Nursing Home Alternatives to Consider

Your loved one and aging

It’s a common scenario. Adult children have an older family member who is no longer able to live completely independently. There are lots of misconceptions about senior care and long-term care that can lead people to delay making decisions — sometimes, until an urgent situation makes it necessary.

It’s important to realize long-term care isn’t an endpoint. There are numerous options for care, depending on a person’s functional and medical needs, financial situation and personal priorities. Planning ahead can help you make the best decision for your loved one and keep them safe and happy.

When is living alone no longer a good idea?

The first step is to get your loved one to take a comprehensive geriatric assessment, a questionnaire that helps evaluate a person’s health and well-being. It looks at things like physical function, nutrition, medical conditions, mental health and social support, which, when looked at together, can determine if a senior can stay safe in their home. It usually is used for people aged 65 or older who have a serious illness, such as cancer, or are showing signs of frailty.

“Typically, this assessment takes about two hours and can shed light on specific needs, issues and concerns,” says Steven Buslovich, a New York-based physician and cofounder of Patient Pattern.

He notes that this geriatrician-administered assessment also will evaluate medication-related risk factors, such as polypharmacy, which is the use of five or more prescription medications. This is significant because it might determine that someone’s medications are causing fatigue, lethargy or cognitive concerns.

Aging in place

If someone has mobility issues — like limitations to strength or range of motion — strategically placed ramps, grab bars and other aids might help them stay in their home safely.

It is important to consider what structural modifications may need to be made, such as widening doorways or installing a walk-in shower with seating in the bathroom. At the same time, don’t forget simpler but equally important efforts like removing obstacles that can contribute to falls, such as furniture that presents a trip hazard, loose rugs or slippery flooring.

Occupational therapists can also do an in-home safety evaluation. This process involves the therapist coming into the home and looking for issues that might affect the resident’s safety, such as poor lighting, clutter and other hazards or risks. They can then recommend changes, such as the addition of grab bars, non-slip rugs or mats and/or smoke detectors.

This evaluation can be done at any time, but it’s most appropriate when someone comes home from the hospital or long-term care facility, after an illness or accident or when you are trying to determine if your loved one can still live alone.

Home care

Home care offers support and services for those who don’t require institutional care but may need help with activities of daily living, or ADLs, such as medication management or administration, shopping, meal preparation and bathing assistance. Some people may just need a few hours of help a day, while others may require 24/7 care.

While home care has many benefits, such as ensuring a person’s ability to stay in their home and be surrounded by their possessions and memories, it does have limitations. It lacks the built-in socialization and activities that someone would get in a senior living or long-term care community.

Also, it is important to consider what home health services will cost. Medicare Parts A and B cover only some home health services, such as physical therapy, occupational therapy, medical social services and durable medical equipment — canes, commode chairs and hospital beds, for instance. It doesn’t cover things like the cost of aides who come in to help with activities of daily living, and those expenses can add up over time.

Senior apartments

For older adults who can still live independently but want more social support, senior apartments are an option. Available to adults aged 55 and older, these offer benefits such as low maintenance costs, smaller living spaces, the ability to keep pets, onsite security and grounds maintenance.

This option can also be a cost-effective compromise between a long-term care facility and independent community living. These typically don’t provide any services for seniors, who will need to make their own arrangements for things like meals, transportation and housekeeping.

The cost for these apartments varies based on factors including location, unit size and amenities, such as pools, onsite dining, high-end recreational offerings and more.

Board and care homes

Reminiscent of the old boarding houses popular in the ’30s and ’40s, these are small, home-like settings where residents have their own room or suite but share some common spaces for dining and socialization. These may be an appropriate choice for people who need some help with daily tasks, such as bathing or dressing. Residents may also get some support with services like meals or laundry.

Medicare doesn’t pay for personal care or room-and-board costs, which can vary considerably. However, it will cover some medical costs incurred while an individual lives in this setting, such as some hospital or ER visits and laboratory tests.

Assisted living facilities

When assisted living first entered the marketplace, it was strictly a social model of senior housing. However, this setting has increasingly taken on a medical component, attracting residents who have a variety of chronic conditions, illnesses, physical limitations and even cognitive impairment.

