Independent retirement living, assisted living, Alzheimer’s care and nursing care…how are they different and how do you choose?
Each year more Americans are living well past retirement age. How we age and the quality of our lives during this stage of life is dependent on many factors – from our overall state of health, to our financial situation, living conditions, and amount of support from others. We would all like to think that we would be able to remain in our own homes, independent and safe for the rest of our days, but for most of us and our loved ones that is not realistic. Making the decision to move to a senior living community and choosing the right level of care and services is one of the most difficult choices we will ever make.
Because it is human nature not to anticipate the changes we may face with aging, all too often planning for senior years is put off or overlooked until we are forced to make a decision under pressure. Even if we have faithfully saved for retirement, we may think of this time as a responsibility-free opportunity to pursue long-neglected interests, not a time to “down-size” our living situation. But what happens when a change in physical, mental or emotional status changes our ability to safely live independently? The key is to begin planning before the need arises, know your options, and understand the different degrees of care provided in each setting.
Senior Living Options
The first thing many people think of when the topic of senior living is mentioned is the stereotypical nursing home or “rest” home for the elderly. Let’s face it, whether we are members of the “Greatest Generation” or aging “Baby Boomers,” today we are looking for something in retirement that is not our granny’s idea of senior living. Fortunately, there are many options for seniors, with services and amenities to fit changing needs and lifestyles.
Independent Retirement Living. Retirement living communities come in many forms, from freestanding cottages or townhouses, to high-rise apartments and garden-style clusters, with the convenience of supportive services such as housekeeping, maintenance, trash pick up, onsite salon and barber shop, banking, meal service, library, exercise facilities and social activities. Many offer a choice of floor plans from large two-bedroom units, to one-bedroom and studio apartments, most with full kitchens and well-appointed baths. Many provide resident parking and scheduled transportation services for shopping and doctor’s appointments. They may provide one to three meals a day included in the price. Depending on the facility, utilities, cable television, WiFi and laundry service may be included in the monthly fee or charged separately. Most facilities do not include telephone or cell service as a part of the overall fee.
Retirement living facilities may be a part of a Continuing Care Retirement Community (CCRC), that provides other levels of care such as assisted living, Alzheimer’s care or skilled nursing, or they may provide additional assistance including medication management and sitter services for a separate fee. Payment for CCRCs can include an initial entry fee (or down payment) with subsequent monthly fees or payment may be based solely on monthly fees.
Retirement communities can be an ideal transitional stage for active seniors who would like to spend less time on household responsibilities, maintenance, yard work and meal preparation and more time traveling, pursuing interests, socializing and enjoying their retirement. It probably is not the appropriate setting for someone who requires more help with the activities of daily living such as bathing, dressing, managing medications, or someone who is having memory issues. While there is no legal definition of retirement living, it most certainly is independent living, meaning a person can choose to eat their meals, socialize, maintain healthy hygiene and come or go as they please.
Assisted Living. Assisted living bridges the gap between living independently and requiring a much higher level of care, such as that provided by an Alzheimer’s unit or skilled nursing care. Assisted living typically offers a combination of housing and meal service, assistance with bathing and dressing, medication management, weekly housekeeping, laundry and other supportive services. Most provide three meals a day as part of the monthly fee, with an additional charge for room service. Assisted living facilities generally offer a 24-hour staff, and periodic checks on the residents throughout the day and night. While assistance with bathing and dressing is generally a part of the basic service, residents have the choice as to how much assistance they will accept. As in the independent retirement setting, residents are free to choose whether to attend meals, maintain basic hygiene, socialize, follow physician’s orders, etc., so it is important for family members to be aware of behaviors of their loved one that might be detrimental to their health and safety. In Mississippi, a resident must be ambulatory to qualify to live in an assisted living situation, meaning they must be able to move about on their own without assistance.
Depending on the facility, there may be a choice of floor plans of one or two bedroom units or studio apartments, with efficiency kitchens including refrigerator, sink and microwave. Costs vary depending on the services provided. The federal government does not regulate assisted living and definitions of assisted living vary from state to state. Assisted living facilities may or may not offer services specifically designed for people with Alzheimer’s disease or other forms of dementia, so it is important to ask.
Alzheimer’s Care (Memory Care) Alzheimer’s care facilities, considered Special Care Units (SCU), are designed to meet the specific needs of individuals with Alzheimer’s disease and other dementias. They can take many forms and exist within various types of residential care. This specialized care is most often provided in cluster settings in which persons with dementia are grouped together in a separate unit, on a floor or in a special building within a larger residential care community. Some states have legislation requiring nursing homes and assisted living residences to specify exactly what specialized services their Alzheimer’s care units provide, such as a trained staff, specialized activities, and ability of staff to care for residents with behavioral needs.
In some ways Alzheimer’s care units are similar to other assisted living facilities in that they offer a combination of housing and meal service, assistance with bathing and dressing, medication management, weekly housekeeping, laundry and other supportive services. Most provide three meals a day and snacks as part of the monthly fee. However special attention is given to safety and security to prevent residents from wandering outside the facility. These special units offer 24-hour staff, and periodic checks on the residents throughout the day and night. Daily activities are designed to stimulate cognitive function and encourage social interaction. Most facilities offer private or semi- private rooms with adjacent baths. Most Alzheimer’s care facilities require that a person must be ambulatory, meaning they must be able to move about on their own without assistance in order to qualify for residency in the unit.
