Anne, seventy-six, sank gratefully into the chair across from me, exhausted from her search for a facility. Before I could say hello, she sighed, “I’m so tired and confused. I’m not sure where my husband needs to be. For three years, I’ve taken care of him at home, and we’ve been fine,” she continued. “Then last Saturday morning, I couldn’t wake him up. I got scared and called 911. He’s been in the hospital for five days now, and I need to find a place for him by tomorrow. The doctor says I can’t take care of him at home any longer.
“So the discharge planner at the hospital gave me this list of facilities,” she went on. “The first one I saw was a small six-bed house. The next was a large, two-story hotel-type place that felt too big. The third looked like a hospital. I know he doesn’t need a hospital, but what am I looking for?”
“It can get complicated, Anne,” I confirmed. “The two most common levels of care are assisted living and nursing homes. Because of federal regulations, all nursing homes resemble hospitals. Assisted-living facilities look more homelike.”
Assisted Living
Although the generic name is “assisted living,” these facilities are known variously throughout the country as board and care, residential care for the elderly, retirement home, adult congregate-living community, congregate-care retirement, and many other names. In the United States, assisted living is the fastest-growing type of senior housing. Unlike federally regulated nursing homes, assisted-living facilities are regulated by individual states; therefore, there is enormous variety across the country, ranging from small board-and-care cottages to elaborate hotels. Interestingly, in some states, schools have been converted into assisted-living facilities, reflecting the demographic changes in America!
The goal of assisted living is to assist with basic personal needs, such as bathing, dressing, and grooming, while keeping the resident active and engaged in the community. Assisted living fosters independence, personal dignity, and privacy. In many facilities, transportation to movies, shopping, or other outings may be available. Assisted living may also offer partial health care, such as “medication management” (taking the correct pills on time).
Fire safety regulations require that residents in assisted living be physically and mentally able to get themselves out of danger in case of emergencies such as earthquake or fire. Increasingly, however, there is a blurring of definitions as to how these regulations are enforced. For example, fire regulations are being more loosely interpreted to allow mentally competent residents with physical restrictions to stay in assisted living. It is important to be aware of your parent’s abilities regarding emergency issues.
While assisted-living facilities do not offer comprehensive twenty-four-hour medical and nursing care, they generally do provide the following:
1. Assistance with bathing, dressing, grooming, and personal hygiene
2. Twenty-four-hour supervision
3. Three meals a day
4. Medication management
5. Assistance with toileting and incontinence issues
6. Housekeeping and laundry
7. Social activities, such as ceramics and exercise classes, lectures, shopping, and outings to local theater
8. Emergency call system (In the bathroom and by the bed, a call cord is required to notify staff in case of emergency)
Cost Is a Consideration
Since Medicare does not pay for assisted living, and Medicaid pays very little, virtually all expenses are out-of-pocket for families or residents. Currently fees range from $2,000 to $8,000 a month. Services may be covered by one all-inclusive monthly rate, or they may be à la carte based on individual needs. When searching for a facility, it is important to ask what that monthly fee includes, as well as what it does not include. Look carefully at elaborate fee structures, as they can add hundreds, even thousands to the monthly bill. Are there different charges for different levels of care? Is a deposit required? What are the total monthly costs?
Where Does Your Family Member Belong?
As an introduction to community living, assisted living is preferred because of the homelike atmosphere. Considering that moving a parent out of her home will probably cause guilt and misgivings, the transition is easier and less threatening for both of you.
As I sat and talked with Anne, it became clear to me that her husband was an assisted-living candidate—he could get out of a chair unassisted and his physical needs were well within the parameters of assisted-living care. Once we had determined his status, Anne wanted to revisit the other assisted-living facilities she had seen. “What should I look for?” she asked.
“Fortunately, a walk-through in assisted living is less complicated than a walk-through in a nursing home,” I told Anne. “Here is a guide to help you evaluate the facilities”:
1. Do the residents have the same level of abilities or disabilities that your family member has? In some facilities, the majority of residents may be in advanced stages of dementia. In others, they may be attending lectures on current events and participating in exercise classes. Which facility would be best for your parent?
2. Does the facility have a homelike environment? Would you be comfortable visiting?
3. Will the facility offer a measure of privacy and independence for your parent?
4. Is there a smoking policy?
5. Are the activities in places that are accessible if your parent uses a walker?
6. Watch residents engaged in an activity. Are they enjoying themselves? Are they socializing? Is there interaction between the activities director and the residents?
7. Is the facility too large or small for your parent? Just as some teenagers prefer a large or small college, your parent may have a preference as well.
8. Is there an emergency call cord by the bedside and in the bathroom?
9. Does the staff greet or acknowledge you as you walk by?
10. Look at staff-resident interaction; does the staff treat residents with respect and dignity?
11. Is there an unpleasant odor? Although odor should not be an issue in assisted living, it can be a red flag that there are housekeeping and personal-care problems.
12. Does the food look appetizing? Do residents seem to enjoy their meals? Would you be allowed to sample a meal?
13. Does the facility have a van to transport your parent to shopping, the theater, or to his doctor’s office?
14. Is the facility licensed? If not, it means the care is not being monitored by the state, and this puts an added responsibility on the family.
15. Ask who is responsible for the health care of your parent during a medical emergency. For example, if your parent needed medical attention during the night, who would arrange it?
Be Aware of Your Parent’s Needs
As your parent ages in place at the assisted-living facility, be aware that the status of his mental and physical health will change. When you notice his physical needs increasing, or his cognitive abilities diminishing, it may be time to reassess whether the facility is still offering the appropriate level of care. If you find that your parent is not taking his medicine, that his clothing is soiled, that he is losing weight, or that his behavior is changing, speak with the administrator and voice your concerns. Ask if the facility can continue to safely and successfully accommodate your parent as his health and medical needs increase. If the administrator says yes, but your parent continues to lose weight, or fails to take his medications, begin looking into nursing home options before a crisis develops. You do not want a call from the facility saying, “We can no longer take care of your parent.” Nor do you want your parent to remain in a level of care that is inappropriate for his needs.
Time to Relocate Once More
Most families are relieved to find a homelike assisted-living facility where their parent is safe and socially engaged. For a time, it can be the ideal situation. You may think, Dad can just remain here. He’ll never need a nursing home. However, assisted living should not be considered an alternative to nursing home care. As residents become more frail and forgetful, the assisted-living environment can become dangerous to their health and safety. The average length of residence in assisted living is three years. In my experience, the most common reason for discharge is the need for a nursing home. This surprises many families who do not expect another relocation. Just as they become accustomed to assisted living, it is time to educate themselves about nursing home care.
Society has a bias against nursing homes, but professionally run, caring homes do exist. To locate them, you must become a sophisticated, knowledgeable consumer. The next chapters are an essential guide to finding a high-quality, professional nursing home that will care for your parent and be helpful and supportive to your family.