Choosing a care facility for your loved one

What the ALF?

First and foremost, at this point you have weighed all options and decided that finding a facility is the best decision for your loved one (LO). If you are beating yourself up or have any feelings of guilt, that is normal, but I would encourage you to try to let that go…for the sake of all parties involved. If you need to talk it through with friends, family, or a counselor, then do that for yourself. At this time, you are making the best decision that you can in the best interest of your LO. Sometimes their needs can best be managed in a facility. I know many seniors who thrive in facilities and live the rest of their years still able to experience purpose and joy. You might get resistance from them at first, but most of the time they do adapt, and much of the time it becomes their “home” where they eventually feel comfortable in. The best thing you can do is arm yourself with knowledge. Do your homework, tour facilities, check references and reviews, and make the best decision you can with information that you have. This transition can be challenging for all parties involved, but it will get better. Do not wait for an emergency to occur to make the decision to move them. When things are rushed or decisions are made out of desperation, the experience is much more difficult.

Most families try to decide whether a skilled nursing facility or an assisted living facility would be best. Let’s talk about some of the main differences between the two.

What is assisted living?

Assisted living is a care option designed for older adults who require some type of assistance with their activities of daily living (ADLs). ADLs include basic self-care tasks such as feeding, grooming, toileting, bathing, dressing, and showering.

Assisted Living Facility:

Assisted living facilities (ALF) range in size from as few as 6 residents (see residential ALF) to as many as 100 or more. There are larger facilities that have multiple floors. These are the ones that sometimes look like big hotels! The residents often have their own rooms or apartments. They offer all the ALF services and sometimes have nurses on staff. If your LO enjoys being social, going to various activities, and dining in a larger dining room with others, this option is appealing. Some can specialize in memory care in a free-standing building or an ALF may have a memory care wing if your LO needs specialty care due to dementia/alzheimers or other cognitive diagnoses. These units have staff that specialize in memory care.

A resident may continue to live as independently as possible in this setting but can receive assistance in the areas in which they are no longer independent. The ALF provides 24/7 care, housekeeping, laundry, assistance with medication management, internet, meals, and activities/exercise. They often have a healthcare provider that rounds at the facility if the resident would like to receive in-house services vs. having to go out for their primary care appointments. They can have access to homecare services or hospice services as needed just as they could if they were in their own home. Some ALFs offer beautician services and bus transportation services for outings. Transportation for personal appointments are not typically provided however they can assist in arranging transportation for your LO. Usually the family or friends will take the resident to their appointments. Some ALFs are furnished and some allow you to bring your own furniture. ALFs have trained staff that have to meet educational requirements and pass a level 2 background screening to provide care. There are trained staff to assist the residents with medication management if needed. ALFs are not required to have nurses on staff, however some do have nurses and some are run by nurses. There are different types of licenses that the ALFs have that will determine the level of care they offer. There are Standard, Limited Nursing Services(LNS), Extended Congregate Care(ECC), and Limited Mental Health(LMH) licenses. There are also specialties in memory care/dementia. Although an ALF provides 24 -hour care, if a resident requires that medical or nursing care be available 24/7, then they may be more suited for a skilled nursing facility. A resident in an ALF cannot require total care with their ADLs, with the exception of them being admitted to hospice, provided the facility can provide the level of care needed. ALFs are not covered by Medicare or insurance UNLESS a person has a long-term care insurance policy that can help cover some costs. Check their life insurance policy as well for any possible benefit. A resident often has savings, pension, maybe the money from the sale of their home, veterans’ assistance, social security, or Medicaid that helps cover the cost. Not all ALFs are Medicaid providers so that is important to inquire about. Some residents will spend their money down and then apply for Medicaid as soon as they are able. Medicaid does not pay for room and board but covers supportive benefits if someone is eligible.

