Client Education

Housting Options

What Are the Options?

By: Margaret N. Gallos, Special to AccentCare

There are several housing options for seniors, depending on various factors, including health and finances. Here is a primer on some of the choices.

1) Independent Living

Most seniors prefer to live independently in their own homes. Increasing numbers of seniors are living the life they choose thanks to an increase in housing options as well as skilled and non-skilled attendant & personal care and support services. Even seniors with serious health problems and disabilities can remain at home if they have appropriate help.

Why do seniors prefer staying in their homes? According to Barbara Lancaster, a New Jersey-based certified public accountant, certified financial planner and chartered life underwriter, the reasons seniors may wish to remain in their home include the following:

Expenses are manageable.
Religious and cultural activities are nearby.
The doctor and dentist are nearby.
Family and friends are close.
The neighborhood is safe.
Community support systems are accessible.
Everything in the home and area is familiar.

If your older loved one wishes to remain at home, you may need to make some changes in the house or apartment to accommodate the senior? advancing age and/or declining health or abilities. At the same time, you should evaluate other areas in which the senior may need assistance. Meals, personal care, housekeeping, skilled care are some of those areas, and myriad ways exist to make the senior? life easier and more comfortable.

A) Care at Home

It allows seniors to remain independent by providing necessary services such as skilled nursing, therapy, social work services and personal care in the senior? home. More than 20,000 providers deliver attendant & personal care services to some 8 million individuals dealing with acute illness, long-term health conditions, permanent disability or terminal illness. Home care providers include visiting nurse associations, government agencies for disease control and community health education, for-profit attendant & personal care agencies, private non-profit attendant & personal care agencies, hospital-based agencies, rehabilitation facilities, and agencies based in skilled nursing facilities.

Appropriate for: Seniors who do not require 24-hour care and who wish to remain in their own homes.

Services: Case management; skilled nursing; physical, speech and occupational therapy; as well as housekeeping, hospice, personal care, Meals on Wheels, shopping, visitors, transportation, home maintenance and repair and Emergency Response System. The types of providers that offers these services, as classified by the California Association for Health Services at Home, are:

Medicare-certified home health agency, which provides skilled nursing and one or more therapeutic services such as physical or occupational therapy.
Licensed home health agency, which provides skilled nursing and, frequently, attendant & personal care aide services. This category specializes in working with private insurance companies, although many agencies are certified to accept Medicare and Medicaid.
Hospice, which provides palliative care to the terminally ill and support for the primary caregiver and family members. Medicare pays for this service, as do most private health insurance and HMO policies.
Home infusion pharmacy, which provides pharmaceuticals and related high-tech services such as antibiotics to the home. If such a pharmacy provides or arranged for skilled nursing, it must be licensed as a home health agency.
Home medical equipment company, which provides medical equipment, products and supplies in the home.
Home care aide organization, which provides supportive services such as nonmedical personal care (help with activities of daily living such as bathing and eating) and homemaking.
Interdisciplinary professional services, such as physical therapy/rehabilitation and mobile X-rays.

Cost: The fees for attendant & personal care vary from region to region and from agency to agency based on the types of services offered. Most attendant & personal care companies contract for a minimum number of hours. In Southern California, rates average about $15 an hour. Overnight care or nighttime respite care for eight to 12 hours may be payable by the hour or for a flat rate of about $120 for 12 hours. On the East Coast, day rates are in the neighborhood of about $16 an hour. These are the attendant & personal care services that are not covered under Medicare but are for paid out of pocket or through long term care insurance.

Pros: Home care allows a senior with moderate needs to remain independent and among familiar people and surroundings. This choice may be less expensive than institutional care depending on the level of services required.

Cons: Arranging the appropriate services ? even determining what those would be ? can be very time-consuming for family members. You must locate providers, interview them, hire them, manage them (you?l be their employer of record) and fire them, if necessary. All the responsibilities of an employer will fall to you, including insurance and bonding. You will need to periodically re-assess the senior? needs and alter services and care accordingly.

