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.