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SINCE YOU CARE I N C O OP E R AT ION W I T H T H E NAT IONA L A L L IA N C E F OR C A R E G I V I N G Caregivers face many challenges as they search for information and make decisions about how best to provide care to their loved ones. To help meet their needs, MetLife offers Since You Care® — a series of guides which provide practical suggestions and useful tools on a variety of specific care-related topics. CHOOSING AN ASSISTED LIVING COMMUNITY What Is Assisted Living? Assisted living is a term that describes a kind of housing option for older adults that combines independent accommodations with support services such as dining, wellness, social activities, personal care, medication management, and more. Assisted living helps older adults to enjoy a lifestyle that allows for independence, dignity, and social involvement, with the benefits of assistance to meet their daily needs. It generally includes 24-hour supervision, housekeeping, meal preparation, and assistance with activities of daily living. Different names for assisted living sometimes indicate the size of the housing arrangement. They may be referred to as residential care communities, adult congregate living communities, board and care, personal care homes, retirement homes for adults, or community residences. The names vary widely because each state, not the federal government, provides oversight and regulation of its own residences. Definition and Philosophy Assisted living communities also strive to meet the social, emotional, cultural, intellectual, and spiritual well-being of their residents.1 The autonomy, dignity, and independence of the older adult are the core philosophies. An important part of this philosophy is the desire to accommodate the changing needs and preferences of individuals, helping them to remain as independent as possible in an environment that gives them the security of knowing that people are available should they need assistance at any time. History and Profile Assisted living became a viable option for older adults in the mid-1980s, and the number of residences has been growing ever since.2 Currently there are over 39,500 residences with about a million residents.3 In a 2006 survey, the average age of residents was 85, and 76% were women.4 Many needed help with at least two activities of daily living such as bathing and dressing, while 91% needed help with housework, and 86% needed help with their medications.5 Some assisted living communities also provide care for those with cognitive impairments related to illnesses such as Alzheimer’s disease. When to Consider an Assisted Living Community Assisted living is an appealing option for those who do not need the skilled medical attention that a nursing home would provide, but would enjoy the benefit of being around others in a community setting. It may be a welcome alternative to maintaining a house and a car, preparing meals, and coping with inclement weather. For others, it may be a decision that is reached as a result of a change in health that has had a significant impact on lifestyle. For example, after taking a fall and sustaining an injury, you may find that the older adult becomes more anxious about walking and becomes isolated and depressed, and as a result eats less and 2 loses weight. These may be indicators that living alone is no longer a safe option. Answering these questions may help clarify your older loved one’s needs: Does the older person need help with the following: • Getting into and out of a shower safely • General housekeeping • Managing medications • Managing personal care • Supervision for personal safety Things to Consider Locating a Community When you have decided that assisted living is the right option the question becomes, “How do we find the one that best suits his or her needs?” Planning ahead, when you are not in crisis, will give you the opportunity to explore the different populations served, settings offered, and available service options. Your family member’s physical and mental needs will serve as guideposts for your decision making and discussions with admissions personnel. Seek recommendations and referrals from doctors, friends, and other community agencies. Your Area Agency on Aging or State Office on Aging are good resources to start gathering information regarding rules, regulations, and the availability of assisted living communities in the area. (See Resources to Get You Started on page 6.) Choosing a Community When choosing an assisted living residence, you want to consider one that embraces the philosophy of consumer choice as described below by the National Center for Assisted Living and the American Health Care Association.6 You should expect to: • Be treated with dignity and respect • Be informed of services available and the limitations of those services • Manage your personal funds • Retain and use your personal possessions • Interact freely with others both inside the residence and in the community • Have freedom of religion • Control your health-related services • Maintain your privacy • Be free to exercise your rights and responsibilities as a resident • Have the right to voice or file grievances See Resources to Get You Started (on page 6) and Useful Tools (on page 7) for checklists and references to help you choose a community. Location Location may be of key importance, in order to be near friends, family, and familiar, quality medical