Many of us hope to stay in our homes as we grow older. Often we are able to do that. But later in life—usually by our 80s and 90s—some of us need a hand with everyday activities like shopping, cooking, or bathing. A few of us need more help on a regular basis. Maybe that means it’s time to move to a place where expert care is available around-the-clock.

Where to start

Do you think that your family member can’t live at home any longer? It might be your husband or wife, a parent, aunt or uncle, or even a grandparent. You’ve added a hand rail on the front steps and grab bars in the bathroom. You made plans for a home health aide to come to the house every day. You arranged for help with meals, and you visit every day. But now you wonder if staying at home is the best choice. Where do you go for help? Here are some answers to that and other questions that you might have as you look for the best place for you or your relative to live.

Sometimes the need for help grows over time. For example, Bob is 87 years old. He has lived alone since his wife died ten years ago. For the last few years, he has needed more and more help doing things for himself. First, he had trouble making meals. So, he ate a big lunch at the local senior center until last year when he gave up driving. Now sometimes his daughter drops off meals. Other times meals are delivered by a local program. The stairs in his house are getting too hard to climb. Bob also forgets more and more things. He often forgets to take his blood pressure medicine. He has also left the burner on the stove turned on several times. He doesn’t want to move in with his daughter and her family, so Bob and his daughter are looking for a new place for him to live.

Over the last year Bob’s daughter has been thinking this time might come. She knows what’s available. She’s looked into how they will pay for the care her dad needs. Bob too has been doing some planning. He is sad about leaving his home, but he has been preparing for the time when he’d need more help. He even put his name on a waiting list for a nearby retirement community that he liked. Now they have an opening there. The admission coordinator at the community will help him decide if he can live in one of their apartments or needs to be in their assisted living facility.

Bob and his daughter were lucky. Sometimes you need to make a choice quickly. If you haven’t planned ahead, then making a decision might not be so easy. For example, Alice and her husband have lived in their house for 50 years. At 84, she still loves to cook and work in her garden every day. Last week she slipped in her bathroom, fell, and broke her hip. Now after an operation to fix her hip, she needs to go somewhere for nursing care and rehabilitation. Her doctors don’t know if she’ll ever recover enough to go home again. Her children live hundreds of miles away. But her husband and family only have a few days to find a place.

Alice and her family were not prepared like Bob and his family. The social worker and discharge planner at the hospital will help them find a place for Alice to go for therapy after she leaves the hospital. But if she is too frail to go home after her hip heals, she and her family will have to choose a place for her to live permanently.

What the choices are

There are two kinds of senior living facilities based on how much help is needed:

• Assisted living facilities
• Skilled nursing facilities or nursing homes.

You should think about an assisted living facility if you or your relative don’t need a lot of medical care but do need more help than can easily be gotten at home. Assisted living homes can give someone as much help as needed with daily living, but offer only some nursing care or none at all. People often live independently in their own unit. The place provides meals and house cleaning, offers interesting things to do, and takes residents wherever they need to go, like the doctor or the shopping mall. They can also provide help with bathing, dressing, and taking medicines, if needed.

Some assisted living facilities are part of a continuing care retirement community or lifecare community. These communities offer independent living and skilled nursing facilities as well as assisted living. Sometimes assisted living help is set up in a home with only a few residents. These are often called board and care homes.

If your relative becomes very frail or suffers from the later stages of dementia, more care could be needed. A nursing home or skilled nursing facility may be necessary if someone:

• needs round-the-clock nursing care,
• might wander away without supervision,
• needs help with meals, bathing, personal care, medications, and moving around,
• needs more help than the current caregiver can possibly give, or cannot live alone.

These places supply 24-hour services and supervision, including medical care and some physical, speech, and occupational therapy, to people living there. They might also offer other services such as social activities and transportation. As a rule, the rooms are for one or two people. Some places want residents to bring some special items from home to make their rooms more familiar. Some even allow a pet or make it possible for couples to stay together.

Both assisted living and skilled nursing facilities sometimes offer special areas for people with dementia. These areas are designed to meet the special needs of these people and to keep them safe from wandering.

How to choose

Ask questions. Find out about what is available in your area. Is there any place close enough for family and friends to visit easily? Doctors, friends and relatives, local hospital discharge planners and social workers, and religious organizations may know of places.

Also, each state has a Long-Term Care Ombudsman. They have information and may be able to answer questions about a place you are considering. The ombudsman is also available to help solve problems that might come up between a nursing home and the resident or the family. To find your state long-term care ombudsman, contact the Administration on Aging’s Eldercare Locator at 1-800-677-1116 or www.eldercare.gov.

Is the person in need of long-term care a military veteran? They might be able to get help through the Department of Veterans Affairs programs. You can check by going to www.va.gov, calling the VA Health Care Benefits number, 1-877-222-8387, or contacting the VA medical center nearest you.

