Overview of Assisted Living

Assisted living care is designed to help individuals who are not able to perform normal daily activities, such as personal hygiene, housekeeping, and preparing meals, but who don’t require 24-hour nursing care.

There isn't necessarily any best age for assisted living. Instead, the decision to use these services is based on whether or not your loved one can live safely and comfortably in their own home. Residences are available for individuals who are intellectually or developmentally challenged, but the majority house older adults. The focus of this article is on older adult care only.

You'll find out who lives in assisted living residences, what services are provided, and how the different types of assisted living residences compare. You'll also learn about financial assistance, assisted living regulations, and tips for selecting an assisted living community.

Who Lives in Assisted Living Residences?

Aging in place remains the care preference for the majority of older adults, but at some point, home support for many becomes inadequate to meet needs. Assisted care communities are places to live as fully as possible in later years. 

Assisted living is the fastest-growing sector of the long-term care continuum. More than 800,000 older adults reside in approximately 29,000 residences in the United States. Seventy percent are women and 30% are men. The majority (50%) are aged 85 years and older, 31% are 75-84 years, 13% are 65-74 years, and 6% are younger than 65 years old.

Assisted living is similar to skilled nursing in that both are considered long-term care services that provide care for older adults. The difference is in the reason for care. Assisted living provides long-term help with activities of daily living (ADLs). Skilled nursing provides short-term rehabilitation services post-surgery and long-term care for individuals requiring daily medical care.

Assisted Living Services

Assisted living communities are based on the principles of providing personalized care, service with dignity, encouraging independence, and promoting family involvement and connection with other residents.

Residents live in their own apartments or rooms and share common areas. Staff provide oversight and services to meet each resident’s unique needs, based on assessments and service plans, as well as unplanned needs as they arise. In most settings, a few levels of care are offered, with residents paying more for higher levels. 

Services vary by state and by each facility within a state, but they typically include:

• Meals
• Laundry
• Housekeeping
• ADL assistance
• Transportation
• Recreational activities
• Self-administered medication management
• Off-site medical and dental care coordination
• 24-hour supervision, security, and on-site staff
• Registered nurse (RN) or licensed vocational nurse (LVN) on-call availability

Types of Assisted Living Residences

About 56% of assisted living communities are chain-affiliated, with the remainder independently operated. Residences vary in size, but the average is 39 licensed beds.

The three different types of residences for older adults are comprehensive communities, specialized communities, and continuing care retirement communities (CCRCs).

Comprehensive Communities

These facilities house residents with a wide range of common older adult medical conditions, such as heart disease and arthritis. Smaller communities may exclude individuals with Alzheimer’s disease or other dementia, whereas larger facilities may segregate residents with dementia in a separate wing or floor. 

Specialized Communities

Older individuals with Alzheimer’s disease currently represent 34% of all assisted living residents. Because this group requires additional care not commonly available in comprehensive communities, the number of specialized residences, often called memory care homes, have grown in recent years.

Similarly, the growth of the older population with Parkinson’s disease and other motor conditions has led to the development of specialized communities for individuals with these conditions.

Continuing Care Retirement Communities

Continuing care retirement communities, also called life care communities, provide different levels of older adult service in one location. Residence options include independent living (apartments or houses), assisted living, and skilled nursing care. Where residents live is dependent on the level of care needed.

Those who start in an independent setting are able to receive home care until increased needs require them to move to the assisted living facility. Those who require rehabilitation services or daily medical care move from independent or assisted living settings into the nursing home.

How to Pay for Assisted Living Care

Unfortunately, Medicare does not pay for assisted living. Medicaid does not pay for room and board costs; however, about 18% of residents (or almost one in five) rely on Medicaid to pay for daily services. Each state varies on whether it covers assisted living services, and each facility within a state decides whether or not it will accept Medicaid.

Other ways to pay include:

• State non-Medicaid programs
• Veteran’s programs
• Long-term care insurance
• Life insurance benefits and conversions
• Savings
• Assisted living loans

For your state’s Medicaid policies and its other financial assistance options, you can go to websites like Paying for Senior Care to see a listing of eldercare options for each state.

