Elder/Adult Dependent Care

Retirement Communities and Nursing Homes

Click here for a printable version Continuing Care or Life Care Retirement Communities
" Life care " or " continuing care retirement communities " (CCRCs) contract to take care of your elder for life for an entrance fee and monthly payments. These communities often contain, on one site, a range of housing from individual apartments to skilled nursing facilities. Some communities contract with nearby nursing homes to fulfill this agreement to provide "care for life." These sites usually have dining rooms and a full range of lifestyle options. There's a great variation, however, so you should ask enough questions to feel comfortable.

These questions might include:

What is the entrance fee? Is the monthly fee reasonable and affordable?
What are the health care obligations and is there adequate staff?
What services are covered by the monthly fee? Is the admission fee refundable?
What is the CCRC's financial status? Is it solvent? What is the track record?
Do the fees increase with level of care? Who decides when the resident is no longer able to live independently and must move to the " assisted living " quarters?
Are there enough nursing home beds to accommodate everyone? Are nonresidents admitted to the skilled facility?
If possible, go over a CCRC contract with an attorney before signing. The terms should be checked through the State Department of Insurance, 1-800-927-HELP (927-4357), and contracts for several communities should be examined.

Nursing homes, also called convalescent homes, are licensed by the Department of Health Services, 1-800-554-0352, to provide both skilled nursing and custodial care. Residents may be recovering from a hospital stay and in need of rehabilitation and personal services such as grooming and bathing, or may be admitted because of a terminal illness or debilitating disease such as Alzheimer's, when 24-hour care is needed. These homes are traditionally called Skilled Nursing Facilities (SNFs), which provide 24-hour nursing care, or Intermediate Care Facility (ICFs), which provide similar services to SNFs but not around the clock.

The traditional image of nursing homes brings unease, but these facilities have changed dramatically over the past 50 years. Although half of those aged 65 and older stay in a nursing home at least once in their lives, these facilities are no longer just places where people go to die. For example, nursing homes handle patients discharged from hospitals who don't need an acute level of care but are not yet ready to return home.

There are two primary considerations about nursing homes when this becomes the only sensible option for the well-being of your elder. The first is emotional; the importance of the transition from family home to nursing home is not always acknowledged. The change can represent a series of losses, and support systems should be in place before this move is made. Secondly, it is important to do strong financial planning beforehand. Public programs such as Medi-Cal pay for nursing home care, but if your elder is not qualified for this government entitlement, then typically most of the costs (in the Bay Area, they can reach $72,000 a year) will be out-of-pocket. Medicare only covers the "skilled" aspects of nursing home care, not custodial services.

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Choosing a Facility
Choosing a nursing home is a difficult proposition at best, both physically and emotionally. Ideally, you would have time to plan ahead, but that is not always possible. You can find nursing homes through your local senior information and referral office, and the State Ombudsman Office located in Oakland, (510) 638-6878. (Ombudsmen are trained professionals who advocate for patients and families in long-term care facilities; they answer complaints, investigate facilities, etc.) Ask hospital discharge planners, social service and family service agencies, friends and neighbors, and check the Yellow Pages under "Nursing Homes" and "Homes-Residential Care."

Four important factors in choosing a facility are: what kind of care is needed, what financial resources are available, what location is best, and what kind of lifestyle is desired. California Advocates for Nursing Home Reform (CANHR), 415-974-5171, is also a good resource for questions and concerns about nursing homes. They can be reached Monday through Friday from 9 a.m.-12 p.m. and between 1 p.m. and 5 p.m.

Consider other options before placement in a nursing home. Sometimes all an elder needs is personal care services at home, closer monitoring by a physician (diet, hydration, medications) or home repair and modification. Consult with as many professionals as you can before making a placement.

Payment options and finances are especially critical to understand long before nursing home placement is considered. Familiarize yourself with long-term care insurance policies, also known as "nursing home policies," and Medi-Cal eligibility rules before considering placement. One source is the California Partnership for Long-Term Care, 1-800-CARE-445 (227-3445), or CALPERS, which offers insurance policies for state employees.

There are many excellent sources for learning about Medi-Cal eligibility. One is your local HICAP office, or Health Insurance Counseling and Advocacy Program which offers free counseling to Medicare beneficiaries about health insurance options. Ask about "spending down" assets to required levels (around $2,000, though the amount varies by state); eligibility requirements, application procedures and processing time; the possibility of liens on real estate after the death of the person in the nursing home; "spousal impoverishment," or the ability of the well spouse to remain in the family home with a certain level of assets; and other forms of health insurance such as "Medigap" policies, which supplement Medicare coverage. Your local Social Security office can also help you.

Location is critical because it can make the difference in your loved one's ability to have visitors frequently, and your ability to visit as often as needed or desired. Take into account your elder's social situation before deciding to relocate. A sense of loss of friends and familiarity can be more devastating that the move itself.

Lifestyle preferences can influence the choice of a convalescent facility. Some of them are geared toward active residents; some have special ethnic menus and activities. Size of the facility is also important. The smaller ones may be more intimate but with less to do and larger ones will be more stimulating, but may provide less personal attention.

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Medicare Coverage
Care in a skilled nursing facility (SNF) is the only type of nursing home care that Medicare covers. It does not pay for services that are primarily custodial (bathing, grooming, housekeeping). There are thre parts of Medicare coverage: Part A (hospital insurance), Part B (medical insurance), and Part C (prescription drug benefit). Part A can help pay for care - inpatient hospital care, post-hospital skilled nursing care, post-hospital home health care, and hospice care - at a SNF under five conditions:

The medical condition requires daily skilled nursing or skilled rehabilitation services that can only be provided in an SNF.
The individual has been in a hospital at least three days in a row before being admitted to an SNF.
The individual is admitted to the facility within 30 days after leaving the hospital.
The care in the SNF is for the same condition treated in the hospital, or for a condition that arose while receiving care in the facility for a condition treated in the hospital.
A medical professional certifies that the individual needs, and is responding to, skilled nursing or rehabilitation services on a daily basis.

Some of this coverage can also transfer to care in the home.

Part B has annual deductibles (about $124 a year) and co-insurance, and can be signed up for during special enrollment periods. It pays about 80 percent of physicians' services, other medical services and supplies, home health care services, outpatient hospital care, diagnostic tests, ambulance, second opinions and durable medical equipment. To find out about the monthly premium, call your local Social Security office.

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Looking for a Nursing Home
Here are some tips to consider when looking for a nursing home:

How will your family meet expenses? What are the base costs? What are add-on costs (e.g., laundry, bandages, beauty salon)?
Is the facility Medicare- or Medicaid-certified? What rehabilitation services are provided?
Is the home clean and odor-free? Are requests for assistance responded to quickly?
Does the nursing home require that a resident sign over personal property or real estate in exchange for care?
Are the residents happy, alert, groomed, clean, well-fed, healthy? Are they restrained to wheelchairs, lethargic?
What levels of care are available, and are they appropriate to your elder's needs?
What is the staff-to-resident ratio?
How often are meals repeated? Are alternatives available, as required by law? Are there any ethnic-specific diets?
Can residents bring their own furniture and personal effects to decorate the room? Is there a safe for valuables and money?
Do activities cover a broad range? Is there an activities coordinator?
Is there a family council for residents? When does it meet and who coordinates it?
What is the procedure for leaving the facility temporarily, such as hospitalization or vacation? Will your elder's place be held?
Is the ombudsman program's phone number listed?
You should visit each nursing home under consideration more than once—unannounced and at different times. Talk to residents and staff, ask what they like and don't like. Take a guided tour, then come back on your own.

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