans Affairs Healthcare. Some palliative care programs are associated with hospice organizations, and some may charge a flat fee for services.
- Hospice care differs from palliative care programs because it is for people who are not receiving treatment for a serious health condition and who are likely in the last six months of their lives. It requires a doctor’s referral. However, sometimes people get better while they are in a hospice care program, and they no longer qualify for hospice. If that happens with your loved ones, they can go back on hospice again at any time. Hospice care is generally covered by Medicare, Medicaid, private insurance, and Veterans Affairs Healthcare. Regardless of where your loved ones live, hospice should provide pain and symptom management, a social worker and a chaplain to provide support for both your loved ones and you as their caregiver, certain medications and medical supplies, and grief support. Some hospice programs also provide volunteers to spend time with patients, and special services like music and art therapy, or speech and physical therapy. One of the most helpful aspects of hospice is they provide qualified nurses to talk with you any time – day or night – and will send a nurse out to the patient if needed. Some hospice organizations have hospice facilities where your loved ones can go for a short-term stay to give you a break, or through the end of their lives. If your loved ones die at home, you will be able to call hospice and they will send a nurse out to handle the arrangements, a social worker to help with logistics and emotional support, and the chaplain for spiritual support.
- The Adult Day Services Locator (National Adult Day Services Association) provides a search tool to help you find adult day care centers in your area.
- The Community Resource Finder (Alzheimer’s Association and AARP) helps you locate housing options of all types (not just dementia care) in your local area.
- The Eldercare Locator (U.S. Administration on Aging) website or toll-free helpline 800-677-1116 offers a search tool to help you find your local area agency on aging.
- Group Homes: A Small-Scale Option for Assisted Living (AARP)
- The Long-term Care Ombudsman Locator (The National Consumer Voice for Long-Term Care) is a search tool to find your state’s long-term care ombudsman.
- CaringInfo (The National Hospice and Palliative Care Organization) provides family caregivers with information about palliative care and hospice care).
- Residential Care Facilities, Assisted Living and Nursing Homes (National Institute on Aging)
- Medicare Care Compare offers a search tool to find, gather information about, and compare Medicare-certified nursing homes, rehabilitation facilities, home health providers, hospice care, dialysis facilities, and doctors/clinicians.
Amy Goyer is a nationally known caregiving expert and author of Juggling Life, Work, and Caregiving. A passionate champion for caregivers, she has also been one her entire adult life, caring for her grandparents, parents, sister, and others. Connect with Amy on Facebook, Twitter, and LinkedIn.