Someone contemplating the onset of old age sent me a question about assisted living arrangements. He knew of my post-retirement work as a non-medical care-giver, and during sixty-plus assignments over nine years I did indeed see a wide range of possibilities. This post is a short summary of what I found.
The first step in getting help is, of course, from family members -- spouse, siblings and children are the usual candidates to become helpers, but before going to a private pay alternative to staying at home, they are always the first step.
Private-duty caregivers are available from a variety of agencies, both medical and non-medical, with a range of costs depending on individual arrangements -- brief assignments, usually with an hourly minimum -- paid thru the agency. Nursing professionals are, of course, more expensive, and the rate will vary from one place to another and according to the amount of business for the provider. Occasional four-hour shifts will cost the most, of course, with more business available at lower rates. My first assignment was as a "live-in", caring for a man who lived alone recovering from a broken ankle. He needed someone to fix meals, get the mail, take him places and take care of other personal needs until he was out of the wheel-chair/walker stage and out of rehab.
I cannot say what costs to expect because there are too many variables. In addition to what the caregiver is paid, the company furnishing the service has many expenses -- secretarial, accounting, payroll, legal, advertising, and of course profits. And those costs vary widely in different parts of the country. I can report that after nine years service and several "increases" I was earning under twelve dollars per hour. But my guess is that clients were charged twice or more that amount depending on how much business they had with the agency.
An alternative to an agency is a private-pay arrangement with a trusted friend or someone recommended thru a church or other organization. Out-of-pocket costs will be lower, but I learned long ago in life that "you get what you pay for." As a retired food service manager I had a post-retirement job for five years in the dining room of a retirement community before working with an agency. During that time I was sent to a continuing education gerontology course at the local community college, and I was able to observe private-duty caregivers among the seniors in the dining room.
I chose working thru an agency for several reasons.
• choice to accept or refuse an assignment
• liability was covered by agency insurance
• job security (demand is nearly always more than supply)
• schedule flexibility (freelance caregivers have no relief other than family members or other caregivers who might take your client)
The biggest reason, I learned later, was having the company as a buffer between the client and his or her family.
The assisted living option
I had a number of assignments with clients in assisted living arrangements, ranging from those who needed minimal assistance to others with more complicated physical and mental needs, until they were deemed candidates for a "higher level of care" (i.e. moving into a skilled nursing facility aka nursing home).
The typical assisted living facility furnishes a private living space for the client to sleep and bathe, with a comfortable place for visitors, reading, writing letters or watching TV. There may or may not be a microwave or fridge as well. Meals are served in a common dining room where residents are assigned to specific seats and tables so that special requirements can be met most efficiently. Dining room seating is an important consideration since that is often the only "community" interactions with other residents.
I don't know what the actual numbers are but my observation is that residents in both assisted living and long-term care arrangements have relatively few visitors. Part of the reason is that non-visiting times are scheduled to enable staff to take care of laundry, housekeeping, meds, food service and scheduled group activities for residents. Most facilities have activities directors who arrange group trips for shopping or other activities, and visitors are sometimes included.
Many facilities include a secure area for residents with dementia who might otherwise get lost or even leave the property. Staff in those areas usually have added responsibilities to assist with eating, dressing or other needs. And in some facilities I have observed spouses living in the general population with a mate confined to the locked area.
Continuing Care Retirement Communities are the gold standard for retirement living. This is a segment of the economy that has only grown bigger as more people with more money live longer. Just this morning I came across an excellent resource from AARP outlining the details.
Continuing care retirement communities, also known as CCRCs or life plan communities, are a long-term care option for older people who want to stay in the same place through different phases of the aging process.
Nearly two-thirds of the communities charge an entry fee, according to a study from commercial real estate services firm CBRE. The average initial payment is $329,000, but it can top $1 million at some communities.
Once residents move in, they pay monthly maintenance or service fees that typically run $2,000 to $4,000.
Other continuing care communities operate on a rental model with no up-front fee. Rent for an independent living unit is often $3,000 to $6,000 a month.
Here is the AARP link. No need for me to copy How Continuing Care Retirement Communities Work but this much is important to know.
Understanding a CCRC contract
Once you’ve settled on a community, go over the contract closely. These contracts have three basic types:
• Extensive life-care contract, also called Type A. This option carries the highest fees, but it will include a full range of services. For example, you will get unlimited assisted living, medical treatment and skilled nursing care with little or no additional cost.
• Modified contract, Type B. This contract offers a limited set of services. Services beyond those contracted incur higher monthly fees.
• Fee-for-service contract, Type C. The initial enrollment fee may be lower, but residents pay for whatever specific services, such as assisted living, skilled nursing or memory care, that they require.
Some facilities also offer a rental contract, Type D; and an equity agreement to purchase a share of your unit in lieu of an entry fee, Type E. Continuing care retirement community contracts are notoriously complex, so whichever type you get, run it by a lawyer before signing.
Some basic contract questions to consider:
• What is the breakdown of fees, and will fees be raised annually? If so, by how much?
• What is the payment schedule?
• What services are included in the entrance and monthly fees?
• What are the charges for services that aren’t included in the standard fees?
• What happens when one person needs the next level of care if you are moving in as a couple?
• What if a resident needs assisted living or nursing care but no spaces are available in those sections?
• Is any portion of a resident's fees refunded to the estate upon death?
• Are entrance fees refundable if a resident decides to leave the community?
A word about long-term care insurance.
I have a rather dim view of long-term care insurance for the same reason I have a bad attitude about insurance policies in general: these products are business models aimed more at the profitability of insurance companies than their presumed "beneficiaries".
I'm sure there are a string of variants, but long-term care policies generally, like term life insurance, cover a pre-defined amount of time in a pre-defined facility at such time that a pre-defined punch list of qualifying eligibility requirements are met. I'm sure there must be advance arrangements in case the beneficiary either fails to live long enough to receive the presumed benefits OR outlives the term of the contract and hits the affordability wall for the duration or his or her life.
A word about Medicaid.
Most Americans have no idea why Medicare and Medicaid are two separate program and I have no intention of summarizing the differences in a paragraph or two. I mention Medicaid simply to note that well over half of all nursing home residents are Medicaid beneficiaries, and in order to qualify for that status must be officially destitute. All of their earthly assets are gone and anything left to their heirs will have virtually no market value.
Both of my parents were Medicaid beneficiaries when they died so I have first-hand knowledge of how the system works. Before my father died years ago he had lived his final year in a nursing home following a stroke. After a Medicare patient has spent three days as a full-time patient in a hospital and the doctor orders he or she be discharged to a rehab facility, Medicare picks up the costs for 99 days. Medicare continues to pay for medical care but on day 100 that patient becomes "custodial" and is personally responsible for "room and board." Whatever income and/or other personal assets belong to that person must then supplement the costs of food and lodging of the facility which, depending on the facility, can easily run into six figures annually. My mother was allowed to keep the house, an automobile and up to $5000 in the bank, but all other income had to be used by the nursing home to pay for Dad's care.
When he died my mother became eligible to receive whichever of their two Social Security benefit was greater and retain the house, personal effects and car. After a few years she sold the house and relocated closer so my sister and I could help her with an apartment. She lived a couple more decades before going to a nursing home, so she easily became another Medicaid beneficiary when the time came. Single individuals who become "custodial" have no need for a house or car, so her assets, and others were liquidated to cover her room and board when she became eligible for Medicaid assistance. She (we) were permitted to keep a small amount of money in her name for personal effects, but her Social Security checks went entirely to the nursing home along with whatever the state arrangements are for the balance of her food and lodging. (Medicare continued to cover her medical needs.)
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