Assisted Living: Care With an Independent Flavor

by Nolo.com
From the Nolo.com Retirement & Elder Care Center

Find out what Assisted Living may have to offer -- and what to look for when evaluating it as a new home.

Assisted living combines much of the homelike atmosphere of independent living with some of the personal care of a nursing facility. It provides extensive personal assistance and services, plus round-the-clock monitoring, that are not offered by independent living residences and that would be extremely expensive if arranged through home care. On the other hand, assisted living permits residents to maintain some of the privacy and independence that are lost in more institutional, and more expensive, nursing facilities. Assisted living is the fastest growing type of seniors residence -- fitting the needs of millions of seniors who cannot make it entirely on their own, but who do not need full-time nursing care.

The residences discussed here come under a variety of names: assisted living, sheltered care, residential care, board and care, boarding home, catered living, congregate living and group home. Although each facility or residence differs somewhat in the type of housing and level of services and staffing provided, all of them, regardless of name, have certain things in common. They provide:

domestic services, including meals and housekeeping
assistance with personal care and the activities of daily living, but not nursing care, and
close monitoring to help ensure residents' health and safety.

The Basics

Assisted living provides a room or small apartment -- usually rented -- intended to help maintain a homelike setting, plus a range of services to assist residents with those tasks of daily life made difficult for them by the loss of some physical or mental capabilities.

Types of Living Spaces

There are several kinds and sizes of assisted living housing: full-size one-bedroom apartments; studio apartments with small kitchenettes; studios without a kitchen, or with a partial kitchen that has no cooking facilities; single rooms; and shared rooms. An assisted living apartment or room may be furnished or unfurnished. Even if a space is furnished, at some places residents are permitted to bring in some furnishings of their own, which can make a new place feel more like home.
Assisted living apartments and rooms tend to be smaller than living spaces intended for the general public. They are often fitted with safety devices such as handrails and special bathroom fixtures, and may include a hospital bed if needed. In addition to the small rooms and space-eating fixtures, people tend to bring more of their own furnishings than would otherwise fit easily into the space. As a result, many assisted living apartments feel crowded and even smaller than they are. It is often difficult for a new resident to adjust to the smaller, more cramped quarters.

Special Care for Alzheimer's or Disorientation

Many people suffer mild symptoms from the early stages of Alzheimer's or other age-related disorientation. Their need for monitoring and assistance make independent living too difficult or dangerous, but they do not need the high level of care provided by a nursing facility. For them, assisted living is often an excellent solution.
However, the kind of assistance these people need is different from that required by those who have only physical limitations. The same assisted living residence that provides good care for someone with only physical frailties does not necessarily work well for a person with mild dementia. Most assisted living facility administrators will tell you that they are experienced with Alzheimer's residents. But it is the quality of that experience that counts. Most important is whether the staff is trained to handle the difficulties of dementia sufferers. You want staff trained to provide special attention to residents who are mildly disoriented -- not merely to shuttle them from one place or activity to another, but if necessary to explain what is going on, without treating the residents as children.
If you are considering an assisted living facility for someone with mild disorientation problems, watch how the staff interacts with current residents who have similar difficulties. And pay close attention to how the staff -- not just the administrator who gives you a tour -- interacts with you or your loved one during a meal, an activity, or an explanation of facility rules.

Services Provided

The main difference between assisted living and independent living residences -- usually housing complexes built or renovated for older residents who are basically able to care for themselves -- is that assisted living meets a higher level of daily needs. While assisted living does not offer either the medical care or the level of attention of a nursing facility, it does provide personal care in a resident's living space as well as common areas, meals and household tasks, and extensive monitoring of each resident's physical condition.

Personal Assistance.

The reason most people move to assisted living is that they need help with one or more of what are known as the Activities of Daily Living (ADLs). ADLs include eating, bathing, dressing, continence and using the toilet, walking and getting in and out of bed or chair.
An assisted living facility will help a resident with any ADL, but not all the time, and not any time a resident wants help. Instead, a schedule will be developed which takes into account the resident's needs and the staff's availability. For example, an aide might help a resident get in and out of bed in the morning, once or twice during the day, at bedtime and once again during the night. Or a resident will be given a full bath three or four times a week, but not every day.
When you consider a particular assisted living residence, ask precisely what it offers regarding the specific ADLs with which you need assistance. If the facility offers you the kind and frequency of assistance you believe fits your needs, make certain that care is spelled out in the written residence agreement you and the management sign.