providers. If possible, consider a community within a 20- to 30-minute drive, in order to maintain contact and encourage visitors. Services and Costs Assisted living communities usually charge a base rate which covers a certain set of the services. Other services are offered at an additional cost. The fees for services vary considerably by community size, and the number of services included in the base rate vary, impacting the overall cost of care. As residents age, they may experience a reduction in their capacities and require additional services over time that were not required when they entered the community. Check with the community to find out which of these are included in the base rate and which ones may be offered à la carte: • Care management and monitoring • Help with activities of daily living • Housekeeping and laundry • Medication management • Recreational activities • Security • Transportation • Two meals per day or more • Increase in frequency and time for personal care • Incontinence care • Laundry service beyond basic service • Meals delivered to living quarters • Specialized care for dementia Find out if there are different levels of care. If someone needs more services or care, how would that be determined? Would they be able to move to a higher level of care within the same community? Would the family be notified? When and how is it determined that a resident is no longer appropriate for the community? SINCE YOU CARE 3 The cost for an assisted living community can vary dramatically by location. The national private pay base rate for assisted living is about $3,031 per month, or $36,372 annually,7 and some may charge an additional admission fee. Most medical insurance, including Medicare, does not provide any reimbursement for assisted living. Assisted living is a covered service in many long-term care insurance policies, as it is becoming an increasingly popular long-term care service option. Many comprehensive long-term care insurance policies cover costs associated with room and board in assisted living, but there can be other charges based on the needs of the individual. Individuals who have a policy should check with their insurance company and review their plan to determine how benefits are paid for assisted living services. Although the majority of residents pay out-ofpocket, a number of states provide subsidies or Medicaid waivers that cover assisted living for those who meet Medicaid income and asset guidelines.8 Medicaid waivers enable residents of the state to receive community-based long-term care services, such as assisted living. Information on community-based care can be obtained by contacting your Area Agency on Aging or State Office on Aging, or contacting the federally funded Eldercare Locator at 800-677-1116, or online at www.eldercare.gov. (See Resources to Get You Started on page 6.) Be sure to ask about billing, bed reservations, refunds, and payments. Take the time to carefully review the contract. Do you understand everything in it? Does the contract specify all the services that your family member needs and how frequently they are provided? Are health services included? Which ones? Does the contract address levels of care? Take into account your loved one’s resources and the amount of time he or she is expected to be in an assisted living community. It is always good to speak to a financial professional and an elder law attorney when planning for long-term care. 4 Size Assisted living residences may have as few as three rooms or as many as 200. Most have between 25 and 120 units.9 A smaller residence may be in a traditional home in a residential neighborhood, offering residents a room. A larger residence may be a community, offering apartments with a central dining area and recreation areas. If the community is spread out, is the staff available to help accommodate individuals who may need assistance with walking or using their wheelchairs? What type of setting would your family member prefer? Bigger does not always mean better and small does not confirm that your family member will receive more care. Staffing As you are looking at different communities, you will want to compare the staff. The attitudes of the staff will tell you a lot about the residence. You may also want to look into the turnover rate of staff, and note how they interact with residents. If you visit at different times during the day you will be able to observe how the staff members balance the residents’ needs with the competing demands, and how they carry out house rules and routines. Also, you will want to know whether there is a nurse on staff for medications and assessments. If not, determine who is responsible for the process and evaluating the care needs of the residents. Medical and Specialized Care For individuals who have a cognitive impairment like Alzheimer’s or a similar disorder, and who require supervision for personal safety, you will need to find a setting that is dedicated to providing specialized care. You will need to consider your family member’s mental and physical health needs, and consider whether the environment will provide the needed stimulation to help him or her thrive emotionally, and with dignity. You will want to know what services and systems are in place to provide your loved one with adequate health care oversight, monitoring, and access to emergency medical care. What transportation is available to assist residents with getting to their