Mary Trvalik never wanted to be an expert on assisted-living facilities, but she became one.
“The two most important things I learned that make a big difference are the attitude of the parent and the commitment by the assisted-living facility to putting care at the forefront,” says Trvalik. “My mother was a real trouper and was open to looking at places to live. But my mother-in-law was frightened to live at home alone yet also didn’t want to move.”
Dee Pekruhn, director of life plan community services and policies for Leading Age, an association of nonprofit providers of aging services, says that in some ways searching for an appropriate assisted-living location is like finding the right college for a young adult.
“It’s important to find a place that’s the right fit for someone,” says Pekruhn. “Hopefully, someone will spend a long time there with just enough support to remain independent.”
One area of confusion for many families is that the phrase “nursing home” has become a catchall term for senior housing. However, senior housing includes a spectrum of arrangements, including independent living, assisted living, memory care centers and skilled nursing centers.
“Usually people in assisted-living communities need help with two or three daily activities at most, such as managing their medications or preparing meals,” says Monique Eliezer, chief of sales, marketing and strategies for Ingleside, the umbrella organization for three life plan communities in the Washington, D.C., area, which offer multiple senior housing options on each campus. “Assisted living is independent living with some help. But the help is personal and directed by the residents, who tell us what they want.”
Most states regulate assisted-living facilities and require them to provide three meals each day, laundry and housekeeping, medication management and help with two or more daily activities, says Eliezer.
“The majority of assisted-living facilities are stand-alone communities, with a small percentage that are part of a larger life plan community,” says Sue Johansen, a senior vice president, community network with A Place for Mom, a senior housing referral service which is free to consumers.
The spread of the coronavirus in nursing homes naturally generated concern about the health and safety of residents in all types of senior housing.
“Assisted-living facilities are doing everything they can with the available resources to keep out covid-19 and prevent further spread,” says Rachel Reeves, director of communications for the National Center for Assisted Living, an advocacy, educational and professional development organization. “Family members should ask about the current situation within a facility, infection control policies and procedures, availability of testing and supplies as well as adaptations to follow social distancing guidelines.”
Triggers to start the search
Deciding when assisted living is needed can be difficult for families, but Reeves says early warning signs — including unpaid bills, missing medication or general confusion — could mean it is time to consider caregiver assistance.
Trvalik’s mother, who is 93, had caretakers for her husband in her home who stayed on to help her after he died in June 2018.
“At Christmas in 2019, we realized she needed a change and my mother was open to looking at assisted-living places,” says Trvalik. “My mom was part of the decision to move into Asbury Methodist Village in Gaithersburg [Md.]. We all recognized that they really care for the whole person and understand that their residents have histories and interests. The lifestyle there is an extension of the life she was living before. It also helps that she has a 96-year-old friend who lives there and showed her around.”
Michele Rubinstein, whose mother lives in Ingleside at King Farm in Rockville, Md., began looking at assisted-living facilities when her then-79-year-old mother was visiting another daughter and neglected to take her medication. The family noticed she was becoming forgetful.
“Alzheimer’s and dementia run in our family and after my father passed away six years ago my mother said she didn’t want to be a burden on us,” says Rubinstein. “We made a list of her priorities and mine and we agreed we wanted her to be close to me, to have her medical care taken care of and to be able to bring items of sentimental value with her when she moved.”
Typically, people start to think about assisted living when they are in their mid-to-late 80s, says Pekruhn.
“The best time to do the research on assisted-living facilities is before any trauma happens,” says Eliezer. “As soon as your relative starts to decline, it’s best to start looking into it. We do assessments on each person because there are many different levels of assisted living and services for each level that we can provide.”
Rubinstein says talking to your parents as early as possible about their future and getting them to drive some of the discussion can ease the transition.
“Even though my mother said she didn’t want to be a burden on us, it was still difficult for her to pack up and move,” says Rubinstein. “A couple of weeks before she moved, she was complaining that we were taking away her freedom, but then she found out she has friends who live at Ingleside and they took her under their wing. It’s a nice surprise to see her more engaged than before.”
Unfortunately, the decision to move someone into an assisted-living facility often comes as a result of a dangerous or difficult situation such as a fall, leaving the stove on or consistently leaving the keys in the front door.
“Some families end up calling 911 multiple times per week, so their conversation can be specific and direct with their family member to explain that they can’t manage the situation anymore,” says Johansen. “Other conversations are more nuanced, with the child needing to help their parent understand that this is a health and quality of life issue.”
For other families, discussing assisted living can become a family battle.
“If the relative doesn’t want to move into assisted living, then the child may need to confidently talk about the enjoyment to be had in the community with activities,” says Johansen. “Rather than saying it’s a place where they will be taken care of, it should be presented as a place where they will have fun.”
A third party outside the family can sometimes ease the tension over the issue.