Assisted Living Regulation

Assisted living facilities are licensed and certified by each state. Although each state is unique, regulations typically include criteria for a range of concerns:

• Resident contracts, which should be provided before move-in and include detailed cost of services and admission and retention policies
• Staffing documentation, which should include rules on credentials requirements, background checks, and continuing education
• Individualized assessment and service plan process defined
• Description of type of ADL and other support services provided
• Self-administered medication management provisions, which include what staff level is authorized to provide such support
• Food service provisions, including the number of meals provided and policy for modification for individual dietary needs
• On-call medical emergency provisions
• Room/apartment sizes, roommate rules, and number of people sharing a bathroom
• Security, inspection, and monitoring requirements
• Medicaid waiver availability
• Remedies and sanctions for facilities that are noncompliant

Two excellent resources are available for researching your state’s regulations:

Each year the National Center for Assisted Living (NCAL) publishes the “Assisted Living State Regulatory Review,” which summarizes key state requirements. You can access individual state information from their most recent report.

A Place for Mom provides a state-by-state guide to assisted living rules and oversight and lets you find licensure inspection reports for individual facilities in your state.

How to Choose an Assisted Living Community

Choosing an appropriate assisted living community for yourself or a loved one can be an emotional, challenging, and time-consuming task. 

These government agencies are a good place to start:

Eldercare Locator
800-677-1116 (toll-free)
eldercare.acl.gov

National Association of Area Agencies on Aging
202-872-0888
www.n4a.org

If you’re not up to the task, referral agencies, such as A Place For Mom or Paying For Senior Care can help. Referrals are free, as these agencies are paid by the residences. 

On-Site Review

As with searching for any kind of living space, you can only get so far virtually. When you’ve narrowed your choices, you need to visit in person. 

Assisted Living Questions

When you visit or talk to a facility, consider asking the following questions.

Facility design:

• Is the building and its surroundings safe and well-maintained? 
• Is the decor home-like, fresh, well-lit, and attractive? 
• Are common spaces comfortable and encourage gathering?
• Is the floor plan easy to navigate and has adequate signage?
• Are there enough handrails and grab bars?
• Are there elevators, widened doors, and wheelchair ramps? 
• Are floor coverings non-skid and regularly cleaned?
• Are all areas clean, odor-free, well-ventilated, and suitably heated/cooled?

Individual unit features:

• Are different sizes and types of units available?
• Does each unit have a 24-hour emergency response system? 
• Do bathrooms have handrails, seated showers, and other safety features?
• Are bathrooms individual per unit or shared? 
• Is the unit furnished or can residents bring their own belongings?

Are the following services provided?:

• Meals
• Laundry
• Housekeeping
• ADL assistance
• Transportation
• Recreational activities
• Self-administered medication management
• Off-site medical and dental care coordination
• 24-hour supervision, security, and on-site staff

Are there additional services offered? If yes, describe and state whether they are included in the contract or require additional fees.

Administration and staffing:

• How long has the facility been licensed?
• What kind of experience and training does your staff have?
• What is your staff-to-resident ratio?
• Who performs the initial needs assessment and development of a personalized written service plan? How often is the plan updated?
• Is staff available to provide 24-hour assistance with ADLs as needed?
• Which staff members are authorized to manage self-medication?
• Who coordinates medical and dental care visits?
• Is there an RN/LVN either on-site or on-call 24/7?
• What are your visiting policies?

Meals:

• How many meals are provided per day?
• Does the menu change daily?
• Can meals be modified to specific dietary needs or special requests?
• Are there set times for meals?
• Can residents keep food in their units?

Activities:

• What types of activities are available to residents? 
• Is there a posted activity schedule?
• Are residents encouraged to participate? 
• Do residents go on regular outings or do volunteers come into the community?
• Can residents easily arrange for transportation?

Contract:

• Is a contractual agreement available that specifies all services provided and all fees?
• Are there different costs for various levels or categories of services?
• Are all services included in the monthly fee? If not, what services are not covered and what are additional fees?
• What are your billing, payment, and credit policies?
• What are the policies and fees for move-in and discharge?
• When may a contract be terminated and what is the refund policy?
• Are there any government, private, or corporate programs available to help cover the cost of services?
• Are units currently available or is there a waiting list?

Subjective Impressions

As you tour the facility, notice:

• Does the staff interact with the residents with a caring, positive attitude?
• Do the residents look well cared for and content? 
• Finally, is this a community in which you or your loved one would be comfortable? 

Summary

Moving from a home to a skilled living locale is a major life event, both for the individual needing to relocate as well as for family and friends. Assisted living residences can provide support to people who can no longer live safely and comfortably at home.

Different types of assisted living residences provide different types of services. Programs are available to help with the costs of assisted living. Follow this guidance when choosing the right assisted living facility for your loved one.