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Article 37
Growing old in a good home
Innovative ways for seniors to get care without going to a nursing home
By Joseph P. Shapiro
It doesn’t take a mind reader to know that you don’t want to
their own pockets. “It’s remarkable. It’s a rejection of the traditional way we’ve taken care of frail seniors in the United
States,” says David Schless, president of the American Seniors
Housing Association. For some seniors and their families, insurance can help with the cost, which can reach tens of thousands of dollars a year.
And finding these new alternatives is not always easy.
Nearly 40 percent of the beds in assisted-living facilities are in
just three states—California, Florida, and Pennsylvania. Those
fortunate enough to live in states like Oregon or Washington,
where experimentation in long-term care is encouraged, find
more choices. Don’t rely on your doctor to point you toward the
best option; studies have found that doctors tend to be among
the least informed about alternatives to nursing homes. And
don’t wait until a crisis happens—the day Mom falls or Dad is
diagnosed with Alzheimer’s disease. Here’s a look at the most
common options:
end up in a nursing home. Nobody does, it seems. Which is why
the number of nursing home residents dropped by about 10 percent during the past decade—a period when the number of
Americans over 75 grew by 27 percent. So if older Americans
aren’t in nursing homes, where are they? Franklin Alexander
has one answer. At 92, he’s living in his dream house with a
sweeping cliffside view of the ocean, caring for his wife, Myrtle. She’s 95 and has dementia. But the couple wouldn’t have
that choice without the help of an innovative California HMO
that provides in-home aides and medical supplies. “We’re staying in our home looking out at the blue Pacific,” says a grateful
Alexander, “instead of going into a nursing home.”
The Alexanders and millions of other seniors are making
aging a better prospect for the rest of us by demanding—and
getting—a growing array of alternatives to the nursing home.
Many nursing homes provide high-quality care, especially for
people with intense medical needs. But fears over loss of privacy and independence are driving more seniors to other options. Today, there are just 1.5 million nursing home residents
over age 65. Assisted-living facilities—private apartments with
staff to provide some care—now serve about 800,000. Independent apartments with simpler services, like prepared dinners,
serve 1.5 million. Another 625,000 seniors live in continuingcare retirement communities, which offer all the levels of care
people need as they age, from independent apartments to full
nursing care. Tens of thousands more live in group homes and
adult-foster-care facilities. And some 6 million chronically ill
and disabled older people get help at home, sometimes even
with ventilators, IV tubes, and other complex medical procedures.
Opting for these arrangements means opening your wallet—
wide. Government picks up the tab for nearly 60 percent of
nursing-home costs nationwide. But it won’t help much with
these new forms of long-term care. Though 38 states pay for
some assisted living, the programs are minuscule, covering
fewer than 100,000 poor people. Medicare covers home care,
but just for 100 visits in the weeks following a hospital stay. So
seniors increasingly are paying their long-term care bills out of
Assisted living
Reinvent the nursing home and the result might look a lot like
assisted living. Instead of the shared rooms of a nursing home,
residents live in private apartments, usually with kitchenettes
and bathrooms. There’s staff available to help residents eat,
bathe, and dress. Some meals are included, as are services like
housekeeping, laundry, and transportation. And although assisted living doesn’t provide medical care, the staff will often
supervise medications. One quarter of the facilities offer special
wings for those people who have Alzheimer’s disease and other
forms of dementia.
Costs: A private studio apartment runs about $27,000 a year,
less than two thirds the cost of a nursing home. Ninety percent
of residents pay out of pocket. Long-term-care insurance policies, which once covered only nursing home care, now commonly help pay for assisted living.
Advantages: More homelike than nursing homes, some
properties are designed to resemble upscale hotels, complete
with marble lobbies and concierge services. Residents get help
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Article 37. Growing old in a good home
At Acacia Adult Day Services in Garden Grove, Calif.,
Estela Murguia paints, Kuniko Pittenger (next page)
sings "God Bless America," and Thao Pham does tai chi
exercises. Adult day care provides a community for elderly people and can give their home care-givers a respite.
It's another way to stay "in the happy environment of [your]
own home."
Questions to ask: How will the facility meet the changing
needs of residents as they grow older and need more care? Ask
about possibilities and be specific. “It’s striking what families
go in not knowing,” says Catherine Hawes of Texas A&M University, who conducted federal studies of assisted living. “More
than three quarters [of assisted-living residents] leave and do so
needing a higher level of care. They go in thinking this is forever.”
