Author Archives: Dianne Savastano

Planning for Alternative Living Arrangements

As we age, at some point in our lives, we may experience a downward progression; it could be physical, cognitive, or some combination. And while each individual’s experience will vary, there are some consistent patterns.

For some of us, the change in type and degree of care required will also require a transition to an alternative living environment(s). There are multiple options, each with its own cost. In most cases, these costs come as a surprise.

As to whether long-term-care insurance makes sense, I refer my clients to their financial advisor. A decision to embark on such insurance products needs to be made in the context of a greater financial plan.

Insurance aside, here are some important things to understand about possible living environments…

Private Care in the Home

At the time we begin working with them, most of our clients are living independently in a free-standing home, condominium, or apartment. Often, some type of medical crisis results in someone (temporarily or permanently) not being able to transition back to their home without some assistance.

The first transition is often the introduction of private caregivers for a few hours per day, providing enough assistance that a move is not necessary. As needs increase, care could eventually be required 24/7. At that point, a family must determine if it can afford the cost. In our area, the average fee per hour for home health aides is $30.00 ($720 per day).

Live-in companions may be a less expensive alternative, provided there is an appropriate space (a private bedroom) in which the caregiver can live. The cost can range between $280 and $350 per day. An important consideration is whether the caregiver’s duties are such that they can sleep at night. If the person being cared for has needs throughout the night, some families supplement by having a live-in and then another caregiver for the night shift. Again, cost must be considered as this type of care is prohibitively expensive for most families.

Is Assisted Living a Good Alternative?

Assisted living residences are for older adults or people with disabilities who require help with some of the routines of daily living. Most provide limited nursing care, housekeeping, prepared meals, and structured activities as needed. Ironically, in order to “qualify” to live in these environments, individuals must be able to function somewhat independently.

Assisted living communities vary tremendously across any number of dimensions, so diligent research must be done to find an appropriate match. The cost in Massachusetts is approximately $220/day.

Some assisted living environments are specifically designed for individuals experiencing cognitive decline. These can be a great alternative, allowing an individual to live in the least restrictive environment possible, while remaining safe. Here, too, individuals must qualify by being at a certain level of independence at the time they move in (many families wait too long, leaving more restrictive environments as the only option). In Massachusetts, the cost is approximately $275/day.

Long-Term/Nursing Home Care May be a Final Transition

This level of care includes a comprehensive range of coordinated medical, personal, and social services to meet the physical, social, and emotional needs of people who are chronically ill or disabled. A nursing home facility may be the best choice for people who require 24-hour medical care and supervision. Some facilities have units dedicated to those who have long-term needs because of advanced cognitive impairment. Unfortunately, there never seems to be enough supply of this level of care.

This is the most extensive custodial care a person can get outside of a hospital and the average cost in our area is approximately $500/day.

Traditional Skilled Home Care Services — Where Do They Fit?

Skilled home care services consist of nursing, physical, occupational, and speech therapies that can be delivered when someone is living in a private home or an assisted living environment. Such services are a bridge to returning home and are covered by insurance.

They most often begin following a hospitalization, helping someone achieve their maximum level of functional ability as they recover from an acute illness or injury. In the past, these services were known as “visiting nurse care,” but now they are referred to as skilled home care.

What About Hospice Care?

Outpatient Hospice services can be added to all levels noted above and consist of nursing, physician, social work, pastoral care, etc. Hospice care is covered by insurance.

Hospice care can also be provided in a residential facility, although there are few Hospice in-patient beds in the community and the criteria to be transferred to one, and for it to be covered by insurance, are quite strict. Some of this care is delivered in separate “Hospice Houses,” while some is delivered in a dedicated unit in a traditional nursing home.

Final Thoughts

As we work with clients regarding alternative living arrangements, we coach families to think about the least restrictive environment in which someone can succeed. It’s important to be highly creative, tapping into all the resources available, including family, friends, and community support.

But don’t stop there. It’s critical to consider the next move and the move after that, as an individual’s status changes and potentially declines. Ideally, you want to minimize the number of transitions, since each one can be incredibly disruptive to an older adult and can contribute to increased confusion as they adjust to a new and different setting. We often encourage making a move before it may be entirely warranted, because in the long-term, it can lead to greater stability and the need for fewer transitions.

