Residential Care Options: Housing Options

By Family Caregiver Alliance

Choosing the right place for a loved one to live, if not at home can be challenging. The options available depend on the kind of care that is needed, your loved one’s personal preferences, and finances. All facilities require a TB skin test and medical form completed by the doctor before admission.

Some decisions can be made proactively, before there is a need, such as investigating independent living, Continuing Care Retirement Communities (CCRCs), or Multi-Level Retirement Communities (MLRCs). Other times the decision is made reactively—when the need is immediate. It may be helpful to find a facility that has multiple levels of care, or you may do well with a facility that does the one specific thing you need, e.g., dementia care. If you are comfortable with changes in living situations, you can make a decision based on current needs, knowing that you might have to change to a different situation as your loved one’s care needs increase.

There is a spectrum of residential living facilities available to seniors and people with disabilities. They range from total independence to dependent care provided in skilled nursing facilities. Below are the kinds of care outside the home that are found in most urban and suburban communities. Fewer housing options are available in rural communities. These facilities may go by different names in your area. To get information on local residential options search senior housing online and call your local AAA (Area Agency on Aging) located in each county. In some areas you can find AAAs by dialing 211, or on FCA’s Family Care Navigator.

Independent Living

Also known as Retirement Community or Senior Living Complex, this is a non-medical living situation that allows people to live in their own apartment. Some subsidized independent living is available for individuals with low income—often federally funded U.S. Department of Housing and Urban Development (HUD) housing.

Provides: May include an optional meal plan, housekeeping, social/recreational activities and outings, and transportation to shopping and medical appointments. Some offer emergency alert system in apartments.

Options: For an extra charge, may include medication management and help with personal care.

Requirements: Ability to be active and independent in most aspects of life, such as socializing, walking, dressing/personal grooming, meal prep, money management, etc.

Cost: Costs vary greatly due to location and overall scale of the community. Available housing cost subsidies are typically governed by state and federal regulations. Most subsidized housing has a waiting list. Be sure to ask about the criteria for how someone is selected off of the list, e.g. first-come-first-serve, or need based, etc. If care services are needed, such as medication management, bathing assistance, etc., it may be available for purchase at the residence or hired independently through an outside agency.

Advantages: Independence and privacy; freedom to come and go as desired; freedom to cook for one’s self if you like; and sometimes larger apartments and resident parking.

Disadvantages: If a resident requires more care due to physical or cognitive decline, they might need to move to another facility or another level of care within this facility. Or the resident would be responsible for hiring in-home care in order to stay in the apartment.

Continuing Care Retirement Communities (CCRCs)

Continuing Care Retirement Communities are a buy-in model: you own your own home or condominium. However, CCRCs have all levels of care, from independent living to skilled nursing, and there is usually a lifetime contract for care within the facility. There may be a large campus with individual homes as well as buildings with apartment/condo-like residences.

Provides: Most services including meals, social and recreational activities, personal care and medication management, to skilled nursing care as needed. Often has recreational facilities and other services such as swimming pool, tennis courts, salon/spa, theater, chapel, resident parking, ride service for non-drivers, etc.

Options: Depending on the CCRC agreement, residents may have access to, or be able to hire, help in order to stay in independent living rather than moving to the assisted living part of the facility.

Requirements: Financial eligibility determined by residence.

Costs: Depends on the residence, but generally equivalent to buying a house in the community. Monthly fees are charged which can be upwards to several thousand dollars, in addition to a buy-in fee. Some facilities will provide lifetime care if the individual runs out of money. Long-term care insurance usually does not cover independent living, although it might help if additional care is needed for assisted living or a hired caregiver. Medicare/Medicaid might cover some nursing home care if it is accepted by the facility. Read the contract carefully as there are several different kinds of CCRC agreements.

Advantages: All levels of care are provided in the same community, so there is no need to be uprooted if care needs change. There is usually a lifetime contract so that care is provided even if resident’s finances are depleted. Most CCRCs allow the resident to sell the condo when they are no longer living in it (if it is privately owned).

Disadvantages: May have to use the facility’s medical team as opposed to an outside physician. Tends to be very expensive to buy into the community. Some preclude someone with a pre-existing condition such as a diagnosis of dementia, from purchasing a contract.

Multi-Level Retirement Communities (MLRCs)

Similar to CCRCs in services provided and options available, with all levels of care on the same campus (independent living, assisted living, skilled nursing), however the resident rents the apartment/room, rather than buying in. The monthly cost is similar to an Assisted Living Facility, with the cost increasing as the level of care increases.

