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Guide to Long Term Care Planning

About Retirement Care Communities

by Thomas Day

Chapter 1--Retirement Housing Considerations

Putting Retirement Housing Options in Perspective
Relocate or Stay Put?
Making the Decision to Relocate With Future Care in Mind
Home Care in Your Home or in The Home of a Family Member
Reverse Mortgage
Housing for the Elderly Poor

Chapter 2--Worry-Free Retirement Living Arrangements

Master Planned Active Adult Communities
Planned Communities With No Age Restriction
Condominiums, Cooperatives and Seniors Apartments 
About Homeowner's Associations

Chapter 3--Retirement Care Living Arrangements

Sharing a Home or Hiring a Live-in Paid Caregiver
Independent Living Facilities and Congregate Housing
Assisted Living and Residential Care
Alzheimer's Facilities or Alzheimer's Special Units
Nursing Homes
Combined Care Communities 
Continuing Care Retirement Communities

 

Chapter 1--Retirement Housing Considerations

Putting Retirement Housing Options in Perspective  

Senior housing options can be confusing to someone who has never approached the subject before. For example, upscale exclusive senior communities are sometimes called by the following names: age restricted senior communities, active adult communities, retirement resort communities, golf resort communities or adult retirement communities.

As another example consider assisted living. Depending on the state in which they are licensed, assisted living facilities could be called by one or a number of following names: Alternative care, Residential care, Personal care, Adult congregate living care, Board and care, Adult living facilities, Supported care, Enhanced care, Community based retirement facilities, Adult homes, Sheltered housing, Retirement residences or Adult foster care. In some states the term "assisted living " or the term "residential care services" encompasses all of the above titles and in other states certain of the above titles are carved out and licensed for specific services of their own.

Assisted living is commonly the term that experts use to define all of these services. But, to further add to the confusion, states that license the concept under the term "assisted living" define this service in all kinds of various ways. Some states allow for unlimited personal services and for help with activities of daily living, and even allow limited nursing care or special waivers for more continuous nursing care. Other states are more restrictive about what kind of services assisted living can perform.

Often the definition of a particular senior housing term is dependent upon the person writing about the subject. The reason for the confusion is that most retirement care and senior housing arrangements provide overlapping services among the various categories. And depending on the state a commonly accepted term for retirement living in one state might be licensed for somewhat different services in another. Or a state might use a different descriptive title for the same services under a commonly accepted title in another state.

Some writers put undue emphasis on certain arrangements such as continuing care retirement communities or independent-living, when only a small part of the over age 65 population is using such arrangements. By far, most people over age 65 are living in their own homes or rental homes and the great majority of Americans who are receiving eldercare are living in their own homes or in the homes of their children.

The chart below puts into perspective the number and types of senior living arrangements at the end of the year 2000. The services outlined below will be discussed in greater detail further on. 

Estimates of senior living arrangements in the United States at the end of the year 2000.

Total numbers

% of total age 65+ population

U.S. population age 65 and older

34,992,000

100.0%

Age 65 and older owning and living in their own homes

27,434,000

78.4%

Age 65 and older renting, living with family or other

2,976,000

8.5%

Available assisted living beds

1,706,000

4.9%

Age 65 and older residents living in nursing homes

1,475,000

4.2%

Available seniors apartments 821,000 2.3%

Available independent living community beds

239,000

0.7%

Available continuing care retirement community beds

171,000

0.5%

Available units, combined care communities

171,000

0.5%

Census information was derived from the national census online. Seniors owning their own homes and age 65 and over nursing home residents were taken from the 2003, Statistical Abstract Of The United States. All other data were derived from the following source:

"The NIC National Supply Estimate of Seniors Housing & Care Properties enumerated a total of 46,131 seniors housing properties with supportive services in the U.S. with a capacity to hold more than 3.4 million seniors as of 1999-2000. Of these 46,131 properties (3,411,891 beds), 50% were assisted living communities, 34% were nursing facilities, 7% were in dependant living communities, 4% were continuing care retirement communities (CCRCs), and 5% offered a combination of property types. Seniors apartments (that is, seniors housing properties without supportive services) were estimated at 11,726 properties and 821,173 units. For more details, see the Supply Estimate in the NIC Publications . For numbers of properties added since 2000, see theconstruction starts section of NIC's Key Financial Indicators "

Below are some useful links that might help you find sources of senior retirement living arrangements on the Internet:

  • The National Care Planning Council - Find Retirement Communities with Care in your area
  • A Place for Mom.com - free referral service that offers information about housing options and care communities for senior citizens.
  • Active Adult Living - national directory of new and resale age-restricted active retirement communities listed by state. Listings include pricing and community contact information.
  • New LifeStyles Online - source for senior living and care options. Offers a listing of all state licensed senior housing facilities and care agencies across the U.S.
  • Retirement Housing Online - provides information about active adult retirement communities throughout the United States as well as worldwide.
  • Retirement Living Information Center - offers resources for senior living.
  • Retirement Net - featuring homes, properties, golf course and water front living. manufactured and site built homes available.
  • Retirement Resorts - helping seniors identify extraordinary retirement communities. These ARRI-certified Retirement Resorts are featured in The ARRI Retirement Resorts WorldBook.
  • Senior Housing Net - national directory of retirement homes, assisted and independent living facilities, senior citizen apartments, nursing homes and more.
  • Senior Living Alternatives - directory of senior housing options including nursing homes, retirement communities, and assisted living opportunities listed by region.
  • Seniors Housing Guide- lists Northeast Florida's nursing homes, retirement homes, and senior housing facilities.

Relocate or Stay Put?

As people age many of them become--to use common phraseology--" set in their ways ". Many people become attached to their homes and even though there may be compelling reasons to find another living arrangement, most people will go to extreme lengths to remain in their homes. We define a home here as a residence where someone has lived for a number of years. It could be an owner occupied residence, it could be a rental property where someone has established themselves for many years or it could be an elderly individual or couple living in the home of their children or another member of the family.

There are other compelling reasons to remain in the home besides becoming too attached to it. Finding a new residence might take a person further from children, grandchildren or special friends. Community activities, social circles, clubs, schools, church, charity service and other similar endeavors may be left behind if a person moves. Convenience of transportation, shopping, medical services, entertainment and similar services might also be sacrificed with a move.

The older a person is, the more likely a move will be a difficult decision. Such things as the cost of a move, the availability of long-term care services, the availability of reliable medical services and state and county support services must also be considered in a move. Leaving home can be traumatic for an older person. It can end special life patterns, including friends and routines, producing great anxiety and feelings of loss. However, if an elder is socially isolated, if it's too hard to finance upkeep or home repairs or if the home design cannot accommodate disability, then the person should consider alternate housing arrangements.

Aside from a need for the kind of long-term care which can't be handled at home, there may be some other motivating reasons to move to a new location. Consider the following:

  • If the neighborhood has deteriorated and safety is a concern.
  • To be near children (70% of those 65+ live within 1 hour of a child).
  • To match the home's facilities to senior's faculties.
  • To avoid climbing stairs
  • If assets are tied up in the home and cash is needed.
  • If driving is no longer possible and available transportation is not adequate.
  • If retired, no longer needing to work and looking for a new lifestyle and experiences.
  • If there is a desire for a warmer climate, new vistas and a need for challenging recreational experiences.

Active seniors, seen as move-down buyers may be moving down, not in size, but in their home maintenance.

Since 1960 the trend has been to move from cities to rural or suburban settings with warmer climate and recreational opportunities (Fuguitt and Beale, 11/93, Journal of Gerontology). Recently we see more active senior communities, apartments and complexes for the elderly, offering medical care components in older urban neighborhoods.

It's a good idea to compare the home's current costs against what a new home, senior retirement community, independent-living facility, seniors apartment, senior congregate living, assisted living, or continuing care retirement community would cost. There are many potential hidden financial and social costs that need to be considered. Assisted or group retirement living may not be much more expensive than staying put. Or, perhaps due to other hidden costs it may be more expensive. Consider the following:

  • New mortgage
  • Very high buy-in fees
  • Home owner's association fees
  • Club fees, green fees and other social obligations
  • Higher property and income taxes
  • Maintenance fees
  • Special assessments
  • Higher fire, theft and liability Insurance
  • Higher electricity and gas and other utility costs
  • Water, sewer and trash pickup fees
  • Additional telephone, Internet and cable fees
  • More expensive meals
  • Additional transportation costs
  • The need for car ownership due to inadequate transportation options at the new location ( costs of ownership, maintenance, repairs, insurance)
  • Housekeeping costs
  • Laundry costs
  • Linen service costs
  • Cleaning costs
  • Additional travel costs
  • Higher food costs
  • The headache of coping with a homeowner's association
  • Excessive rules, regulations and restrictions associated with living in a planned community

One should always be aware of what one is getting into when buying into a planned community with a homeowners association. Some associations are well run while some can make life extremely miserable for their members.

Making the Decision to Relocate With Future Care in Mind

Healthy retirees in their late fifties or early sixties seldom worry about the need for long-term care when making decisions about where to retire. This is unfortunate since the probability of needing long-term care later in life, especially for currently healthy individuals, is very high.

Exactly what is long-term care?

It refers to a broad range of supportive medical, personal and social services needed by people who are unable to meet their basic living needs for an extended period of time. This need may be caused by accident, illness or the frailty of old age. A rapidly growing category of long-term care disability is also due to cognitive impairment from stroke, depression, dementia, Alzheimer's, Parkinson's and so on. According to the Alzheimer's association, about one out of every two persons over age 85 will develop dementia at some point.

Care from another person may be needed to help with the inability to move about, dress, bathe, eat, use a toilet, medicate and avoid incontinence. Also care may be needed to help with household cleaning, preparing meals, shopping, paying bills, visiting the doctor, answering the phone and taking medications.

More long-term care is received at home and in community facilities than is received in nursing homes. Of total care provided, 78% is home or community based.1 One quarter of American households are involved, directly or indirectly, in a care giving environment. This represents 22.4 million families, 64% of them trying to juggle demands of full-time jobs with demands of care giving.2 But long-term care is not just for the old. Out of the total population receiving it, 43% are under the age of 65. Out of 12 million Americans receiving care more than 5 million are of working age3 For those over 65 there is a 41% chance they will spend an average of 2.5 years in a nursing home.4 The combined lifetime risk of needing home and community care as well as nursing home care is about 6 out of 10.5

The nature of long-term care in our society is changing. Medical science is keeping us alive longer and there are fewer early sudden deaths. Fewer deaths mean more prolonged health problems requiring long-term care. In addition the population of those over age 65 is increasing while the younger population is stagnating. This trend will continue to put pressure on aging services including long term care.

