Assisted Living

Assisted Living and Residential Care

Assisted living, also called residential care, is a type of living arrangement in which personal care services such as meals, housekeeping, transportation, and assistance with activities of daily living are available as needed to people who still otherwise live on their own in a residential facility. Assistance with activities of daily living may include help with bathing, dressing, toileting, diapering, medicating, helping with daily living decisions and moving from one place to another. In many cases residents pay a regular monthly rent and the care services above are added as extra cost as needed. For many facilities, the cost of care is included in the monthly rent. Many facilities provide levels of care based on need and charges are uniform for each level. For instance, a level or grade 1 care might cost an additional $400.00 a month. A second level or grade 2 might cost $800.00 a month and so on.

The definition of the term assisted living varies from state to state. One of the reasons so many terms exist for similar facilities is that each state has its own licensing requirements and regulations to govern these facilities to ensure quality care. Here are some examples of the titles states use for assisted living:

• Residential care
• Personal care
• Adult congregate living care
• Board and care
• Adult living facilities
• Supported care
• Enhanced care
• Adult homes
• Sheltered housing
• Retirement residences
• Adult foster care
• Community based retirement facilities

Some States also license various categories of care under some of the titles above. For example, a state may license categories under assisted living, board and care and personal care. Or another, licensing convention is to license small facilities as one level of care and larger facilities as another level of care under the same name. Each category has its restrictions and requirements for care giving. The difference in licensing is usually based on the size of the facility and the services it can offer. For example, residential or board and care is usually a converted home or small facility with three to ten beds where the caregiver is a homeowner or single proprietor with little or no support staff. These facilities typically are not allowed to offer much care beyond bathing, dressing, providing meals or helping residents move around. Some of these homes however, may contract with home health agencies, home visiting doctors or nurses to provide care for their residents.

The cost for board and care homes is typically much less than with large new assisted living facilities. People who operate board and care homes have a love for the elderly and in essence are taking these people into their homes to care for them as if they were family members. Unfortunately, because of their small size these operations have little money to advertise and their residents usually come to them from referrals or word of mouth.

Assisted living fills a gap between home care and nursing homes. Years ago, before assisted living, a person needing professional care went to a nursing home even though the care didn't always merit the intensive supervision and control of a nursing home. The fairly new alternative of assisted living provides a more homelike environment for people needing or anticipating help with activities of daily living or incidental activities of daily living but for which 24-hour nursing care is not a necessity. Instead of the hospital environment of a nursing home, ALF's look more like apartment buildings with private rooms or suites and locked doors. Instead of a nurse's desk, there is a help desk. And instead of a hospital-like lounge area and sterile cafeteria, assisted living has gathering areas with couches, fireplaces, gardens, atriums, etc. Central dining areas look more like banquet rooms and often offer entertainment during or after mealtimes. Meaningful activities and chats with neighbors in pleasant surroundings, keep residents active and stimulated.

The above description would be typical of newer facilities with 20 to 200+ beds. The States also license a variety of other assisted living facilities, some of them being converted homes as discussed earlier, others converted hospitals, some are dedicated areas in independent retirement communities and others are dedicated hospital wings. There are at least 15 differently name living arrangements that could be called and licensed as assisted living. But at a minimum the essence of all these facilities is to provide an assistive environment. Assistance for individuals or couples who for either medical reasons or to gain freedom from being tied to maintaining a home prefer instead to have someone else do the cooking, cleaning and gardening. In addition, ALF's offer help with transportation, medicating, bathing, dressing, toileting, health monitoring and moving from one place to another but only if the disabled person can move with the assistance of no more than one aide. Some states may allow facilities to have a resident nurse or therapist to help with minor medical problems. And some states even allow variances for assisted living to offer limited nursing home services.

Prior to assisted living, many people had to reside in nursing homes but didn't need the level of care provided. Yet there were few options for other living arrangements. With assisted living, these people now have the choice of a more homelike environment at about half the cost of a nursing home. Demonstrating the popularity of ALF's over nursing homes is the fact that the number of nursing home beds in this country has increased only slightly over the last decade to about 1,800,000 beds, whereas assisted living beds have grown from about 600,000 to well over 1,900,000 beds over the same period.