doctors? Is there a therapeutic exercise or fitness program? What are the procedures for getting emergency medical attention? How often do residents get health care monitoring? If, for example, your loved one takes a blood thinner, it will be important to make sure that the staff of the assisted living community will be able to arrange for a lab to come to the residence to draw blood, and then coordinate the necessary follow-up with the doctor, and if necessary, the pharmacy. As a family member, you are the link, the one who can assure that your loved one’s health care needs are recognized and appropriately addressed. How to Evaluate the Quality of Care Since assisted living communities are overseen by state governments the regulations vary from state to state. Ask whether the community is licensed in your state. To learn about the regulations in your state, you can download the Assisted Living State Regulatory Review, at www.ncal.org/about/2008_ reg_review.pdf, which is published annually by the National Center on Assisted Living (www.NCAL. org). This comprehensive guide summarizes the regulations in each state and reviews a wide range of important requirements on such issues as medication administration, staffing, and move-in and move-out conditions. To obtain a printed copy, call 202-898-2855. Another way to check on the community is to contact your local Long-Term Care Ombudsman to see if there are any complaints on file against the community. See www.ltcombuds man.org or call 202-332-2275 to obtain an ombudsman in your state. Additionally, you will want to use your senses when you visit the communities. You and your loved one will be able to observe how different staff interact with the residents, whether the meals are appetizing and prepared to accommodate dietary needs, and whether there are scheduled activities that will meet your loved one’s social needs. You may also want to make one unannounced visit. Notice whether there are any disagreeable odors or high noise levels, as well as the overall condition of the community. Making a Successful Transition With any move, there is always a period of adjustment. Give your family member time and stay involved and visible in his or her life. Learn the names of people to contact for giving and getting information about your family member. Be sure to praise good work and show appreciation to the staff. Find out procedures for sharing your concerns, and don’t be afraid to speak up when you see a change that concerns you. Individuals whose families are involved in a positive way generally have higher morale and receive better care. SINCE YOU CARE 5 Resources to Get You Started Internet Sites AARP Books and Publications AARP offers several assisted living resources that can be downloaded and printed. They include: • Assisted Living Facility Evaluation Checklist • Assisted Living: Weighing the Options, a guide CHOOSING AN ASSISTED LIVING FACILITY: CONSIDERATIONS FOR MAKING THE RIGHT DECISION, 2nd Edition that can be used as a starting point to determine if assisted living will meet your long-term care needs or those of a loved one. It also provides a listing of other resources. This booklet provides an overview of various areas related to assisted living, tips for getting started if you are considering assisted living, and important questions to ask when evaluating facilities. It is produced by the Consumer Consortium on Assisted Living (CCAL), with support provided by the MetLife Mature Market Institute. Copies are available for $12.95 each (including shipping and handling). To order, write to CCAL, 2342 Oak Street, Falls Church, VA 22046. Make checks payable to CCAL. You may also download and print an order form from their Web site at www.ccal.org, or call 703-533-8121 to obtain a printed copy. • What Is Assisted Living Housing? This article provides an overview of assisted living and the services it provides. These resources can be accessed at: www.aarp.org/families/housing_choices/ assisted_living/ AARP also provides several free online seminars related to family caregiving. One of these seminars, Housing Choices, explains the different types of assisted living facilities and the services they offer. It also provides a guide to evaluating facilities. This seminar and the others on caregiving can be found at: www.aarp.org/learntech/family_care/. HOW TO CARE FOR AGING PARENTS This book is a useful starting point for those finding themselves in a caregiver’s role for parents or any older relative. It provides information on health care issues, caregiver concerns, community- and facilitybased services, as well as an extensive listing of helpful agencies and organizations with contact information to assist caregivers. Morris, Virginia, Workman Publishing Company; October, 2004, $18.95, ISBN: 0761134263 THE ASSISTED LIVING FEDERATION OF AMERICA (ALFA) The Assisted Living Federation of America’s Web site contains a searchable assisted living facility provider directory, state rule, and regulation changes, and new developments in the industry. ALFA also produces a downloadable booklet, Guide to Choosing an Assisted Living Residence, that can be accessed at www.alfa.org/files/ public/ALFAchecklist.pdf. WHEN SOMEONE YOU LOVE NEEDS NURSING HOME, ASSISTED LIVING, OR IN-HOME CARE A comprehensive book, written by psychologists, that covers essential material in easy-to-understand language. Included is a comprehensive resource section, checklists, and