Regulation: Varies by state, but for the most part, no oversight or licensure exists for attendant & personal care agencies that provide non-skilled nursing services. However, agencies that provide services such as skilled nursing must be licensed as home health agencies, and if they serve Medicare beneficiaries, must be Medicare-certified. Home care providers in California may choose to be accredited based on standards proposed by the National Association for Attendant & Personal Care, the Community Health Accreditation Program, the Accreditation Commission for Attendant & Personal Care or other organizations.

Financing: Payment for non-skilled attendant & personal care is paid out-of-pocket or by long term care insurance unless the senior is undergoing an acute episode and qualifies for the skilled services of a Medicare-certified home health agency. Non-skilled care includes housekeeping, meal preparation, grocery shopping, laundry, assistance with personal care and reminders to take medication. Medicare covers skilled care, such as nursing and physical and speech-language therapy during acute illnesses. Approximately 7,500 home health agencies are Medicare-certified. The Medicaid (Medi-Cal in California) program covers part-time, intermittent skilled care for low-income persons.

B) Senior Housing

This category includes senior communities, shared living residences, group housing and subsidized senior housing. It also includes intergenerational home sharing (seniors share their home with younger people, often students); exchange of service (the renter does chores in exchange for reduced rent), boarders (renters) and communal living (private bedrooms with shared dining).

The chief benefit of all these options is that seniors have independence but are not alone. The right choice will depend on your senior? finances, your senior? preferred lifestyle and the availability of options in your area. County or state Offices on Aging can be a great place to learn what options are available in your area. These agencies are also called Divisions on Aging, Divisions on Health and Senior Services and similar titles.

An explanation of two types of senior housing follows.

Shared Living Residences

Shared living residences, also called cooperative housing, are becoming increasingly popular. These homes are built or adapted for use by seniors who want to live independently yet enjoy the sociability and security of living in a home with other seniors.

?Not all older people want to live in high-density senior apartments or facilities. Shared residences create a sense of family, yet each senior enjoys a private space within the residence,? says Marjorie Marlin, executive director of Cooperative Housing Inc. in Bridgewater, N.J., which has developed several residences in New Jersey.

Appropriate for: Independent, lower-income, healthy seniors who enjoy socializing with their peers. Ages typically range from the mid-60s to mid-90s.

Services: An on-site house manager coordinates menus, does grocery shopping, oversees repairs, transportation, etc. Some home health care is accepted.

Cost: Most of the residents working with Cooperative Housing in New Jersey live on Social Security and a small pension. Rent in cooperative housing generally runs 30% of the resident? adjusted gross monthly income with an additional fee for cable television, food and a house manager? services.?

Pros: Social interaction, independence and a sense of ?home.? Seniors can furnish their private bedrooms and bathrooms with their own furniture and accessories. Some residences offer ?supportive housing,? which includes the support services that allow individuals to age in place.

Cons: Not all seniors want to live in a communal situation. This is not an option for seniors who prefer solitude.

Regulation: City ordinances determine whether a single-family home can be used by non-related individuals. Also, some municipalities do not consider shared-housing agreements to be landlord/tenant contracts.

Financing: If the senior pays into medical insurance, those payments will be deducted from his or her income before the rent is pro-rated. The corporation or non-profit agency managing the residence will subsidize the remainder of the rent through grants and fund raising. Federal subsidies may also be available.

Senior Communities

Also called independent living retirement communities, these are planned, designed and managed to provide for the housing needs of independent seniors. The housing is generally single-family or apartments, although about 15 percent of retirees choose to live in communities composed of mobile homes.

Appropriate for: Independent, ambulatory seniors.

Services: Varied, but usually include meals, housekeeping, activities, transportation and security.

Cost: Variable, depending on the type of housing (single-family home or apartment), the region, the services offered and the senior? income. A monthly fee may also be charged for maintenance of the common grounds and facilities. Low-income housing is available, funded by the government.

