Q. We are currently caring for my mother-in-law, Margaret, in our home. We enjoy having her with us, but as her needs keep becoming greater, we find that she may need more support than we can provide.
I have read that when a senior has a progressive medical condition or serious health needs, assisted living or a nursing home may be the best option. I’m confused though. What is the difference between the two options? How can I decide which would be better for her? Does Medicaid cover assisted living and nursing homes, if she qualifies? Thanks for your help!
A. When a senior loved one needs more help than can be provided in the home, it may be time to make a move. But many people, like you, are confused when it comes to the difference between assisted living facilities and nursing homes.
Both nursing homes and assisted living communities focus on keeping seniors safe, healthy, and happy. Both provide support with Activities of Daily Living (ADL), such as bathing/showering, dressing, toileting, transferring (getting in and out of a chair or in and out of bed), and managing incontinence. Both also provide support with instrumental activities of daily living (IADLs), such as managing medications, cooking, laundry, and other personal care. Assisted living is often a good option for seniors who need some extra help and support, or even for those who need some assistance with all ADLs. Nursing homes, by contrast, offer more comprehensive support to those with more extensive medical needs.
Is Assisted Living the Ideal Choice?
An assisted living community might be an ideal option for someone who has some health problems and needs some help with ADLs. In fact, many seniors who choose assisted living remain independent aside from a few daily tasks.
Assisted living communities are not healthcare facilities. They are not required to have any nurses or doctors on staff or to offer any medical services, although many assisted living communities do have a nurse on staff, and many do offer some medical services, especially help with diet and nutrition issues.
Assisted living residents usually live in their own private one bedroom or studio apartments and share numerous common areas. They typically have access to many services, including up to three meals a day; assistance with personal care; help with medications, housekeeping, and laundry; 24-hour supervision, security, and on-site staff; and many opportunities for social and recreational activities and outings.
These are some reasons a loved one might consider assisted living:
- Not as much assistance needed: Assisted living is for people who need some help with daily care, but not as much help as a nursing home provides. Some assisted living residents drive their own cars, cook some of their own meals, and come and go freely.
- Additional levels of care offered, if needed: In most assisted living facilities, 4 “levels of care” are offered, with residents paying more for higher levels of care. At most assisted living communities, The highest level of care memory care, where services are offered for those with Alzheimer’s disease and other forms of dementia.
- Amenities: Assisted living communities provide socialization opportunities and an event calendar with many activities that make it easy to get out and about. They also provide a full complement of dining, housekeeping, maintenance, and other ancillary staff throughout the day.
Determining if Assisted Living is Right for a Loved One
Consider these statements below from Seniors Guide to determine if a couple of them describe your loved one to see if assisted living might be the right option
__ Having an extra set of hands would be helpful.
__ I would like to connect with others and don’t want to be isolated by living alone.
__ Having meals prepared for me would be helpful.
__ I no longer feel safe living in my home.
__ I need help getting in and out of the tub or shower, or need help bathing.
__ I need help getting dressed.
__ I do not have family or friends nearby if I need help with daily tasks.
__ I need help navigating the stairs of my home.
__ I grab onto furniture for stability as I move around my home.
Does Medicaid Pay for for Assisted Living?
Virginia: Medicaid does NOT cover assisted living in Virginia. It only covers nursing home care for those who qualify, and in-home care for those who need the nursing home level of care but have family members available to help them age in place at home.
Maryland: Medicaid does NOT cover assisted living in Maryland. It only covers nursing home care for those who qualify. And, unlike Virginia, Medicaid does not currently cover in-home care in Maryland.
District of Columbia: Medicaid does cover the cost of assisted living in DC under some circumstances. DC Medicaid also covers in-home care, as well as nursing home care of course.
Paying for Assisted Living
Assisted living can be a viable option when a person can no longer live alone, but such facilities come with a steep price. In the 2019 Cost of Care Survey conducted by Genworth Financial, $5,000 to $8,000 per month is common for assisted living in our area, depending on the level of care needed. And keep in mind that Medicaid is not going to cover the cost of any of this, unless possibly you live in DC.
Some people have the means to pay for assisted living with their own income and retirement nest eggs. However, savings easily can become depleted by a $60,000 – $90,000 annual bill for assisted living. You could also consider paying for assisted living with a life insurance policy or a hybrid LTC insurance policy, as described in my article from earlier this year, “How to Afford Assisted Living.”
When a Nursing Home Might Be the Best Choice
Also known as skilled nursing facilities, nursing homes provide the highest level of care possible outside of a hospital. Nursing homes deliver 24-hour care to seniors who have complex medical conditions and need a high level of hands-on assistance and monitoring.
In nursing homes, a licensed physician supervises each patient’s care, a nurse is always on the premises, and other medical professionals, such as occupational, physical, or speech therapists, are also on hand. Many nursing homes have medical equipment that is normally found in hospitals, such as X-ray equipment, hospital beds, and Hoyer lifts, and a few nursing homes even have ventilators. In addition, almost all nursing homes offer short-term rehabilitation services where an adult of any age can stay before returning home after a medical operation or procedure.