Latest innovation: Sunrise Assisted Living, an industry
founder 20 years ago, gave the field a new twist earlier this year
when it started “At Home” Assisted Living by Sunrise. The
idea: to provide the services of assisted living but in a person’s
own home. After suffering congestive heart failure last month,
Mary Crunkleton, 74, didn’t want to move from her apartment
in Arlington, Va. Sunrise sends an aide to help the woman, who
uses a wheelchair, get dressed and bathe. Technology provides
a lifeline. Crunkleton wears a bracelet with a button she can
push to summon help in an emergency, and last week Sunrise
installed a machine that helps her take the right medications at
the right time. A nurse fills the device, which is the size of a portable television and sits on her coffee table. An alarm sounds
when it’s time to take a pill. If Crunkleton doesn’t remove the
remaining independent as long as possible, and it’s hard to get
lonely in a place with a lot of social interaction, exercise classes,
and van trips to museums and malls. Overconstruction means
many facilities are competing by lowering prices or guaranteeing no rent increases for a year.
Problems: The virtual absence of regulation. “It’s the wild,
wild West out there,” says William Benson, a former federal official on aging policy. Move in and you might find hidden fees
for things you thought you were already paying for—like
laundry service, a nurse to supervise your medications, or
simply someone to bring a meal to your room. These can add
hundreds of dollars to your monthly bill. The rent also can rise.
As needs for care increase, you may still have to hire a home
health aide. And facilities in many states can evict residents
with little notice.
Assisted living is not for those who don’t like living and
eating in a group setting, especially with older people who may
be very frail or have dementia. It also helps not to be fussy.
Maine humorist John Gould, in his new book Tales from Rhapsody Home, writes about the food at his pseudonymous assistedliving facility: “Everything is of the finest quality. Then they
cook it.”
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ANNUAL EDITIONS
pill, the system beeps the Sunrise care center 15 miles away and
a staffer calls her or a daughter.
A nursing home is just a short walk from their spacious threebedroom cottage. Smith, who is a retired college administrator,
has one bit of advice: Move in while you are younger and
healthy in order to take full advantage of the activities—and pay
a lower entry fee.
Problems: It’s tough to determine if the CCRC you are considering is the dream place where you want to spend the rest of
your life. At least 10 percent of those who enter later leave, usually forfeiting most or all of the entry fee. When the concept was
newer, in the 1980s, a string of CCRCs went bankrupt, leaving
residents without their promised home. Failures are rare now
that states require CCRCs to keep larger cash reserves.
Questions to ask: Is the facility accredited by the Continuing Care Accreditation Commission (202-783-7286)? It
checks consumer protections and the quality of health care, as
well as a CCRC’s financial health. And do your own investigation, advises Larry Minnix, president of the American Association of Homes and Services for the Aging, which sponsors the
voluntary accreditation group. Ask the facility for its latest audit
report or get the information from the state insurance commission, which in most states regulates CCRCs. If the contract is
“lay-friendly and easy to read, that’s a good sign,” says Minnix.
Still, get a lawyer to review it. Ask whether you can get the
apartment you want now or if you have to wait. Find out what
happens if the nursing home is full when you need a bed. And
check the refund policy.
Latest innovation: Friends Life Care at Home, based in
Blue Bell, Pa., provides the services of a CCRC, but in a person’s
own home, and it finances care through an insurance plan.
Continuing care communities
These combine different kinds of care in a single setting, so residents can live independently as long as they are able, move to
assisted living when their needs are greater, and even switch to
a nursing home, if needed. A continuing care retirement community can be a single high-rise building close to an urban
center or a complex on a bucolic campus. Usually residents get
an apartment, but some CCRCs offer small houses. “All inclusive” or “life care” facilities usually cover all long-term health
costs. Others charge less up front and more for greater care as
you need it. Ninety-four percent of CCRCs are run by nonprofit
groups.
Costs: Bring your checkbook. The average entry fee is about
$110,000 for a two-bedroom apartment and at least triple that at
more luxurious communities. You rarely get equity in an apartment. And you must pay monthly fees—which average close to
$2,000 for a two-bedroom—that can rise each year.
Advantages: Peace of mind. All forms of long-term care are
guaranteed and nearby, which can be especially appealing for
couples. “We’d seen a lot of people our age struggle when one
went into a skilled nursing facility 6 miles away,” says 76-yearold Glenn Smith. “Then someone has to drive Momma over to
see Daddy every day.” So Smith and his wife, Kathleen, moved
to a CCRC atop a hill overlooking Oregon’s Rogue River Valley.
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Article 37. Growing old in a good home
An aide fixes Patricia Cairn's hair at home. Cairns, 75, also gets help bathing, and preparing meals. In a nursing home,
"I wouldn't eat."
year from the family of 94-year-old William Henrich, who was
in a nursing home after breaking his hip in a fall. Henrich
wanted to return to his idyllic home in a forest he had planted.
