If you have concerns about the ability of an aging parent or relative to live independently, you may want to investigate assisted living—and sooner rather than later. "The best time to look is six months to a year before your parent will need to make the move," says Paula Carder, an assistant professor at the Institute on Aging at Portland State University in Oregon, and co-author of "Inside Assisted Living: The Search for Home" (Johns Hopkins University Press, 2009). If you wait until your parent is being discharged from a hospital or rehab center, you'll have fewer choices. And, as an investigation we conducted a few years ago clearly showed, finding a good, safe, and affordable facility can be problematic due to states hodgepodge system of licensing, inspection, and staff training standards of varying strictness.
Assisted-living facilities are residential units that sometimes include a kitchen, housekeeping, meals, transportation to doctors and activities, and various levels of personal assistance. Fees can run $5,000 a month or more, depending on the size of the unit and the care that's needed. The average length of stay is about 22 months.
More than 900,000 Americans now live in about 39,500 assisted-living facilities, according to estimates, but there is no federal oversight of the industry. Each state sets its own definition of assisted living and decides what licensing procedures and inspections are required. One result is that there are more than 26 designations used to refer to what is commonly known as assisted living, including "residential care," "board and care," "adult home," and "retirement residence."
The following game plan will help you find the best facility for an aging relative.
Is assisted living appropriate?
Your first step is to make an honest appraisal of whether your relative can continue to live at home. If he or she needs only a minimum of help and dislikes the idea of moving, home care might be a better choice. But for gregarious people who are beginning to experience a decline in function, assisted living might be a good option.
For help assessing your relative's physical, mental, and financial situation, consider consulting a geriatric-care manager, who should be knowledgeable about the assisted-living options in your area, including the facilities' financial strength. You can search for one on the National Association of Professional Geriatric Care Managers website, at www.caremanager.org. "You can also get recommendations from family doctors or local senior centers," says Molly Shomer, an elder-care adviser who runs the ElderCareTeam.com website.
Several websites provide information on nearby facilities. "I like SnapforSeniors senior housing locator," says Kathleen Cameron, former chairwoman of the Consumer Consortium on Assisted Living (CCAL), a nonprofit advocacy group. "It seems to be the most comprehensive, and it has some good information on long-term-care and funding options, too." Shomer recommends NewLifeStyles.com. "You aren't required to enter personal information on the site, and it doesn't make referrals, which prevents lots of annoying phone calls later," she says.
Once you have a list of facilities, make an appointment to visit them with your parent or relative. You can find a checklist of things to look for and questions to ask on the CCAL website.
Your first tour will probably be led by the director of marketing. You will see the common areas and available apartments. Notice if the facility's décor suits your parent's taste, but don't let that be the deciding factor. "Nice chandeliers and fancy furniture don't provide good care," Shomer says. Of course, the place should be clean and well lit. Look for safety features like grab bars on all the walls, including the hallways, and nonslip flooring materials, especially in the bathrooms. Try to have a meal while you're there to check out the food.
Watch for red flags
Observe the interaction between staff members and residents. Is it cheerful and respectful? Do staff members seem genuinely interested in the residents? If you see few residents in the common areas or participating in activities, it might signal that the facility is not full, which could bode ill for its financial stability.
Get a copy of the admissions contract and the residence rules. If you sense reluctance by administrators to part with such information at this early stage, consider it a red flag. The facility's contract outlines fees, services provided, and residents' rights, and explains who will handle medications, when reassessments of a resident's condition take place, and when a resident might be asked to leave because he or she needs more services than the facility provides.
The contract should also specify whether a resident is allowed to return to the same unit after a hospital stay. Nursing homes are required to hold a room for Medicaid patients, but many assisted-living facilities are not. Make sure that yours will.
Return unannounced several times to your top two or three choices. Visit at different times of day, especially around mealtimes and the early evening to see how they are managed at busy and quiet times.
Ask to speak with the residence administrator. "Even if it means coming back for another appointment, this is important," Carder says. "He or she is the person who sets the mood and philosophy of the whole place." When you meet, ask to review the facility's licensing or certification inspection report. This should be readily available to the general public and will outline any complaints or black marks the residence has received during inspections. Ask how any problems were corrected.
Also ask about who will draw up the care plan for your relative and how much input he or she and the family will have. Find out how the facility will accommodate your relative's current and future needs. For example, someone with diet-controlled diabetes might eventually need insulin. How will the facility handle that? Find out how many employees are assigned to each resident. And look for a facility that has a licensed nurse on duty or on call at all times. Ask about the staff's training in such areas as safety, emergency care, first aid, mental health, residents' rights, and medication administration.
Add up the costs carefully
When you've narrowed the field to one, review the fees. Note the costs for any extra services your relative will need, policies regarding the return of a deposit or down payment, costs involved during hospitalizations, and the possibility of unexpected rate increases. Most costs for assisted living have to be paid out-of-pocket.
The national average monthly base rate for an assisted living unit (which includes room, board, and some personal care) was $3,550 last year, up from $2,379 in 2003, according to a survey by the MetLife Mature Market Institute. Make sure you take into account the possibility of added costs if your relative needs more assistance than the level covered in the base rate. For example, if more help is needed with what are known as instrumental activities of daily living, such as medication management, the average additional fee is $347 a month, according to the MetLife survey.
Contact your state's long-term-care ombudsman, who acts as an independent resident advocate. He or she will have a record of complaints lodged against a facility and how they were handled. You can find your state's contact information through the National Long-Term Care Ombudsman Resource Center, at ltcombudsman.org, or by calling 202-332-2275.
Finally, have the contract reviewed by an attorney before you sign it. You can find one in your area who specializes in elder-care issues on the website of the National Academy of Elder Law Attorneys, at naela.org.