The Future of Elder Care: Part 1: Elder Cohousing

In my work with families who are placing a loved one in a care community, I am often asked about the future of long term care. Many people I talk with are uncomfortable with the concept of long term care for themselves but think it's adequate for their parents. I have good news and bad news: There is an alternative to long term care options known as Elder cohousing, but don't expect it to show up in your neighborhood anytime soon.

The cohousing model was adopted from Denmark and migrated to the US in 1988. Initially conceived as multi-generational cohousing, neighbors adopted rules and built structures that allowed them to live supportively with one another, sharing common facilities and incorporating non-hierarchical decision-making, two of the six main characteristics that all cohousing communities share. Now, a similar concept, Elder cohousing, is becoming more popular with the 50 and older crowd in the US. Elder cohousing is an environmentally sustainable alternative to the existing models of housing for boomers and elders alike who yearn for their independence within a supportive community environment.

There are three elder cohousing projects that have been completed in the US. The three lucky states are Virginia, California, and Colorado. To date, there are eight elder cohousing projects actively underway according to Eldercohousing.org. Some communities are spearheaded by a group of friends or neighbors; others are formed by a few members who then recruit other future "neighbors" for investment and participation.

Studies suggest that people remain healthier and may live more independently if they have strong community ties. Cohousing fits this prescription perfectly as each member of a cohousing project has duties and contributions they are expected to provide. In one cohousing community, members' professions included the following:
* Architect and Project Manager
* Technical illustrator/painter/sculptor
* Librarian
* Builder/Developer
* Teacher
* Retired English professor
* Financial planner
* Ombudsman
* Psychotherapist
* Retired businessman
* Social services for youth in prison.

If a member of an elder cohousing project needs care at some point in their journey, they continue to live at the site for as long as possible. Members are expected to help provide for one another; some will hire in-home care or employ caregivers for those who are in need. In the event that a member needs to live in a long term care community, members of the elder cooperative will continue to remain a part of the member's life. This allows members to age in place for as long as possible, decreasing the financial, psychosocial, and health burden of the individual.

If you would like to learn more about elder cohousing, or how to form your own cohousing project, visit www.eldercohousing.org.

Amie Clark, Founder, The Senior List
www.theseniorlist.com

Assisted Living- The Good, Bad and the Ugly

There are almost 35,000 Assisted Living Facilities licensed and operating in the US today. These communities range widely in size, price and amenities and are all fiercely competing for your businesses. The real trick is finding the one the suites your needs, life-style, and pocketbook.

What is Assisted Living?

The typical Assisted Living model is based on apartment style living with care services built in. This model encourages independence and autonomy while providing supervision and daily assistance with care needs. Meals are typically served in a main dining area with the intent of a social gathering while enjoying meals selected by the residents. Activities will be offered, including outings, scenic bus rides, and trips to the grocery store, bank, and doctors visits on designated days of the week.

What type of care is provided in Assisted Living?

Assisted Living provides custodial care, not medical care.

• Bathing, Dressing, Toileting, Grooming, Mobility, Medication Management
  
• Cooking, Housekeeping, Transportation, Laundry

What can I expect to pay for Assisted Living?

Most Assisted Living facilities structure their costs on an "ala carte" system. You will be quoted a "base cost" or "room and board cost" ranging from $1500-$3000 per month, depending on geography, size of apartment, and amenities offered. Expect to see additional costs added on right away. Based on an assessment of your care needs, the price will increase accordingly. This price can vary from month-to-month, especially if care needs drastically improve or decline over time.

What are the advantages to Assisted Living?

• Less expensive than nursing home care
• Private apartments to optimize privacy, autonomy, and independence
  
• Three meals a day served in a social dining atmosphere
• Security and call bell systems
  
• Designed with accessibility in mind (roll-in showers, etc)
• Exercise programs
• Care Services available- to be used as little or as much as you require
  
• Activity programs designed to keep residents active, social, and healthy
• Most have a beauty parlor on site

What are the limitations of Assisted Living?

• Despite staff presence and encouragement, some residents can become isolated
• Most do not allow residents to cook, for safety reasons
• Assisted Living can not accommodate residents who are wandering or exit seeking
• Minimal staffing requirements in most states. On average, expect to see 1 caregiver for every 30 residents during peak hours, and much less at night
• While facilities tout their abilities to care for residents through the end of life, many will ask families to hire private caregivers or transfer to a higher level of care if the residents needs are beyond the scope of their staffing levels

What do I look for in an Assisted Living community?

• Ask to see the latest survey
• Invite yourself to lunch (most will happily invite you first). Do you have menu options? Can family or friends join you for a meal? What is the cost for guest meals?
• Do the other residents interact well with each other? Are the staff friendly and kind? Do they know the residents by name?
  
• What is the caregiver-to-resident staffing ratio for each shift?
• Is a nurse available? What hours is the nurse in the building?
• Does the facility have a comfortable atmosphere? Is it clean? Are there any noticeable odors? What safety features are available?
• Is transportation available? Is there an additional cost?
• How often is the care plan reviewed? Is the resident or responsible party involved in the review? (they should be)
• What is the turn-over rate for staff? *Note* Most facilities have a high turn-over rate. It's a huge problem. What is the facility doing to keep current staff and attract new quality caregivers?
• If you have a pet, ask about any fees you will be expected to pay for your pet. Typically, an additional move-in fee and cleaning deposit will be incurred.
• What cost of living increases can be expected? (we have noticed 3-6% yearly for most communities)
• If the community can no longer meet your needs, how much notice will you receive and what assistance will be available to relocate to another level of care?
• Trust your instincts!!!

Who pays for Assisted Living?