Call. Once you have a list of possible places, get in touch with each one. Ask basic questions about openings and waiting lists, number of residents, costs and methods of payment, and their link to Medicare and Medicaid. Take a few minutes to think about what’s important to you or your relative, such as transportation, meals, activities, connection to a certain religion, or special units for Alzheimer’s disease.

Visit. Make plans to meet with the director of nursing and director of social services. Medicare offers a nursing home checklist to use when visiting (see Help in Planning). Some of the things to look for include certification for Medicare and Medicaid, handicap access, no strong odors (either bad or good ones), contact between staff and current residents, volunteers, and the appearance of residents. If the nursing home is a member of the Joint Committee on Accreditation of Healthcare Organizations, ask to see that group’s review of the home. Ask yourself if you would feel reassured leaving your loved one there.

Visit again. Make a second visit without an appointment, maybe on another day of the week or time of day, so you will meet other staff members. See if your first thoughts are still the same.

Understand. Once you or your relative have made a choice, be sure to understand the facility’s contract and payment plan. If you don’t understand it, you could have a lawyer look them over before signing.

How to pay

There are several ways to pay for nursing facility care for people over age 65. They are:

• Medicare
• Private pay
• Medicaid
• Long-term care insurance.

Let’s see what happened after Alice left the hospital. She went directly to a skilled nursing facility. It had a rehabilitation unit where she began to receive physical therapy. Medicare covered most of her costs for the first few weeks as she got better. Then she had a stroke which left her unable to move her left arm and leg. While she was in the hospital for the stroke, her doctors decided Alice should probably not return home. She no longer qualified for Medicare to pay for her nursing home care.

• Many people believe that Medicare will pay for long stays in a nursing home, but
  it doesn’t. The Federal Medicare program and private “Medigap” (Medicare supplemental) insurance only cover short times of home health or nursing home care. They pay for a short stay in a nursing home for someone who is getting better after leaving the hospital, but still needs nursing care and therapy.

Alice’s husband started to pay for her care on his own, but they didn’t have a lot of savings. When they had used most of their savings, her husband arranged for her to apply for Medicaid. The good news about Medicaid is that her husband did not have to sell their home for her to qualify for this support.

• Many people start paying for long-term care with their own money (private pay). Later they may become eligible for state-run Medicaid. Each state decides who qualifies for this program. Contact your state government to learn more. Keep in mind that applying for Medicaid takes at least 3 months.

Alice’s children are now looking into buying long-term care insurance for themselves. They don’t want to have the same worries if they need nursing care when they are older.

• Long-term care insurance is a private insurance policy you can buy years before you think you might need it. Each policy is different. Your state’s insurance commission can tell you more about private long-term care policies. They can also offer tips on how to buy long-term care insurance. These agencies are listed in your telephone book, under “Government.”

Help in planning

Planning for long-term care is not easy. People’s needs change over time. So do the rules about programs and benefits. What someone qualifies for may change from one year to the next. There is some help. The following resources are online. If you or your relative don’t have a computer, there may be one at your local library or senior center.

Care Planner from Medicare is online at www.careplanner.org. It has details about different care options. You can answer questions online about needs and resources to get a list of suggested services, as well as helpful resources.

Medicare has two resources on its website, www.medicare.gov, which may be useful. First, Nursing Home Compare helps you learn more about nursing homes you may be interested in. They also have a Nursing Home Checklist with tips to use when visiting homes. Second, many states have State Health Insurance Counseling and Assistance Programs (SHIPS). These programs can help you choose the health care plan that is right for you and your family.

Making a smooth transition

Moving to a care facility can be a big change for the whole family. Some facilities or community groups have a social worker who can help you prepare for the change. Allow some time to adjust after the move has taken place.

Regular visits by family and friends can make this move easier. This reassures and comforts the person getting used to a new place. Visits are good, too, for keeping an eye on the care that is being given. They also help family to develop a good relationship with the staff caring for their loved one.

Other Resources

Other sources of information on long-term care and other issues of interest to older people include:

FirstGov for Seniors
www.seniors.gov

American Association of Homes and Services for the Aging
2519 Connecticut Avenue, NW
Washington, DC 20008
202-783-2242
www.aahsa.org

Assisted Living Federation of America
11200 Waples Mill Road, Suite 150
Fairfax, VA 22030
703-691-8900
www.alfa.org

Continuing Care Accreditation Commission
2519 Connecticut Avenue, NW
Washington, DC 20008
202-783-2286
www.ccaconline.org

Alzheimer’s Disease Education and Referral Center (ADEAR)
PO Box 8250
Silver Spring, MD 20907-8250
1-800-438-4380
www.alzheimers.org

The National Institute on Aging (NIA) has free information on health and aging. Call or write:

NIA Information Center
PO Box 8057
Gaithersburg, MD 20898-8057
1-800-222-2225
1-800-222-4225 (TTY)
www.nia.nih.gov

National Institute on Aging
U. S. Department of Health and Human Services
National Institutes of Health
September 2003