At the same time the number of aged is growing, the supply of non-paid care givers is shrinking. Many of these traditional care givers--women--are now working due to an increase in single parent households and due to increased income needs of dual parent households. Also, families are having fewer children thus affecting the future supply of care givers. And finally, many family members are moving away and are unable to help because they don't live close by. These are all factors that reduce the pool of available care givers. And this lack of traditional family care givers is forcing more people to spend out-of-pocket for the services of paid professionals or, so-called formal care.

References: (1). "More Spend Time Caring for Elders" USA Today, March 18, 1997; (2) "The Lowdown on Long Term Care" Business and Health, August 1995; (3). Employee Benefit Research Institute, Research Brief 163, July 12, 1995; (4). "A Shopper's Guide to Long-term Care Insurance" National Association of Insurance Commissioners, Kansas City, MO (5) The Washington Post, April 1996; (6) South Florida Business Journal, May 29, 2000 (7) "A Shopper's Guide to Long Term Care Insurance", National Association of Insurance Commissioners, Kansas City, MO (8) Samuel X. Kaplan, "The Case For Self-Funding Corporate-Sponsored, Employee-Paid Long Term Care Benefits", Compensation and Benefits Review, May/June 1995

Many adult retirement communities put little emphasis on the need for care, precisely because people who are attracted to these types of developments don't want to associate with other seniors who have major health problems. A person contemplating moving to a new location to retire should seriously consider whether professional long term care services will be available in the new area. Otherwise, a costly and difficult move to a new location may be required in the future to find these services.

Home Care in Your Home or in The Home of a Family Member

Suppose a person decides to stay in their home. Most housing is designed for young, active and mobile people. To live at home, an active person must, at the very least, be able to drive, go shopping, cook and do household chores. Many of us will lose one or more of these abilities as we grow older.

One option to stay in the home is to purchase in-home services, to cope with declining abilities. For a fee, an army of workers will appear to cut the grass, wash the windows, cook the meals, do the shopping, and even provide personal care and/or skilled nursing care. This is certainly an option but it could be expensive and require a lot of management and coordination. Perhaps, one of the children living close by may be able to coordinate the services. Or a more common option for people who do not have family close by is to use a professional, personal care manager. The use of a care manager or the care management services of a personal home health agency is becoming more common.

Some elders are able to move in with their adult children and family, or vice versa, perhaps after some home reconstruction. If this is an option, be sure that everyone in the family is OK with the decision. Sometimes a son-in-law or daughter-in-law may not be too happy living with their spouse's parent.

Be aware of the possibilities of lifestyle conflicts, the physical demands of 24-hour oversight, and changes in marital and familial relationships. Be sure to work out the finances and living arrangements before the move, especially if it's a long distance move. On the plus side, multi-generation households offer a special quality of life, especially if there are grandchildren, and it is much easier to monitor diet and medications with the elder in the household.

Sometimes children or grandchildren move into the senior's home, perhaps after modifications. If this happens, be sure to consider all the financial and lifestyle ramifications, as well as issues of control, privacy and inter dependence.. There are some ways to provide for more privacy. By making some changes in the house, a separate self-contained unit called an accessory apartment can be created - if zoning laws allow. Entrance is usually separate from the main house.

If long-term care is needed in the home, there are a great number of services that can help the child or grandchild caregiver cope with the task. Many of these are community services with no fees. Please go to the following articles on this site for more details: About Long Term Care at Home, About Area Agencies on Aging, Using a Care Manager,The Caregiver's Handbook, Personal Care Home Care, Assistive Services and Equipment.

Reverse Mortgage

Sometimes the decision to sell an existing home is a forced decision. The elderly homeowner may not have the income or savings to pay for maintenance, remodeling, taxes or yard care. In fact a sale may be necessary to free up equity in order to live on. Or the elderly person may need funds to pay for caregivers to come into the house. The house may need to be sold in order to generate enough money to pay for this care, meaning that care may have to be provided in a rental unit or the home of a child or friend. A reverse mortgage might solve this problem and allow a person to remain in his or her home.

A reverse mortgage is a special type of loan used by older Americans to convert the equity in their homes into cash. The money obtained through a reverse mortgage can provide seniors with the financial security they need to fully enjoy their retirement years.

The reverse mortgage is aptly named because the payment stream is reversed. Instead of the borrower making monthly payments to a lender, as with a regular first mortgage or home equity loan, a lender makes payments to the borrower. A reverse mortgage loan is just like a conventional mortgage--the borrowers own their homes and hold title to them and the banks own liens against the properties. But unlike a conventional mortgage, borrowers do not make any monthly mortgage payments while they are alive and occupying their homes.

Virtually anyone can qualify. The borrower must be 62 or older. There is no credit check or income test to qualify.

The money from a reverse mortgage can be used for ANYTHING: daily living expenses; home repairs and home improvements; medical bills and prescription drugs; payoff of existing debts; education; travel; long term health care; prevention of foreclosure; and other needs. If your home needs physical repairs (mandatory repairs) in order to qualify for a reverse mortgage, a portion of the proceeds will be set aside for this purpose.

You can choose 3 options to receive the money from a reverse mortgage: 1) all at once (lump sum); 2) fixed monthly payments (for up to life); 3) a line of credit; or a combination of a line of credit and monthly payments. The most popular option, chosen by more than 60 percent of borrowers, is the line of credit, which allows you to draw on the loan proceeds at any time.

At the death of the last borrower or the sale of the home, the loan is repaid from equity in the home. Any remaining equity (which is often the case) goes to the heirs. Almost all reverse mortgages are the HECM loan which is guaranteed by FHA mortgage insurance. If there is not enough equity to cover the loan, the insurance satisfies the loan by paying the deficit. With a HECM loan, the bank will never come after the heirs to satisfy the mortgage obligation.

Housing for the Elderly Poor

Help With Finding Affordable Living Arrangements
According to the U.S. census bureau, in 2002, 31% of households with a member over the age of 65 made less than $1,250.00 per month. It appears from these data roughly one in three of all elderly households are struggling to get by. For those elderly poor paying rent or still paying mortgages the census bureau estimates well over 50% of household income goes towards housing costs. It's not surprising that at least 1/3 of all housing for the poor is occupied by people over age 65. Nationwide there are 2.9 million subsidized apartments available for 5.1 million low-income families that could qualify for government assistance with affordable housing. Many of these are elderly. Many others for various reasons do not apply.

The elderly frequently are reluctant to find out about low income housing options and many are missing out on opportunities for comfortable housing at affordable prices. The best source for those over age 65 to find out about low income housing in their area is to contact their local Area Agency On Aging. This is an extremely valuable resource and should be utilized. There are about 655 AAA's serving every urban and rural corner of the United States. To contact a local agency in your area click here.

HUD Section 202 and Section 801 Apartments
In 2004, the department of Housing And Urban Development (HUD) made available $789 million in housing assistance grants to help the nation's very low-income elderly and people with disabilities. The grants include $643.6 million for the elderly under Section 202 and $145.6 million for people with disabilities, many of whom are elderly, under Section 801.

HUD's Section 202 program helps expand the supply of affordable housing with supportive services for the elderly. It provides very low-income elderly with options that allow them to live independently but in an environment that provides support activities such as cleaning, cooking, transportation, etc. HUD provides two forms of Section 202 funds for senior housing:

  • Interest-free capital advances to private, nonprofit sponsors to finance the development of supportive housing for the elderly. The capital advance does not have to be repaid as long as the project serves very low-income elderly persons for 40 years.
  • Project rental assistance funds provided to cover the difference between the HUD-approved operating cost for the project and the tenants' contribution towards rent. Project rental assistance contracts are approved initially for 5 years and are renewable based on the availability of funds. The available program funds for a fiscal year are allocated to HUD’s local offices according to factors established by the Department.

Private nonprofit organizations can apply to develop a Section 202 project if they can, among other requirements, submit a resolution that they will provide a minimum capital investment equal to 0.5 percent of the HUD-approved capital advance, up to a maximum of $25,000 for national sponsors or $10,000 for other sponsors. Public entities are not eligible for funding under this program although in 2004 HUD amended its rules to allow private developers to share funds with the nonprofit and receive tax benefits. There are just too many nonprofit's that find it difficult to qualify for these funds and the money is being underutilized.

Occupancy in Section 202 housing is open to any very low-income household comprised of at least one person who is at least 62 years old at the time of initial occupancy. To be classified as "very low-income," a household income cannot exceed 50 percent of the area median income. Contact your local housing authority to determine eligibility. Low-income senior housing may be available in your area. The website of the US Department of Housing and Urban Development (HUD) can help you locate local HUD offices that can supply you with a list of low-income senior apartments in your area. Please be aware that waiting lists may be lengthy for such housing as it is in very high demand in most places.

Some Section 202 apartments have Section 8 Vouchers so that the tenant only pays 30% of her income for the rent. Section 8 rental subsidies are discussed below. Other Section 202 apartments may have set rents that are usually well below the rents charged by private apartments.

HUD's Section 811 program provides housing for households with one or more very low-income individuals, at least one of whom is at least 18 years old and has a disability, such as a physical or developmental disability or chronic mental illness. The term "person with disabilities" also includes two or more people with disabilities living together, and one or more persons with disabilities living with one or more live-in attendants. The program allows persons with disabilities to live independently in their communities by increasing the supply of rental housing with the availability of supportive services. Many of the elderly have disabilities and might qualify under this program.

To be classified as "very low-income," a household income cannot exceed 50 percent of the area median income. However, most households that receive Section 811 assistance have an income less than 30 percent of the area median. Generally, this means that a one-person household will have an annual income of about $12,075. Low-income senior housing may be available in your area. The website of the US Department of Housing and Urban Development (HUD) can help you locate local HUD offices that can supply you with a list of low-income senior apartments in your area. Please be aware that waiting lists may be lengthy for such housing as it is in very high demand in most places. The rental cost is typically 30% of one's income.

HUD provides the Section 811 funds to non-profits in two forms:

  • Capital advances.This is money that covers the cost of developing the housing. It does not need to be repaid as long as the housing is available for at least 40 years for occupancy by very low-income people with disabilities.
  • Project rental assistance. This is money that goes to each non-profit group to cover the difference between the residents' contributions toward rent and the cost of operating the project.

Section 8 Housing and Rent Subsidies
A form of subsidized housing grew in popularity in the early 1970s. Congress created the Section 8 housing program in 1974, including elements that allowed local authorities to subsidize housing rehabilitation, initiate new construction, and subsidize rents in existing private-market housing. Congress also authorized a rent subsidy voucher, issued to an eligible low-income family, which allows the family to search for and lease housing in the private rental market. Under this Section 8 Program-now known as the housing choice voucher program - the family pays 30% of its income toward the privately set rent, while the housing agency pays the difference, up to a certain "fair market rent" level, set by HUD. Property owners who honor these vouchers must allow the renter to receive assistance in an apartment for at least one year. Owners must also abide by HUD rental rules and submit periodic government paperwork.

