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Alternatives to Nursing Homes

The reality is that it’s sometimes impossible or too expensive for an elderly person in poor health to remain at home. Other seniors may simply wish to live with others rather than be isolated. Fortunately, over the last two decades there has been an explosion of supportive housing alternatives for seniors, and the options are no longer limited to an agonizing choice between staying at home or moving to a nursing home. If you (or a loved one) do not require round-the-clock skilled nursing care, one of these supportive housing alternatives may be just right.

Supportive housing options range from board and care homes to large institutional complexes. Supportive facilities provide food, shelter and personal assistance while encouraging independence and personal dignity. The services offered may include help with activities such as eating, dressing, preparing meals, shopping, as well as monitoring and other supervision.

The main alternatives are board and care facilities, assisted living facilities and continuing care retirement communities (CCRCs). But these broad categories encompass a huge range of options in terms of services and costs. Generally, the more you pay, the more services you get. There’s a range of quality as well, with some facilities excellent and others not the sort of place you would want to send a loved one to. This means you need to research the options carefully before making a choice, and this section can help you in that process. But if you can find a high-quality facility, supportive housing can make a great deal of sense. It’s reassuring to know that help is there to take care of tasks like cooking, cleaning and home maintenance.

Board and Care Facilities

These are group residences that can range in size from as few as two residents to more than 200. They may also be referred to as residential care facilities, homes for the aged, or community-based residential facilities. Such facilities provide room, board, and 24-hour supervision, as well as help with some of the five activities of daily living (eating, dressing, bathing, using a toilet, transferring from one position to another) and the instrumental activities of daily living (ADLs) (preparing meals, walking outdoors, taking medications, shopping, housekeeping, using the telephone, handling money).

Such facilities generally do not provide any medical services. These homes may be unlicensed, and even licensed homes may rarely be monitored by the state. Costs can range from $350 to $3,000 a month. For those with very limited incomes, Supplemental Security Income (SSI) may help pay the cost of these homes. Medicaid may also reimburse the monthly fee, depending on the state and the resident’s Medicaid eligibility.

Assisted Living Facilities

These facilities offer basically the same services as board and care homes, but in a more “upscale” and homelike environment. Housing is often in small apartments and there’s generally more space, more privacy and more recreational options. A premium is placed on retaining as much independence in living as possible, and care is more individualized. Despite the emphasis on independence, twenty-four hours a day supportive services are available to provide different levels of help with activities of daily living. There also may be more medical supervision than in a board and care home, depending on the facility.

While costlier than board and care facilities, assisted living facilities nevertheless are often less expensive than a nursing home. Assisted living facility residents agree to pay a monthly rent, which can range from less than $1,000 to $6,000 a month. According to a 2004 MetLife survey, the average cost of an assisted living facility in the U.S. is $2,524 a month, or $30,288 a year. The highest average monthly cost was in Stamford, Connecticut, at $4,327, while the lowest was Miami, Florida, at $1,340.(For information on the full survey, click here.)

This rent may cover all services or there may be charges for services above the monthly fee on a per-use basis. Residents generally pay the cost of medical care from their own financial resources. Some costs may be reimbursed by an individual’s health insurance program or long-term care insurance policy. Because assisted living facilities are usually less expensive than nursing homes, many state Medicaid programs now provide some type of funding for elderly residents who qualify for the Medicaid program.

However, assisted living facilities are an emerging industry and not all states regulate such centers to protect residents from substandard care or questionable business practices. For details of regulatory activities in specific states, click here.

If you’re looking for names of assisted living facilities near you, check out the online resource This site not only searches facilities by city, county or zip code, but it often provides evaluative information as well. The site also describes each state’s regulations covering assisted living facilities.

Continuing Care Retirement Communities (CCRCs)

CCRCs offer the entire residential continuum — from independent housing to assisted living to round-the-clock nursing services — under one “roof”.Residents pay an entry fee and an adjustable monthly rent in return for the guarantee of care for the rest of their life. Because CCRCs maintain an assortment of on-site medical and social services and facilities, residents can enter the community while still relatively healthy and then move on to more intensive care as it becomes necessary. Nursing care is often located within the CCRC or at a related facility nearby. In addition to health care services, CCRCs also typically provide meals, housekeeping, maintenance, transportation, social activities, and security. Communities range in size from about 100 to 500 living units

CCRCs are so diverse in their offerings and personality that the saying in the industry is that ‘if you’ve seen one CCRC, you’ve seen one CCRC’. The physical plants of CCRCs run the gamut from urban high-rises to garden apartments, cottages cluster homes, or single-family homes. Some CCRCs provide units that are designed for people with special medical needs, such as Alzheimer’s disease.