worksheets. Bornstein, R. and Languirand, M. (2009). New York, NY: Newmarket Press, Revised edition, $16.95, ISBN: 1557048169 6 12 ASSISTED LIVING COST CALCULATOR1 Family and prospective residents may use this worksheet to estimate the monthly cost of needed services. Not all items may be applicable to your situation. Space is provided to add other charges not listed. $______________________ Entrance and/or Initial Assessment Fee $______________________ Selected Unit and Basic Service Package $______________________ Cost for Meals $______________________ Cost for Housekeeping $______________________ Cost for Personal Laundry Service (Perf line - Does not print.) $______________________ Cost for Linen Service $______________________ Cost for Medication Management or Assistance $______________________ Cost for Personal Care Assistance (bathing, dressing, eating, etc.) $______________________ Cost for Recreational Field Trips $______________________ Cost for Transportation $______________________ Cost for Telephone Service $______________________ Cost for Cable Television $______________________ Beauty Shop Charges $______________________ Other (specify) $______________________ Other (specify) $______________________ Other (specify) $______________________ Total Estimated Monthly Charges 1(Taken wholly and in part from National Center for Assisted Living and the American Health Care Association at www.longtermcareliving.com/assess/al/assisted7.cfm.) MMI00015(0109) ©2009 Metropolitan Life Insurance Company, New York, NY L11087022(exp1011) ASSISTED LIVING CHECKLIST When you are looking for an assisted living community for a loved one, please consider using the following checklist to help you make the best choice. • Moving In What does the moving in process entail? What are the paperwork requirements and the time frames involved? How is the initial assessment managed? Who completes the assessment? • Service Planning Are the family and the resident involved in the service planning process? How often are residents’ needs assessed? Who completes the assessment? Are there special programs for memory-impaired residents and residents suffering with dementia? Are there accommodations for memory-impaired residents to be outside and exercise? How are emergency situations managed? What is the protocol for such events? What happens if the health care needs of a resident change? Under what conditions are residents asked to move if there is a change in health status? (Perf line - Does not print.) • Services and Activities Does staff assist residents in administration of medication? Does the residence use a particular pharmacy? If applicable, does that pharmacy participate in the individual’s Medicare Part D prescription drug plan? MMI00015(0109) ©2009 Metropolitan Life Insurance Company, New York, NY L11087022(exp1011) Are there professional nursing services on-site? If not, does the staff assist residents and families in making arrangements through a home health agency? Are the services of a physical, occupational, or speech therapist available or arranged? Is transportation provided for medical appointments and recreational purposes? Is there a fee? Are there resident and family councils? How often do they meet? What are the suggestion, complaint, or grievance procedures? (Perf line - Does not print.) What recreational and spiritual activities are available? Obtain or review a copy of the activities calendar. • Staff Ask about the residence’s staffing patterns and philosophy about staffing. What training and qualifications are required for staff? Are there on-going training programs provided for staff? Observe staff and resident interactions. Are they positive? Courteous? • Cost and Fees What is included in the basic monthly cost? Ask for a written copy. Does the residence have a written schedule of fees for extra services? If so, request a copy. Under what circumstances might the fees change? How much notice is given if there is a fee increase? Is there a security deposit? What is the refund policy? Can service agreements and/or contracts be amended or modified? MMI00015(0109) ©2009 Metropolitan Life Insurance Company, New York, NY L11087022(exp1011) • Dining and Food Services Does the residence accommodate special diets? Does a dietician or nutritionist review the menus? Request or review copies of the menus. What are the criteria for residents to eat meals in their rooms? • Living Space and Accommodations Are the resident rooms furnished or unfurnished? What is the policy about personal belongings? Are there patios and courtyards available for resident use? Is there an area for resident gardening? Does the residence provide security? Are pets allowed to reside in the residence? If so, are there additional fees and/or deposits? If not, are pets allowed to visit? (Perf line - Does not print.) • Licensure and Certification Is the residence licensed? Ask to review the last licensing/certification report. If the state requires the administrator to be licensed or certified, is it current? Does the staff actively participate in trade or professional associations? • Safety Does the residence have an emergency preparedness plan? How are the emergency and evacuation plans reviewed with the resident after admission? Does the residence have a fire sprinkler system throughout the residence? Where are the smoke detectors located? MMI00015(0109) ©2009 Metropolitan Life Insurance Company, New York, NY L11087022(exp1011) LONG