As you think about your future and that of individuals in your life who may be aging and need assistance, look to create opportunities for conversations about long-term care choices. The ideal situation is not arranged in the heat of a crisis — it is planned for, affordable, and occurs with minimal disruption.

Recommended Reading and Resources: Long Covid and Seniors

‘That’s Just Part of Aging’: Long Covid Symptoms Are Often Overlooked in Seniors

Researchers estimate that 32% of older adults in the U.S. who survived Covid infections had symptoms of long Covid up to four months after infection.

Whatever your age, we encourage you to be assertive within the healthcare system so that you may obtain the care you need.

Medicare Advantage Plans Often Deny Needed Care, Federal Report Finds

Those who work with us regarding Medicare selections know that I am not a huge fan of Medicare Advantage Plans.

My criticisms evolved from years of troubleshooting administrative barriers when clients (and my parents!) attempted to access care. This federal report was not a surprise to me.

Working Effectively with Professional Caregivers

Over the past few months, I have shared how my mom experienced a fall that resulted in left-sided fractures of her shoulder and foot and prevented her from bearing weight on her left side for 12 weeks. In preparation for her return home from the skilled nursing facility that she was in for more than three weeks, I hired private caregivers to assist for four hours each morning, so that I could work and my dad could rest.

The efforts of these incredible women have helped my mom make tremendous progress, accomplishing all she can for herself within her physical limitations. Additionally, the time their involvement returned to me allowed me to coordinate care for mom, so that I could be her care partner, rather than her caregiver. I could not have done this without them.

What is a professional caregiver?

There are many job titles and certifications among professional caregivers. In general, all of these roles involve assisting another person to live as independently as possible. More specifically…

  • Basic Caregiver Certification — ideal for family members who want to assist their loved one with activities of daily living
  • Certified Nursing Assistant (CNA) — prepares caregivers to work in a range of settings from the hospital to the home
  • Home Health Aide (HHA) — knowledge of the fundamentals of medical care, caring for the elderly, how to handle emergencies, and caring for individuals aging in place
  • First Aid and Emergency Care — prepares caregivers to perform things like CPR and teaches critical skills that can make all the difference in an emergency
  • Certified for Hospice, Palliative, and End-of-Life Care — requires knowing how to support individuals through a terminal illness and at the end of life
  • Certified for Specific Needs and Conditions — training that requires more specialized care such as dementia care, diabetes care, or Parkinson’s disease care

I need a caregiver, where do I start?

First, identify how much time in a day is needed to care for your loved one.

Then ask:

Do I need this person to assist with…

  • Rehabilitation?
  • Maintenance of the status quo and/or slow decline?
  • Assistance through end-of-life?

The knowledge, skills, and abilities required are different for each setting.


In this case, the caregiver will assist with activities of daily living (ADL), encouraging the individual to do as much as possible for themselves. Over time, the individual does more and the caregiver does less.

Also, with physical and occupational therapists coming to the home just twice per week, the caregiver will follow through and reinforce what the therapists have worked on. In my mom’s case, this includes encouraging and overseeing a daily exercise program. It is my belief that without this support, mom would not have made the tremendous progress she has achieved.

The goal in this setting is for the number of hours needed from the caregiver to gradually decrease until care is no longer needed.

Maintenance/Slow decline

Here, the caregiver does more for the individual as the person is able to do less for themselves. In these circumstances, the caregiver’s involvement may start out small, but play an important role in allowing an individual to remain in their home longer and with some degree of independence.

Over time, responsibilities increase and time spent with the individual may grow. Eventually, the situation may require multiple caregivers working in shifts.


Here, adjustments must be made continuously to do as much for the individual being cared for as possible, to promote their comfort and safety. Sometimes, caregivers even participate with the decision making, along with the family, to administer medications to relieve pain and suffering. Flexibility, empathy, and critical thinking are definitely needed in this setting.

In these circumstances, the caregiver’s services often wrap around care that a family provides. Privacy and quality time with one’s family must be taken into consideration when a schedule is outlined. Nighttime is often when these caregivers support families, allowing them to rest and be present for their loved one during the day.

Where do I find the right person/team?