HouseWorks hired a contractor to install an elevator and make
other renovations—at a cost of $60,000—and then found a
round-the-clock aide. It was a happy return for the former accountant before he died in February.
One additional service can help people with dementia and
other care-intensive needs to remain at home: adult day-care
centers. They offer a place to get meals and medical care and
spend the day—often giving crucial respite to a spouse or other
family caregiver. Most are run by not-for-profit agencies.
Costs: The fee for a private-pay, licensed home health aide
runs about $15 an hour. A nurse can cost two to three times
more. If you’ve got heavy medical needs, or require round-theclock care, the tab adds up quickly. Still, Henrich, for example,
ended up paying less—$170 a day—for his live-in aide than the
$240 a day he was charged for a shared room in the nursing
home. Recent government cutbacks reduced the amount of
home care that Medicaid and Medicare will cover, but most
long-term-care insurance policies now cover home care.
Advantages: Home sweet home. More than 90 percent of seniors say they have no intention of leaving the comfort of their
home or community.
Problems: It can be lonely. Help from family or friends is
often needed to make it work. Aides may have minimal training.
And the support at home may not be enough: The older resident
may still one day end up in an assisted-living or nursing home
facility.
Questions to ask: Does the home-health agency require, as
many still do, that you use three or more hours of care each day?
If so, you may be paying for far more than you need. Does the
agency do criminal background checks on aides and provide
references? What happens when the inevitable happens and the
Members sign up while healthy but are guaranteed care in the
future—such as subsidized meals delivered to their door and
nursing care. Jacqueline Knopf, debilitated by a progressive
neurological disease, got a virtual nursing home set up in her
own bedroom. Friends Life Care last year provided daily visits
from a registered nurse, who monitored her bed sores and diabetes. An aide also came three days a week to help her bathe.
Knopf died last November at age 77. Says her husband, Charles:
“She received every care that she would have received in the
medical wing of a nursing home, except she got it in the happy
environment of her own home.” Without buildings to manage,
Friends Life Care can charge substantially less. For a 70-yearold, its most comprehensive plan charges a $21,250 initial fee
and $315 a month. The company operates in the Philadelphia
area only but plans to expand to Maryland and Washington,
D.C.
Living at home
Most people traditionally have gotten long-term care at home,
usually from a family member. But today there’s often no one
nearby to help out—a result of high divorce rates, smaller families, and more mobility. So more seniors or their children turn
to home-health agencies. These days, sending an aide into a
home to provide hands-on care is just part of what innovative
agencies do. Some, like California Home Care and Hospice of
Merced, Calif., will arrange a house call from a dentist or look
after the cat when you go to the hospital. Nurses provide medical care; home health aides assist with personal care like
bathing.
Piecing together the array of services can be dizzying. Sometimes, a home-health agency will help. New “eldercare service”
companies provide a case manager to broker whatever services
you may need. HouseWorks in Newton, Mass., got a call last
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ANNUAL EDITIONS
A van picks up Vesta Coulson, 74, of Long Beach, Calif., who is on her way from home to an eye appointment.
A new twist on managed care
the person who is getting the care feels that he had a say in
choosing it. Otherwise, resentment can undermine the most
loving efforts to find a parent or spouse a good place to grow
old.
aide you choose doesn’t show up or quits? Interview two or
more aides before signing up.
Latest innovation: Surprise, it might just be much-despised
managed care. Think of a Medicare HMO that, in addition to
medical coverage and prescription drugs, offers home-care
aides, home medical supplies, and other crucial assistance.
That’s the idea behind social HMOs, or SHMOs, like the SCAN
Health Plan of Long Beach, Calif. For Eve Graham, 75, SCAN
sends her husband, Robert, 78, who has Alzheimer’s disease, to
an adult day center five hours a day, five days a week. The
center charges about $40 a day; SCAN pays half and also buys
the family $100 a month in medical supplies. A caseworker
visits the home regularly to help troubleshoot any problems.
Four SHMOs across the country serve some 80,000 Medicare recipients. A recent study showed that they’re successful in
helping the elderly avoid long-term stays in nursing homes.
Yet no matter how good these programs may sound on paper,
a long-term-care arrangement has the best chance of working if
WHERE TO LEARN MORE
These resources can help you identify the best long-term
care options.
• Referrals. For services in your area, call the national
Eldercare Locator at (800) 677-1116.
• Personal advice. Geriatric-care managers may
charge a hefty fee but can show you what is available.
• Background. Check the Web for information about
kinds of care. Start with the federal Administration on
Aging’s site, www.aoa.gov.
From U.S. News & World Report, May 2l, 2001, pp. 56-61. © 2001 by U.S. News & World Report, L.P. Reprinted by permission.
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