Qualification for section 8 rental assistance follows the same rules outlined in the section above. Adjusted individual household income cannot exceed 50 percent of the area median income. Section 8 pays any rent which exceeds 30% of a tenants adjusted monthly income. For example, if your landlord charges $500 per month for rent and you make $1,000 per month, you would pay $300 (30% of your monthly income) and Section 8 would pay $200 (the difference between what you can afford and what your landlord charges).

The voucher program has continued to win broad support from policy makers who see it as an efficient, effective alternative to public housing. In 2001 the bipartisan Millennial Housing Commission called it the "linchpin" of federal housing policy. Today it serves about 1.9 million households in communities around the country and is a vital means of addressing the housing needs of low-income people.

The Section 8 program is also overburdened and it is getting difficult to get the subsidy. Many people now wait for years to receive the subsidy. And things are getting worse. In the last three years, since 2001, the Section 8 budget nationwide has ballooned by 27 percent. In the past, HUD has paid actual costs of the program. Beginning in 2004, costs are frozen at August 2003 levels plus an allowance for inflation. Many housing authorities across the country which administer section 8 funds claim, because of burgeoning costs, this freeze will cut back on the amount of available subsidized housing.

To add to this dilemma, much grant-based Section 8 housing was built in the seventies and eighties and the required twenty year commitment to the government to maintain subsidized rentals on these properties has expired. Property owners are converting subsidized projects at an alarming rate into market-based rental properties. This is further cutting back on the amount of available housing for the poor.

Local Government Housing Authorities and Subsidized Housing
State and local governments also provide money and tax incentives for affordable housing for the poor. In partnership with public, private and non-profit agencies, local government housing authorities develop and manage a continuum of affordable housing options from special needs housing to large apartment communities to elder housing.

Local housing owned and administered by a housing authority might be built by donated money, money generated through issuing municipal bonds, grants from the state or other sources of money. In addition, the authority might manage properties created through special tax incentives.

Housing authorities also administer Federal programs, including:

  • Public housing. These are "the projects" which blight many cities. Now that they are recognized as a general failure, they are being slowly phased out. This program is of little interest to landlords as there is no way for them to participate, nor would many want to do so if they could.
  • Privately owned subsidized housing consisting of privately owned buildings, subsidized directly by HUD, with a rent charged to the tenants which is set by HUD.
  • Block grants. In this scheme, money is channeled through Washington to individual States and local governments, who administer programs tailored to their own needs, but approved by HUD. Such programs are growing in popularity because they permit politicians to fulfill the requirement that Federal money be spent as far away as possible from its source. Thus, money from Massachusetts is sent to California to fund housing programs while money from California is sent to Illinois, and from Illinois to New York, and so on. The true cost of the "Federal money," i.e., the cost of everybody else's program, is effectively concealed from the people of Massachusetts by this stratagem, that State's congressional delegation getting credit for the subsidy, without having to explain the cost.
  • Section 8 funds. Already discussed in the previous section.

To find out what your local housing authority has to offer in the way of affordable elder housing contact your local Area Agency On Aging. Click here to contact the Area Agency On Aging.

Energy Assistance and Weatherization 
Federal funding through the Low Income Home Energy Assistance Act of 1981 provides funds to pay utility costs for low income families. Funds are provided through the Department Of Health And Human Services. Eligible families include households at or below 125 percent of federal poverty guidelines; and households who provide documented need (as determined through the application process). Once eligibility has been met priorities are given to:

  • Roughly equivalent to extremely low- to very low-income households (0-60 percent of the area median family income);
  • Elderly
  • Disabled
  • Families with small children or special health conditions.

Funds are also available for an emergency relief program during times of severe weather conditions. Eligibility is determined by proclamation of the president of the United States.

The Weatherization Assistance Program for Low Income Persons is designed to promote energy efficiency in the residences of low income Americans. The program provides for energy related improvements to homes, and educates consumers about energy conservation. Grants are made available through the Department Of Health And Human Services. The program goal is to reduce the energy cost burden of low-income households through energy efficiency. The structure must be able to benefit from being weatherized. Qualifying households are those at or below 125 percent of federal poverty guidelines. Once qualified, priority is given to the following:

  • Families at or below 125% of the federal poverty guideline.
  • Roughly equivalent to extremely low- to very low-income households (0-60 percent of the area median family income)
  • Households with small children (under the age of 6).
  • Households with the highest energy cost and lowest income.
  • Households with an elderly resident.
  • Households with a disabled resident.

Once again, contacting the local area agency on aging can put you in touch with this program in your area.

Rural Housing
Elders living in rural areas or in towns of population less than 5,000 face a unique problem when it comes to retirement housing. Property values are typically low and home sales opportunities in many rural areas are lacking. This means some rural seniors don't have the choice of selling and relocating. In addition, many rural seniors live in mobile homes that are not on permanent foundations and as such they cannot qualify for home equity loans to fix up the property nor do they qualify for reverse mortgages.

Although the availability of housing projects managed by housing authorities is rare in rural environments some Federal programs are still available. HUD's Section 202 program provides capital grants to nonprofit sponsors for construction and rehabilitation of apartments for persons 62 years old and over. Housing financed under this program may include appropriate support services. Approximately 25 percent of Section 202 funding must be set aside for use in rural areas. Other HUD rental programs which support elderly rural housing needs include the Section 8 new construction and rehabilitation program, which provides a developer with rental assistance attached to the housing unit. Low-income seniors can also receive the Section 8 rental assistance vouchers, which provide rental assistance to tenants for use in private market housing. In addition, HUD's two large block grant programs, HOME and Community Development Block Grants (CDBG), also support production of affordable housing for elderly persons.

The RHS--U.S. Department of Agriculture's (USDA) Rural Housing Service (RHS)--Section 504 home repair program provides loans up to $20,000 and grants up to $7,500 to very low-income, rural homeowners to repair their homes and remove health and safety hazards. The grants are available only to persons 62 years or older to make their homes safe, sanitary, and decent. Section 504 loans, although not restricted to elderly homeowners, are made at an affordable 1 percent interest rate for a term of 20 years. The Section 504 program has helped many very poor seniors get amenities such as running water and an indoor bathroom for the first time in their lives.

RHS, also administers the Section 533 Housing Preservation Grant program (HPG), which provides grants to nonprofit organizations for the rehabilitation of homes. HPG is regularly used to assist elderly homeowners with rehabilitation work.

Although RHS has no specific rental housing program for elderly persons, special regulations and requirements in the Section 515 rural rental housing program allow its use to develop congregate housing for elderly, disabled, and developmentally disabled persons. Elderly tenants may also reside in Section 515 housing that is not expressly set aside for elderly residents. The Section 515 program has seen steep budget cuts in recent years, which have drastically reduced its effectiveness in serving the rental needs of rural elders.

Medicaid Assistance
Medicaid is a program to help the elderly pay for long-term care when their income and assets can't cover the cost. Traditionally, Medicaid has covered the so called "aged"--people over age 65--in nursing homes. In a sense the nursing home becomes a new government subsidized residence because Medicaid covers the cost of room and board as well. In fact many residents of nursing homes under Medicaid could be living under different circumstances were not for the fact that they have no money to pay for the other circumstances. About 70% of nursing home residents are receiving some form of payment from the government. For these people Medicaid has become the provider of their retirement living arrangement as well.

Medicaid also offers limited home- care and assisted living but the bias is to provide long-term care in a nursing home. If a person qualifies for a home care waiver or assisted living waiver, Medicaid may only pay a portion of the room and board or pays nothing at all.


Chapter 2--Worry-Free Retirement Living Arrangements

The retirement living arrangements below do not include services for long-term care needs. But, because the communities are oriented towards seniors, independent private services may be more readily available in these communities than in other mixed-age communities. However, if a person is anticipating the need for care and wants a retirement living arrangement where care will be part of the arrangement, the communities below are not the right choice. That person wants the living arrangements discussed in the section titled " Retirement Care Communities" below.

One reason someone would pick one of the living arrangements in this section would be to do away with the burden of home maintenance and yard care. Along the same lines these living arrangements also allow a person greater freedom to leave the new home to go on long trips and be assured that the home is safely protected. In addition many of these communities offer a higher level of security than people might now experience in their current circumstances.

Master Planned Active Adult Communities

These master planned communities are developed specifically for people over certain prescribed ages such as age 55, age 62 or age 65. At least one member of the household must meet the age restriction. These arrangements almost always offer individual, owner occupied units and the appeal of these communities is to offer active seniors selling their existing house to trade equity from the old home into a newer, more attractive unit about the same size or larger. Because these are planned communities most of the lawns, parks and recreational amenities are owned by all of the homeowners as common property. The homeowner may only be responsible for interior maintenance of his or her home and some minor exterior maintenance since units are relatively new. ( community sponsored contractors may be available for exterior work as well). Crews are also available for yard work and landscaping. All other maintenance and replacement is taken care of by the homeowners association and paid for by fees assessed to all owners. Many of these communities are gated and patrolled by security forces.

These communities are often called by the following names: active adult communities , age restricted communities, resort communities, golf resort communities or adult retirement communities. Adult communities are built to accommodate a wide variety of retirement aspirations and goals. But a common thread for all seniors is the opportunity to move to a safer environment and be rid of costly repairs and yard maintenance on an older home. In addition seniors are lured by the prospect of associating with other seniors their own age and enjoying such amenities as a swimming pool, golf course, clubhouse or entertainment room, shuffleboard, tennis, walking or bike trails, social clubs, Internet groups and exercise rooms. More upscale communities might offer additional amenities such as private lakes and docks, private ocean going docks, country clubs, horseback riding and stables, vacations or local day adventures, gift shops, hair salons and so on.

For seniors who like an urban environment, adult communities are built as high rise, apartment-style buildings in large cities. For seniors who want adventure in a rural environment, adult communities are built in mountain, desert or seaside resort areas. For seniors who want a warm climate, adult communities are available in the desert southwest, in southern Texas and in Florida. By far, a majority of seniors wanting to move to a retirement community desire to stay close to children or grandchildren, so active adult retirement communities are being built all over the United States in large cities, not so large cities and in the suburbs where the primary choice of location is determined by where the family is.

The housing also varies from simple apartments to high rise condominiums to single family detached housing. Costs range from a low of $25,000 to well over $500,000. Some communities are upscale only and may cater to high income seniors. Some communities are designed for more moderate income and they might offer affordable housing in the range of $50,000.00 to $100,000.00. Some communities offer manufactured housing of about 800 square feet for anywhere from $20,000.00 to $40,000.00. And some communities offer a mix of all types of the housing mentioned above. Smaller homes might be segregated in one area and larger homes in another.

To give us an idea of the preferences of seniors seeking adult communities, a recent survey conducted by the Del Webb Corporation revealed that:

  • Two million baby boomers likely will move to active adult communities
  • Half of boomers plan to work part-time after retirement and consequently demand home offices.
  • Wiring packages integrating computer, security and entertainment systems are a hot selling point.
  • Great rooms are tops on boomers’ design priorities; gourmet kitchens rank higher than swimming pools.
  • Boomers want to retire to homes the same size as their current homes.
  • Flexible spaces that can be used for recreation rooms, guest quarters or play areas are increasingly popular.