Pros: Security, companionship and activities that can improve the senior? quality of life, no more yard work. Age-segregated housing may create a more peaceful environment than an ordinary neighborhood.

Cons: Generally, on-site medical and nursing care are minimal. Minimum-age restrictions at some may preclude some people from buying in. In these communities, seniors must be independent. If they cannot remain independent, they either must move to a different level of care within the community (if available) or move to another type of facility.

Regulation: Senior housing facilities developed or subsidized through federal programs are monitored by the federal Department of Housing and Urban Development.

Financing: Costs and services vary widely, starting with subsidized housing and senior apartments, for which residents pay a percentage of their income and charitable organizations make up the remaining costs. On the high end of the scale are units purchased by residents with additional fees ranging from $1,000 to $2,000 monthly for services, taxes and utilities. These units or homes are paid for by the resident? savings or bank financing.

2) Continuing Care

Seniors may choose to leave their homes and move into another environment for any of the following reasons:

Their current home's expenses are excessive.
The house and/or yard are too big and difficult to maintain.
The house is physically inconvenient because of stairs or heavy doors.
The house is physically inconvenient.
The neighborhood is deteriorating.
The senior no longer drives and public transportation is unavailable.
Children and friends live far away.
Doctors and emergency help aren't nearby.
A medical condition that can't be taken care of at home or health needs that can't be met at home.
Home care not an option because of cost, medical condition or other reasons.

Seniors without family members or other support systems may benefit from out-of-home placement if they have long-term medical, nursing or personal care needs. According to the New Jersey Department of Health and Senior Services, more than 85 percent of nursing home residents are single or have outlived their spouses, and 50 percent have no living children.

A) Continuing Care Retirement Communities (CCRCs)

CCRCs offer seniors the piece of mind that comes with knowing they are ensured access to independent living, assisted living and nursing attendant & personal care in a single setting. Under a long-term contract, they enter in good health and can move into on-site assisted living or nursing facilities if the need arises. CCRCs are also known as life care communities.

Appropriate for: The senior must be healthy and ambulatory when entering. The senior may then age in place, using increased on-site services and other housing options as needed.

Services: Living unit or room, meals, and health care coverage up to the nursing home level. They typically include nursing and other health services, meals, housekeeping, transportation, personal assistance and recreational and educational activities.

Cost: Most CCRCs require a significant entrance fee and monthly payments thereafter. The entrance fee is insurance for future care. The senior must also pay monthly maintenance fees. Some CCRCs offer services on a rental basis. The rates vary significantly depending upon the type of housing and the services and health care provided. Within the CCRC category are life care facilities, which charge higher fees and have more services.

Pros: Combines independent living and the security of long-term care. Opportunities for socializing are plentiful.

Cons: The up-front fees may be unaffordable. The senior? health status may prohibit acceptance into the community.

Regulation: State licensed.

Financing: Private funds

B) Assisted Living Facilities

The goal of assisted living is to help seniors continue living as independently as possible. The category includes multi-unit settings, ranging from several seniors in a boarding home to many residents living in a high-density facility. Also included are comprehensive personal care homes or facilities, assisted living residences, assisted living programs, alternate family care, respite care, residential care facilities, adult residential care homes, basic care facilities, enriched housing, adult foster homes and supported residential care facilities.

Assisted living facilities fall into three categories: intermediate care facilities, for seniors who need assistance with activities of daily living (toileting, dressing, bathing, transferring, eating and continence) and medical services; residential care facilities, for seniors who need only assistance with activities of daily living; and foster- or family-care facilities, which provide assistance with daily living for one to four paying residents.

Appropriate for: Seniors who may need assistance with household chores, medication and personal assistance. Also for seniors who want to live in a facility that can accommodate changes in their level of care.

Services: Meals, housekeeping, activities, transportation, security and assistance with personal care. Support services are available 24 hours a day.

Cost: Prices vary by region and by the type of facility and services provided. In North Carolina, a private room in an assisted living facility runs about $2,200 to $2,500 per month. In New Jersey, the same room costs about $2,800 to $3,300. Facilities usually offer three to five levels of care, with monthly price differentials of approximately $300 between levels. Specialized Alzheimer? care can run an additional $400 to $500 per month.

