Long-Term Care

The prospect of long-term care concerns many older people. The likelihood of needing long-term care increases greatly as people age. Older people are more likely to develop chronic disorders and to have problems functioning. Learning about the many types of long-term care can help people choose the right time and place for this care. How long care is needed varies from weeks to years to indefinitely.

Long-term care focuses on helping people function. It helps them do the activities necessary to care for themselves and to live as independently as possible. These activities include basic daily activities (such as eating, dressing, bathing, grooming, and walking) and other activities (such as shopping, balancing a checkbook, doing laundry, and cleaning). Long-term care usually includes help with health care. Most long-term care facilities also provide social and recreational activities.

Many people have their first experience with long-term care after a hospital stay. During a hospital stay, many older people lose some or all of the ability to care for themselves. Thus, they may need to go to a long-term care facility for rehabilitation and recovery. This move can be physically and psychologically demanding. People have to adjust to many new faces and to new routines for sleeping, bathing, dressing, eating, and other daily activities. The move happens quickly, with little time to adjust.

Most people associate long-term care with a change in residence: to a retirement community, an assisted living community, a board-and-care facility, a life-care community, or a nursing home. However, only one third of older people who receive long-term care live in an institutional setting. The others receive care in their own home or the home of a family member. This care is usually provided by family members or friends. If needed, health care practitioners may visit the home to provide additional care. People who receive care in institutions usually have more physical and thinking (cognitive) problems and less social support from family members and friends.

What type of arrangement is possible depends partly on the person's needs (medical, functional, social, and emotional). However, it also depends on the person's preference, finances, and social support (for example, the family's willingness and ability to help). One person may be able to live at home with the help of a spouse. Another person with similar problems but without family support may need to go to a nursing home.

After the type of arrangement needed is determined, a particular facility must be carefully chosen. Within each type, facilities differ considerably in environment, services (including health care), activities, living arrangements, and rules. Sometimes the difference is simply a matter of what a person can afford, but even within a price range, quality varies.

Retirement Communities

Retirement communities are designed for people who can live independently but who need or want some help, mainly with caring for a home. Some older people choose to move to a retirement community before they need additional help. They may move because they do not want the responsibility of maintaining a large house and yard or because they have become lonely or isolated.

Retirement communities consist of a group of apartments, townhouses, or detached homes. These communities provide some services, such as transportation, entertainment facilities, some on-site nursing services, community meals, laundry services, and house cleaning and maintenance. Such services enable older people who are reasonably well to live independently. Retirement communities may arrange group activities, such as trips, game nights, or lectures by guest speakers. Some have recreational facilities, such as swimming pools and golf courses. The homes are usually designed for older people. For example, they may have only one floor. Retirement communities enable some people to postpone a move to a facility that provides more intensive long-term care.

Some retirement communities are part of a life-care community. Life-care communities provide as much care as people need for the rest of their life.

Because retirement communities vary so much, people should ask questions to make sure the community they are considering is suitable for them.

• Is there an entrance fee in addition to the monthly fee? Which services, activities, and amenities are included in the monthly fee?
• What services, activities, and amenities are available? Is there a bank, beauty salon, post office, or general store? Is transportation readily available for trips to local shopping areas, doctors' offices, and other health care facilities? What social and physical activities are available?
• What is the minimum age to live in the community?
• Are the facilities well maintained? Are the living units and their setting pleasant? Is there enough parking?
• Are there service people to help?
• Are meals provided?

Assisted Living Communities

Assisted living communities are designed for people who can care for themselves if they have some help with daily activities. These communities can help older people who have problems with memory, who get confused, or who have physical problems. Some communities have special units for people with dementia where residents can be closely monitored.

Assisted living communities vary from small and homey to large and elaborate. Residents usually have their own apartment or a bedroom with a bathroom. These communities provide meals, help with daily activities (including personal care), and offer some social and recreational activities. Residents can choose which activities and services they want. Most assisted living communities provide some health care, including 24-hour supervision if needed. Doctors and nurses may visit regularly, and physical therapists may be available. Services and activities offered vary greatly from community to community. Also, regulations for these communities differ from state to state.

When people need intensive treatment, they may have to move to another facility, such as a hospital or rehabilitation center. They may move back to the assisted living community if they are able. But to hold their living space while they are gone, they must continue to pay for it.

People who move to assisted living communities usually need help with daily activities because they have some limited health problems. Assisted living communities prefer people who do not need help moving (transferring), for example, from bed to chair. But even when people become relatively impaired, they may be able to stay in these communities because of the help provided. How much help is provided varies considerably from community to community. Generally, an assisted living community is not an alternative to a nursing home. More often, it is a transitional living arrangement, followed eventually by a move to a nursing home. Assisted living communities are usually less expensive than nursing homes because they provide less care. However, they can still be expensive. Usually, Medicare and Medicaid do not pay for assisted living communities.

Board-and-Care Facilities

Typically, board-and-care facilities, also called rest homes, are similar to assisted living communities. They are for people who need some help, particularly with personal care. Board-and-care facilities provide a room, meals, help with daily activities, and occasionally some health care. In board-and-care facilities, people usually live in rooms, as in a college dormitory, rather than in apartments. Some facilities have a very homelike atmosphere.

Board-and-care facilities are not as closely regulated as nursing homes or even some assisted living communities. Many provide good care, but some do not. Some facilities attempt to care for people with very different needs. For example, younger people, many of whom have an untreated or a poorly treated mental disorder, live side by side with older people who do not have a mental disorder. In such an arrangement, the older people may feel uncomfortable or awkward.

Older people and their family members must carefully evaluate a board-and-care facility. They should ask what the facility does and does not provide and make sure that the staff members can meet the needs of the residents and treat them well.