It is important for seniors considering a move to one of these communities to be aware of potential high cost assessments down the road. This is especially true of sprawling, large acreage developments with roads, golf course, grounds and common buildings. Part of the monthly fee from the homeowners association should include a set aside for reserve funds for the replacement of the community's infrastructure. Unfortunately, some association boards don't plan well for the future and without adequate reserves there could be the possibility of a very large assessment to take care of crumbling infrastructure in the future. This is especially true where the association has not dedicated roads, water lines, sewer lines and lighting to a local municipality but instead owns these structures as part of the common property of the community. Check out the provisions for reserves and the ownership of roads and service lines before a purchase is made.

For those people desiring to experience one of these retirement communities without actually purchasing, there is sometimes an opportunity to rent one of the properties before purchasing. This might be a good idea.

Planned Communities With No Age Restrictions

Planned communities are designed around a social or geographical concept. The goal may be to incorporate a choice area of woodland or other natural feature into the development of a large tract of land. Or the design might include the layout and land use, including commercial and residential areas, for an entire community . Whereas planned communities are generally very large projects, a Planned Unit Development (PUD) might incorporate the design and development of a smaller commercial or residential property.

The concept of a Planned Unit Development is to maximize the land use while still retaining the building density prescribed by the local government. This might mean clustering houses together in one area of the property and parking, recreation, playgrounds and other amenities in another portion of the property. Because of this common use of the property, the individual owners of dwelling units on the property control the green areas, playgrounds and other amenities as common property. A PUD is a development that has all of the following characteristics:

  • The individual unit owners own (or have a leasehold interest) in a parcel of land improved with a dwelling. This ownership is not in common with other unit owners
  • The development is administered by a homeowners association that owns (or has a leasehold interest) in and is obligated to maintain property and improvements within the development (i.e., greenbelts, recreation facilities and parking areas) for the common use and benefit of the unit owners
  • The unit owners have an automatic, non-severable interest in the homeowners association and pay mandatory assessments
  • For the purpose of this definition, a condominium project is not a PUD

Some planned communities may be for seniors only whereas others may have no age restrictions, but; may attract seniors who are selling older homes and looking to use the proceeds for a newer home in a community with amenities and the availability of yard care services.

This arrangement may appeal to seniors who do not want to live in the structured adult retirement community outlined in the previous section. It gives them the opportunity to live in a mixed-age neighborhood, perhaps in a more secure area, where some of the headaches of home ownership may have been removed. On the other hand, the introduction of the homeowner's association with a planned community may bring problems of its own. Please read the section on homeowner's associations below.

Condominiums, Cooperatives and Seniors Apartments

Condominiums
Planned communities described in the section above, come about because of the desire to develop land and build dwelling units that are part of a larger community plan. Homeowners in a planned community own their dwelling and the land on which it is situated. Other parts of the development such as amenities, parks, parking, roads and other infrastructure are owned jointly by the community.

A condominium or condo as it is commonly called is a form of ownership and not a development plan. However, a condo project may be part of a planned community as well. The owner of a condo unit has title to all of the interior airspace and the interior walls, ceilings and floors of his or her dwelling unit. The rest of the superstructure including the exterior, the land and all of the amenities belong to all the other condominium owners as common property. Certain exterior parts of the unit such as a carport, balcony, patio or storage unit are part of the common property but are set aside for the exclusive use of the owner.

The advantage of owning a condo is that the dwelling space is solely owned and not a rental, thereby allowing the owner to carry a mortgage that would someday be paid off or to pay cash and never have to make payments again. This is opposed to a rental for which one must pay as long as one lives. The owner of a condo is not a renter and can never be evicted. Another advantage of a condominium is that the owner is only responsible for maintaining the interior of the unit. All other maintenance on the exterior, on the grounds and on all other common property is handled by a property manager or done through contract or hired maintenance. Maintenance is paid through monthly fees assessed to each property owner.

Condominium developments also offer security. It may be only a minimum level where the community is well lighted and other homeowners are coming and going such that residents feel more secure. Or security could be very tight with gates, guards , locked doors, security systems and other safeguards. Because of the security and the minimal amount of maintenance required, many seniors buy condos to live in perhaps for a few months a year and then feel safe leaving the unit unoccupied to travel the rest of the year. Or owners may own more than one condo unit and spend time during the year living in their units in their various locations.

Many condominium complexes offer additional amenities to their members. Such things as a clubhouse, sauna, playgrounds, exercise facilities and equipment, meeting rooms, tennis courts and shuffleboard and possibly a swimming pool; although, the liability and upkeep of swimming pools is forcing many newer developments to forgo this benefit for members.

Homeowners elect a select number of their fellow homeowners--typically five to seven homeowners--to represent them on the homeowner's association board. The board may also be called a board of directors or a board of managers. Board members are elected such that their terms expire on a staggered year to year basis so that there isn't a complete turnover of board members in one year. The board has the responsibility of taking care of maintenance on the project, making sure rules are followed and setting aside reserve funds to pay for future capital improvements or replacement of worn out infrastructure.

Condominiums may be high rise buildings with units like apartments, or they may be town houses with two or more units per townhouse, or they may be individual structures or even individual houses. Non-high rise condos typically have little open space or lawns thus cutting down on the cost of yard maintenance. There is a growing tendency all over the country to build new condominiums that cater exclusively to the elderly. Some developments may even have age restrictions.

Condos can be luxury units with more living space and interior appointments than the typical home or they can be apartment sized or even apartments that were once rentals and have been converted to condominiums. Buying into a condominium complex sometimes carries with it more market risk than buying into a single owner housing neighborhood. If the complex is poorly managed, property values may decline over time, the renting out of units by owners may increase, security may deteriorate and trying to sell the property at some future date may be very difficult. It is extremely important to check out the management of a condo property prior to buying. Please read the information in the section on homeowners associations below. 

Cooperative Housing
Like a condominium, cooperative housing is a form of ownership. With a condo, described in the section above, the owner has title to all of the interior of his or her to dwelling. With a co-op the person has a lifetime lease to occupy the property and the ownership is in a corporation that controls the property. A cooperative is really a form of renting. The difference is the co-op owner has a say in how the property is managed, how rents are set and how rules are made and enforced. And more importantly if the owner abides by the provisions of the lease, he or she can never be evicted. There are also tax advantages to this type of living arrangement as opposed to owning the property out right.

There are two types of stock ownership arrangements in cooperative housing. With one a separate entity owns the property and pays the property mortgage and taxes and the members of the cooperative own stock in the management of a master property lease, meaning they can handle maintenance, determine rents and enforce the rules. With the other form of ownership the stockholders themselves own the property and manage it as well.

A person wanting to occupy one of the units on the property must buy stock from one of the other members who is willing to sell it. There are different types of stock ownership forms. In one, the stock can be sold at market value, that is, the actual market value of the property is divided by the number of stockholders. With other forms of ownership the value is held constant, below market value, to allow people with limited resources to buy in.

As housing costs continue to climb and the housing market tightens, housing cooperatives have become an increasingly attractive housing option. For constant value stock purchase options, it may mean the ability to find a nice apartment at a low entry cost in an otherwise tight apartment market. With the establishment of a secondary market for cooperative loans, conventional financing is more readily available. Personal tax deductions, lower default and turnover rates, lower tax assessments, reduced maintenance costs and resident participation and control are further incentives for choosing the cooperative route to home ownership.

The following information was taken from the web site of the National Association of Housing Cooperatives its link is http://www.coophousing.org/

What is a Housing Cooperative?
In the United States, more than 1.5 million families of all income levels live in homes owned and operated through cooperative associations. People of varying needs and desires have found several ways to apply cooperative concepts in meeting their housing needs.

Cooperative housing is not a new concept. The first housing cooperative in the nation was organized in New York City in the late 1800s. Today, there are over 1,500,000 units in cooperative housing communities throughout the United States, with large numbers located in major urban areas such as New York City, Washington, D.C., Chicago, Miami, Minneapolis, Detroit, Atlanta, and San Francisco.

Cooperative members own a share in a corporation that owns or controls the building(s) and/or property in which they live. Each shareholder is entitled to occupy a specific unit and has a vote in the corporation. Every month, shareholders pay an amount that covers their proportionate share of the expense of operating the entire cooperative, which typically includes underlying mortgage payments, property taxes, management, maintenance, insurance, utilities, and contributions to reserve funds. There are many benefits to cooperative ownership. Some of these include personal income tax deductions, lower turnover rates, lower real estate tax assessments, reduced maintenance costs, resident participation and control, and being able to prevent absentee and investor ownership.

Housing cooperatives come in many shapes and sizes: cooperatives include townhouses, garden apartments, mid-and high-rise apartments, single-family homes, student housing, senior housing, and mobile home parks. The purchase price of cooperative membership can be left to the market or the price can be maintained at below market in order to preserve affordability. All cooperatives share a common set of principles adopted by the International Cooperative Alliance.

The key aspect in any cooperative is democratic control by the members in order to achieve an agreed upon common objective. Democratic control is typically accomplished through governance by volunteer boards of directors elected from the entire membership. In addition to the board, co-ops often have many committees, such as a membership committee, maintenance committee, activities committee, and newsletter committee. Most co-ops hire a manager or management company to perform management functions; smaller co-ops will often have no paid staff or management but will have members handle all the maintenance and operations responsibilities.

Senior Housing Cooperatives
Senior housing cooperatives are housing communities designed for senior citizens. A number of different types of senior housing cooperatives exist. Cooperative Services, Inc., is a senior mutual housing association with over 40 buildings in 4 states, housing over 5,000 seniors of modest means. The Senior Cooperative Network helps develop senior housing cooperatives in rural areas. In addition, retirement oriented communities have been developed using the cooperative form of ownership, most notably in popular sunbelt locations.

Manufactured Housing Communities (also known as Mobile Home Parks)
A growing number of manufactured housing communities own the land comprising the community on a cooperative basis. Cooperative ownership gives manufactured home residents control over management and operating costs of the park, while owning a manufactured home of their own. 

Seniors Apartments
Seniors only apartments allow seniors of modest income to rent in a community with people their own age. Surprisingly some seniors with a lot of income and assets also may desire, for various reasons, to rent rather than buy. There are upscale senior apartments designed for them as well. Senior renters may be individuals who have owned a home or have been renting all of their life but desire to move to a community that supports senior needs. Most senior renters are single women. For those who are selling their homes to occupy a senior apartment there may be numerous reasons for the change. Consider some of the following:

  • A divorce may require the divorcing couple to sell the house in order to split up their share of the equity
  • There may not be enough income to pay the costs to remain at the current location
    A senior apartment environment might provide the social and emotional support a single senior needs
  • The current home may need to be sold in order to free up equity that can be invested and produce income to pay for rent in a senior apartment
  • The current home may need to be sold because the senior can't climb stairs, needs a wheelchair friendly environment, or can no longer take care of maintenance and yard work
  • The senior may want to travel and not have to worry about a home, thus renting an apartment makes more sense
  • The move to an apartment may be temporary because the single senior one day will need a care community or will move in with family. An apartment is easier to leave than trying to sell a home at that point.