Most importantly, CCRCs guarantee a life-long place to live. Assisted living and even skilled nursing facilities make no such guarantees, and in fact they may ask you to leave if they believe they cannot provide the care you require.

The downside of CCRCs is the cost, which can be more than those with low or moderate income and assets can afford. Prices depend on the amount of care provided, the type of contract, and the unit’s size and geographic location. Entry fees run from $20,000 to more than $500,000, with monthly charges ranging from $200 to $3,200. Often seniors use the proceeds from the sale of their home to make the initial investment in the retirement community. However, keep in mind that the Internal Revenue Service does not allow home sellers to roll over their capital gains into the purchase of a CCRC unit. Thus, a tax may be due on gains from the sale of a home even though a CCRC unit is being purchased with the proceeds.

You may be able to get a refund of your entry fee on a declining scale if the refund is requested within a short time after moving in. Generally a refund will no longer be available after a specified period of residency. Some refundable fees revert to your estate when your unit is sold, while others do not.

CCRC fee arrangements

Although the entry and monthly fee arrangement is the most common, some CCRCs offer rental or equity arrangements. Under a rental arrangement, residents pay only a monthly fee, which typically covers housing and designated services (sometimes including health care services). Under equity arrangements, residents purchase their residence in the same way they would a cooperative apartment or condominium, although the resale of the unit is usually limited to those who meet the community’s eligibility criteria. Residents then may purchase service and health care packages for an additional fee.

CCRCs often allow you to choose from three different fee schedules:

Extensive contracts, which include unlimited long-term nursing care at little or no increase in the monthly fee. This arrangement requires residents to pay a higher fee initially;
Modified contracts, which include a specified duration of long-term nursing care, beyond which fees rise as care increases; and
Fee-for-service contracts, in which residents pay a reduced monthly fee but pay full daily rates for long-term nursing care.
As with assisted living facilities, the regulation of CCRCs is spotty. These institutions are strictly regulated in some states, while not at all in others, and there is no overarching federal agency that watchdogs retirement communities. A private non-profit organization, the Continuing Care Accreditation Commission (CCAC), accredits CCRCs. The CCAC accreditation process is voluntary. Its high cost and the length of time it takes to complete means that accreditation is a good indicator of a facility’s quality. The CCAC’s Web site lists all CCRCs that have been accredited. Go to

Nevertheless, a CCRC’s lack of accreditation should not necessarily be taken as a bad sign. One of the most important considerations is the financial soundness of the facility. In selecting a community, experts recommend choosing a “mature” facility, one that has been in business a number of years. Also, know who the CCRC’s sponsor is. The Society of Friends (Quakers), for example, has been in the CCRC business for quite a while and its facilities are reputed to be excellent. The American Association of Homes and Services for the Aging is the national association for the non-profit CCRCs (most CCRCs are operated by non-profit groups). The group’s Web site includes tips on selecting a CCRC. Go to

CCRC entry requirements:

Most CCRCs require that a resident be in good health, be able to live independently when entering the facility, and be within minimum and maximum age limits. As a prerequisite to admission, facilities may also require both Medicare Part A and Part B, and perhaps Medigap coverage as well. A few are now even requiring long-term care coverage as a way of keeping fees down. Some CCRCs are affiliated with a specific religious, ethnic or fraternal order and membership in these groups may be a requirement. Of course, applicants will have to demonstrate that they have the means to meet the required fees. You may be placed on a waiting list, since CCRCs are often sought after.

CCRC residents usually fund their care out of their own pockets. However, Medicare, and at times Medicaid, can be used to pay for certain services, and most CCRCs accept either Medicare or Medicaid. Although Medicare does not generally cover long-term nursing care, it often covers specific services that a CCRC resident might receive, such as physician services and hospitalization. Because the financial requirements for residence are fairly strict and the costs are relatively high, very few CCRC residents are eligible for Medicaid.

How to evaluate a facility and contract:

Deciding on a CCRC is a once-in-a-lifetime choice, and it is a decision that should be made carefully. Many communities allow prospective residents to experience life at the facility. Each community has an agreement or contract that lays out the services provided. You should make sure you understand the contract before signing, and you would be well advised to seek legal or financial counsel before entering into any agreement.

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