Not all residents of ALF's need care or assistance. Many are there because they want a simpler lifestyle without the worry of maintaining a home and they seek the companionship of other people their own age. They also may have chosen assisted living over an independent retirement community because they may need some minor help with Instrumental Activities of Daily Living such as taking medications, but they anticipate a time when they may need the more intensive care available with an ALF. As of 1996, ALF residents who were independent with ADL's (needing no assistance) were as follows: eating--88%, transferring--84%, toiletting--78%, dressing--58%, bathing--49%. A recent survey of assisted living administrators estimated that 24% of their residents received assistance with 3 or more activities of daily living, such as bathing, dressing and mobility. They estimated that about one-third of residents had moderate to severe cognitive impairment. Many assisted living residents receive no help at all with care.

Who Pays for Assisted Living?

Estimates of the cost of an ALF range from 40% to 60% of the cost of a nursing home. In many areas a median cost with assistance might be around $2,400 per month. Medicare does not pay for ALF's. About 75% of all costs are paid by residents out of personal funds or family assistance. SSI pays for 14% and 2% is covered by long-term care insurance. Medicaid pays for about 9%.

Because the government participates little in the cost of assisted living, individuals anticipating a future need for ALF would do well to consider the purchase of long-term care insurance. All modern comprehensive policies cover ALF's (you must, however, qualify for benefits under the policy). Insurance is certainly more cost-effective than paying out-of-pocket. Depending on your age, 20 years' worth of premiums as an example, might only cost 3% to 10% of the actual amount the insurance policy would pay for a 3 year stay in an ALF. That's a lot cheaper than paying 100% out-of-pocket.

A 1996 survey by the American Health Care Association reveals that 59% of ALF residents are admitted from their homes and the other 41% come from nursing homes, hospitals or other ALF's. Some ALF's have found a niche in providing care to Alzheimer's or other dementia patients and many ALF's are exclusively dedicated only residents requiring memory care. Dementia often requires intense supervision but not necessarily from the more costly skilled medical staff found in nursing homes. According to the Alzheimer's Association, at least 5% of those over 65 and 46% of those over 85 suffer from mental impairment. This provides a potentially large market for ALF memory care facilities.

Choosing an Assisted Living Facility

An ALF staff worker can tell you whether you or a loved one will qualify for assisted living. But you may be forced to choose a nursing home instead because the level of care that an ALF can offer is dictated by the licensing provisions of that particular facility. In the event that you are turned down for care by one ALF, it is very important to get evaluations from other facilities. Many ALF's have found ways to stretch eligibility and you shouldn't give up after one try.

Below is a copy of a reprinted article from the Assisted Living Federation of America's Assisted Living Today Magazine, copyright 1999, ALFA. This article is found on-line at https://www.alfa.org/public/articles/details.cfm?id=77.

How to Choose a Residence

Making the right choice is easier when you thoroughly evaluate residences using these criteria -
By Elizabeth Parker Welton MSW, LCSW

Assisted living residences, in both rural and urban areas, allow today's consumers to be highly discriminating in their choice of a residence. A wide range of choices, however, may produce confusion and anxiety. With choice often comes the implied responsibility for making the 'right choice.' Family members engaged in this search sometimes feel like they're looking for a needle in a haystack without the benefit of a map.

ALFA has developed a complete checklist to be used in the evaluation and selection process. Consider the following elements when searching for that needle in a haystack.

Atmosphere: Family members involved in the selection process must look at the residences they visit through the eyes of the person who will be living there. When touring facilities, family members often comment, 'I could imagine myself living here.' Although that is a positive reaction, what is truly relevant is whether they can imagine their loved one living in that setting.

How does the prospective resident react when he or she meets the staff and other residents? Is the decor welcoming and homelike? Do the current residents appear to be compatible with your loved one? Will the particular personality and culture of that setting support the physical, emotional, mental, and spiritual needs of the prospective resident? The answer to that question is critical in determining the success of your and your loved one's choice.

Make several return visits to the residence on the top of your list to experience staff and residents in a variety of situations. Although crisis sometimes necessitates a more immediate choice, it is always ideal to take the time to make a slower and more informed decision guided by as much information as you can gather.

Physical Features: A residence that is modern and tastefully decorated almost always creates an initial favorable impression. However, an aesthetically pleasing setting that is not designed to maximize comfort and ease in functioning may not be a particularly wise choice. For example, a beautifully decorated unit that does not have doorways wide enough to easily accommodate a wheelchair does not allow for ease and comfort in movement. A bathroom that is too small to permit a wheelchair or walker to enter without precise maneuvering also reflects poor design. Hallways that are long and/or poorly lit without handrails may confuse and overwhelm elderly residents.