Senior apartments are found in many communities. They can vary in terms of services but typically offer apartment living and services designed specifically for independent active seniors 55 and older. Since many of these residences are designed for active seniors, most do not offer meal service, housekeeping or medical assistance. More upscale apartments may offer amenities like swimming pools, meeting rooms, saunas, clubs and socials, hair salons, gift shops, linen services, dry cleaning, laundry services, private maid services and more.

Senior apartment complexes are usually located near senior centers, parks, shopping malls, golf courses and public transportation. Many offer van services along with monthly road trips to shows and casinos.

About Homeowner's Associations

Property owners in a planned community, a condominium project or a cooperative become automatically, mandatory members of a homeowner's association. Membership entails the following:

  • Payment of monthly fees or in the case of a cooperative, rents, to cover maintenance. A portion of the fees also goes to a reserve fund for major repairs, new construction and replacement.
  • Agreement to follow the written rules and regulations of the association.
  • Payment of periodic special assessments approved by the majority of homeowners.

Fees and assessments cannot be withheld simply because the homeowner is unhappy with the how the money is spent. Associations have the right to apply property liens, use collection agencies, apply fines or bring court action to assure payment of fees and assessments.

Homeowners or stockholders also elect three to seven members of their community to represent them on the association board. The association board, board of directors, board of managers, homeowners association board or whatever else it is called is responsible to manage the commonly held property for all members of the association. Written documents in the form of articles of incorporation, declaration of conditions, covenants and restrictions (CC&R's), bylaws and community rules dictate the action of boards and other members of the association.

Boards spend money collected from fees and special assessments to hire maintenance people or contractors and when necessary to contract for major improvements. Boards also enforce compliance with association provisions and rules by sending letters of compliance to offenders or assessing fines.

Some communities seem to get along just fine year after year with no problems while other communities seem to constantly be at each other's throats and splitting hairs with members of the board. It is not desirable to be a member of a contentious community. Before buying into a complex that has a homeowner's association be sure to talk to others in the community about relations and attend one or more board meetings.

Some communities elect capable and fair members to their boards and in other communities less capable people seem to end up on the board. Poorly run and poorly managed boards result in poorly managed property and can lead to a poor community spirit and an eventual decline in property values. Neighbors may be sending letters of complaint constantly to the board over petty issues. Over-zealous or prejudiced application of rules may cause bad feelings. Rules pertaining to parking, behavior of guests, conduct of children and grandchildren, management of household pets, noise, smoking, use of the clubhouse and pool and other amenities and additions or changes to the outside of a person's property seem to be the issues causing the most contention. In poorly managed complexes it may be easy to buy in but difficult to sell out.

A well managed property will typically use a professional property manager or contract management services. Boards who try to manage the maintenance themselves are a recipe for disaster. Self maintenance invites nepotism, self interest dealings, potential embezzlement and poor future planning because of a lack of continuity when new board members take over. A well managed property will also have an adequate reserve fund. Unless there is a reasonable explanation for it, such as a recent major project, if the reserve is small or lacking, absolutely, positively do not buy into such a property. You will be making a big mistake.

Poorly written and vague governing documents may also contribute to poor property management. Always obtain a copy of all documents and read them carefully before purchasing. Make sure operating papers contain at least the following conditions:

  • Provisions for the censure or removal of dishonest or undesirable board members.
  • Mandatory requirements and guidelines with an accompanying formula for setting aside reserve funds.
  • Controls and oversight from association members on how reserve funds may be spent.
  • A cap on the percentage of property allowed for renters.
  • Provisions to prohibit board members from self interest dealings, to become employees of the association or to hire relatives or for that matter other association members who happen to be friends.
  • Provisions requiring the board to keep members informed of the financial condition of the association and actions of the board on a regular basis not just once a year at an association meeting.

The following was written by William King. Bill King is a Certified Residential Real Estate Appraiser and Licensed Real Estate Broker. His website is http://www.valueone.com/index.asp.

It seems that more attention has been paid in the last few years to the health of associations than ever before. With the increased focus on budgets and planning, the gap between well-run associations and mismanaged associations appears to be widening. This ultimately translates to a wider gap in resale values. How big an affect does the association’s budget and reserve planning have on your value? What impact might a pending special assessment have on your resale plans? What steps can you take now to ensure maximum value upon resale?

The increasing sophistication of buyers, agents, lenders and appraisers is resulting in more requests for budget and reserve data as part of the buying process. Simply put, an under-funded association is going to cause some buyers to look elsewhere, or reduce the amount they are willing to pay for a unit based on anticipated increases in dues to make up the budget shortfall. More and more buyers are looking into this aspect of their purchase in advance of buying than ever before. Total housing cost is a critical factor in the home buying decision. For some buyers, an unexpected jump in monthly housing cost can be the difference between keeping and losing their home.

An under-funded association also becomes more vulnerable to poor quality materials and workmanship when addressing repair and replacement of its common area components. By getting behind the curve, the appeal of going with the low bid is increased. Poor quality exterior materials and workmanship may mean a potential buyer never sees the inside of your unit.

Pending special assessments, announced or not, also cause some buyers to shop other properties. To the condo buyer, a special assessment is an additional out of pocket expense. While the individual unit may be in excellent condition, the property is essentially a "fixer upper". The seller used up the (roof, pool, etc.) and is now selling the property in as-is condition. As is the case in detached homes, "fixers" are typically discounted not only by the anticipated cost of repair, but also an added amount for their willingness to take on the problem.

For many owners, their first exposure to the budget and planning process for common areas comes well after buying and taking possession of their unit. The announcement of a special assessment or the outright failure of a common area component (like a leaky roof) triggers their involvement in the association. At that point the emphasis is on damage control, not advance planning, and planning cannot come into focus until the more immediate problems are solved.

Attending association meetings, being involved in the planning process and treating the common areas as an extension of your living space are critical in maintaining the value of your unit. As buyers their agents and lenders' appraisers place more emphasis on the association when evaluating an individual unit, it becomes increasingly important for the homeowner to be proactive in their association in advance of planning to sell.

 

Chapter 3--Retirement Care Living Arrangements

Sharing a Home or Hiring a Live-in Paid Caregiver

Some families may have raised their children or live in a home with extra bedrooms and desire to have an elderly person living in their home to watch over and take care of. They may advertise their intent in the newspaper or there are private organizations that match home owners with potential elderly renters. Some states may require licensing and screening for this type of arrangement, especially if the elder person receives caregiving services. The best way to find these arrangements would be to start with your local area agency on aging. Click here for contact.

Sometimes young couples or college students are looking for inexpensive or no cost housing and are willing to make an arrangement with the elderly to live in their home and help take care of them. In this case the person or her family desiring a live in caregiver would place an ad in a local or campus news paper. Very often the live-in caregiver might be a niece, nephew or grandchild who is willing to take care of their older relative in exchange for free lodging. Or another common arrangement is for a single daughter to move in with one or more parents and take care of them in their own home

Finally, for those elders who have sufficient funds, an advertisement can be placed for someone to live in the home, receive free lodging and be paid to be an exclusive care giver. With the current trend for children to move hundreds of miles away from their parents this is becoming a more common alternative for the elderly who wish to remain in their homes. Finding a paid, live -in care giver often can be contracted to a personal home health agency or a personal care manager. To find a personal home health agency in your area look under "home health agency "in the Yellow Pages. To find a personal care manager in your area look under "senior services "in the Yellow Pages. Personal care managers to help with the coordination and care of the elderly are becoming an increasingly important service.

Independent Living Facilities and Congregate Housing

Independent living or congregate housing communities are residential communities for active older adults who want an enjoyable lifestyle free of the worries and trouble of home maintenance. They are similar to any apartment, condominium, or single-family development, except that they provide special services, including security—an important consideration for many residents. Most independent living communities are fully secured; staff members greet and screen all visitors around the clock. Residents can leave home for extended periods of time knowing that their living quarters will be safe.

The difference between this living arrangement and those discussed previously is there is more accommodation made for care. These communities will offer linen services, maid service, handyman help, meal programs, transportation and even help in getting around the facility as long as it doesn't require a major commitment from the staff. In many respects these communities are similar to assisted living which will be discussed below except assisted living also is licensed to provide care services such as help with bathing, dressing, toileting, diapering, medicating, helping with daily living decisions and moving from one place to another. Some independent living communities accommodate care needs by providing access to home health services from an independent agency. This allows a person needing care to remain in the community and not have to move and leave friends to go to a care facility.

Assisted living and congregate living look very similar and offer elders similar amenities. Also costs may be similar in the case where assisted living tacks on extras for care; consequently, many elderly will choose assisted living over independent living because of the added assurance of having care available and not having to move to a new location to receive care. The number of new assisted living beds far exceeds the number of new independent living beds constructed each year. Recently the difference between congregate or independent living and assisted living has been further blurred because many independent living communities now provide sections licensed as assistant living and the difference in names has become a matter of semantics. The reverse is also true. Newer communities designed for assisted living will also have a separate section for independent living.

Most independent living communities are rental communities, but a few are condominiums or single-family communities in which residents must purchase their own units or homes. Costs and services vary widely. In some communities, a monthly fee covers many services, while in others a fee-for-service system is used. The most common type of retirement residence will have a mix of studio, one room apartments with a private bath and some one and 2 bedroom apartments. Most of the moderate to budget category retirement residences will only have studio one room apartments available. These tend to be older facilities construction before 1980. Since 1985, there have been a number of facilities constructed that have luxurious amenities with few studios and mostly one and two bedroom units.

This reflects a change in the demand for this type of housing. Seniors that need or desire this type of housing have a strong preference for one and two bedroom apartments if they can afford it versus the one room studio apartment. This may reflect a growing affluence as well as a preference change in the elderly that are moving to this type of residence.

A few independent living communities offer subsidies based on strictly defined need. There is almost always a waiting list for subsidized units. To learn more about what is available, contact your local Area Agency on Aging.

Early stage Alzheimer's patients may be accommodated in a congregate or independent wing of a multi-level campus. Many Assisted Living Communities will accept and successfully house early stage residents. As the disease progresses patients develop argumentative behavior, "sundowning" and wandering habits. Generally the communities best equipped to deal effectively with this middle stage patient are Alzheimer' communities which are typically specially licensed and constructed assisted living facilities.