Pros: Many of these facilities offer special housing and services for seniors with Alzheimer? disease.

Cons: Not appropriate for seniors who need 24-hour nursing or medical care.

Regulation: State licensing requirements varies from state to state and type of facility.

Financing: Medicaid assistance (availability varies from state to state), private funds, Supplemental Security Income (SSI), long term care insurance.

3) Dependent Care

When a senior is no longer able to live independently because of compromised mental or physical health or lack of support services, a long-term care facility can be an excellent choice. This category also includes hospice, which serves people with terminal illnesses.

A) Long Term Care Facilities

Also called nursing facilities, theses are long term care facilities that provide custodial care, nursing, psychosocial and rehabilitative services on a continuing basis. They are also known as skilled nursing facilities and convalescent homes.

Do not assume that placement is permanent. Some residents stay only a brief while to recuperate. Others need very long-term or permanent care. Try to find a nursing home that will encourage and enable your senior to be as active as possible.

Appropriate for: Seniors who need daily skilled nursing care and assistance with activities of daily living. Referral is often by a physician; in some states, physician referrals are mandatory. This can be a good setting for disabled people with multiple recent hospitalizations or health problems requiring multiple types of services.

Services: Mandated services and offerings vary by state. In general, however, services include room and board, skilled nursing care, assistance with daily personal care, physical and respiratory therapy plus other modalities as needed, recreational, spiritual, physical, educational and community activities.

Cost: Typically about $140 to $250 per day. Some facilities charge extra for locker rental and other options.

Pros: On-site health care and support services. Organized activities, opportunities for socializing.

Cons: Not all facilities are equally equipped to take care of special-needs residents, such as those with head trauma, tracheostomy, etc. Some facilities do not accept Medicare and Medicaid patients.

Regulation: These facilities must meet standards set by state and local laws and regulations, and they must be state-licensed. Facilities certified for participation in Medicare and Medicaid also operate under federal regulations. Regular, official inspections ensure fire, safety and health requirements are met. Nurse aides must have completed a 90-hour training course.

Financing: Some residents or their families pay for the care out of their private funds or with long-term care insurance. Others (whose finances are depleted) rely on Medicaid to cover the costs. The federal Medicare program will cover limited rehabilitative services when it is determined that the individual will benefit from such care.

B) Hospice

Hospice provides terminally ill individuals with medical care emphasizing pain management and symptom relief. Hospice may be provided in the patient? home or in a hospital or stand-alone hospice center. Eighty percent to 90% of hospice patients choose to remain in their own homes.

Appropriate for: Terminally ill patients with a life expectancy of six months or less.

Services: Case management, skilled nursing care, housekeeping, pastoral and grief counseling, and respite for caregivers. Hospice volunteers may provide companionship and transportation to medical appointments. Hospice providers increasingly work with nursing-home patients on-site.

Cost: In 1997 hospice care cost about $108 per covered day of care, according to the Hospice Association of America. Patients pay for costs not covered by insurers.

Pros: The senior remains in familiar surroundings and is kept as pain-free and comfortable as possible. Family members may benefit from many hospice services and need not file any insurance paperwork related to the senior? care.

Cons: Family members may be physically or emotionally unable to manage the care of a terminally ill person.

Regulation: In some states, the state Department of Health licenses hospices or their personnel, and the department certifies hospices in every state. Certification qualifies the hospice to receive payment from Medicare and Medicaid, when applicable. Certified hospices meet basic federal and state standards, where required.

Financing: Medicare nationwide; Medicaid in most states. Most private health insurance and HMO policies also include hospice coverage. Hospice programs backed by foundations, medical institutions and grants may offer to subsidize the care for uninsured individuals.

Melanie J. Davis, based in Somerville, N.J., is a freelance writer who contributes to a variety of media, including newspapers and Web sites.