To keep it simple, think about individuals in your life or network whom you trust. Then ask for suggestions. You can also turn to professionals like us to assist with the process.

Most of the time, we hire from reputable private homecare companies with whom we’ve worked. We can trust that the caregivers have been adequately vetted, hired, and trained, and that they are insured and actively managed. Other times, families establish private employment arrangements in which the family takes on the role of recruitment, interviewing, hiring, managing, insuring, paying, etc. In both scenarios, I have had mostly positive experiences.

How do I manage a caregiver?

Although I knew the skills and abilities of mom’s caregivers, I still had to take on the role of outlining expectations and providing background information/training. It was important that they knew of mom’s restrictions, that we agreed on a means of two-way communication, and that they provided continuous feedback as her situation improved.

Overall, it’s critical that someone in the family take on this quarterbacking role. Don’t assume that the agency or caregiving individual will manage this for you.

What can I learn from a caregiver?

The skills and experience of professional caregivers are amazing. The observations and feedback mom’s caregivers relayed to me were invaluable; they noticed things I missed and always had fabulous suggestions for troubleshooting challenges and providing care.

For example, it was the caregivers who taught my dad and me how mom could be transferred with help from just one other person. What a relief this was because dad and I struggled with this for the first three weeks she was home, and we were exhausted!

Final Thoughts

Private caregiving is a profession that does not always receive the respect it so rightly deserves.

Should you require caregivers for your loved ones, be prepared to invest in developing relationships with these wonderful professionals and be open to learning and growing from the experience they bring into your home. I am eternally grateful for the incredible women that I trust completely to care for my mom. That says it all!

Recommended Reading and Resources: Home Health Care

What I Learned From My Family’s Home Health Experience

Aging In Place Is All The Rage, But It Is Not Easy

Policy makers should keep in mind that organizing and delivering services at home can create tremendous challenges and expense for patients and their families.

President Signs Health Care Provider Protection Act Into Law

This article shares information about the impact of the pandemic on healthcare professionals and efforts that will be made in the future to address the problem.

More about the Dr. Lorna Breen Health Care Provider Protection Act, here.

Mourning our parents can start before they die. Here’s how to cope with anticipatory grief.

“It isn’t her parents’ death she fears — it’s what might lead up to it, because she’s seen it before.”

Meet the Underdog of Senior Care

The Program of All-Inclusive Care for the Elderly, funded by Medicare and Medicaid, has quietly succeeded in enabling some older Americans to age in place.

Healthcare Planning: Don’t Wait for the Crisis

Last month, I received an email from Patricia and Walter, an older couple who were thinking about working with us. Here is an excerpt of what they asked:

“In our meeting, we would like to have you explain what services Healthassist will provide for us after the initial assessment. Do you help families if they need care in the home? Do you vet and engage such help? Do you help your clients with filing a claim with Long-Term Care insurance companies to identify if they are eligible for benefits? Or if it becomes clear that living at home is no longer possible, do you work with families to determine the best alternative living arrangement?”

My answer to all of these questions was “Yes.”

Soon after, Patricia and Walter engaged us and we began planning for as many possible scenarios as we could think of, including several that thought through how care would be delivered as they aged. Their goal was to age at home and to only consider an alternative living arrangement in very specific circumstances.

As an inveterate project manager myself, Patricia and Walter’s proactive approach to handling their healthcare warmed my heart!

A Gift to Yourself and Your Family

Most of our clients reach out to us for the first time when they are in crisis. Maybe an unforeseen hospital admission has occurred. Maybe an older adult is about to be discharged from a rehabilitation facility and the family is unsure where their loved one should now reside.

In all cases, time is of the essence. Further, the family may feel overwhelmed by the process and unsure how to balance the competing forces, priorities, and moving parts. We respond with tremendous urgency and do our best to manage the process in a way that meets the needs of the family and the older adult in question.

But… it’s not ideal.

Healthcare for an older adult typically involves a maze of primary care physicians, physician specialists, healthcare facilities, and insurance coverages. None of it is simple and when decisions must be made on a tight timeframe, options are much more limited — not only is there less time to explore alternatives, but there are also fewer options available.

A better approach — and in my mind, one of the greatest gifts you can give to yourself and your family members — is to have a plan in place in case you become ill and/or physically unable to care for yourself.