The costs of this type of senior housing vary tremendously, from $500 a month to over $4,000 a month. What does an elderly person get for $500 a month? Usually it is a small one room apartment with its own bath and a roommate. Yes, that's right a roommate. Every retirement residence that offers three meals a day activities, maid service and free transportation will only offer such attractive rates if an elderly person will share a one room apartment with another senior. Many facilities accept those seniors who are on SSI (a special income subsidy through Social Security for those with less than $800 a month income and no financial assets) but always require that they share an apartment with another senior. The average current cost for a studio apartment begins at about $1400 a month for all non-subsidized senior housing. Add about $400 a month for a one bedroom, $1,000 extra for a full apartment with kitchen and about $400 extra a month for a companion. Monthly fees usually include meals, maid services, utilities, transportation and so on.

One of the most striking things that has changed in this type of housing is the average age of the person who moves in today versus years ago. The average age today of the typical resident who moves in is 83 according to most facilities surveyed. In 1980 the average age was approximately 75. The change in the average age of the residents has brought with it a number of changes as well in the services provided the residents of these facilities. With advanced age there is more demand for personal care services and special services like escort service to the dining room for the more frail residents.

Some facilities have taken the approach of segregating those elderly who require assistance from those who don't in a separate wing of the residence with its own dining room and activity areas. They feel that they can only attract independent active seniors if they require a level of independent living in the main part of the residence. At this point however, there seems to be no consensus about whether this is a good way to handle the problem of "aging in place" or not.

The following list of activities and amenities was garnered from many web sites and is representative of the many services in dependant retirement living can offer:

Restaurant style dining 
Flexible meal program (180 meals included annually) 
Private dining room 
Complimentary hospitality bar 
Monthly special events dinners 
Housekeeping & Linen Program 
Housekeeping service (every other week) 
Weekly flat linen service 
Activities Program 
Full-time director 
Social events 
Educational & cultural events 
Residents' special interest events 
Transportation Program 
Scheduled transportation 
Planned trips 
Maintenance Program 
Professional maintenance department 
Appliance maintenance 
Building & grounds maintenance 
Health Safety NetTM Program 
Health & Wellness Program 
Independence Plus® services 
Free Health Care Days 
Meridian Health Centers Available 
Full-time Health Services Director 
Emergency alert cord in each apartment 
Fast Track Program 
Home sale assistance 
Timely sale 
Market valuation 
Move-in assistance 
Professional services on-site 
Postal services
Community Amenities
Location 
Convenient to community services 
Residential neighborhood 
Beautifully landscaped 
Outdoor patios 
Adjacent to Ralston Park 
Spacious one- & two-bedroom apartments 
Private balconies & patios 
Walk-in closets 
Wall-to-wall carpeting 
Full size kitchen appliances 
Individually controlled heat & air conditioning 
Cable TV available 
Central TV antenna 
Spacious lounges & meeting rooms 
Library 
Game room 
Craft room 
Exercise room 
Resident laundry facilities 
Hair salon 
Free surface parking 
Covered parking 
Guest accommodations 
Controlled access into building 
Smoke detectors & fire sprinklers 
Walking paths
Independent Living and Senior Apartment Communities
Guide to Retirement Living Staff
Mixed women's and men's chorus groups 
A Bible study group 
Line dancing 
Exercise for Fitness 
Water exercise classes 
An enclosed year-round lap pool and walking track 
Vespers services 
Bridge Club and Card Club 
Horticultural Club 
Computer Club 
A hand-bell choir 
Big Band Club - our 12-member musical ensemble. 
Bristol Village Women's Writers group 
Bowling league 
Indoor lawn bowling 
Bingo 
Volunteers at the Library program 
Ping pong 
Potluck suppers 
Pickle ball 
Tai-chi 
Arts and crafts 
Weaving 
Stained glass art 
Ceramics and pottery classes 
Sewing 
The Village quilting group, Creative Needles.

 

Assisted Living and Residential Care

Assisted living, also called residential care, is a type of living arrangement in which personal care services such as meals, housekeeping, transportation, and assistance with activities of daily living are available as needed to people who still live on their own in a residential facility. Assistance with activities of daily living may include help with bathing, dressing, toileting, diapering, medicating, helping with daily living decisions and moving from one place to another. In most cases residents pay a regular monthly rent and the care services above are added as extra cost as needed. Many facilities provide levels of care based on need and charges are uniform for each level. For instance a level or grade 1 care might cost an additional $400.00 a month. A second level or grade 2 might cost $800.00 a month and so on.

The definition of the term assisted living varies from state to state. One of the reasons so many terms exist for similar facilities is that each state has its own licensing requirements and regulations to govern these facilities to ensure quality care. Here are some examples of the titles states use for assisted living:

Residential care 
Personal care 
Adult congregate living care 
Board and care
Adult living facilities 
Supported care 
Enhanced care 
Adult homes 
Sheltered housing 
Retirement residences 
Adult foster care
Community based retirement facilities

Some States also license various categories of care under some of the titles above. For example a state may license categories under assisted living, board and care and personal care. Or another, licensing convention is to license small facilities as one level of care and larger facilities as another level of care under the same name. Each category has its restrictions and requirements for care giving. The difference in licensing is usually based on the size of the facility and the services it can offer. For example, residential or board and care is usually a converted home or small facility with three to ten beds where the caregiver is a homeowner or single proprietor with little or no support staff. These facilities typically are not allowed to offer much care beyond bathing, dressing, providing meals or helping residents move around. Some of these homes however, may contract with home health agencies, home visiting doctors or nurses to provide care for their residents.

The cost for board and care homes is typically much less than with large new assisted living facilities. People who operate board and care homes have a love for the elderly and in essence are taking these people into their homes to care for them as if they were family members. Unfortunately because of their small size these operations have little money to advertise and their residents usually come to them from referrals or word of mouth.

Assisted living fills a gap between home care and nursing homes. Years ago, before assisted living, a person needing professional care went to a nursing home even though the care didn't always merit the intensive supervision and control of a nursing home. The fairly new alternative of assisted living provides a more homelike environment for people needing or anticipating help with activities of daily living or incidental activities of daily living but for which 24-hour nursing care is not a necessity. Instead of the hospital environment of a nursing home, ALF's look more like apartment buildings with private rooms or suites and locked doors. Instead of a nurses desk, there is a help desk. And instead of a hospital-like lounge area and sterile cafeteria, assisted living has gathering areas with couches, fireplaces, gardens, atriums, etc. Central dining areas look more like banquet rooms and often offer entertainment during or after mealtimes. Meaningful activities and chats with neighbors in pleasant surroundings, keep residents active and stimulated.

The above description would be typical of newer facilities with 20 to 200+ beds. The States also license a variety of other assisted living facilities, some of them being converted homes as discussed earlier, others converted hospitals, some are dedicated areas in independent retirement communities and others are dedicated hospital wings. There are at least 15 differently name living arrangements that could be called and licensed as assisted living. But at a minimum the essence of all of these facilities is to provide an assistive environment to individuals or couples who for either medical reasons or to gain freedom from being tied to maintaining a home prefer instead to have someone else do the cooking, cleaning and gardening. In addition, ALF's offer help with transportation, medicating, bathing, dressing, toileting, health monitoring and moving from one place to another but only if the disabled person can move with the assistance of no more than one aide. Some states may allow facilities to have a resident nurse or therapist to help with minor medical problems. And some states even allow variances for assisted living to offer limited nursing home services.

Prior to assisted living, many people had to reside in nursing homes but didn't need the level of care provided. Yet there were few options for other living arrangements. With assisted living, these people now have the choice of a more homelike environment at about half the cost of a nursing home. Demonstrating the popularity of ALF's over nursing homes is the fact that the number of nursing home beds in this country has increased only slightly over the last decade to about 1,800,000 beds, whereas assisted living beds have grown from about 600,000 to well over 1,900,000 beds over the same period.

Not all residents of ALF's need care or assistance. Many are there because they want a simpler lifestyle without the worry of maintaining a home and they seek the companionship of other people their own age. They also may have chosen assisted living over an independent retirement community because they may need some minor help with Instrumental Activities of Daily Living such as taking medications but they anticipate a time when they may need the more intensive care available with an ALF. As of 1996, ALF residents who were independent with ADL's (needing no assistance) were as follows: eating--88%, transferring--84%, toiletting--78%, dressing--58%, bathing--49%. A recent survey of assisted living administrators estimated that 24% of their residents received assistance with 3 or more activities of daily living, such as bathing, dressing and mobility. They estimated that about one-third of residents had moderate to severe cognitive impairment. Many assisted living residents receive no help at all with care.

Who Pays for Assisted Living?
Estimates of the cost of an ALF range from 40% to 60% of the cost of a nursing home. In many areas a median cost with assistance might be around $2,400 per month. Medicare does not pay for ALF's. About 75% of all costs are paid by residents out of personal funds or family assistance. SSI pays for 14% and 2% is covered by long-term care insurance. Medicaid pays for about 9%..

Because the government participates little in the cost of assisted living, individuals anticipating a future need for ALF would do well to consider the purchase of long-term care insurance. All modern comprehensive policies cover ALF's (you must, however, qualify for benefits under the policy). Insurance is certainly more cost-effective than paying out-of-pocket. Depending on your age, 20 years worth of premiums as an example, might only cost 3% to 10% of the actual amount the insurance policy would pay for a 3 year stay in an ALF. That's a lot cheaper than paying 100% out-of-pocket.

A 1996 survey by the American Health Care Association reveals that 59% of ALF residents are admitted from their homes and the other 41% come from nursing homes, hospitals or other ALF's. Some ALF's have found a niche in providing care to Alzheimer's patients and many ALF's are exclusively dedicated only to Alzheimer's residents. This disorder requires intense supervision but not necessarily from the more costly skilled medical staff found in nursing homes. According to the Alzheimer's Association, at least 5% of those over 65 and 46% of those over 85 suffer from mental impairment. This provides a potentially large market for ALF Alzheimer's facilities.

Choosing an Assisted Living Facility
An ALF staff worker can tell you whether or not you or a loved one will qualify for assisted living. But you may be forced to choose a nursing home instead because the level of care that an ALF can offer is dictated by the licensing provisions of that particular facility. In the event that you are turned down for care by one ALF, it is very important to get evaluations from other facilities. Many ALF's have found ways to stretch eligibility and you shouldn't give up after one try.

Below is a copy of a reprinted article from the Assisted Living Federation of America's Assisted Living Today Magazine, copyright 1999, ALFA. This article is found on-line at http://www.alfa.org/public/articles/details.cfm?id=77.

How to Choose a Residence


Making the right choice is easier when you thoroughly evaluate residences using these criteria - By Elizabeth Parker Welton MSW, LCSW

Assisted living residences, in both rural and urban areas, allow today's consumers to be highly discriminating in their choice of a residence. A wide range of choices, however, may produce confusion and anxiety. With choice often comes the implied responsibility for making the 'right choice.' Family members engaged in this search sometimes feel like they're looking for a needle in a haystack without the benefit of a map.