Board and Care

Also known as Personal Care Homes, Assisted Living Homes, Residential Care Facilities, Residential Care Homes, Adult Home, Adult Foster Care. States have different names for this type of residence.

Non-medical care in a home with fewer than six residents; some private and some shared bedrooms. (Note: The number of residents permitted with this licensing varies from state to state.) Residents share living space, may share a bathroom. The goal is to provide small, intimate, and personalized care in a home-like setting for residents.

Provides: Meals, personal care (bathing, grooming, dressing, incontinence care, help with eating and meal prep, laundry), housekeeping. May offer activities and help with transportation to medical appointments.

Options: Provides medication management, either self-administered or staff-administered, depending on licensing requirements. Some homes have special waivers or licenses to provide psychiatric care, dementia care, and hospice care. For people who have sleeping problems or who tend to wander, look for a home with staff who are awake at night (not all facilities offer this).

Requirements: May have to be able to walk independently, although these residences usually will accept people using walkers and wheelchairs; may have to be able to transfer from bed or chair independently (except hospice patients). Special waivers may be required by state licensing for hospice care or dementia care.

Costs: Often lower than other facilities. Qualifies for long-term care insurance. In states with Medicaid 1915c waivers (HCBS waiver), the cost may be covered for those who qualify for Medicaid (Medi-Cal in California). Supplemental Security Income (SSI) covers the cost for Board and Care Facilities for certain conditions, such mental health patients and people with developmental disabilities. Medicare does not pay. Veteran Administration (VA) may pay.

Advantages: Hospice waiver, dementia waiver will allow a facility to provide specialized care. Smaller, home-like setting is good for residents who don’t like or need a lot of activity, but would thrive with more personal attention.

Disadvantages: May require the resident to transfer independently from bed to chair, etc., and not all have awake staff at night. The environment might not be as stimulating and varied as in a larger facility. May not offer transportation service to medical appointments or other places.

Assisted Living Facilities (ALF)

Also known as Residential Care Facilities for the Elderly (RCFE).

Non-medical facility, larger than a Board and Care, with a building built especially for this purpose with up to several hundred residents. Most facilities offer levels of care, such as independent living, assisted living, and/or memory care unit. Rooms may be studio or one/two bedroom apartments. May or may not have cooking facilities. Each state has different regulations for what is and is not provided. Some are owned by for-profit businesses and others are owned by not-for-profit organizations. The ownership can have an impact on the culture of the residence. Service can vary greatly, so be sure to look beyond the attractive physical appearance of the building and grounds to confirm that the resident care services you need and desire are provided in a high quality manner.

Provides: Meals, social and recreational activities, housekeeping, laundry, some transportation (often to doctors, shopping, outings, etc.), medication management, 24-hour supervision.

Options: Most facilities either have levels of care or a “cafeteria” plan to accommodate changes in care needs. Either way, there is an additional charge for personal care, administering medication, assistance in getting to activities or meals, etc. Residents can receive a higher level of care as needed without moving to a different facility, unless medical needs require skilled nursing.

Requirements: May have to be able to walk independently or with a walking aid. Most accept wheelchairs. Usually need to be able to transfer from chair to bed or similar independently.

Costs: There is a base rate for the kind of room that is rented, such as a studio. There is often a one-time admission fee which is often equivalent to the monthly facility charge. There are additional charges for added services. Memory care has a higher base rate. Qualifies for long- term care insurance. In states with Medicaid 1915c waivers (HCBS waiver), the cost may be covered for those who qualify for Medicaid (Medi-Cal in California). Medicare does not pay. VA may pay.

Advantages: Works well for couples where the care needs may be different for each person. Provides socialization and a community so that residents don’t become isolated in their own homes. Most care needs can be provided in the facility. Often have a specialized section for memory/dementia care. Help is always available. Hospice care is allowed in the facility.

Disadvantages: Large facility might be overwhelming and transition to new place might be harder. Takes longer to integrate into the community and find appropriate social relationships. Costs can be high depending on the community and the amount of care needed. Yearly fee increases are to be expected.

Memory Care/Dementia Facility

Memory care provides specialized care for those with cognitive impairments such as Alzheimer’s disease or similar conditions. This may be a free-standing residence or part of an Assisted Living facility/CCRC/ MLRC. Dementia facility staff are required to have special dementia care training, including continuing education. Facilities must have locked or delayed exit style doors, alert system, or auditory device to monitor exits, so as to provide safety for those who could get lost if they left the facility on their own. Outdoor facility space used by residents must be secured by a fence, gate, or delayed exit system. Residents must not have access to stoves, medications, or any conditions that may be hazardous. Activities are geared to the needs and abilities of the residents and are designed to engage them. Residents may have a private or shared room. Cost is generally higher than Assisted Living, although long-term care insurance and the VA may cover the costs. Medicaid 1915c waivers may also be accepted.

