Everyone (and those who love them) who finds themselves in need of help likely goes through a crash course on eldercare options. It is, like most of our health care system, a confusing array of possibilities. What makes it even more challenging is that even within a single 'category' the options can be very different. Add on top of this personal preference, whether there is a consensus among all parties involved that a change even needs to occur, and the BIg Kahuna of financing, and it is truly daunting. I can only relate my experience, and perhaps that will be helpful. This post will focus solely on the options. I apologize in advance for it's length, but there is a lot to say and I think it is helpful to have it in one place.
1. Life Care/Continuing Care Communities: These can be considered the one-stop shop of retirement communities. These communities include independent-living apartments (sometimes even home), assisted living, and some or all of the following: rehabilitation care, skilled nursing (a.k.a., a nursing home), and a memory care/dementia/Alheimer's facility. Most of these facilities require a significant entry deposit, which may range from $100,000 to over $300,000 (and more) in addition to a monthly fee that normally covers the space one lives in and most utilities and cleaning, meals, many activities, and when in units requiring additional care (assisted living, rehab, skilled nursing, etc) the cost of care beyond what might be covered by Medicare (or other insurance sources). As the level of care increases in intensity, the monthly fee increases (so, one monthly fee for independent living, e.g., $3,000, and higher fees for assisted living, e.g., $6,000, rehabilitation, skilled nursing, e.g., $10,000, etc.). There are some communities that do not require a deposit but generally have higher monthly fees. Note that all, or most, of the entry deposit is returned upon either moving out or to the estate upon the person's death, depending on contractual arrangements. Note also that one can stay in independent living, but incur a hospitalization followed by rehabilitation. That rehabilitation (or skilled nursing care) following a hospitalization is covered by Medicare and would not result in a higher monthly fee.
Most people pay the entry deposit by selling their homes, which can make not being a homeowner a significant barrier to entry. The deposit is often also a sort of insurance policy. Most places also have a policy that you will never be kicked out of the community for lack of funds once you are there. It is important to clarify with each community how they handle this, because there is a range of possibilities. For many, if not most, if you run out of money they will start dipping in to your deposit to pay your monthly fee. If that is exhausted, then the individual will be eligible for Medicaid (or Medi-Cal in California), and the community will receive those funds to cover the costs of care (but are likely to be then limited in the 'type' of accommodation). These scenarios and coverage questions must be asked before signing on as they can be significantly different by community.
Life care/continuing care communities can also be wildly different in terms of amenities. For example, my parents looked at a few of them. One, closest to their home, was what I would call at the much-higher end of the spectrum and truly is designed more for younger elderly, with elaborate fitness facilities with an Olympic-sized indoor pool and high-end hotel-like facilities where they would eat dinner every day. My parents really didn't need to be paying for amenities they would likely never use, and the grandeur of the common areas were not particularly comfortable for them. The deposit was closer to $300,000, but with a lower monthly fee. However, an analysis of this over various periods of time actually showed that the financial outlays were essentially a wash for each of the facilities. Over time, they all cost about the same. This is certainly not necessarily true in all cases. Do a sensitivity analysis, with a complete rundown of assets, various anticipated life spans and needs and associated monthly costs. It is surprising how competitive they can be despite the wide variation in up-front deposits.
Obviously, being on a fixed income, particularly later in life, creates a level of nervousness about the potential for running out of money. Clearly parents need to be well-informed and engaged in the process of looking at financing. That said, especially if parents own their home, life care/continuing care can be an excellent option.
My parents now live in a life care/continuing care community. They have a wellness center on site within interior walking distance where they have transferred their care and like their doctors, they now have all their medications delivered to them, they are a short walk to a bistro for lunch or dinner and a dining room for dinner, the community has a really nice bar where they have their own locker, there is a store and bank on site, a library, a movie theater, weekly maid service, organized activites and outings, a daily van service for shopping, they can be driven to any places the van service doesn't normally go, if either is in need of post-hospitization rehab or skilled nursing they can walk to visit one another, and there is a schedule of services that can be done in their independent living apartment to help keep them there. My father has even had in-apartment health care visits and an EKG. It's pretty awesome. Without an independent-living option, moving would have been a much harder idea to absorb. They still have a car, but it has barely moved in the two months they have lived there, and they see people every day and are gradually making new friends.
