Assisted Living: Care With an Independent Flavor

By Attorney Joseph L. Matthews, Nolo

Find out what assisted living may have to offer — and what to look for when evaluating it as a new home.

Assisted living combines much of the homelike atmosphere of independent living with some of the personal care of a nursing facility. It provides extensive personal assistance and services, plus round-the-clock monitoring, that are not offered by independent living residences and would be extremely expensive if arranged through home care. On the other hand, assisted living permits residents to maintain some of the privacy and independence that are lost in more institutional, and more expensive, nursing facilities. Assisted living is the fastest-growing type of senior residence — meeting the needs of millions of seniors who cannot make it entirely on their own, but who do not need nursing care.

The residences referred to here as assisted living are sometimes also called sheltered care or catered living. Although each facility or residence differs somewhat in the type of housing and level of services and staffing provided, all of them, regardless of name, have certain things in common. They provide:

• domestic services, including meals and housekeeping
• assistance with personal care and the activities of daily living, but not nursing care, and
• close monitoring to help ensure residents' health and safety.

Assisted living provides a room or small apartment — usually rented — to help maintain a homelike setting, plus a range of services to assist residents with those tasks of daily life that have become difficult because of the loss of some physical or mental capabilities.

Types of Living Spaces

There are several kinds and sizes of assisted living housing: full-size one-bedroom apartments; studio apartments with small kitchenettes; studios without a kitchen or with a partial kitchen that has no cooking facilities; single rooms; and shared rooms. An assisted living apartment or room may be furnished or unfurnished. Even if a space is furnished, some places permit residents to bring in some furnishings of their own, which can make a new place feel more like home.

Assisted living apartments and rooms tend to be smaller than living spaces intended for the general public. They are often fitted with safety devices such as handrails and special bathroom fixtures, and may include a hospital bed if needed. In addition to the small rooms and space-eating fixtures, people tend to bring more of their own furnishings than would otherwise fit easily into the space. As a result, many assisted living apartments feel crowded and even smaller than they are. It is often difficult for a new resident to adjust to the smaller, more cramped quarters.

Services Provided

The main difference between assisted living and independent living residences — usually housing complexes built or renovated for older residents who are basically able to care for themselves — is that assisted living gives residents more help in meeting their daily needs. While assisted living does not offer either the medical care or the level of attention of a nursing facility, it does provide personal care in a resident's living space and common areas, meals, household tasks and extensive monitoring of each resident's physical condition.

Personal Assistance. Most people move to assisted living because they need help with one or more of what are known as the activities of daily living (ADLs). ADLs include eating, bathing, dressing, continence and using the toilet, walking and getting in and out of a bed or chair.

An assisted living facility will help a resident with any ADL — but not all the time, and not whenever a resident wants help. Instead, a schedule will be developed that takes into account the resident's needs and the staff's availability. For example, an aide might help a resident get in and out of bed in the morning, once or twice during the day, at bedtime and once again during the night. Or a resident will be given a full bath three or four times a week, but not every day.

When you consider a particular assisted living residence, ask precisely what it offers for the specific ADLs with which you need assistance. If the facility offers you the kind and frequency of assistance you need, make certain that care is spelled out in the written residence agreement you and the management sign.

Health monitoring. In addition to help with daily activities, assisted living facilities monitor a resident's health. That does not mean nursing or other active treatment of a medical condition. Rather, it means keeping track of and helping the resident take the correct dose of medications, helping the resident with self-administered health aids such as prostheses and oxygen, providing emergency call systems and checking on a resident's well-being during the night.

Most assisted living residences have a nurse on duty to check on any resident who has health difficulty or whose physical condition seems to be changing, and to refer the resident for medical care if it seems necessary. Health monitoring may also include coordinating care with the resident's primary care physician and keeping track of a resident's medical appointments. And most facilities provide or arrange transportation to and from those appointments.

Meals. For many people, one of the most attractive things about assisted living is that meals are provided. These facilities have a kitchen and a common dining room where at least two and usually three meals a day are served. The cost of meals is included in the resident's rent or fees. Residents are freed from shopping, cooking and cleaning up; they are assured of nutritious food; and they are brought together for the informal social exchange of a meal with other residents.

There are several things to check about an assisted living residence's food service. First, find out how many meals a day are included, and whether they are all full, hot meals. Then check on the quality of the food; it won't do you any good if you won't eat it. Try several meals in their dining room, and see if the residents seem interested in their food and in each other.

Housekeeping. Assisted living facilities provide laundry and housekeeping services. What that housekeeping includes, however, can vary considerably. Find out how often a resident's bedding and bath linen are laundered. Does the facility do a resident's personal laundry as well? Is there an extra charge for personal laundry? How often (and how well) is an individual room or apartment cleaned?

Social activities and exercise. It is one thing to assist residents with the basics of daily life such as dressing and bathing; that help is guaranteed in a contract with an assisted living residence. It is another thing entirely to help residents lead mentally, physically and socially active lives. This is not a matter of contract, but of the quality and style of service at a good residence. Most facilities plan group activities such as guest lectures and exercise classes, as well as regular gatherings for the residents to visit among themselves. The best facilities also help individual residents participate in these activities to the extent possible and provide alternatives — an assisted walk around the hallways, for example, or a one-on-one chat in a resident's private room — when it's not feasible to participate in a group.

There are several ways to get a sense of the quality of group and individual activities at a particular facility. You can always take a look at what is scheduled for any given week, but it is also important to visit during one of these planned activities to see if residents participate and seem to enjoy doing so. As for more individual attention, find out whether there are any rules against staff spending non-scheduled time with residents. And on all your visits, watch how the staff interact with residents: look for a friendly, relaxed manner on everyone's part.

Costs

Most assisted living spaces are rented, not purchased. The major exception is assisted living as part of a continuing care community.

Basic Rent

Rent depends on the size of the living space. A small room with no cooking facilities will cost much less than a spacious one-bedroom apartment with full kitchen. The rent also varies with the amount of services and staff provided, the location and the overall condition of the facility. And some facilities offer more than one type of rental agreement: A limited contract may include fewer meals and personal assistance than an inclusive or extensive agreement that includes all the services the facility has to offer. Given all these variables, rent for an assisted living unit generally runs 50% to 100% higher than for a comparable independent living unit in the same facility. But it will still be one-third to one-half the cost of a nursing facility of the same quality, in the same area.

Rent Increases

As with any other rental housing, you must consider how much your rent may go up over time. A lease can guarantee the rent for a year or two. After that, rent increases are completely within the discretion of the facility's ownership, unless a yearly limit is included in your rental agreement. If there is no limit, check the facility's record of rent increases over the previous five years. If they have raised rents in large chunks, you have to consider whether they will price you out of your apartment in years to come.

Additional Fees

Some assisted living facilities charge fees in addition to rent. There may be a one-time non-refundable entrance fee. And there may be a fee for certain services not included in the basic assisted living contract, such as extra or delivered meals, extra housekeeping service, local transportation fees or personal care beyond the standard level of care offered in the facility.