Health monitoring.

In addition to help with daily activities, assisted living facilities monitor a resident's health. That does not mean nursing or other active treatment of a medical condition. Rather, it means keeping track of and helping the resident take the correct dose of medications, helping the resident with self-administered health aids such as prostheses and oxygen, providing emergency call systems and checking on a resident's well-being during the night.
Most assisted living residences have a nurse on duty to check on any resident who has health difficulty, or whose physical condition seems to be changing, and to refer the resident for medical care if it seems necessary. Health monitoring may also include coordinating care with the resident's primary care physician and keeping track of a resident's medical appointments. And most facilities provide or arrange transportation to and from those appointments.

Strict Rules Are a Problem for Some People

Assisted living offers close monitoring of residents' physical conditions. This includes keeping track of medications; checking on residents at night and making sure residents eat properly. Assisted living facilities accomplish this by setting up schedules and requiring both staff and residents to follow them. Sometimes, these schedules and rules are too restrictive for a competent, independent minded person.
Depending on your needs, including your need to be left alone, independent living plus home care might fit your personality better than assisted living -- even though that arrangement places the burden on you and your family to organize care.

Meals.

One of the most attractive things for many people about assisted living is that meals are provided. There is a kitchen and a common dining room where at least two and usually three meals a day are served, and their costs are part of the resident's rent or fees. Residents are freed from shopping, cooking and cleaning up; they are assured of nutritious food; and they are brought together for the informal social exchange of a meal with other residents.
There are several things to check about an assisted living residence's food service. First is how many meals a day are included, and whether they are all full, hot meals. Then there is the quality of the food; it won't do you any good if you won't eat it. Try several meals in their dining room, and see if the residents seem interested in their food and in each other.

Housekeeping.

Assisted living facilities provide laundry service and also clean individual rooms or apartments. What that housekeeping includes, however, can vary considerably. How often are a resident's bedding and bath linen laundered? Does the facility do a resident's personal laundry as well? Is there an extra charge for personal laundry? How often is an individual room or apartment cleaned?

Social activities and exercise.

It is one thing to assist residents with the basics of daily life such as dressing and bathing; that help is guaranteed in a contract with an assisted living residence. It may be quite another thing to help residents to lead mentally, physically and socially active lives. This is not a matter of contract, but of the fabric of service at a good residence. Most facilities plan group activities such as guest lectures and exercise classes, as well as regular gatherings for the residents to visit among themselves. The best facilities also help individual residents participate in these activities to the extent possible, and provide alternatives -- an assisted walk around the hallways, for example, or a one-on-one chat in a resident's private room -- if it's not feasible to participate in a group.
There are several ways to get a sense of the quality of group and individual activities at a particular facility. You can take a look at what is scheduled for any given week, but it is also important to visit during one of these planned activities to see if residents participate and seem to enjoy doing so. As for more individual attention, find out whether there are any rules against staff spending non-scheduled time with residents. And on all your visits, watch how the staff interact with residents: look for a friendly, relaxed manner on both parts.

Costs

Most assisted living spaces are rented, not purchased. The major exception is assisted living as part of a continuing care community.

Basic Rent

Obviously, rent depends on the size of living space. A small room with no cooking facilities is much less than a spacious one-bedroom apartment with full kitchen. The rent also varies with the amount of services and staff provided, the location and the overall condition of the facility. And some facilities offer more than one type of rental agreement: a limited contract may include fewer meals and personal assistance than an inclusive or extensive agreement that includes all the services the facility has to offer. Given all these variables, rent for an assisted living unit generally runs 50% to 100% higher than for a comparable independent living unit in the same facility. But they are still one-third to one-half the cost of nursing facilities of the same quality, in the same area.

Rent Increases

As with any other rental housing, you must consider how much your rent may go up over time. A lease can guarantee the rent for a year or two. After that, rent increases are completely up to the facility's ownership, unless a yearly limit is included in your rental agreement. Without such a limit, it is important to check a facility's record of rent increases over the previous five years. If they have raised rents in large chunks, you have to consider whether they will price you out of your apartment in years to come.

Additional Fees

Some assisted living facilities charge fees in addition to rent. There may be a one-time non-refundable entrance fee. And there may be a fee for certain services not included in the basic assisted living contract: extra or delivered meals; extra housekeeping service; local transportation fees; personal care beyond the standard level of care offered in the facility.

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