Residential Assisted Living/Board and Care home/Residential ALF:

This type of ALF is a smaller home, in a residential neighborhood, that provides care for a lower census of residents in a home-like setting, typically up to 6 residents. The same services mentioned above under assisted living are offered in this smaller ALF setting. These facilities typically do not have signage and appear to be a regular home in a residential neighborhood. This setting will likely offer a better ratio of staff to residents due to the smaller census. They are often able to take residents that may require more specialized care. There is always at least one staff on duty 24/7 and a second staff member for part of the day. The staff member is typically responsible for the housekeeping activities and the cooking as well as the personal care. Residents have to meet certain criteria determined by the state to be admitted and the owners may have their own criteria in addition to that.

Adult Family Care Home (AFCH) or Group Home:

This is not called an ALF but still has to be licensed by the state and meet certain criteria. It is a residential home designed to provide personal care services and the amenities, housekeeping, meals, medication management, etc., are similar to the ALFs. The main difference is that the provider must live in the home and services are offered to up to 5 residents. Basically, the caregiver lives there and provides care in their own home. For families who are looking for a home-like setting, this offers a nice option. Having the owners on-site often makes it feel like a family. These homes may be called something different in different states.

Continuuing Care Community:

This type of community offers various housing options that can support your LO through the different stages of their senior years. They may offer independent senior housing, assisted living, memory care, and long-term care. This option allows your LO to move within the same campus and not have to leave when they start to decline.

Skilled Nursing Facility/Long term care/Nursing Home:

These facilities serve residents with physical and mental conditions that require full-time medical care and monitoring. 24/7 personal care with ADLs and round the clock supervision is provided, however a greater degree of medical attention is available. This is typically the best option if a LO’s needs cannot be met at home or assisted living. It is more expensive than assisted living, however is a good place to transition to Medicaid coverage if and when that time comes. Medicare does not cover long term residency however it sometimes will cover short term rehab stays. Medicaid is the primary payer for nursing home long term residency once the resident’s money runs out.

It is a lot to think about. If you are considering these placement options it will make it easier if you can have access to a social worker or discharge planner. This could be through your homecare agency, the hospital, hospice, or rehab. I would also start asking around. Talk to friends about their experiences with assisted living. Ask your homecare therapists and nurses, doctor’s offices, etc. for recommendations. You can google the facilities and websites/reviews. Keep in mind the smaller facilities operate on a much smaller budget and don’t always have elaborate websites. You can do a search for “assisted living facilities near me” and then just call some facilities to set up a tour. There are agencies called “placement agencies” that you can use, at no cost to you, to help you find a facility for your LO. They will narrow down your search based on what is a good fit for your LO. Be cautious, however, to do your homework on reputable placement agencies. Some of them are not contracted with a large number of ALFs which may limit the options presented to you. And although there is no cost to you, the cost is passed on to the ALF for the placement of your LO to their facility. There are some good agencies who truly have the best interest of the resident and the ALF owner at heart. I owned a small ALF and when I needed them, there were some good ones that referred residents and families who were a good fit with our facility and environment.

Whether you search on your own or get help, I would be thorough with asking your own questions directly to the ALF administration. I am going to list some questions you can ask and some tips when making your decisions for placement of your LO.

Schedule a tour with the house manager or administrator if you can. You could try to stop in, but the facilities do get busy, and you do not want to be rushed. Find out who you will be taking questions and concerns to. You want to be sure they are kind and approachable because this will be an important relationship for you and your LO. It is also important for the administrator to know they have a reliable family member or representative to build a relationship with.
When you walk into a facility, first notice the “feel” or the “vibe” of the place. Is it inviting? How is the temperature? Is it clean? What does it smell like? How do the residents look? Are they dressed nicely? Are they falling out of their wheelchairs? Do they have areas where they can congregate or are they all parked next to the nurses station? Now, all of that being said, there are bad days and sometimes things just happen. Despite all efforts, some residents slide down in their wheelchairs…or kick their shoes off…or have behavior problems. They might be short-staffed that day or maybe something burned in the kitchen. But, you should still be able to get a general feel of the place and, if you need to, schedule a second tour.
Notice how the staff interacts with the residents. Are they kind and respectful? Are the staff interacting and engaging with each other and the residents? Do they smile and seem like they like their jobs?