ALFA has developed a complete checklist to be used in the evaluation and selection process. Consider the following elements when searching for that needle in a haystack.

Atmosphere: Family members involved in the selection process must look at the residences they visit through the eyes of the person who will be living there. When touring facilities, family members often comment, 'I could imagine myself living here.' Although that is a positive reaction, what is truly relevant is whether they can imagine their loved one living in that setting.

How does the prospective resident react when he or she meets the staff and other residents? Is the decor welcoming and homelike? Do the current residents appear to be compatible with your loved one? Will the particular personality and culture of that setting support the physical, emotional, mental, and spiritual needs of the prospective resident? The answer to that question is critical in determining the success of your and your loved one's choice.

Make several return visits to the residence on the top of your list to experience staff and residents in a variety of situations. Although crisis sometimes necessitates a more immediate choice, it is always ideal to take the time to make a slower and more informed decision guided by as much information as you can gather.

Physical Features: A residence that is modern and tastefully decorated almost always creates an initial favorable impression. However, an aesthetically pleasing setting that is not designed to maximize comfort and ease in functioning may not be a particularly wise choice. For example, a beautifully decorated unit that does not have doorways wide enough to easily accommodate a wheelchair does not allow for ease and comfort in movement. A bathroom that is too small to permit a wheelchair or walker to enter without precise maneuvering also reflects poor design. Hallways that are long and/or poorly lit without handrails may confuse and overwhelm elderly residents.

It can be extremely helpful to choose a potential unit and have the future resident move about in that space as if he or she is already in residence there. It gives you an excellent opportunity to evaluate how well the space is designed to promote both comfort and ease in movement as well as how it supports independent functioning.

Needs Assessment, Contracts, Costs, and Finances: Assessing the fairness and comprehensiveness of the contractual agreement is important. Most people are accustomed to evaluating and signing contracts fairly routinely. But it will be important to understand any future costs for increased levels of care and service should the resident's physical and/or cognitive functioning decline. It is reasonable to expect costs will increase over time as independent or minimally assisted functioning declines. Being prepared for that eventuality will help you decide whether that particular residence is financially feasible. Visit ALFA's Web site (www.alfa.org) to view a standard 'Consumer Information Statement' or disclosure form, which identifies questions you should ask specific to fees and services.

Another way to determine the viability of a particular residence is to learn whether each resident has a written care plan. Without such a tool, it's possible the care needs of residents will be unrecognized and therefore unmet. A comprehensive care plan should be created with the help and input of the resident, all available family members, the family physician, and any staff members who will have direct contact with the resident. This care plan must be reviewed and updated as the resident's needs change. The process of developing a care plan allows the resident to feel that all of his needs are both recognized and important to those around him. This frequently allays much of the anxiety associated with such a major life change.

Education and Health Care: The majority of people entering an assisted living residence are on at least two daily medications. Many choose this type of setting because medication self administration, among other things, has become difficult. Understand what specific policies are in place for giving medication as well as for any medical emergency that may arise.

Is a licensed nurse available to residents and staff in a full-time capacity? If the prospective resident has chronic hypertension, can you be confident his blood pressure will be taken and recorded on a frequent basis? Does a staff person arrange for visits from a physical therapist, occupational therapist, hospice nurse, etc.? The coordination of services with agencies in the community allows for a full continuum of care to be provided. It not only significantly benefits the health and well being of residents but also establishes the residence as a true member of the outside community. The relationship between the residence and the local community will support the resident in not feeling isolated or sequestered.

Services: Determining as specifically as possible the prospective resident's daily care needs is a critical step in choosing a residence. Make a detailed list of the type of assistance that will be required with each activity of daily living. For example, will this resident require assistance in dressing and undressing? If so, what specific type of assistance will be required? If her clothes are laid out for her, can she dress herself or will she require assistance in the actual dressing process? Does the staffing pattern allow residents who are wheelchair bound to receive help quickly if they need toileting? Inquire about the staff/resident ratio on all shifts. This information will give some indication of how quickly staff can be available to assist residents.

The ease and availability of transportation to shopping, the hairdresser, and other community activities also is important information. The ability to move relatively effortlessly between the residence and the community is another significant way the resident's autonomy and independence are valued and encouraged. Transportation provided by the residence may or may not represent an additional monthly charge.

Cognitively impaired adults may need a different type of assistance in their daily functioning. Are safety measures in place to contain possible wandering? Is the staff trained in techniques important to the care and comfort of mentally confused residents? Are specific areas and/or units designed to provide specialized care and programming for those who are cognitively impaired?

Individual Unit Features: Nurturing the spirit and individuality of residents as they move from their home into a residence is both challenging and achievable. The opportunity to have a choice in one's living space is an important way to achieve this goal. Some people value their privacy and don't thrive in double-occupancy units. Others may feel too isolated in a unit by themselves and will welcome a roommate.

Bringing some treasured pieces of furniture and pictures from home will greatly facilitate the transition and should be encouraged. The presence of a kitchen area in each unit allows for maximum choice and autonomy. Although most prospective residents will acknowledge that they are excited at the prospect of not cooking, the ability to prepare snacks or even a light meal is an important option. One of the fundamental goals of an assisted living residence is to provide comprehensive care to older adults while preserving their ability to be independent and have as many choices in their environment as is feasible. A future resident's participation in the choice of a residence, and the various options available within that residence, will have a direct and vital effect on the quality of that resident's adjustment to his new home.

Social and Recreational Activities: A diverse program of planned activities both within the residence and the community is vital to the happiness and contentment of residents. Does a staff member have sole responsibility to plan and direct social events? Do residents have a voice in planning activities both within and outside the residence? Does the selection of activities reflect the interests and lifestyle of the residents in an appropriate and satisfying way? Are residents who are less social encouraged to participate in activities? Are activities designed to not only nurture the spirit but challenge the intellect? Are activities in the residence consistently well attended by residents?

A well-balanced coordination of activities both within the residence and in the community allows the resident to feel a sense of belonging in both places. Activities are an important way in which social and emotional connections are made in a new setting.

In addition, research shows that the presence of animals in the lives of older adults is another important way of nurturing the spirit. However important and necessary the move to an assisted living residence might be, it involves significant losses. A residence that has a dog or cat viewed as the house pet can provide opportunity for constancy and daily love for someone who may be feeling a sense of loss. Many residences allow a small animal to accompany its owner in the move. When discussing this option with the staff, gain a full understanding of how the animal will be cared for.

Food Service: Food is a significant part of life. We look forward to meals and savor not only the food that we eat but the ambiance in which the food is served. If you polled assisted living residents about what contributes most to their customer satisfaction, food would rank high on their list. One of the universally significant ways in which people feel nurtured is through the food they eat. Keeping that in mind, food preparation should include fresh, diverse, and interesting ingredients.

At each meal, residents should have a choice of entree and dessert. Because individuals' tastes in food differ, no one offering can possibly please everyone. Resident input in the menu selection is another important way of promoting choice and respecting individual tastes.

The kitchen's capacity to provide for special diets that are medically mandated is another critical piece of information to gather. If a resident is feeling too ill to come to the dining room for a meal, can food be delivered to his room?

Is the dining room visually appealing to encourage residents to linger over their meals there? One of the most important avenues for socialization is dining with other people. It represents a natural opportunity to gather and share the events of the day and sometimes a lifetime.

In addition to using the guidelines ALFA has developed for choosing a residence, use your own knowledge of the prospective resident as a guide in making your choice. In what setting will he or she feel most supported and at the same time be able to function most independently? What are the particular and unique physical, mental, emotional, and spiritual needs of this person and in what setting are those needs most likely to be recognized and met?

The goal you set in choosing a residence should not be considered met until a setting has been selected in which the prospective resident can feel physically cared for and can thrive emotionally. Many older adults who are living independently, but struggling each day with physical and/or cognitive disabilities, are isolated and afraid. Moving into the appropriate assisted living residence can relieve the daily struggle to function and release the energy to fully and joyfully engage in life again.

Elizabeth Parker Welton MSW, LCSW is a psychotherapist in private practice in Arlington, VA. She can be reached at 703/524-3169.Be Informed, Be Prepared, Be Thoughtful

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Be Informed:

  • Learn about assisted living. Find out what services are provided by the residences in your area. Keep in mind that residences can vary greatly.
  • Shop around. Finding a new home takes time. Plan ahead to visit as many residences as you can. Know what services you need and what to shop for. Make an appointment to meet with staff.
  • Visit and revisit. Once you've decided on your top choices, revisit each facility at least one more time and at different times during the day. Talk to staff, residents, other family members, and the local long-term care ombudsman.
  • Ask for written material. Information is essential. Review marketing material, consumer information brochures, the resident contract agreement, and state survey information about the residence. Consider having an elder law attorney review the resident contract agreement. Read the fine print.
  • You're doing business so ask the right questions. Find out about prices and what initiates a price increase. How much do the extras cost? Find out how each resident's needs are assessed and monitored. Inquire about policies on refunds, transfers, and discharges. What will happen if the facility closes? Is there an appeals plan for dissatisfied residents?

Be Prepared:

  • Know the costs. Assisted living can be expensive. Be familiar with what each facility charges for each level of care, plus the charges for extra services beyond the monthly rate.
  • Examine your finances. Monthly rates vary. Determine the affordable price range and shop accordingly. Will family members contribute and how much?


Be Thoughtful:


In most cases, adult children play a major role in helping a parent secure an assisted living residence. Respect the interests, needs, and wishes of your loved one. Although many assisted living facilities offer a lifestyle that preserves autonomy and dignity, moving from home to a new place can be a difficult transition. Work together to make plans and decisions. Don't exclude your parent from the process.

From Sen. Charles Grassley (R-IA), chairman of the Senate Special Committee on Aging


Alzheimer's Facilities or Alzheimer's Special Units

There seems to be an growing epidemic, nationwide, of dementia and Alzheimer's. The Alzheimer's association estimates that one out of ten seniors over age 65 will develop dementia and for the people who live beyond age 85 almost half of them will develop some form of dementia. The growing number of Alzheimer's patients is probably due to the fact that the age group older than 85 is skyrocketing. People are living longer.

In the past Alzheimer's and other dementia patients were housed in nursing homes along with other non-dementia residents. And this is still true for patients who rely on Medicaid to provide their care. But, most Alzheimer's patients don't require the intense supervision of a nursing home. For those who have the money to pay for care out of their own pocket there is a growing tendency to receive supervision and care in assisted living facilities dedicated to the care of Alzheimer's and other dementia. Many nursing homes and regular assisted living facilities have wings specifically dedicated for dementia patients as well.

