It’s a common scenario. Mom or Dad has a fall, forgets to eat, mixes up their medications or leaves the stove on. As these incidents happen more frequently, it becomes clear that it is time to get some help. How do you decide if home care or assisted living might be the right answer?
[READ: Assisted Living Checklist.]
Home Sweet Home Care
Home care involves a wide array of services provided in a person’s home. Most commonly, it means a home care aide who provides support with activities of daily living, such as bathing and dressing, preparing meals or doing laundry and cleaning, for example. These aides also may offer socialization and companionship, and they help around the house with tasks such as walking the dog or weeding the garden. This type of home care is referred to as personal care.
Another option is skilled home care. This may involve physical and other therapy services, wound care for pressure ulcers and support with injections and catheters.
The basic goals of home care are to keep residents safe and comfortable in their homes, enable them to be as self-sufficient as possible and slow mental and physical decline. Aides also may prevent avoidable ER visits and hospitalizations by recognizing signs of a new illness or exacerbation of an existing one. For instance, they may be helping someone up from a chair and notice that they’re wincing in pain. Or, the caregiver might uncover that the person had a fall. The caregiver can then work with the family and the person’s physician to address the reasons behind the fall and put a fall prevention program in place.
There are likely to be dozens of home care agencies in your area where you can find qualified aides. They work much like a temp agency where you contract with the caregiver through the organization, which handles payments and logistics. Your local Area Agency on Aging can offer some recommendations on home care organizations. Find yours through the federal Eldercare Locator at 800-677-1116.
You also can use a registry or staffing service to hire a home care aide. These refer you to caregivers who match your needs, and you hire them directly. Your local government may have an available list of registries where you can find home care workers who are specifically trained to perform home care tasks and have some basic knowledge about age-related conditions.
Of course, you can find and hire a home care aide by yourself, via community, church or other contacts. However, it is important to get references, background checks and other information to help protect your loved one.
[READ: Assisted Living Communities: Types of Rooms]
Assisted Living: Home Away From Home
Another option for someone who needs help with activities of daily living, but does not necessarily need 24/7 care, is assisted living. These communities offer a variety of amenities and services that enable residents to enjoy independence, privacy, companionship and safety. These may be luxury, hotel-like settings with a variety of dining options, fitness centers, Olympic-sized pools and more. They may also be a small building with a few residents in rooms or apartments, a common area and a dining room.
Unlike skilled nursing homes, assisted living communities are not federally regulated, and state rules and regs vary significantly. As a result, costs, amenities and services can differ from state to state and community to community.
According to Genworth Financial’s 2021 Cost of Care Survey (the most recent data available), assisted living costs about $4,500 per month. This generally covers the cost of room or apartment rent, meals and a limited number of amenities. Add-on services, such as medications, housekeeping, hair salon or barber shop services or transportation to doctors’ offices, usually will cost extra.
[READ: Steps for Choosing the Right Senior Living Facility.]
How to Pay
In some ways, looking at costs for home care and assisted living may seem like comparing apples and oranges. You need to consider how much care is necessary, how much support you’ll get from friends and families and what services and support may be necessary in the future. Factoring in all these issues, as well as what will be covered by Medicare and other insurance, will help determine the best, most personalized path.
Home care
If you need to pay out-of-pocket for home care, it can be costly. According to Consumer Affairs, the median cost is about $24 per hour.
“This can be affordable if you only need an aide for a few hours a day or a few days a week,” says Jesse Slome, executive director of the American Association for Long Term Care Insurance in Westlake Village, California. However, he notes that if you or your loved one need 24/7 care, it can add up to $200,000 or more over the course of a year.
Medicare Part A pays for some home health services. The emphasis here is on “health.”
The coverage is limited to skilled medical care, such as physical, occupational and/or speech-language therapy; injectable osteoporosis drugs; and durable medical equipment, such as commode chairs, wheelchairs and oxygen equipment. Part-time or occasional home health aide care may be covered, but only if you are also getting skilled nursing care. You must be under a doctor’s care, the services you receive must be part of a physician-created and -monitored care plan and the home health agency you use must be Medicare-certified.
Note that Medicare won’t pay for the most common areas people want home care for, such as 24/7 care, meal delivery, homemaker services and help with activities of daily living.
The good news is that most, or even all, qualified skilled home health services are covered, and after you meet the deductible, which in 2024 is $240, you pay 20% of the Medicare-approved amount for medical equipment. However, before you engage a home health agency and start receiving services, find out from them how much Medicare will pay and what services or items are ineligible for coverage — and what the out-of-pocket cost to you will be.
Medicaid coverage for home care varies from state to state, but in some areas, it covers personal care assistance, such as bathing, dressing and meal preparation. It will be important to find out what coverage is available in your state as you are making your care decisions. For information on how to contact your local or state Medicaid office, call 877-267-2323.
There are also other payment options for in-home help. For instance, veterans with moderate or severe needs may be eligible for a monthly stipend directed toward primary family caregivers. See the VA website for more information.
In-home support may also be available from some social services organizations in your area. For instance, Meals-on-Wheels and other programs bring in meals for older adults in their homes. These also can provide some companionship. Your Area Agency on Aging can provide you with some resources.
Assisted living
Most assisted living is private pay, which means you have to pay for care out-of-pocket. Contrary to popular belief, Medicare doesn’t cover most assisted living costs. As with home care, Medicare will pay for some medical services, such as physical therapy or injections, provided on-site, but it won’t pay for custodial care, such as help with activities of daily living.