A nursing home is the best choice for someone whose medical needs require full-time nursing care or access to services and facilities that are more like the hospital than home. Some individuals must transition to a nursing home full-time after a major stroke or a major bone break or a serious infection, or when a senior is continually in and out of the hospital due to something like repeated falls or repeated urinary tract infections. Because skilled nursing facilities offer extensive care, they can provide more stability to seniors who might otherwise spend extended periods of time in the hospital. Similar to assisted living, skilled nursing facilities provide an event calendar and specialized dining choices.
These are many reasons a loved one might need nursing home care as opposed to assisted living:
- More complex medical needs: A nursing home is the best choice for someone whose medical needs require full-time nursing care or access to services and facilities that are more like the hospital than home. Residents in skilled nursing facilities typically need help that goes beyond ADL care.
- On-site providers: In addition to nurses and aides, skilled nursing facilities typically have on-site providers for physical, occupational, and speech therapy.
- Short-term rehabilitation: Many residents of skilled nursing facilities are not planning on a long-term stay. Instead, a person might enter a nursing home for short-term rehab after a fall.
- Caregiver ratios are lower due to the increased needs of residents. Skilled nursing facilities also have an on-site doctor and nurses, because they are designed first and foremost to provide medical care.
- Dementia care: 60% of nursing home residents have some level of dementia. Because the later-stage symptoms of dementia are so severe, it is safe to assume that if loved one has Alzheimer’s or another form of dementia, a nursing home will be a consideration at some point in the progression of their disease, even though people with dementia can often also stay in the memory care unit of an assisted living facility.
Determining if a Nursing Home is Right for a Loved One
Consider these statements below from Seniors Guide to determine if a couple of them describe your loved one to see if a nursing home might be right for your loved one:
__ There are medical issues that require long-term attention.
__ Alzheimer’s or dementia has been diagnosed, and memory care treatment is not enough.
__ Medical treatments or procedures are needed on a regular basis.
__ Health needs to be monitored daily.
__ Care from a nurse is required daily.
Paying for Nursing Home Care
According to the 2019 Genworth Cost of Care Survey, the cost of nursing home care in our area is around $12,000- $14,000 a month. With long-term care services being so costly, how can anyone afford them without going broke or depleting their assets?
Medicare will pay for short-term rehabilitation that takes place in a nursing care or rehab center following a three-day hospital inpatient stay. But, otherwise, Medicare does not pay for long-term care!
Medicaid, on the other hand, is the single largest payor of nursing home care costs because so many people can’t afford to cover the costs themselves. However, Medicaid eligibility is the most complex area law in existence, and has complex income and asset and functional capacity requirements, making it extremely difficult to qualify, so the help of an experienced elder law attorney, such as myself, is absolutely essential.
Why Nursing Home Care Can be Cheaper than Assisted Living
As explained above, if you are paying privately for your care, nursing home care will be much more expensive than assisted living. However, as also explained above, Medicaid will pay for nursing home care if you have either run out of money or, better yet, if you have hired an experienced elder law attorney such as myself to help you protect your assets and qualify for Medicaid without having to first go broke. For a married couple, we can protect 100% of the family’s assets and get the nursing home spouse on Medicaid. For a single individual, we can protect 40 to 70% of the person’s assets and get the individual on Medicaid. Because of this ability to do Medicaid asset protection, the cost of nursing home care actually winds up being much less expensive than assisted living. When you’re in assisted living, you are almost always paying privately for your care (DC being the only exception in our area). On the other hand, when you’re in a nursing home on Medicaid, the general rule is that you are only going to have to pay just a portion of your monthly income to the nursing home. And if you are married, we can often shift much of the income from the nursing home spouse to the healthy spouse.
Planning for Long-term Care
When it comes to planning for long-term care, Medicaid Asset Protection Planning can be started while your loved one is still able to make legal and financial decisions, or can be initiated by an adult child acting as agent under a properly-drafted Power of Attorney, even if your loved one is already in a nursing home or receiving other long-term care. In fact, the majority of our Lifecare Planning and Medicaid Asset Protection Planning clients come to us when nursing home care is already in place or is imminent.
Generally, the earlier someone plans for long-term care needs, the better. But, fortunately, it is never too late to begin your planning.
To afford the catastrophic costs of long-term care without depleting all of your loved one’s hard-earned assets, your mother-in-law should begin her Long-Term Care Planning as soon as possible. You should also do Incapacity Planning and Estate Planning, if you haven’t done so already. Please call us to make an appointment for an initial consultation:
Elder Care Fairfax: 703-691-1888
Elder Care Fredericksburg: 540-479-1435
Elder Care Rockville: 301-519-8041
Elder Care DC: 202-587-2797
About Evan H Farr, CELA, CAP