Life-Care Communities

Life-care communities (also called continuing care retirement communities) are for older people who want to move only once, to a place that will provide as much care as they need for the rest of their life. These communities guarantee that residents are cared for within the community regardless of their health.

A person may begin by living in a house or apartment. But later, if health deteriorates, the person can move to an assisted living community and finally to a nursing home, all on the same property. Life-care communities offer the security of continued care in one location, without having to move very far. However, many life-care communities are expensive. Some require a large deposit as well as monthly payments and fees for additional services. Sometimes there is an upper limit (cap) for monthly payments and fees. But in many communities, costs increase when the level of services needed increases.

Medicare and Medicaid usually do not pay for residence in a life-care community but may help pay for skilled nursing care when it is needed.

Nursing Homes

Nursing homes are for people who need help with health care for chronic conditions but do not need to be hospitalized. The decision to move to a nursing home may be triggered by a change in circumstances. A disorder may suddenly worsen, or an injury may occur. Function may deteriorate suddenly or slowly but steadily. Family circumstances may change, making care at home difficult.

"Nursing home" is sometimes used as a general term for any long-term care facility. But it specifically refers to skilled nursing facilities. "Skilled" indicates that some of the care included can be provided only by trained health care practitioners. "Nursing" indicates that nurses provide most of the care in the facility. Nurses give residents their drugs, monitor disorders, supervise treatments, consult with doctors about care, and organize most of the activities in the nursing home. The nursing staff includes registered nurses (the most highly trained), licensed practical nurses, nursing assistants, and a director of nursing, who oversees nursing care in the home.

Each nursing home also has a medical director, a doctor who oversees the medical care. In some nursing homes, the medical director is the only doctor who provides medical care. But in most nursing homes, several doctors provide care. Sometimes a doctor who has been taking care of the person before the move continues to provide care. Otherwise, the person chooses or is assigned to a doctor. According to regulations, a doctor must see every nursing home resident at least once every other month. Many residents see a doctor more often because they tend to develop additional disorders, such as infections or confusion. Also, nurses may call a doctor to discuss problems and changes in treatments.

Many nursing homes provide other health care services, such as oxygen treatments and drugs or fluids given by vein (intravenous therapies). Almost all nursing homes provide rehabilitation, including physical, occupational, respiratory, and speech therapy. Many people are admitted to nursing homes specifically for rehabilitation, then are discharged after several weeks.

Dentists and medical specialists, such as ophthalmologists, neurologists, or psychiatrists, may examine and treat residents on site. But most often, people with a specific problem have to be transported to a different site for treatment. Some nursing homes have special units for people with dementia. These units are staffed by specially trained nurses. Many nursing homes provide hospice care for people who are dying.

Almost all nursing homes have a social worker on staff. Social workers help residents adjust to the home. They identify residents who are lonely and withdrawn and help residents, staff members, and family members communicate with each other. They may also help residents and family members make financial arrangements. For example, they may show family members how to apply for Medicare and Medicaid coverage.

Social workers often help coordinate the care provided by the different health care practitioners in a nursing home. These practitioners work together to enable each resident to function as well as possible and to have the best possible quality of life.

Some nursing homes provide the minimum of services in an institutional, impersonal environment. They may resemble hospitals more than homes. However, many nursing homes are trying to change from a more institutional environment with rules and regulations to a more homelike environment that gives residents more control over their care. Some nursing homes permit pets, encourage residents to maintain existing hobbies or develop new ones, and provide many opportunities for contact between residents and people of all ages who live in the community around the nursing home. Providing this kind of environment is complicated because the residents of nursing homes are usually sick and frail. Many nursing homes have dining rooms, recreation rooms, beauty salons, patios, and gardens. All nursing homes provide recreational and social activities.

Nursing homes are highly regulated by the government. State health departments conduct surveys and inspections to monitor and evaluate quality in nursing homes. A copy of this evaluation is kept at the nursing home and can be reviewed by residents and their family members. Many homes also use other programs that monitor and help improve the quality of care. For example, nursing homes that are part of a network or chain usually have their own monitoring programs in addition to those of the government.

Even though nursing homes are monitored and regulated by government, they vary considerably in quality, personality, and cost. So people or family members who are interested in a nursing home should try to get as much information as possible. They can ask the administrator of the nursing home to see the state's evaluation of the home. Similar information is available on the Internet. One evaluation called the Quality Indicator Report looks at how well a nursing home handles specific problems. These problems commonly develop or worsen in residents of nursing homes but can be prevented with attentive care. They include a decline in the ability to do daily activities, undernutrition, weight loss, pressure sores, incontinence, constipation, infections, depression, and use of too many drugs. Whether these evaluations are valid is debated. Nonetheless, they provide information that can help people better compare nursing homes.

Other important questions to ask the administrator include whether the nursing home is certified to provide Medicare and Medicaid coverage, how often care of residents is reviewed, and whether residents and family members are included in the review of care. For some questions, the administrator may direct people to the nursing home's medical or nursing director.

Talking to other people who are familiar with the home is helpful. Such people include long-term care ombudsmen (who visit nursing homes and investigate complaints), doctors, clergy, family members of residents, residents, and employees of the nursing home. Some homes have resident organizations, consisting of family members and friends of residents who meet to discuss issues that come up in the nursing home. These organizations can provide family members of prospective residents with helpful information. However, visiting a home for several hours is usually the best way to determine whether the quality of services is good and whether the home will be a good place for a loved one.

In the United States, Medicaid and private funds pay for most nursing home care. Medicare pays for skilled care for a short time in certified nursing homes if care is needed daily after a hospital stay lasting 3 days or more.

See the sidebar Delaying the Need for a Long-Term Care Facility

See the sidebar Choosing a Nursing Home.

See the table Types of Long-Term Care.