Dillon is 82 years old and lives in the home he’s owned for 50 years. He is able to take care of himself for the most part, but he can no longer drive and he relies on neighbors and family members to bring him groceries. It is getting more difficult for Dillon to prepare meals for himself, so now he sticks to breakfast cereal and other things he does not need to cook. His house could use some repairs. Dillon and his family agree that he is unable to keep up his house, but they do not think he needs the daily care in a nursing home. Is a nursing home Dillon’s only option?
The range of choices for many older people is enormous. Some include living with family, life-care-at-home programs, living in congregate housing, assisted living, and living in a continuing-care facility. Moreover, none of these alternatives is permanent. People often move from one to another as their need for a level of care changes.
Most—if not all—of the alternatives cost much less than living in a nursing home. All of the alternatives discussed in this chapter will give you much more privacy and independence than you will find in a nursing home. Another big advantage to these alternatives is that you would get to have your own personal living space. In a nursing home you would likely share a room with another person.
There is no uniform definition for these alternatives. In this chapter we will use the most popular terms. Keep in mind that these alternatives may be called something different in your community. Some of these alternatives have become popular only within the past few years. In many states these alternatives are not regulated by either the state or the federal government. This is sure to change as our population gets older and these alternatives become even more commonplace. Until then, you must gather as much information on your own as you can in order to make an informed choice.
The main alternatives to nursing homes are retirement communities, continuing-care retirement communities, assisted-living facilities, and home health care. These alternatives differ in the range of medical and personal service they provide to you. Each of these will be discussed in greater detail in this chapter, as well as a few other types of alternative living arrangements that are becoming more popular.
The companies that are building these alternative living arrangements usually focus on more affluent people. While some states allow you to use government funding toward living in these alternatives, many states do not.
One of your great concerns must be whether you are selecting a facility or program that accommodates effectively your possible need for nursing care in the future. If so, do you have the resources to cover the costs? Some institutions do not accept Medicaid; so if you run out of funds, you have to find one that does and then move. That will be disruptive.
CHECK IT OUT
Do not be fooled by flashy brochures and other marketing techniques. Talk with the other residents and their families, and call the references for the service you are considering.
Retirement communities are groups of houses or apartments where you must reach a certain age before you are allowed to move in. This minimum age is usually somewhere between 55 and 65 years of age.
Retirement communities often offer transportation to grocery stores, shopping malls, doctors’ offices, and community events such as plays and movies. Your fee might include one or more meals a day in the main dining room and exercise classes.
Retirement communities differ a great deal in the range of services and amenities they offer, from a few social and recreational amenities on the one extreme, to meals, personal care, medications supervision, and even nursing home care at the other extreme. The costs and payment structures also differ a great deal.
Assisted-living facilities are good alternatives for older persons who can care for themselves but need some help. They are sometimes called residential care facilities, personal care homes, or homes for adults. This is one of the fastest growing types of housing in the country. One of the leaders in the assisting-living industry opened 92 assisted-living facilities in 1998. The same company plans to open 300 more assisted-living facilities by the year 2002.
Assisted-living facilities are for you if you need help with some of your day-to-day activities, such as preparing meals, getting dressed, or bathing. Some may also supervise your taking of medications. Unlike nursing homes, which are highly regulated by your state department of health, assisted-living facilities are usually licensed by your state social services department.
PROFILE OF A RESIDENT
The average assisted-living resident is an 84-year-old single or widowed woman who needs help with at least three of her daily activities, such as preparing meals and getting dressed.
Before signing any contracts with an assisted-living facility, make sure you are clear on what type of care is covered. The facility may offer a basic package of services. If you use any other services, you could be charged an additional fee. Or you may be on your own in finding a particular service. For example, your facility may offer housekeeping services and food preparation for two meals a day. If you need health care services such as physical therapy or help with your medication, that may cost you extra.
Any contract that you are asked to sign as part of the entrance into any facility or program is an important legal document, with consequences that you might later regret. It should be reviewed by your lawyer before you sign it.
Pay special attention to the deposit you are asked to make. Will you or your family be entitled to get it back if you die prematurely? Can you sell your new place of residence and make a profit, or is your interest limited to the investment you have made?
When assisted-living facilities were first built, the residents were not allowed to use Medicaid to pay for their costs within the facilities. During the past few years, however, the states began to realize that many people lived in nursing homes because there was no other choice and that assisted-living facilities were less costly than nursing homes. Letting people pay for assisted-living facilities with Medicaid would actually save money for Medicaid. About two-thirds of the states now let qualified individuals use Medicaid to live in an assisted-living facility.
These can vary from one facility to the next, but in general an assisted-living facility will provide more services than a retirement community. Residents in a retirement community tend to be younger and more physically able than those in an assisted-living facility. Some services that you should look for include:
In a continuing-care retirement community, also known as life-care facilities, you move from independent living to more supervised living as your needs change. It differs from other alternatives in that it combines aspects of retirement communities with nursing home care. In effect, you could move into your own apartment within the community when you are 55 and progress through several levels of care until moving into the nursing home when you are in your nineties.
TALKING TO A LAWYER
When Services Are Reduced
Q. At the time we moved into our community, the association provided a security guard in the parking garage and in the main areas of the building. The security protection is now reduced to video cameras in the hallways and parking garage. Can we force them to bring back the services we were promised when we moved in?
A. In practical terms, that depends on the language of the contract you signed before you moved in. Oral promises are very hard to prove. Check and see what the contract says.