It can be extremely helpful to choose a potential unit and have the future resident move about in that space as if he or she is already in residence there. It gives you an excellent opportunity to evaluate how well the space is designed to promote both comfort and ease in movement as well as how it supports independent functioning.

Needs Assessment, Contracts, Costs, and Finances: Assessing the fairness and comprehensiveness of the contractual agreement is important. Most people are accustomed to evaluating and signing contracts fairly routinely. But it will be important to understand any future costs for increased levels of care and service should the resident's physical and/or cognitive functioning decline. It is reasonable to expect costs will increase over time as independent or minimally assisted functioning declines. Being prepared for that eventuality will help you decide whether that particular residence is financially feasible. Visit ALFA's Web site (www.alfa.org) to view a standard 'Consumer Information Statement' or disclosure form, which identifies questions you should ask specific to fees and services.

Another way to determine the viability of a particular residence is to learn whether each resident has a written care plan. Without such a tool, it's possible the care needs of residents will be unrecognized and therefore unmet. A comprehensive care plan should be created with the help and input of the resident, all available family members, the family physician, and any staff members who will have direct contact with the resident. This care plan must be reviewed and updated as the resident's needs change. The process of developing a care plan allows the resident to feel that all of his needs are both recognized and important to those around him. This frequently allays much of the anxiety associated with such a major life change.

Education and Health Care: The majority of people entering an assisted living residence are on at least two daily medications. Many choose this type of setting because medication self administration, among other things, has become difficult. Understand what specific policies are in place for giving medication as well as for any medical emergency that may arise.

Is a licensed nurse available to residents and staff in a full-time capacity? If the prospective resident has chronic hypertension, can you be confident his blood pressure will be taken and recorded on a frequent basis? Does a staff person arrange for visits from a physical therapist, occupational therapist, hospice nurse, etc.? The coordination of services with agencies in the community allows for a full continuum of care to be provided. It not only significantly benefits the health and well being of residents but also establishes the residence as a true member of the outside community. The relationship between the residence and the local community will support the resident in not feeling isolated or sequestered.

Services: Determining as specifically as possible the prospective resident's daily care needs is a critical step in choosing a residence. Make a detailed list of the type of assistance that will be required with each activity of daily living. For example, will this resident require assistance in dressing and undressing? If so, what specific type of assistance will be required? If her clothes are laid out for her, can she dress herself or will she require assistance in the actual dressing process? Does the staffing pattern allow residents who are wheelchair bound to receive help quickly if they need toileting? Inquire about the staff/resident ratio on all shifts. This information will give some indication of how quickly staff can be available to assist residents.

The ease and availability of transportation to shopping, the hairdresser, and other community activities also is important information. The ability to move relatively effortlessly between the residence and the community is another significant way the resident's autonomy and independence are valued and encouraged. Transportation provided by the residence may or may not represent an additional monthly charge.

Cognitively impaired adults may need a different type of assistance in their daily functioning. Are safety measures in place to contain possible wandering? Is the staff trained in techniques important to the care and comfort of mentally confused residents? Are specific areas and/or units designed to provide specialized care and programming for those who are cognitively impaired?

Individual Unit Features: Nurturing the spirit and individuality of residents as they move from their home into a residence is both challenging and achievable. The opportunity to have a choice in one's living space is an important way to achieve this goal. Some people value their privacy and don't thrive in double-occupancy units. Others may feel too isolated in a unit by themselves and will welcome a roommate.

Bringing some treasured pieces of furniture and pictures from home will greatly facilitate the transition and should be encouraged. The presence of a kitchen area in each unit allows for maximum choice and autonomy. Although most prospective residents will acknowledge that they are excited at the prospect of not cooking, the ability to prepare snacks or even a light meal is an important option. One of the fundamental goals of an assisted living residence is to provide comprehensive care to older adults while preserving their ability to be independent and have as many choices in their environment as is feasible. A future resident's participation in the choice of a residence, and the various options available within that residence, will have a direct and vital effect on the quality of that resident's adjustment to his new home.

Social and Recreational Activities: A diverse program of planned activities both within the residence and the community is vital to the happiness and contentment of residents. Does a staff member have sole responsibility to plan and direct social events? Do residents have a voice in planning activities both within and outside the residence? Does the selection of activities reflect the interests and lifestyle of the residents in an appropriate and satisfying way? Are residents who are less social encouraged to participate in activities? Are activities designed to not only nurture the spirit but challenge the intellect? Are activities in the residence consistently well attended by residents?

