What are the options for residential care facilities?

By Amy Goyer

When Dad stopped driving, he said that he and Mom were going to move to a senior community (Mom had stopped driving 20 years earlier after a stroke). They didn’t want to be isolated. So, they moved into an independent living apartment on the campus of a continuing care retirement community (CCRC).

After a severe injury, illness and extended hospital stay, Mom went to the skilled nursing facility on the same campus as their apartment, where Dad continued to live while she recovered. It was a great arrangement because Dad and his service dog could walk to see Mom several times daily. At the end of her rehab stay, she was able to go back to their apartment for another year before they moved back in with me when they needed a higher level of care than we could afford there.

Like my family, you or your loved ones may be considering a move to a different type or level of residential care to fit changing needs. Maybe they want to downsize and live in a place that provides meals, housekeeping, socialization, and other services. Perhaps they need more support, or their home cannot be made safe for them.

The various options can be confusing, and no two facilities are identical. Often called “levels of care,” the availability, names, and state regulations governing residential care options can vary across states and communities. These are the most common types to consider, along with my tips for how to choose one.

Independent Living (IL) Communities: Residents have their own apartments and can generally take care of their own needs. Usually, essential services like housekeeping, meals, activities, transportation to grocery stores, entertainment, and medical appointments for residents are provided. Some have onsite security and may offer medical alert systems that help residents in an emergency. A la carte personalized services for which you pay additional fees may be offered (like help with bathing, laundry, or medication reminders), which is why I’ve included this option in our residential care list. Residents can come and go as they please without reporting their whereabouts to staff.

Generally, IL fees are paid out-of-pocket, although if a higher level of a la carte services are provided, some residents – like my parents – may be able to use long-term care insurance to help pay for care at the “home health” level.

Assisted Living Facilities (ALFs): This option is for people who need more support. Assisted Living services vary, and costs can differ accordingly. Some facilities include basic services for a flat monthly fee. Others have a base rate, and all services are paid for a la carte, so it’s a good idea to anticipate what future needs may be – and associated costs — as you look at the budget going forward. ALFs offer assistance; don’t assume loved ones will have 24-hour, constant, 1:1 care.

Usually, ALFs assist with personal care in the morning and evening, such as bathing, toileting and dressing; management and administration of medications; three meals per day and snacks; activities; and more supervision and monitoring of residents than IL. Residents will have a call button to request assistance, but depending on staffing, it may take half an hour or more for helpers to arrive. In ALFs that are not explicitly designed for memory care, residents can leave whenever they want to, so if your loved one is at risk of getting lost, be sure to ask about keeping them safe in the ALF.

Fees for ALFs are generally paid out-of-pocket or with long-term care insurance policies, although, in some states, some facilities will accept Medicaid.

Skilled Nursing Facilities (SNFs): Residents in SNFs need more medical care than in ALFs or IL. An SNF, also known as a nursing home, provides the same basic services as ALFs, including help with personal care, meals, medications, and activities. But they should also provide more 1:1 hands-on care; deal with more complicated medical support and treatment; offer physical therapy, occupational therapy and speech therapy; and provide closer monitoring and supervision.

Some go to an SNF for a few months for short-term rehabilitation after an illness or surgery (like my mom did). Others are there for long-term, ongoing care. Some residents can walk and get around the facility independently, while others may be confined to their beds. SNF staff may not be able to get to residents immediately when they use their call button to request help.

Medicare or private insurance may cover SNF fees for short-term stays and rehabilitation. For long-term stays, after Medicare stops paying, Medicaid may cover the costs for eligible individuals. Long-term care insurance can usually be used. Otherwise, residents pay out-of-pocket.

Memory Care Facilities (MCFs): Some ALFs and SNFs have areas designated for those with dementia, providing higher staffing levels, more supervision, appropriate activities, and extra safety features with buildings designed to prevent residents from getting lost. Be sure to get a clear expectation of how much 1:1 care your loved ones will receive, their access to outdoor areas, and their quality of life in the facility.

Continuing Care Retirement Communities (CCRCs): When several levels of care are included on one campus, they are often called CCRCs. The name refers to the fact that residents can continue their care at that campus as their needs change by moving between levels of care. They may include all the previous levels of care listed above, although fewer include memory care. These facilities often offer some extra services to those in independent living because they do have nurses and other staff on the campus.

In some CCRCs, residents pay a hefty fee upon entering the community (and for some, an additional monthly fee is charged based on the level of care), and they are guaranteed care in any of the facilities on campus as needed. Others are based on monthly fees only. The methods residents can pay for care in CCRCs depend on their level of care, although personal funds will be used for those that require a significant upfront payment.

Group Homes (also known as Board and Care Homes) and Adult Family Homes (also known as Adult Foster Homes): These are family-type homes in neighborhood settings. Group homes generally have several older people or people with disabilities. Adult Family Homes may have as few as one resident receiving care, although that may vary from state to state.

People are cared for by the homeowner and/or staff (who may also live there). The number of residents, staffing levels, training requirements and services offered vary according to state laws and policies. They offer services similar to an ALF but in a homier setting. In fact, in some states, they are licensed as small ALFs. Depending on state requirements, they may not have a nurse on staff. They may offer more 1:1 care because they are smaller, or they may offer less because they have fewer staff.

In some states, Medicaid waivers for home-based care may be used to cover costs. Depending on the policy, some may be able to use LTC insurance. Many pay out-of-pocket only.

How to Choose a Residential Care Facility

As you investigate options, here are some tips to help you get a realistic picture of the care your loved ones will receive and the best place for them to live:

  • Get a physician’s evaluation. For some, physical and occupational therapy consults will also be helpful.
  • Consider current and potential future needs. Will the facility be appropriate as their needs change?
  • Visit facilities multiple times, including unscheduled visits. If possible, bring your loved ones for visits after you have narrowed down the choices.
  • Talk with residents and their families without facility staff present.
  • Sample the meals on a typical day and ask staff how dietary restrictions are handled.
  • Observe activities.
  • Observe the resident and staff attitudes, their levels of contentment, and how they interact.
  • Ask to review detailed policies and licensing/certification requirements as well as the most recent state reviews or surveys.
  • If facilities accept Medicare (even if you aren’t using Medicare to pay for their services), find information about their ratings, staffing, health inspections and quality measures on Medicare’s Care Compare website.
  • Ask staff how emergencies, such as a fall or a sudden illness, would be handled.
  • Ask how COVID-19 infections are handled among staff and residents.
  • Ask how direct care staff and administrators will communicate with family caregivers. Is there a family council?
  • Remember that, in addition to their health and personal care, your loved ones’ quality of life is vitally important. Pay attention to issues that are important to them, such as the ability to spend time outdoors, use of a television, socialization, the comfort of their bed and chairs, quality of food and ability to make personal choices.

Resources

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.