The design of the facility accommodates supervision of the residents and entry and exit into these units are restricted due to the tendency of people with dementia to wander. Activities are encouraged especially singing because patients seem to respond well to music. To help residents identify their rooms, "memory" cabinets, which resemble windows and contain photos and other memorabilia, are located at the room entrances. In shared rooms, each wall is painted a different color to help residents recognize their space. Beds are placed directly on the floor to prevent injury due to the tendency to wander at night and many facilities work very hard at not restraining residents physically or chemically.

 

Nursing Homes

Nursing homes accommodate two types of senior services. The first are acute care services for patients who are recovering from a hospital stay or a major surgery. The nursing home does not become their residence since the average stay for an acute care patient is about twenty days. The other senior who uses a nursing home is the long term care resident who may spend an average of two years in a nursing facility. Although a nursing home is associated with medical care, most long term care patients will finish out their lives in a nursing facility as their primary residence. Very few return to their homes. Unfortunately this doesn't have to be the case. For most residents, the same kind of care received in a nursing home could be offered at home. This is because not that many nursing home residents need 24 hour supervision from a nurse. The reason home care is not an option is because it is typically cheaper for government programs to provide long term care in a nursing home.

About 70% of nursing home residents are receiving help from Medicare or Medicaid and Medicaid pays approximately 50% of the total of all nursing home costs. And the great majority of the other residents who are paying out of their own pocket are going through Medicaid spend down, depleting their assets in order to qualify for Medicaid. All of these people relying on Medicaid simply don't have the income or resources to receive care at home and live out their lives at home. They have to rely on Medicaid to provide room and board as well as the care that qualifies them for room and board in the nursing facility. Unfortunately Medicaid favors nursing home care to provide long-term care to the aged. For all practical purposes a nursing home as a retirement care community is a government Medicaid-provided, living arrangement. It is simply another very expensive form of government provided housing.

Medicaid programs are under a great deal of pressure nationwide to provide care in assisted living facilities or in the home and some state Medicaid programs have done a good job in converting care in that direction. But, by and large, the bias is to continue care in nursing homes. In fact Medicaid rules require anyone wanting home care or assisted living to spend 90 days in a nursing home first before they can transfer to the other living arrangements. This illustrates the bias of Medicaid towards nursing homes.

We will not take up the space to talk about selecting nursing homes here. The Internet is replete with thousands of sites designed to find nursing facilities and to help in the selection of the proper facility. Considering the number of nursing home beds compared to elders living in other retirement care arrangements there seems to be an inordinate amount of attention directed towards nursing homes.

Combined Care Communities

Reference has been made above to in dependant retirement communities also being integrated with assisted living. Many care provider organizations are taking this one step further and providing independent living, assisted living and nursing care within the same building or in close proximity to each other. Not only is this a cost advantage to the care provider to share costs and clients among the facilities but it's an advantage to the resident who can maintain ties to the community, to a spouse and to friends in the facility. It's also an advantage to the care recipient's family since they do not have to relocate their loved ones to another facility.

Integrating care into combined care communities seems to be a trend that will continue to grow.

Continuing Care Retirement Communities

Continuing care retirement communities (CCRCs) or life care communities as they are often called, are popular with upper middle and higher income elders. Usually sponsored by a nonprofit organization or religious group, this living arrangement has a great deal of appeal to people who want upscale and stimulating living arrangements but are still concerned about the future need for long term care. Many of these communities are located in beautiful settings or in areas such as seacoast or mountains where there are plenty of outdoor activities.

The concept is the same as the combined care communities discussed in a previous section above. Independent-living, assisted living and a nursing home are found on site in a continuing care community. In addition medical services, provided by a geriatric nurse practitioner or visiting doctor, may also be available in larger communities. Because of the increasing prevalence of Alzheimer's more and more existing care communities are also offering special Alzheimer's wings. Residents of continuing care communities pay an up front lump sum, cash payment and ongoing monthly living fees.

The original concept of a CCRC was to provide a guarantee to living quarters and long-term care services as long as the resident was alive. This in essence was a form of retirement and long term care insurance and the concept was to pay a large cash sum up front in order to fund a cash reserve to "insure" that a resident would receive the services promised at no additional cost in monthly fees. Some communities even had insurance companies underwrite this risk in the form of an insurance policy. Because of the emphasis on care for life these communities were often called life care communities. Over the years the guarantee of living arrangements and services has not worked as well as envisioned.

Today most continuing care communities still charge an upfront fee and monthly living fees but the guarantees with most communities only cover an assurance that a resident can have access to care on the premises and not have to move. With most communities the additional cost of long term care has to be covered out-of-pocket by the resident.

Continuing care communities today are most popular in the North East, along the Atlantic seaboard, in Florida, Texas, Oregon, Colorado and California. Such communities are generally very large complexes of high-rise apartments with scores of activities and amenities for their active adult residents. These complexes are tightly managed. Some CCRCs are affiliated with a specific ethnic, religious, or fraternal order, and membership in these organizations may be a requirement for entrance into the community.

Potential residents are carefully screened for good health and adequate savings and income. The majority of CCRCs require potential residents to have a medical examination to assess their physical and mental status. Selected pre-existing conditions may cause a CCRC to refuse an applicant. Some CCRCs require residents to have both Medicare Part A and B. Naturally, residents must be able to meet the entrance fee and monthly payments. People who do not qualify are not accepted.

You should apply while you’re still healthy. Even facilities that accept people who aren’t healthy do so only on a space-available basis, with priority going to their own current residents. People who wait until their first health crisis to apply to a retirement community might not get in. The last can be a deal-killer. Many people are reluctant to leave their homes when they’re still perfectly capable of living independently. As one retirement community executive put it: “It’s a major lifestyle change at a point in your life when change is not easy.”

The continuum of care in these communities is tightly structured and residents have a secure feeling that they will never have to leave the area again. This is probably the primary appeal of CCRC's today. This is also probably the reason that residents are still willing to pay large up front fees in order to live in such communities as opposed to no up front fees in combined care communities. In addition, CCRCs are most appealing to single people who have no family or who don't want to burden a family with their care and to married couples, who want to remain close to each other even if one moves into the facility's nursing home.

Some communities are still trying to offer guarantees but communities will give residents choices depending on how much the president is willing to pay. Contract choices might include:

A so called "life care contract" that guarantees a continuum of care for a buy-in fee and the same continuing monthly fees regardless of the level of care needed. (This does not mean that inflationary increases in ongoing monthly fees cannot occur.) Very few residents can meet the high cost of this type of contract and very few complexes can meet the stringent state requirements for life care contracts.

The more common fee-for-service "continuing care contract" which covers shelter, residential services, and amenities. While emergency and short-term nursing care is usually included in the contract, access to long-term nursing care is guaranteed only at daily nursing care rates. Entrance and monthly fees are lower under this type of contract because residents are responsible for all long-term nursing and health care costs.

All communities have some form of a return of the living fee during a trial period. Some communities may also offer limited return of entrance fees if the resident dies too soon or under other special circumstances.

It is highly advisable to have an attorney review a CCRC contract before any commitment is made.

Below is a description taken from a sales brochure for a large Florida non profit corporation offering continuing care communities in a number of Florida locations:

As part of the Westminster Communities of St. Petersburg, Westminster Shores, along with Westminster Palms and Westminster Suncoast, are backed by Westminster Retirement Communities, one of Florida's oldest and largest not-for-profit senior housing and healthcare organizations.

Nestled on 75 acres of lush, wooded paradise, Westminster Woods is situated on the shores of Julington Creek, a half-mile wide arm of the St. Johns River. The community offers the benefits of a natural setting with the convenience of close proximity to Jacksonville's big-city amenities.

Residents of Westminster Manor pay an entrance fee upon move-in, and a monthly service fee. The entrance fee is a one-time payment that provides the following benefits:

  • Assures the resident of a home at the community
  • Guarantees priority admission to our assisted living and health care centers
  • Greatly reduces fees for convalescent care, assisted living, and health care
  • Gives an option for estate preservation by including several refund options
  • Gives the ability to finance the entrance fee at competitive rates.

The monthly service fee covers virtually all the costs of living in the community, and usually includes:

Daily meals 
Utilities 
Activities, programs, and entertainment 
Limited convalescent care 
Housekeeping services 
Apartment or villa maintenance 
Scheduled transportation 
Security personnel 
Parking 
Clinic and wellness services 
Cable television 
Beauty Salon
Barber Shop
Chapel
Shuffleboard Courts
Croquet Courts
Resident Service Coordinator
Convenience Store
Putting Green
Library
Fireside/Game Room
Computer w/Internet

Here is another description:


Holladay Park Plaza is a high-rise in downtown Portland that features a gym, a spa, an indoor pool and an outdoor walking track to keep residents fit, along with a library, art studio and woodworking shop for pursuing hobbies. That’s in addition to onsite services like a beauty parlor, a barber shop and a travel agency, plus shops and restaurants across the street at Portland’s Lloyd Center mall.

Below are some recommendations for people considering buying into a continuing care retirement community.

  • Take the CCRC's marketing tour and observe the upkeep and safety of the facility. Does it appear clean, and are the grounds kept up? Are there appropriate hand rails or grab rails in the bathing areas and hallways? Are the sprinkler systems and fire extinguishers easily accessible?
  • Verify the type of training given to the staff. Ask to see training policy and procedure manuals to make sure that the facility does indeed train the way it says it does.
  • Ask if the facility does national criminal background checks on staff. Some only do local or state background checks. Also, what type of pre-employment drug screening does it do, and is drug screening ongoing?
  • Compare staff numbers with other CCRCs you are considering, looking at the number of staff on each shift for the weekend and weekdays.
  • Find out about the types of food choices a facility offers and whether it is able to accommodate special dietary needs.
  • Be sure to ask about the reciprocal agreement that the CCRC has with other CCRCs for skilled nursing or assisted living wings within the communities, should those wings be full at the time a senior needs to make that transition.
  • Look at the range of activities on site and off site, and see if they meet the senior's needs. Are there activities off site at least twice a week? Does the facility offer activities such as religious services, lectures, discussion groups, and arts and crafts classes on site?
  • Inquire if a facility has a wellness center that can meet clinical needs such as memory impairment services or weight control and blood pressure checks. Also, how close is the nearest hospital in case of an emergency?

Continuing retirement communities aren’t cheap. Most have hefty entry fees that typically range from $20,000 to $200,000 or more, depending on the size and location of the apartment or home you choose. Ongoing monthly fees might average about $2,000, although the toll can rise if the facility charges extra for medical care.

The community will want to make sure you can afford its ongoing costs, as well. Holladay Park Plaza in Pennsylvania likes to see applicants with assets equal to at least three times the entrance fee, which ranges from $44,000 to $200,000, and incomes at least twice the monthly fees, which range from $1,100 to $3,300.

Cornwall Manor in Cornwall, Pa., for example, charges $1,200 to $1,800 a month for its independent living apartments, depending on their size and location. Residents who need assisted living are charged an additional $88 to $155 a day, while nursing care runs $173 to $193 a day.