2. Assisted Living Facilities: There are now in most areas a plethora of assisted living facilities. They offer a lower level of care from nursing homes, including help with activities of daily living (bathing, dressing, toileting, supervision of medication, escorts to meals, and making sure people are safe). These facilities are designed for people who need help, but do not need 24-hour nursing care offered by a skilled nursing facility/nursing home. Depending on what state you live in, 'assisted living' can mean something different, and may also be called something differently. There is no national standard or licensure. People usually have their own apartment, and often much of the time live fairly independent lives. There is a fairly wide variation in facilities and what they offer, so it is important to do comparison shopping and ask lots of questions. Normally, these facilities are paid on a monthly fee basis, and may also have a schedule of fees for additional services. Assisted living fees can coverage wide range from about $3,500 to over $6,000 per month. Be sure to find out what is covered in the monthly fee and what is considered additional and on a fee-based schedule.
Again, beyond the need for assistance, a huge selling point for assisted living is being among other people. Living alone where one rarely sees other people is truly challenging, and frankly likely accelerates the aging process. It is also natural that the world becomes a much smaller place, because one spends so much time in one's own head. Thus, when things happen that challenge that inside world, they become a much bigger deal.
3. In-Home Care: There are a wide array of possibilities for in-home services in most communities that can help peeople stay in their homes longer. Services are generally provided at around $20 per hour, and the people doing the care are often certified nursing assistants. They may not be. Services can include all sorts of activities, including cooking, cleaning, reminders to take medications, driving people to the grocery store, pharmacy or appointments (or doing the shopping themselves), bathing, dressing, toileting, etc. It can be a terrific arrangement for some people, but likely will also require some supervision by family. People who do not normally have some other person in their home may be challenged with supervising a home aide or even resent their presence. A common refrain in my experience was, "why am I paying this person $20 an hour to sit around here" or " she doesn't take much initiative." It can be challenging for some to ask for help and to manage that help. It may require some coaching and asking questions like... what help might you ask for? For my parents, this arrangement lasted maybe a week, which is not uncommon.
4. Rehabilitation Facilities: Generally speaking rehabilitation facilities are designed for short-term stays. Most often, rehabilitation needs come directly after an inpatient hospitalization and are thus covered by Medicare at 80% for the first 20 days, followed by 80% plus a $133 co-pay for an additional 10 days. After 30 days, the patient is responsible for payment. Sometimes the 80% is accepted as full payment.
5. Memory Care/Dementia/Alzheimer's/Specialty Care Facilities: Eventually nearly everyone has memory issues. There are some good options for specialty care for memory issues, dementia, and Alzheimer's. Again it is really important to shop around and do lots of site visits, including visits at different times of day. What is it like in the morning, at lunch time, what do people do in between, how often are people left alone, how attentive are staff? The cost is likely to be similar to a skilled nursing facility.
6. Skilled Nursing Care/Nursing Homes: This is what most think of when the subject of needing additional care comes up. And, it keeps people from wanting to explore options. I truly doubt there has ever been a person who said, "I can't wait to move into a nursing home." Fortunately, most really don't need to do so and there are truly very good options to help people at whatever level of need they might have that do not include nursing homes. Yet, this may be the only viable alternative based upon a need for a higher level of care. It pays to do a LOT of site visits, as nursing homes are all over the map in terms of quality and cost. Generally speaking, most fall into a range of $7,000 to $12,000 per month, and ongoing skilled nursing care is not covered by Medicare. Eventually, most people spend down their assets and qualify for Medicaid to pay for their care.
That is my "quick" round-up of available options. There may be more in your area, but hopefully this gives an idea of what options are out there and how important it truly is to plan ahead as much as possible. For my parents, the initial response to looking at life care/continuing care communities was that they didn't need that kind of care. It is not really so much about that, as it is looking at day-to-day living, how much they get out into the world and interact with other people. It helps keep people engaged with the world beyond the television news. It is a lifestyle shift that can open up all sorts of new possibilities and even help keep them healthier longer.