Skilled Nursing Facilities (SNFs)

Also known as Nursing Homes, Convalescent Hospitals, Rest Homes

SNFs provide care for individuals who need nursing care, but don’t need to be in a hospital. These are medical facilities with 24-hour nursing supervision, with a requirement that there be at least one RN on duty at all times. SNFs are able to help with complex medical treatment such as feeding tubes, ventilators, oxygen, wound care, injections (such as insulin) or IV medications, as well as care for someone who is bed-bound.

Provides: Rooms are similar to a hospital with one to three beds per room. Meals are provided as well as some social activities. For individuals needing rehabilitation, there are trained occupational and physical therapists on staff (Patients are often discharged to a SNF for short-term rehabilitation after hospitalization. This is usually covered by insurance.) Nursing care and personal care are provided at all times. Medications and more complex medical care provided.

Options: For a higher cost, an individual can have a single room. Therapies can continue if paid for privately after insurance coverage ends. There is a daily rate for patient care after insurance deems no more “skilled care” is needed (something that requires a professional to do).

Requirements: Facilities vary on what higher level of medical care is provided, for example, not all skilled nursing facilities will accept ventilators or feeding tubes.

Costs: Nursing homes are the most expensive form of care. If a private room is desired, the cost is also much higher. Medicare will pay for rehabilitation for a maximum of 100 days after a hospitalization as long as there are skilled needs, e.g. ongoing physical therapy or certain medical procedures. Most stays for rehab are two to three weeks. Medicaid will pay for an individual to be in a nursing home indefinitely if they have ongoing care needs. Long-term care insurance and the VA also can be accessed to help cover part of the cost of nursing home care. Note: Not all nursing homes accept Medicaid. Medicare, Medicaid, and private insurance cover on a short term basis for rehabilitation. The VA has SNFs in some locations where veterans can get ongoing care.

Advantages: If resident qualifies for Medicaid, then costs for care are covered. All medical care is provided without the need to find additional care if health declines.

Disadvantages: More institutional setting with other residents also more disabled, so these facilities may seem depressing.

Eden Alternative and Greenhouse Project

National movement to improve care for people in facilities to make them less institutional and more responsive to the individual needs of residents. To learn more and see if there is a facility near you, visit www.edenalt.org or www.thegreenhouseproject.org.

A Word About Cost

Costs vary in different parts of the United States and change regularly. These are some websites that help you calculate the costs in your area:

https://acl.gov/ltc/costs-and-who-pays

https://www.ltcfeds.com/tools/cost-of-care

Where to Find Help

Many community organizations can help you find what is available in your area. Listed below are the main government agencies that are responsible for overseeing senior care residences. Often your best resource is word of mouth and online rating services with honest consumer reviews. If you have friends or family who have had positive experience with a given facility, check with them first.

Professional in-person and online senior housing finding services and private case managers who can be hired to manage the search for appropriate housing can help. Although some are free to you, typically they receive a finding fee from the facility if their referral results in a contract to move to the facility. Given this incentive, be sure to ask if their senior housing recommendations include all possible facilities that fit your requirements or only those who they have a fee arrangement. Different agencies specialize in different kinds of facilities, so you want to find one that can help you find the kind of care you need.

Resources

Family Caregiver Alliance
National Center on Caregiving
(415) 434-3388 | (800) 445-8106
Website: www.caregiver.org
Email: info@caregiver.org (link sends e-mail)
FCA CareNav: https://fca.cacrc.org/login
Services by State: https://www.caregiver.org/connecting-caregivers/services-by-state/

Family Caregiver Alliance (FCA) seeks to improve the quality of life for caregivers through education, services, research, and advocacy. Through its National Center on Caregiving, FCA offers information on current social, public policy, and caregiving issues and provides assistance in the development of public and private programs for caregivers. For residents of the greater San Francisco Bay Area, FCA provides direct support services for caregivers of those with Alzheimerʼs disease, stroke, traumatic brain injury, Parkinsonʼs, and other debilitating disorders that strike adults.

Residential Care Options: Five Tip Sheets

1. The Right Time
2. Housing Options
3. Choosing the Right Place
4. Caregiving Doesn’t End When Your Loved One Moves
5. Visiting Someone in Dementia Care