• Private Pay (you)
• Long Term Care Insurance- Check your policy for coverage, waiting periods, etc...
• Medicaid- If you already qualify for Medicaid, or will qualify in the near future, make sure the facility you are considering has a Medicaid contract- many do not. You can check with the facility or your local Agency on Aging office for a list of contracted facilities in your area. If a facility does have a contract, chances are they are trying to balance Medicaid v.s. private pay in the building. Some will have a waiting list for Medicaid, so plan ahead. Do not wait until a crisis to start your search!!!
• MEDICARE DOES NOT PAY FOR ASSISTED LIVING

If you are just starting your search for an Assisted Living Community, you may consider working with a geriatric care manager or placement and referral agency to guide you. These professionals will know the communities in your area and save you valuable time and energy.

Amie Clark, Founder of The Senior List
www.TheSeniorList.com

What is a Retirement Community?

Retirement Communities/ Independent Living Facilities are most appropriate for seniors who can manage their health care needs on their own or with assistance from family in an apartment type setting. Independent Living does not offer health care services or assistance, but may offer a monthly meal plan, housekeeping, social activities, and transportation. Some communities will partner with an In-Home Care agency to provide some services to residents. Services may include Medication Management, Bathing and Grooming Assistance, or Incontinence care. If additional care services are being provided, at some point the cost of the apartment and care will equate that of an Assisted Living Community. Some Independent Facilities are located on a campus where other levels of care are offered should one need them in the future.

Independent Living costs range from $1000-$2500 per month, depending on apartment size, amenities, and meal plan. Some Independent Facilities will provide one to two meals per day and may offer a meal plan if a resident prefers to cook occasionally.

Only private pay is accepted at Independent Facilities. Medicaid does not cover housing costs for Independent living. Long Term Care Insurance typically does not cover Independent Living, but may cover the cost of outside in-home care services.

What are the advantages of a Retirement Community?

• Nutritious Meals, Activities, and Housekeeping offered
• Maintain Independence in a social setting
• No upkeep or utilities to manage (except personal phone and cable)

What should I look for when searching for a Retirement Community?

1. I personally prefer retirement communities to be adjacent to another level of care, most commonly, an assisted living or residential care facility. If a move occurs in the future, it is much easier to move across the courtyard instead of the other side of town.
2. What amenities are offered? Are the activities varied? Is an exercise program offered?
3. If your loved one is driving, is there reserved and covered parking available for residents?
4. Are pets allowed? Is smoking allowed on campus?
5. How involved is the management staff in the lives of the residents? Will they notify you if they see changes in your loved one?
6. How often are meals served? Is there a flexible meal plan option? Is the cost of meals included in the overall price?
7. How is the food? Invite yourself for lunch (most will offer)- observe staff interacting with the residents. Is there a social atmosphere in the dining room or are residents keeping to themselves. Do residents seem happy? Do the staff know the residents by name? The dining room is a great indication of the "mood" of the building.
8. How does the physical building look? Is it well kept? Are repairs needed? Ask about the maintenance response time. How available are they for minor repairs for the resident's apartments (light bulbs, hanging pictures, etc...)?
   

When is it time to transition to higher level of care?
First, I would suggest that if a resident requires care to begin with, a retirement community will only be a temporary solution. If a resident has lived in a retirement community and is requiring more supervision, can't safely manage daily activities, and requires frequent checks from staff, a higher level of care is needed.

Amie Clark, Founder of The Senior List
www.TheSeniorList.com

What is In Home Care?

In Home Care is designed to support those who do not desire or need to leave their homes, but do require assistance with one or more of their daily activities. Care in the home can take on a variety of shapes and sizes and can incorporate family, friends, and professional assistance. I think most people, given a choice, would prefer to receive assistance from someone they know, family or friends. There are certainly situations, however, that family or friends providing care is not appropriate, or does not appeal to everyone, including the family and friends. If professional support needs to be hired, here are a few considerations and questions to ask the agencies you are interviewing.

1. Most In-Home Care agencies have hourly minimums, usually 2-4 hrs. If a shift does not meet these minimums, the client may still have to pay for the full shift.
2. Make sure the agency you are considering is licensed, and caregivers are bonded and insured.
   
3. What kind of training and orientation do the staff participate in?
4. Is there a nurse to oversee the caregivers and provide training?
5. What is the process if a caregiver is sick or does not show up for a shift?
6. What are the fees? Do you pay less for longer shifts? Does the agency bill monthly or weekly? Do they provide transportation to doctor appointments, grocery store, etc...?
7. Does the agency have access to other resources in the community should you need them?
8. Check inspection results at medicare.gov.
   
9. Ask to see references and testimonials. You can review online ratings from other consumers.
   

What is the advantage of hiring my own private caregiver?

• generally less expensive than working with an agency
• caregiver is your employee, they work for you.
• may be able to exchange care services for room and board, this works well for students

What is the advantage of hiring an agency?

• agency pays taxes, insurance, etc... No liability on your part, less risk
  
• shift will always be covered
• agencies are regulated and must pass inspections to operate
  

What type of Assistance can a caregiver provide?

• Bathing/ Grooming
  
• Light Cleaning
• Shopping
• Laundry
• Meal Preparation
• Toileting
• Dressing
• Mobility
• Night care
  

How Much Does In-Home Care Cost?
I have seen quite a range for costs, anywhere from $12-$22 per hour, depending on geography and duties of the caregiver. If the caregiver is a CNA, the cost will typically increase due to training that the individual has received.

Who Pays for In-Home Care?

• Private Pay (you)
• Long Term Care Insurance- check your policy for restrictions and make sure agency is able to accept payment from Insurance provider
• Some Health Insurances- check your policy
• Medicaid- offers limited in-home care programs for those who qualify

Amie Clark, Founder of The Senior List
www.TheSeniorList.com