Medicaid may pay for some assisted living in some states. However, even in those instances, you have to spend down your assets before it kicks in. This means that you have to use up your money, including savings, pensions and other assets, before coverage starts.
Medicare Advantage, offered through private insurers, may help cover some custodial care costs, but you will need to check with specific plans to see what they cover and how this might help if you enter an assisted living community.
As with home care, there are other potential sources of financing for assisted living. These include long-term care insurance, which can help pay for services like physical therapy, rehab and assistance with activities of daily living in assisted living. However, it is important to note that this insurance won’t pay for everything. For instance, it won’t cover the monthly rent or room and board fee.
Elsewhere, veterans, as well as spouses or widows/widowers of veterans, may benefit from Veterans Aid & Attendance benefits and Housebound allowance. Such veterans’ benefits can range from about $1,000 to over $2,000 per month.
Making the Decision
Deciding between home care or assisted living can be challenging, and it requires weighing several factors and issues including:
— Personal needs and health issues.
— Financial resources.
— Family and community resources.
— Personal preferences.
Personal needs and health issues
This element requires an honest assessment of your or your loved one’s health care status, prognosis and needs.
For instance, Dr. Timothy Holahan, assistant professor of medicine at the University of Rochester Medical Center and geriatrician and medical director in New York, says, “A big issue is the need for medication management and administration. If the only necessary support is having someone organize pills for the week and/or reminding or helping the person to take their medications at the right time, home care might be adequate.”
However, he notes that if someone is having problems, such as continually taking medicines incorrectly, missing doses or not getting prescriptions filled, the home may no longer be safe for them.
Financial resources
It is important to realistically address what is affordable now and in the future. This means a detailed assessment of your finances and future earnings.
“The truth is that many people will need progressively more care, and this should be considered in weighing costs,” says Dr. Sarah Howd, a geriatric medicine specialist in Rochester, New York. She notes that even if the person and their family can afford it, 24/7 home care may not be the best solution.
“I’ve seen people who have had 24/7 care at home who don’t do well when they enter a facility because they are used to that level of attention. Suddenly not having it can be a very difficult adjustment,” she explains.
Family and community resources
It is important to be realistic about how much family and community support someone will have if they stay in their home.
“You are looking at 4-5 hours a day during the week for things like meals, laundry and cleaning. This is doable if you can supplement that with the help of family and friends in the evenings and on weekends. If you don’t have this support, you may want to consider AL (assisted living),” Holahan says.
Slome stresses the importance of not making assumptions about what caregiving help family and friends will be able and willing to provide.
“Someone may think their daughter, brother or friend will be able to bring them meals and come on the weekends to clean house, walk the dog and make some meals. However, they may not realize that these individuals have other obligations and commitments,” he observes.
He also notes that family and friends feel more comfortable with a loved one in assisted living where the person is safe and they can just visit and spend quality time together.
Socialization is another issue to consider here.
“If you have someone who lives at home and is more functionally impaired and isolated, it is important to consider how and when they will get visitors and social support,” Holahan explains.
This can be especially challenging if the person is single, lives alone and has few or no friends or family living nearby.
“Consider if your loved one might benefit from an environment where they can socialize and engage in activities. Sometimes, people actually will improve cognitively when they are in such a setting,” Holahan says.
One compromise, Holahan suggests, might be an adult day care program. These are community-based programs where people can go for socialization, activities, meals and/or snacks during the day. However, he stresses that these programs are best for individuals who are still cognitively intact and physically more mobile.
Personal preferences
“Most people want to stay in their home, but there may come a time when that isn’t possible. When this happens, there are some things to do that can make it easier,” Slome says.
For instance, look for an assisted living community close to friends and family, and bring in furniture, décor and personal items to make it feel like home. For pet owners, it will be important to find a pet-friendly community where they can bring their dog or cat. If someone loves gardening, seek a unit with a little yard or patio where they can have some plants.
Before You Move
Prior to making any decisions, Howd suggests asking: What is going on to make you concerned? What are you noticing to suggest you or someone else needs support?
Start with a safety evaluation to determine what help might be necessary.
“If all someone needs is some support with meals and cleaning, home care may be fine,” she says.
If the issues are more complicated and the person needs more physical help with grooming, hygiene and mobility, assisted living may be a better option to keep the person safe and comfortable and prevent or delay decline.
Before you commit to any assisted living community or home care agency, it is important to do some research: What do online reviews say? What do current residents say? What are the costs, and what do these include? What additional or add-on costs might you be expected to incur?
Dr. Charles Crecelius, a Missouri-based physician and long-term care facility medical director, offers, “Visit the community, and at least have a meal there. Make sure they will accommodate special needs like pets or visiting grandchildren. Find out about rules regarding things that are important to you.”
Holahan adds, “Talk to staff and residents.”
Have a list of questions to ask, including what would happen if you run out of money.
“I encourage families to ask about the financial, medical and functional thresholds that may cause their family member to be unable to live there anymore. What supports, options or assistance might be available?” he says.
Holahan suggests considering assisted living that is part of a continuing care retirement community, which has various levels of care on one campus. A CCRC may make it easier if someone has to move to skilled care.
“It would be wise to ask about things like the make-up of the community, such as how many residents have a diagnosis of dementia,” Crecelius advises.
This can help give prospective residents a sense of how they’ll fit in and how long they may be able to stay there.
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Assisted Living vs. Home Care: What’s the Difference? originally appeared on usnews.com
Update 02/15/24: This story was previously published at an earlier date and has been updated with new information.
