While the majority of older adults wish to remain in their home as they age, it is sometimes necessary and safer for an older adult to relocate. There are a variety of long-term housing options for older adults. These options differ in price, degree of assistance and amenities.
Before evaluating housing options, caregivers and older adults must consider two things. The first is finding out where the older adult would prefer to live, while the second is weighing where it is safest for the older adult to live.
Long-Term Housing Options
The first option, and usually preferred option, is aging in place. Aging in place is a phrase that refers to an older adult who stays in their home as they age rather than transitioning into a facility or community. Typically, to make aging in place possible, caregivers and older adults must seek out in-home assistance or make modifications to the home. For example, home care aids may be hired to handle some daily tasks or personal care responsibilities. Home modifications may include installing grab bars, adding new lighting or using assistive devices. It is important to consider an older adult’s physical and cognitive limitations as well as their financial and social situation before deciding on aging in place.
The alternative to aging in place is moving to a new home, which may be a smaller house, apartment, condominium, independent living community, assisted living community, nursing home, continuing care retirement community or memory care community. The cost of each option can vary greatly, but typical price ranges are provided in the following section for reference. Notably, long-term care insurance, Medicaid and veteran’s benefits may help cover the costs of long-term residential care. Consult a financial professional or your state Medicaid office for an explanation of what may be covered in your situation.
- Independent living communities may be single-family homes, apartment buildings or townhomes designed specifically for older adults. While services and costs vary greatly depending mostly on amenities, most communities offer security, housekeeping, social events and transportation to make independent living easier and more enjoyable. (Typical cost: $24,000-$48,000 per year)
- Assisted living communities may be apartment-like buildings or shared residential houses. Generally, each resident has personal living space and is provided with meals, limited nursing care and assistance with personal care such as bathing, dressing, toileting and taking medications. Social activities are usually offered as well. Some facilities also offer memory care services. Many states require no training for personal care workers in assisted living. You might want to inquire about what training and supervision the community provides for personal care workers. Families are often under a false assumption that the staff can and will identify medical problems that arise. Again, personal care staff are often not trained to identify medical problems. While they may see obvious changes that have occurred in the person’s medical status, they will likely miss more subtle changes. We know that for older adults, identifying changes early, that are often quite subtle, prevents many serious problems from developing. Notably, many families continue to provide support after the move to an assisted living community, often increasing their involvement as care needs increase. Some assisted living communities offer a financially tiered approach, increasing the fees as the need for personal support increases. Some do not even allow the person to remain when needs increase significantly. It is important to discuss what and how much additional support the organization will provide, and what the cost would be for additional support as needs increase. This is a common source of conflict between families and the assisted living organization. (Typical cost: $25,000-$50,000 per year)
- Nursing homes provide meals, more extensive personal care and support than is found in assisted living, and social activities. In every state there is also a requirement to provide 24/7 nursing care. Nursing home residents can choose to have their medical care supervised by their personal doctor or, in some cases, can opt for the nursing home’s medical director to oversee the care. Most communication with the doctor, or in some cases a nurse practitioner, is through the nurse in the nursing home. Most nursing homes employ social workers who assist with admissions and discharges, and help with financial questions. Therapists work with residents to promote functioning and independence. Reimbursement for therapy services is limited to specific circumstances. Not all residents are eligible for therapy reimbursement. It's important to inquire about whether and for how long therapy might be ‘covered’ by your insurance. All nursing homes are audited by state surveyors to monitor the quality of care they provide and to document infractions and quality problems. These audits are available to everyone. Each nursing home is required to make their most (Typical cost: $80,000-$90,000 per year)
- Continuing care retirement communities (CCRSs) offer the options of independent living, assisted living and nursing homes all in one community. One benefit of this combination is that older adults who experience a decline in their ability to manage on their own, or are recovering from an illness or injury, do not have to move to a new location. This is particularly appealing for couples who wish stay together if one had a serious health issue and needed a higher level of care. (Typical cost based on level of care: $24,000-$90,000 per year)
- Memory care communities are designed specifically for older adults with dementia or Alzheimer’s. Generally, nursing and personal care are provided along with planned activities tailored to those with cognitive limitations. Memory care may also be offered by assisted living facilities. (Typical cost: $60,000-$72,000 per year)
How To Evaluate Communities
Once you have evaluated the older adult’s needs, considered financial limitations and decided on the level of care that is needed, it is important to visit and evaluate prospective communities. It is recommended that at least three different facilities are inspected for comparison. It may be helpful to schedule a formal visit with an administrator and then also make an impromptu visit on a weekend. Here is what to look for:
- Cleanliness, including odors environments.
- Where do residents spend their time, are the common areas active?
- Are employees friendly and engaged with residents?
- Do advertised and planned daily activities actually occur?
- Can residents bring their own furniture and decorations?
- Is the property secure? (Check especially if it is a memory care community.)
- Are there plants and animals around that bring residents joy?
- Ask to speak with the families of other residents or attend a family/resident meeting.
- Ask to see the report from the latest survey
- Ask about the turnover rate for nurses and Certified nursing assistants. Turnover rates are a good indicator of overall quality
- Consult the federal government website to learn about nursing home resident rights. (https://www.cms.gov/nursing-homes/patients-caregivers/finding-home )
- Get help finding and evaluating nursing homes in your area by consulting Medicare - Compare Nursing Homes - Find Healthcare.
Here are some questions to consider during your visit:
- Do residents have the same staff care for them over time or do you rotate staff ? (Consistently assigning the same staff, over time, results in better quality of life and better care for residents)
- How often does your medical director visit? (Many medical directors have very little contact with residents and are not very involved in the care. You might want to talk with the person’s doctor or nurse practitioner to find out how they oversee the care of people admitted to nursing homes.)
- What is your ratio of registered nurses to practical/vocational nurses? (the more RNs, the better the outcomes for residents. At minimum, there should be an RN working on the unit, (not as an administrator, on every daytime shift)
- Do you support end of life care in the facility? Do you provide continuing education in palliative or end of life care for your CNAs and nurses? Do you work with hospice to provide the care? (High quality end of life care requires special knowledge. It is reasonable to ask about how well trained the staff are to provide it)
- What is the monthly cost for the level of care the older adult requires?
- Is there a fee charged for move-in?
- What activities are offered? How are activities tailored to different resident abilities and interests?
What religious services are offered and how are residents assisted to attend?
- Can residents select from different menu options? How much choice do they have? How does the dietary staff respond to resident preferences for specific foods?
- What is the ratio of residents to staff? (should be no more than 15:1 for assisted living and 8:1 for memory care)
- Talk to family members and residents to find out about quality of life, what their days are like, how well staff respond to their needs
- What role do families play in developing the plan of care, evaluating the quality of care, addressing problems with quality of care or quality of life? (some communities have active family groups or councils that meet regularly with administration to address problems.