“If someone is resistant, then it might help to rely on a physician’s advice or a friend to suggest that moving into an assisted-living community could be helpful,” says Gretchen Moshier, administrator of Kindley Assisted Living, part of Asbury Methodist Village, a continuing care retirement community in Gaithersburg, Md. “It’s much better for everyone if the parent is on board with the need for extra help and sees that they’ll be able to do things they enjoy.”
Most families start searching online for assisted-living locations, then tour in person. Virtual tours and video chats have become common during the coronavirus outbreak. Typically, assisted-living housing is an apartment with a private bathroom. Some include a kitchenette with a refrigerator and microwave, but stoves are not usually allowed for safety reasons and all meals are provided.
“At Kindley at Asbury Methodist Village we have one-bedroom and studio apartments that residents can personalize,” says Moshier. “We’re ‘person-centered’ and take the time to get to know each resident. We’re flexible in our programming and develop new activities when people come in with new interests.”
Common activities include lectures, book clubs, art classes, gardening, music lessons, singing, fitness classes and, in normal times, outings to shops and cultural attractions.
Rubinstein and her mother toured several facilities in 2018 before choosing Ingleside at King Farm, looking at the quality of the housing and the activities she could participate in at each location.
“She had friends at King Farm and was able to bring in her own living room and bedroom furniture, which made the transition easier,” says Rubinstein.
For Rubinstein, it was also important that her mother will be able to stay in the same community even if she needs more care and services in the future.
“While we were touring places, we carefully watched to see how people interacted with each other and the staff,” says Rubinstein. “We checked out the room sizes and the meals and the daily activities.”
Trvalik recommends visiting each facility more than once if possible, to try the food and survey the activities to determine whether your parent would be comfortable there.
“One thing that helped my mother is that she moved into an apartment rather than a single room, so she has her paintings, her bed, her couch and her favorite chair from her house,” says Trvalik. “On the flip side, my mother-in-law has less space and often wishes she could go back home.”
Of course, an essential part of any assisted-living center is the medical and personal care provided to residents. Residents are typically assessed before they move in to estimate the level of care they need and then reassessed at frequent intervals.
“Families should ask about the level of staffing and the training of various staff members,” says Moshier. “They should ask about whether memory care and therapy are available in the assisted-living facility or just in a specialized memory care center.”
Residents can continue to see their own doctors as well as on-site medical experts if they wish.
Financial and legal planning
The cost of assisted-living facilities varies widely according to their location, services and amenities. The median annual cost of assisted living was $48,612 in 2019, according to the Genworth Cost of Care Survey, compared to $102,200 for a nursing home and $52,624 for a full-time home health aide. A Place for Mom has a cost index to help families understand their options.
“Some assisted-living facilities charge everything in one all-inclusive price that depends on the level of care needed by the resident,” says Moshier. “Others start with a low baseline fee but then charge individually for services, which can add up quickly.”
Monthly costs at Kindley Assisted Living at Asbury Methodist Village start at $9,300 and are higher for residents who need more care. The average entrance fee is $6,500 for people who come directly into the assisted-living section of the community, says Moshier, but the majority of residents transition in from the independent-living section. There is no fee charged for transitioning from one section to another within the community.
About 40 percent of residents have long-term care insurance, says Moshier, which helps defray some costs. Most people pay for assisted living with private funds.
Trvalik’s parents were extremely frugal and provided well for their future, she says. That gave her and her sisters more options to consider for their mother’s care.
“They had done estate planning that covers the costs and then we made sure to do a new power of attorney to give my sister, who lives in Maryland, broader options to make decisions on my mother’s behalf,” says Trvalik. “We automated all my mother’s bills, have a health care proxy and are preparing to sell her car and her house.”
Most people pay for assisted living with retirement savings, pension income or the sale of the parent’s home.
For many families, the transition for a family member to assisted living is traumatic, but it shouldn’t be, says Pekruhn.
“I wish people would see the move as a life-affirming one and recognize that they are still living independently, just with some basic support,” says Pekruhn. “A good assisted-living facility can help someone put off nursing care longer because they get help with nutrition, stimulation from being with other people, exercise and someone to monitor their medications.”
Questions to ask at assisted-living facilities
Most assisted living facilities have a robust website with information that can help families understand what services and amenities are provided to residents. While each family will have individual questions, some of the important topics to cover include:
● Where is the nearest hospital?
● What type of medical support is available around the clock?
● Is there an emergency call system in each room or apartment?
● How do you provide security for residents so they feel safe but not imprisoned?
● What measures are in place to prevent the spread of illness among residents?
● Is there memory care support within the assisted-living facility?
● What activities are available for residents and how frequently are they offered?
● Are religious services available on site or is transportation provided for residents who wish to participate in services nearby?
● Can residents in the assisted-living section participate in activities with residents of an independent-living facility?
● What is the meal plan?
● What is the room or apartment like where my family member will live? Is there a kitchenette? Can we bring our own furniture?
● Is there a continuum of care available at the same place or will residents need to move if they begin to need more help?