A well-balanced coordination of activities both within the residence and in the community allows the resident to feel a sense of belonging in both places. Activities are an important way in which social and emotional connections are made in a new setting.

In addition, research shows that the presence of animals in the lives of older adults is another important way of nurturing the spirit. However important and necessary the move to an assisted living residence might be, it involves significant losses. A residence that has a dog or cat viewed as the house pet can provide opportunity for constancy and daily love for someone who may be feeling a sense of loss. Many residences allow a small animal to accompany its owner in the move. When discussing this option with the staff, gain a full understanding of how the animal will be cared for.

Food Service: Food is a significant part of life. We look forward to meals and savor not only the food that we eat but the ambiance in which the food is served. If you polled assisted living residents about what contributes most to their customer satisfaction, food would rank high on their list. One of the universally significant ways in which people feel nurtured is through the food they eat. Keeping that in mind, food preparation should include fresh, diverse, and interesting ingredients.

At each meal, residents should have a choice of entree and dessert. Because individuals' tastes in food differ, no one offering can possibly please everyone. Resident input in the menu selection is another important way of promoting choice and respecting individual tastes.

The kitchen's capacity to provide for special diets that are medically mandated is another critical piece of information to gather. If a resident is feeling too ill to come to the dining room for a meal, can food be delivered to his room?

Is the dining room visually appealing to encourage residents to linger over their meals there? One of the most important avenues for socialization is dining with other people. It represents a natural opportunity to gather and share the events of the day and sometimes a lifetime.

In addition to using the guidelines ALFA has developed for choosing a residence, use your own knowledge of the prospective resident as a guide in making your choice. In what setting will he or she feel most supported and at the same time be able to function most independently? What are the particular and unique physical, mental, emotional, and spiritual needs of this person and in what setting are those needs most likely to be recognized and met?

The goal you set in choosing a residence should not be considered met until a setting has been selected in which the prospective resident can feel physically cared for and can thrive emotionally. Many older adults who are living independently, but struggling each day with physical and/or cognitive disabilities, are isolated and afraid. Moving into the appropriate assisted living residence can relieve the daily struggle to function and release the energy to fully and joyfully engage in life again.

Elizabeth Parker Welton MSW, LCSW is a psychotherapist in private practice in Arlington, VA. She can be reached at 703/524-3169. Be Informed, Be Prepared, Be Thoughtful

Be Informed:

• Learn about assisted living. Find out what services are provided by the residences in your area. Keep in mind that residences can vary greatly.
• Shop around. Finding a new home takes time. Plan ahead to visit as many residences as you can. Know what services you need and what to shop for. Make an appointment to meet with staff.
• Visit and revisit. Once you've decided on your top choices, revisit each facility at least one more time and at different times during the day. Talk to staff, residents, other family members, and the local long-term care ombudsman.
• Ask for written material. Information is essential. Review marketing material, consumer information brochures, the resident contract agreement, and state survey information about the residence. Consider having an elder law attorney review the resident contract agreement.
• You're doing business so ask the right questions. Find out about prices and what initiates a price increase. How much do the extras cost? Find out how each resident's needs are assessed and monitored. Inquire about policies on refunds, transfers, and discharges. What will happen if the facility closes? Is there an appeals plan for dissatisfied residents?

Be Prepared:

• Know the costs. Assisted living can be expensive. Be familiar with what each facility charges for each level of care, plus the charges for extra services beyond the monthly rate.
• Examine your finances. Monthly rates vary. Determine the affordable price range and shop accordingly. Will family members contribute and how much?

Be Thoughtful:

In most cases, adult children play a major role in helping a parent secure an assisted living residence. Respect the interests, needs, and wishes of your loved one. Although many assisted living facilities offer a lifestyle that preserves autonomy and dignity, moving from home to a new place can be a difficult transition. Work together to make plans and decisions. Don't exclude your parent from the process.

From Sen. Charles Grassley (R-IA), chairman of the Senate Special Committee on Aging

Combined Care Communities

Some independent retirement communities also integrate with assisted living on the same campus. Many care provider organizations are taking this one step further and providing independent living, assisted living and nursing care within the same building or in close proximity to each other. Not only is this a cost advantage to the care provider to share costs and clients among the facilities but it's an advantage to the resident who can maintain ties to the community, to a spouse and to friends in the facility. It's also an advantage to the care recipient's family since they do not have to relocate their loved ones to another facility.

Integrating care into combined care communities seems to be a trend that will continue to grow.