Options for questions to ask for any facility type:

Ask what the staff to resident ratio is.
Ask about the staff turnover? Has their staff been here long?
Is the staff trained on elder abuse and neglect?
Is staff trained on how to care for residents with dementia?
Are all of your staff background checked?
Ask about rates.
Ask if you have the option of private or a semi-private room.
Ask about levels of care and whether your LO will be able to “age in place” and stay there as they decline.
Ask how often you can meet or talk about the status of your LO?
Ask if they will be able to stay there if they end up on hospice and require total care.
Ask if staff is available to provide 24-hour assistance with ADLs as needed?
How often do they get showers? What do you do if my LO doesn’t want to take a shower?
Are the showers and bathrooms accessible by walker/wheelchair?
Ask how many residents share a bathroom?
What kinds of activities do you do? Do they get to go for walks or go outside?
Are residents allowed to have an overnight guest?
Ask about the guest parking area.
Are there religious services available onsite?
Ask if there is a policy on sexual interaction between residents?
Ask if the state inspection report is available for families to see?
What are common reasons that a resident would be asked to move out? How much notice is required?
Is there a generator in case of power outage?
What common spaces do the residents share to socialize?
Is there ever live entertainment?
For the smaller facilities, ask if the night staff is allowed to sleep or do they stay awake?
Ask what kind of food and meals are made. If your LO doesn’t like what is served, ask what their options are. Do they offer snacks?
Be sure to ask specifically how much assistance the staff can provide with transfers and personal care. Some facilities can provide more care than others. Ask what happens if your LO declines and requires 2 people to transfer.
Ask what the process is if your LO falls? Will you be notified?
Ask if your LO can receive therapy if needed?
Ask what their protocol is if your LO exhibits some adverse behaviors or becomes combative?
If your LO needs standby or assistance for their mobility, ask if they are supervised with mobility to and from the dining area or bathroom.
When asking about rates, ask if the rate they quote you is all inclusive or just base rate? Ask about add-on charges such as disposable briefs, extra snacks, charge for meals being brought to their room, and toiletries.
Ask if you can stop by unannounced. Find out their visitation hours.
Ask how you should coordinate doctor’s appointments and transportation.
You can ask if a hair stylist comes to the facility.
Ask if pets are allowed or if there will be animals in the house.
Ask who their visiting doctor or nurse practitioner is.
Ask if they have a podiatrist that comes to the house.
Ask if you can bring your own furniture if you choose to and how many personal belongings can be brought in. Can the resident decorate their room? Bring a small refrigerator? You definitely will want to have personal items from home and their bedroom that will bring them comfort and familiarity.
Ask if smoking is allowed? Do they allow staff to smoke?
Ask if your LO can call you when they want to. Do they have their own phones? Do they share a house phone? Should you get them a cell phone?
Are there set times for meals? Can they eat in their room?
Ask if they do anything special for birthdays and holidays?
Ask if there is a TV in the room and wifi?
Ask how your LO can call for help in the night? Do they have call buttons or allow the battery-operated doorbells to ring? Do they use alarm pads for safety if they are worried about residents climbing out of bed and falling.
What is the evacuation plan for any natural disasters that could occur. We have hurricanes here in Florida, so we had an evacuation plan for those.
Ask about their community fee which is a fee upon move-in.
Ask how they have their medication schedule coordinated.
Ask if you can use your pharmacy or if they have a preferred pharmacy they like to use.
Ask about the bathroom cleaning schedule and how often they do laundry and change the sheets.

You can also ask if they provide any respite at their facility where you can have them stay a short period before you make a final decision about a permanent move in. Some facilities offer adult daycare which is a great way to slowly have your LO adjust and acclimate. You may have more questions of your own. Of course the answers to these questions will differ, especially between larger and smaller facilities.