Assisted living communities don’t offer the level of medical care that nursing homes do. For instance, unlike nursing homes, they aren’t required by federal law to have a medical director, the clinical care leader, and they have fewer clinical staff like nurses and certified nursing assistants.

Today, assisted living residents generally get their own apartment or unit, with access to common areas and amenities, such as a laundry room, onsite dining halls/cafes/restaurants and outside spaces, including gardens, patios and pools.

Most assisted living costs aren’t covered by Medicare, so expect a price tag of about $4,500 per month or more. Many facilities offer a la carte services, so you may be able to pick and choose which services and amenities you want as one way to reduce costs. Elsewhere, some long-term care insurance can help pay for assisted living. This is coverage that people generally purchase before age 65, and it’s designed to cover some long-term care that isn’t covered by Medicare or other private health care insurance.

Continuing care retirement communities

These are sort of a one-stop shop of care. They consist of independent living, assisted living and nursing home care on one campus. Housing options include everything from houses, cottages and apartments to townhomes and duplexes. The main advantage of continuing care retirement communities, or CCRCs, is that they enable people to limit their moves as they get sicker or require more care and services. They also have a high staffing ratio and a significant number of registered nurses on staff.

However, these facilities can be expensive. Most require a hefty entry fee of $100,000 or more; $300,000 is the average. There is then a monthly cost that will depend on things like the setting, its location and amenities and the size of the unit. Medicare doesn’t cover CCRCs, nor do most long-term care insurance plans.

Medicare PACE programs

The Centers for Medicare and Medicaid Services’ Program of All-Inclusive Care for the Elderly, or PACE, offers a combination of services that enable seniors to continue living in their homes or with family members while utilizing some long-term care services. These services, for instance, can include adult day care, where an older adult goes during the day for recreation, socialization, meals, prescription drug management, physical therapy, emergency services, social work counseling and transportation.

Your physician can help you determine if your loved one might be right for this program. It isn’t a substitution for nursing homes or high-level care, but it may help some people stay in their homes or live with their families for a longer period of time.

In PACE programs, a group of health care professionals works with seniors and their families to provide person-centered care. PACE enrollees are often required to use a PACE-preferred doctor, so it is important to know this upfront in case you have a specific practitioner you want to use.

Medicaid beneficiaries do not have to pay monthly premiums for the long-term care part of PACE, but those with Medicare must pay monthly premiums for both long-term care and Medicare Part D drugs. While PACE fees vary, costs average $4,000 to $5,000 per month.

Respite care

For short-term needs, consider respite care. This option provides services and supports to enable family caregivers to take a break so they can go on a vacation, go to work, run errands or just rest and refresh.

This kind of care can include bathing and hygiene services and some recreational activities and opportunities for socialization. The cost can be anywhere from $100 to $300 per day.

Some respite care programs are provided in the individual’s home; others are based in senior living communities or adult day care centers.

Personalize, prioritize and prepare.

It is important to weigh all the options and be realistic about what your loved one will need now and in the future. Cost alone isn’t an adequate determinant of the best level of care for an individual, nor what facility or community is the best.

“Needs, issues and other factors vary from person to person. The most important things to think about are safety and quality of life,” says Barbara Resnick, a professor at the University of Maryland School of Nursing. “Knowing the individual and being open to the fact that their situation and wishes can change is key.”

She stresses that it’s important to do your research and get past misperceptions or preconceived notions. For instance, she stresses, “you have to put yourself in the mindset of being impaired, physically ill and needing two hours to get dressed or ready for bed.”

Despite what you may think, it’s not always best or desirable for an older person to stay in their home. An assisted living facility or other facilities, including nursing homes, can provide socialization, meals and snacks, activities and other things seniors can’t get at home. These can make life joyful and purposeful, as well as safe.

Nursing home alternatives to consider

— Aging in place.

— Home care.

— Senior apartments.

— Board and care homes.

— Assisted living facilities.

— Continuing care retirement communities.

— Medicare PACE programs.

— Respite care.

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