Answer by Jeff Atkinson, Professor of Law,
DePaul University School of Law, Chicago, Illinois
The original CCRCs charged a one-time fee when you moved in that covered all the services that would be available to you. It did not matter whether you wanted or needed those services. Today a CCRC would more likely ask for a one-time initiation fee followed by a monthly fee or rent. After that you may be charged for any service that you use within the facility.
Some CCRC contracts state that you are guaranteed care for your lifetime, even if you run out of money. This is part of what your initiation fee covers. Other CCRC contracts reserve the right to make you leave if you can no longer pay. Be sure you find out whether you have guaranteed lifetime care. If you will be asked to leave when you can no longer pay, what kind of notice will you receive? How much time will you have to move?
The apartment complex of the CCRC will often be connected by a hallway to a nursing home. If your spouse goes into the nursing home, you would be able to stay in your apartment and walk down the hall to visit your spouse. Even if the nursing home is in a separate building on the campus, you will be quite close to your spouse.
Like most of the other alternatives, home health care is almost always less expensive than a nursing home. (An exception is when you need 24-hour care or other treatment that is unusually costly.) Plus, you get to stay in your own home, which gives you more independence and privacy.
This is one of the few alternatives for which Medicaid will pay. If you are receiving skilled nursing care (as opposed to help with day-to-day activities such as housekeeping) in your home, Medicaid may pay for part of the care you receive if you meet income and asset tests.
Medicare also pays for more home care than is generally presumed. But it takes a sophisticated advocate to navigate through the definitions of “homebound,” “part-time or intermittent care,” and “skilled care.”
Because you are getting care in your home, there is little supervision unless your doctor makes home visits. There is no way for you, your doctor, or even the home health care agency to know for sure that you are getting the care you need. Your doctor may not be aware of some of your health concerns or of some of the problems that may arise unless you tell him.
This puts more responsibility on your family to make sure you have a regimen of health care at home. However, there are reputable, licensed agencies that provide this type of care and may be bonded regarding the persons assigned to provide your care.
If you choose home health care, you should address other concerns, such as the security of your valuables, as you will have strangers in your home on a regular basis. You may need the assistance of your family to make sure you do not become the victim of elder abuse, which can occur when people become careless regarding their own security and the security of their property.
Approximately 400 groups, many of them nonprofit, offer to help elderly people find younger people to share their homes. Home sharing works like this: The older person provides a room or shares the whole house with a younger person. The younger person takes care of the housekeeping and meals and provides company for the older person. In exchange, the younger person pays little or no rent.
You get to stay in your own home much longer, and you have someone to help with the upkeep. You stay independent and connected with the community. Your family gets peace of mind, knowing that you are not alone and that there is someone there to help care for you. You have the added security of a stronger person with a clearer mind being there for you if someone tries to take advantage of you or to break into your home.
If you have lived in your house for decades, it may be difficult for you to adjust to someone new living in your home. You may feel as if a stranger is invading your privacy. Even small adjustments, such as moving the furniture around or cooking a food you have never tried before, may seem like a big deal at first.
There are hundreds of groups that offer this service. These groups are a better option than putting a classified ad in the newspaper. The service you choose should find out—in great detail—the lifestyle habits of any person the service is considering putting into your home. The person’s references should be checked, as should yours. If the service finds a person that might be a good match for you, a meeting should be arranged. Then it should be up to the two of you whether you want to live together. Some of these services will also act as a go-between if you and your new roommate are having trouble adjusting to living together.
Begin by asking friends and neighbors in your church and community. Nursing homes, geriatric doctors, and associations for retired people may also be able to provide you with information on these services. Check with your local senior center or center on aging or with the state center on aging. Do an Internet search by asking your favorite search engine to search on “home sharing elderly” plus your state.
Cooperative shared housing is living with other older people in a family-style house that is owned by an agency. This house is in a residential neighborhood.
You would have your own room, as would several other older people. You would be responsible for your own personal care. Cooperative shared housing is usually less expensive than a retirement community. It gives you a chance to be independent and still have companionship. You are free to come and go as you would in your own home. If you want privacy, you can simply go into your own room and shut the door.
A manager that works for the agency would have a room in the house as well. The manager would prepare all your meals and take care of all the housekeeping. The agency might also provide other services, such as visits from a nurse.
When people from several age groups live together in one housing complex or community, that is an intergenerational home or community. For instance, an apartment complex may include families with young children, college students, and one or more floors that are equipped as assisted-living areas for the elderly. The students and families pay less rent because they spend part of their week working in the assisted-living areas. In this way you remain a part of the larger community.
People who miss their own families or who enjoy being around young children like the interaction that intergenerational living provides. The residents look out for one another and create a stable sense of family that many older people find comforting. Residents can become like grandparents to the children in the building.
Not everyone likes being around young children. If you are easily bothered by the sound of babies crying, balls bouncing, or children playing, this is not for you.
There is a growing trend toward the intergenerational community. Instead of selling your house and moving into an apartment, you would buy a smaller home (sometimes called a villa) in a development that is geared for several different age groups. The housing association would take care of your landscaping. The exterior of your house would be maintenance free. Your neighbors would be other retirees and families of all age groups.
A REPRESENTATIVE COMMUNITY
A New York intergenerational community includes 175 single-family homes, 50 townhomes, 48 villas, and an apartment building with 168 apartments for retirement-age people only. There is an on-site health coordinator for the residents. All of the apartments are equipped with a push-button emergency-response system.
These developments usually offer a clubhouse, a pool, and exercise facilities. It gives you the feeling of a close-knit community while allowing you to keep a high level of privacy. These communities do not offer the health care services that some retirement homes and assisted-living facilities provide. This type of housing is growing in demand as our population ages, though, and some builders are beginning to offer those services to entice you into their development.