Nursing Facilities (Long-Term Care) Nursing care is a category of care, in which round-the-clock monitoring and long-term medical treatment are provided. Most nursing facilities have services and staff to address issues such as nutrition, care planning, physical therapy, recreation, spirituality and medical care. Most offer private or semi-private furnished rooms with adjacent baths. Different nursing facilities have different staff-to-resident ratios. Also, the staff in one nursing situation may have more experience or training with dementia than the staff of another. Nursing facilities or units are licensed by the state and regulated by the state and/or federal government.
Nursing care facilities offer housing, meal service, daily personal care and assistance with bathing, dressing, toileting, and physical therapy, as well as providing on-site healthcare. Nursing care facilities are designed to give consistent and ongoing medical care with physician oversight for patients whose conditions do not require hospitalization.
There are three levels of nursing care: skilled, intermediate, and custodial.
SKILLED care is the highest level of service. It must be prescribed by a physician and may only be performed by or under the supervision of technical personnel, such as a Registered Nurse, Licensed Practical Nurse, or physical therapist.
INTERMEDIATE care is less intensive than skilled care and is appropriate for individuals who do not need 24-hour attention.
CUSTODIAL care is appropriate once specific technical personnel are not needed for daily care but the individual is not likely to make further significant improvement.
Additional Services For additional personal care, some families or individuals choose to supplement the services provided in independent living, assisted living, Alzheimer’s care or nursing care settings with the optional services of a personal sitter, who is paid by the hour to supervise a sick or memory challenged patient. In the institutional settings of most assisted living, Alzheimer’s or nursing care facilities, sitters are not allowed to administer medications. They provide companionship and assistance with daily activities. Many continuing care retirement communities provide a staff of sitters for residents who request the service, at an hourly rate in additional to monthly residential fees.
Where to Start The time to start investigating senior living options is not when it is apparent that they are needed, but before, when there is time to weigh the pros and cons, take a serious and honest look at what services you or a loved one wants and needs, and do your homework to determine what facilities are available in your area. It’s a good idea to discuss your options with your primary care physician, who can provide recommendations as to the appropriate setting based on your needs and capabilities. Your choice of type of care may also be subject to State or Federal regulation and assessment by the facility.
Once you have determined the level of care that is appropriate, narrow down the choices to three or four that offer the services you need and schedule appointments to tour the facilities, eat in the dining room and talk to residents. Ask to see a typical apartment, review floor plans and check out the special amenities that are offered. It’s recommended that you visit a facility more than once before making a decision.
Following are questions you might ask yourself before choosing which senior living setting is best for you.
• Do I prefer to live at ground level or on an upper floor? How do I feel about elevators?
• How far is it to the dining room from an available apartment?
• What are the amenities offered that I will actually use, such as an exercise room, card room, library, movie screening room, salon/barber shop, etc.?
• Are religious services offered?
• Am I more comfortable in a large facility with lots of activities and amenities or in a smaller setting where I will know more of my neighbors?
• Do I know anyone who is a resident at this facility?
• Is this facility close enough for my family and friends for them to visit often?
• How is the food and what are the times meals are served?
• Is adequate security provided on the grounds and in the building?
• What is the atmosphere of the facility? Formal? Structured? Friendly? Casual?
• What can I afford to pay? What are my options in terms of financial assistance?
NOTE: Options for paying for senior care vary from private pay, to long-term care insurance, to social security, Veterans benefits, Medicare and Medicaid and are not the same for different facilities and levels of care. For more about paying for senior care we refer our readers to LongTermCare.gov and VA.gov as a place to start.
Help Is Available
Alzheimer’s Association 24/7 Helpline care consultants can help you with residential care decision-making and provide you support. Call 800.272.3900 or visit Community Resource Finder.
Medicare’s Nursing Home Compare provides detailed information about the past performance of every Medicare and Medicaid certified nursing facility in the country.
Assisted Living Federation of America (ALFA) offers information about assisted living, a checklist of questions to ask when considering a facility, and a provider directory to identify facilities in a particular area.
Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) website allows you to search for accredited long-term care facilities. An accredited facility is a nursing home or assisted living that meets very high standards of care set by JCAHO.
THE TAKE-AWAY Only you and your loved ones can make the final decision about which category of care and which facility is best for you. Remember to make your choice based on your current needs, not what your interests once were, i.e., don’t pick a golf-based senior community when it’s been years since you hit the links or a large, spread out community when you are having mobility issues. Be honest with yourself and your family about what you are looking for and what you need in a senior care setting. Finally, know that your needs can and probably will change in the future. Don’t be afraid to admit when or if you need more help. The beauty of a continuum of care is that your needs can be met as they arise. Your wellbeing, safety and quality of life depend on finding the right senior living setting for your stage of life.