TERM CARE COMMUNITY COALITION The Long Term Care Community Coalition is an organization that advocates for the elderly on issues of state and national policies that affect care. They publish two consumer guides on assisted living, Thinking of Moving to an Assisted Living Residence? and Resident’s Guide for Assisted Living: Maintain Your Independence, Choice, & Control, that can be downloaded at www.assisted-living411.org. Copies are available in limited quantities. To cover postage and handling, send $1.50 per guide to: LTCCC, 242 West 30th Street, Suite 306, New York, NY 10001. NATIONAL ACADEMY OF ELDER LAW ATTORNEYS (NAELA) NAELA (www.naela.org) is the organization for attorneys that deal with the many issues facing older adults and the disabled. NAELA attorneys can assist their clients with estate planning, long-term care issues, power-of-attorney, wills, and trusts. Within the site is a search field to find an elder law attorney in your area. There is also a very helpful question and answer section that will assist in the search for an elder law attorney. You can reach NAELA by phone at 520-881-4005, or via mail at: NAELA, 1604 N. Country Club Road, Tucson, AZ 85716-3102. NATIONAL ASSOCIATION OF AREA AGENCIES ON AGING (n4a) The n4a (www.n4a.org) is the umbrella organization for the 655 Area Agencies on Aging throughout the United States which provide information and services, and coordinate and administer programs for older adults. The federally funded Eldercare Locator, established by the U.S. Administration on Aging in 1991, and administered by n4a in partnership with the National Association of State Units on Aging, provides callers with information about local services by zip code. Trained professionals, including a Spanish-speaking information specialist and a 150-language line service, answer callers to the Eldercare Locator. Call 800-677-1116, 9:00 a.m.8:00 p.m. EST, or go to www.eldercare.gov. TDD/ TTY access is also available with instructions provided online. NATIONAL CENTER FOR ASSISTED LIVING (NCAL) This organization’s Web site, www.ncal.org, provides information for consumers on assisted living, assisted living news, educational news, links to additional assisted living resources, as well as a consumer checklist that may be downloaded. Useful Tools The following tools will help you evaluate assisted living facilities: • Assisted Living Cost Calculator • Assisted Living Checklist Endnotes 1 National Center for Assisted Living, Guiding Principles for Assisted Living. www.ncal.org/resource/GuidingPrincipals forAssistedLiving.pdf 2 Gross, Jane, “Under One Roof, Aging Together Yet Alone,” New York Times, January 30, 2005. www.nytimes.com/ 2005/01/30/national/30assisted.html 3 American Association of Homes & Services for the Aging, Aging Services: The Facts. www.aahsa.org/article. aspx?id=74#GeneralFacts 4 National Center for Assisted Living. www.ncal.org/about/ resident.cfm 5 Ibid 6 American Health Care Association and National Center for Assisted Living. www.longtermcareliving.com/assess/al/ assisted3.cfm 7 MetLife Mature Market Institute, The MetLife Market Survey of Nursing Home & Assisted Living Costs, October 2008. 8 ALFA, Guide to Choosing an Assisted Living Residence. www.alfa.org/files/public/ALFAchecklist.pdf 9 Ibid SINCE YOU CARE 7 ABOUT THE AUTHORS Since You Care guides are prepared by the MetLife Mature Market Institute in cooperation with the National Alliance for Caregiving and MetLife’s Care Coordinators. MetLife Care Coordinators are available to MetLife’s long-term care customers and their caregivers to help identify and resolve caregiving questions and concerns through counseling and referral. MetLife Mature Market Institute® Established in 1997, the Mature Market Institute (MMI) is MetLife’s research organization and a recognized thought leader on the multidimensional and multi-generational issues of aging and longevity. MMI’s groundbreaking research, gerontology expertise, national partnerships, and educational materials work to expand the knowledge and choices for those in, approaching, or caring for those in the mature market. National Alliance for Caregiving Established in 1996, the National Alliance for Caregiving is a nonprofit coalition of national organizations that focuses on issues of family caregiving across the life span. The Alliance was created to conduct research, do policy analysis, develop national programs, and increase public awareness of family caregiving issues. 4720 Montgomery Lane, Fifth Floor Bethesda, MD 20814 www.caregiving.org MMI supports MetLife’s long-standing commitment to identifying emerging issues and innovative solutions for the challenges of life. MetLife, a subsidiary of MetLife, Inc. (NYSE: MET), is celebrating 140 years and is a leading provider of insurance and financial services to individual and institutional customers. This guide offers general advice, however, it is not a substitute for consultation with an appropriate professional. Please see a health care professional, attorney, or other appropriate professional when determining how the information and recommendations discussed in this guide apply to your specific situation. For more information about the MetLife Mature Market Institute, please visit www.MatureMarketInstitute.com. 57 Greens Farms Road Westport, CT 06880 E-mail: MatureMarketInstitute@metlife.com MMI00015(0109) 12 ©2009 Metropolitan Life Insurance Company, New York, NY L11087022(exp1011)