You may want to take a notebook and jot down notes of likes and dislikes because it is easy to forget some information after touring several places. I’m sure the location of the facility will also be an important consideration.

Tip: Be honest with the administrator about your LO’s condition and/or any behaviors they should be aware of. Although it is true that you are there to evaluate and assess the facility, they also will be assessing you and your LO to make sure it is a good fit. It will be very important for them to have a good picture of the resident they will potentially be caring for so they can ascertain whether they can meet their needs. There are so many variables in admitting a new resident. Different facilities have different criteria. What I often see happen is that the resident is presented to the facility in one way (by families, hospitals, rehabs, placement agencies), however when they arrive, the administrator soon realizes that the resident is not at all like he/she was described. Sometimes the resident needs to be placed quickly so information about the resident’s abilities may be exaggerated. The problem with this is multifold. First of all, it may end up that the facility cannot meet their needs and will have to give the resident notice to move out. Second, if the facility cannot meet their needs, then it puts the resident at risk for an accident to occur. Third, it breaks trust and could hurt the relationship with the facility/admin moving forward. If there are any undesirable behaviors or special needs that you know may create an issue in the future, it is best to discuss it up front. I found that the families that were open and honest about their LO’s condition were the ones I was more willing to work with and problem solve with to ensure a good and safe transition. Examples might be: “mom tries to get out of bed without assistance several times a night to use the bathroom” or “my dad hates democrats and screams at the tv every day during the news” or “dad falls a lot at home” “my mom will not allow a male caregiver to help her”. You get the picture. No surprises are the best.

Should I bring my LO on the tour?

This is another personal decision that you will need to think through depending on the status of your loved one. Sometimes when the LO comes for the tour and they have “somewhat accepted” the idea of moving into a facility, they can identify things that they like or dislike that might help direct the questions you will want to ask the administrator. It will give you LO a sense of control and contribution to the decision. It gives the facility staff a chance to greet them and make them feel warm and welcomed. On the flip side of that, if they are still in denial or resistant to the idea, then it could be very difficult for all parties. If they have dementia, it may be best to wait until the actual move-in. They do not always have an awareness of time and it may just create unnecessary anxiety prior to the actual move in date. Understandably families do not like seeing their LO upset and I have seen families change their minds all together about placement because their LO became upset during a tour. Sometimes families do the tours, narrow it to the top two places, and then bring their LO. Some families have to make the tough decision to bring their LO straight from the hospital or rehab and tell them that this is where they will be staying because they are not safe to go home. I believe sometimes this is the best option. There are always ways to try and buffer the situation and ease them into the idea, depending on their personality and temperament. Some respond well to being given a time frame such as, “Mom, we found a place that meets your needs and we think you will like it. We need you to give it two months and see what you think.” Some have called the ALF a “rehab setting” or a “transition living arrangement” so their LO settles with the idea that it is a place to live until they get stronger and can hopefully go back home.

Most of the residents that I have had and have seen at other facilities will need an adjustment period, understandably. They will be nervous, scared, and maybe angry. Be prepared that your LO might make a lot of complaints and find reasons to want to leave. Of course you will need to take all of their concerns seriously, but just be aware that it might take time. Work with the manager/admin/staff on the best way to help them adjust. Sometimes the best option is to have family not visit much the first week to give them time to adapt. It can take several weeks to adapt to a new environment, especially if they have dementia or other cognitive impairments.

I hope some of this information has been helpful for you. You are doing the best you can and your LO is lucky to have an advocate when there are so many out there that have no one to represent them. Always know that you have options and can change your mind down the road if you are not happy with the decision you made. My last bit of advice is to stay connected to the staff, administration and your LO. Do your best to remain understanding when things don’t go perfectly, but stay present, observe, ask questions, and visit or call when you can. The coordination of care is improved when families are involved and supportive. Good luck on your journey.

Thank you for your caregiver heart

Love,

Heather