Assisted Living

There are times when an older adult needs more assistance than can be provided in the home when it comes to personal care. In many cases, however, the older person still may not need the round-the-clock skilled nursing and medical care that a nursing home provides. In that case, an assisted living arrangement might be an option to consider in order to protect the older person’s independence and privacy for as long as possible.

Is Assisted Living Right for You?

Assisted living facilities (ALFs) have many names, including "adult care facilities" or "residential care facilities." ALFs are licensed by state governments through the Centers for Medicare and Medicaid Services. Since ALFs are not licensed by the federal government, the services provided and quality controls vary by state. More than 500,000 people live in ALFs, and this number is expected to grow as our population ages. Even though ALFs offer a social model of care (not a medical one), they provide residents with a support staff and meals, as well as assistance with activities of daily living such as dressing and bathing.

Older adults have a variety of choices in ALFs, ranging from smaller, simple home-like environments, to larger, fancier accommodations. This wide range in types of ALFs allows people to choose a home that best suits their needs, tastes, and financial situation. Most ALFs offer private rooms or apartments. Special care units that focus on Alzheimer’s disease and other forms of dementia are also becoming more common.

ALFs are required to provide a variety of services, including:

  • 24-Hour staffing to meet the scheduled and unscheduled needs of residents (Note: This does not mean that skilled nursing must be available 24 hours a day.)
  • Social services
  • Housekeeping and laundry
  • Recreation and meals
  • Help with activities of daily living (ADLs)
  • Health-related services (e.g., help with medication management)
  • Transportation

Other services vary considerably from state to state. For example, depending on licensing requirements, giving and managing medications may be handled by unskilled, skilled, or fully licensed nursing staff.

Most older adults must pay for assisted living themselves, although some states now may pay costs through Medicaid. Generally, care in an ALF is less expensive than in a nursing home. Part of this difference in cost is because ALFs provide less service and have less overhead. In addition, ALFs generally have fewer regulations to observe (at least for now) and are therefore able to operate with fewer expenses.

Types of Assisted Living

Group Homes

Group homes are houses or apartments where two or more unrelated people live together. These include domiciliary care, single-room occupancy residences, board-and-care homes, and some group living situations. Group homes vary in the types of residents that live there. For example, many can accommodate people with chronic mental illness or dementia. Most group homes are run as for-profit businesses, and some states require licensing.

Residents share a living room, dining room, and kitchen but usually have their own bedrooms. Advantages of this arrangement include a lower cost of living and ability to socialize with peers. Independence and ability to function are supported through the interdependence and relationships of the residents. Opportunities for socialization are increased, reducing social isolation. Resident-to-staff ratios may also be higher than in other supported-living environments.

Adult Foster Care

Foster care homes generally provide room, board, and some help with activities of daily living. This is provided by the sponsoring family or other paid caregivers, who usually live on the premises. Adult foster care has the advantage of maintaining frail older adults in a more home-like environment. Regulations for foster care vary by state, and some states require licensing. Some states will cover costs of adult foster care through their Medicaid programs. Perhaps the longest experience with adult foster care is in the state of Oregon, where it is used as an alternative to long-term care and institutional living. 

Sheltered Housing

Sheltered housing is often in a home that offers personal-care support, housekeeping services, and meals. Social work services and coordination for activities can be added to these programs. Charges to clients are based on a sliding scale, which may cost up to 30% of income. 

Continuing-Care Retirement Communities

Some older adults may choose to live in a continuing-care retirement community (CCRC). These communities usually have a variety of living options, ranging from apartments or condominiums, to assisted living and then to skilled nursing home care. Often, older adults enter the CCRC in the more independent living areas.  If they become more disabled, they may progress to the assisted living and skilled care areas.

Health care in CCRCs is generally provided using three financial models:

  1. The all-inclusive model.  This provides total health care coverage, including long-term care.
  2. The fee-for-service model, in which payments match the level of care.
  3. The modified coverage model, which covers long-term care to a predetermined maximum amount.

Most CCRCs require an entry fee, which may or may not be refundable, plus a variable monthly fee to pay for rent and supportive services. Monthly fees vary, depending on the level of care being provided. Older adults generally pay to live in these communities, though some facilities have beds for skilled care that are funded by Medicare or Medicaid.