Of course, for many older adults, it is reasonable to assume that were something unexpected to happen, a spouse and/or children would be there for them. For others, it may not be so clear. We have many clients who do not have family and even if they do, they are not close by.

Whatever the circumstances, having a plan in place, even if there are others who will gladly step up to offer support, will make the entire process go more smoothly for all involved.

Here are four things to consider as you develop that plan…

#1. What is the status of your health now and who is on your team?

Patricia and Walter manage chronic medical conditions, take several medications, and have different primary care physicians and specialists that they see regularly. They each have different preferred hospitals and pharmacies.

Understanding their medical conditions and the team they have in place to assist them (including the interrelationships between providers) was of great value so we know whom to turn to should a medical event occur. We made sure the right provisions were in place for their physicians to share confidential and protected information with us and their healthcare proxy through the implementation of signed HIPAA release forms.

Further, we gained access, with permission, to the use of their Patient Portals, allowing us to do the following:

  • Review their medical records, both from the past and in real time
  • Schedule in-person and virtual appointments online, with their providers
  • Initiate email communications with their providers and their support staff

#2. What is the functional status of your current living situation?

We met Patricia and Walter in their home, allowing us to conduct a functional assessment in the setting in which they plan to age.

A functional assessment is an objective review of an individual’s mobility, including the ability to transfer out-of-bed, walk, and manage stairs. It includes a demonstration of the ability to perform activities of daily living such as self-care/bathing, dressing, feeding, and toileting, and the ability to communicate effectively both verbally and/or through alternative means.

Seeing them perform in their own living space established a baseline, allowing us to identify immediate and potential modifications that can be made in the event a decline in any functional ability occurs. Patricia and Walter were already planning a home construction project that included moving their master bedroom and a new bathroom to the first floor. The design widened doorways and provided ample space to accommodate assistive devices such as a walker or wheelchair, if ever required.

#3. Who are your care partners, including alternates?

Patricia and Walter agreed that they would first turn to each other for assistance in both physical care and decision making. Both had named each other as healthcare proxy and had prepared a living will to outline their wishes, both for medical care and for care to be delivered in their home.

But what if that were no longer possible? They have no children, and their respective siblings are much older, with health issues of their own. So, we turned next to their named healthcare proxy alternates. The names were there, but very little communication had gone on between Patricia and Walter and these individuals regarding the level of responsibility involved in being a healthcare proxy, or what the couple’s individual wishes were if the healthcare proxy alternate had to make decisions on the couple’s behalf.

The couple had already worked with their financial advisor to plan for the financial support of home-based care and had named a durable power of attorney to make financial decisions on their behalf if necessary. Their plan included the purchase of a long-term care policy with a generous daily benefit to help defray the cost of care at home. But again, no communication between relevant parties had happened.

Having laid much of the groundwork on their own (well done!), what was now needed was a meeting to discuss the interrelationship between all players. We set that up to include Patricia and Walter, their alternate healthcare proxy, their durable power of attorney, and Healthassist. Documents were shared in advance and during the meeting we reviewed the couple’s wishes and the roles of each party involved.

#4. How will everyone work together?

We agreed in the meeting that our role at Healthassist will be one of “first line communicator” with the couple’s physicians and healthcare team. We will act as “interpreter” for others about what might be going on medically.

Patricia and Walter will keep their healthcare proxy informed through planned meetings. As a result, this individual will know the intimate wishes of the couple and be able to make decisions as necessary.

Finally, we committed to working in tandem and as hard as we could to honor Patricia and Walter’s wishes that they remain in their home. When and if the time comes, we will turn to the durable power of attorney to provide the financing necessary to execute the home-based plan.

The meeting was a great success. The healthcare proxy alternate was thrilled to know he would not be alone in all of this. Patricia and Walter were relieved to know they not only had a plan in place but had both personal and professional help ready to assist them with achieving their goals.

Final Thoughts

I often describe our role at Healthassist as being futurists, anticipating how illness and aging can impact our clients’ functional abilities and their ability to care for themselves.

When we have the privilege of working with a family that is interested in planning, we are much more likely to be successful in achieving their desired outcomes.

In short, it is a marriage made in (or, in this case, before) heaven!