Long-Term Care

Are you attempting to weigh assisted living versus nursing home care as an option for yourself or a family member? Many Americans just like you are doing exactly that. They’re looking for clear answers about senior living possibilities and the differences between them. Thankfully, this article can help to find some of those answers.

With help from this article, you can start making informed decisions that result in a comfortable, connected, and care-focused quality of life for you or your loved one. After all, a lot of today’s nursing homes and assisted living facilities are warm, homelike communities where older adults enjoy kindness and respect, make new friends, entertain visitors, and pursue satisfying leisure activities.

As you’ll discover, there isn’t just one main difference between assisted living and nursing home care. Rather, each type of senior care community has several special and defining characteristics. In this article, you’ll learn more about those differences as they relate to the following aspects:

Terminology

The “assisted living vs. nursing home” topic is best understood when you know what each term means. It also helps to know the other terms that are frequently used for the same types of senior care options. To that end, here are basic definitions that begin to clarify the difference between nursing home and assisted living options.

An assisted living facility (ALF) is a place where seniors or adults with disabilities live semi-independently and receive limited help with certain day-to-day activities. Assisted living communities tend to provide various hospitality and personal care services, 24-hour emergency response protocols, and regular opportunities for recreation and social interaction. The exact levels of care and types of services that are offered vary from facility to facility and often depend on state regulations. Other terms that are sometimes used when referring to assisted living include:

• Assisted care
• Residential care
• Supportive housing
• Supported living
• Adult foster care (in facilities with no more than four residents)

A nursing home is a place where residents who cannot live independently receive extensive and ongoing care due to old age, disabling medical issues, or other kinds of physical or mental conditions that require continuous monitoring or supervision. Nursing homes tend to provide more frequent and comprehensive personal care services than what you will find in assisted living facilities. They also provide easier access to skilled nurses. In some cases, people use the following terms when describing nursing home care:

• Long-term care
• Extended care
• Rest home
• Care home
• Intermediate care home

A skilled nursing facility (SNF) is a specific type of nursing home (or a special unit within a nursing home) that focuses on providing services that can only be carried out by registered nurses (RNs) or licensed practical or vocational nurses (LPNs or LVNs). Skilled nursing facilities are mostly intended for people who need short-term medical care or rehabilitative services outside of a hospital following surgery or other serious medical treatments. Examples of skilled nursing care procedures include:

• Giving injections
• Inserting catheters
• Using aspiration devices
• Inserting IV feeding lines
• Treating widespread skin diseases
• Applying dressings to infected wounds
• Assessing and educating patients
• Planning, managing, and evaluating patient care

Personal care (also known as custodial care) is assistance that doesn’t require the skills of a registered or licensed nurse. That’s why personal care is a stronger focus within facilities that provide assisted living (vs. skilled nursing facilities, which have a stronger focus on skilled care for medical conditions). Examples of personal care services include:

• Helping residents eat, bathe, get dressed, or go to the bathroom
• Administering routine oral medications, ointments, or eye drops
• Applying creams for minor skin problems
• Repositioning residents in their beds
• Changing dressings for non-infected wounds
• Helping residents walk, get around in wheelchairs, or stay mobile through other means
• Assisting with routine maintenance of bladder catheters or colostomy bags
• Supervising residents who have dementia

Common Types of Residents

When it comes to weighing nursing home versus assisted living options, it’s essential to understand who is best served by each type of facility. That way, you can feel more confident in your decision-making while potentially avoiding a costly or unnecessary move later on.

Assisted living is usually suitable for people who:

• Are open to the idea of getting assistance
• Can benefit from a more socially engaging living environment
• Are able to walk or use mobility devices on their own
• Need a limited amount of supervision or personal care assistance
• Are lucid or have only mild cognitive problems
• Want or need to be free of the responsibilities of home ownership

Nursing home care is often necessary for people who:

• Need daily medical care and/or a lot of personal care assistance
• Aren’t able to walk or get around in other ways without help
• Are too sick or frail for home care
• Need round-the-clock supervision or monitoring
• Have severe problems with incontinence
• Are likely to need frequent visits to the hospital
• Have moderate to severe cognitive problems
• Have complicated medical, emotional, or mental conditions
• Resist when being given assistance
• Display problematic behaviors

Many assisted living facilities welcome residents who have early to middle-stage dementia, including people with Alzheimer’s disease. When those residents require 24-hour supervision (for their own safety and the safety of others), they often need to move into nursing homes that have special memory care units.

Typical Living Spaces

Everyone wants a comfortable living environment. That’s why most assisted living facilities and nursing homes strive to create warm, homelike atmospheres where residents can socialize and accommodate visitors. However, beyond that shared goal, these two types of senior living options tend to have some very recognizable differences when it comes to the actual living spaces they offer.

Assisted living facilities:

• Tend to feature private or shared apartment-style units or studios
• Often feature units with small kitchens
• Generally give residents a lot of freedom in decorating their spaces
• Provide communal dining rooms
• Provide a lot of shared recreational space
• Serve about 28 residents each day, on average, according to CDC

Nursing homes:

• Mostly offer shared or private hospital-style rooms
• Sometimes provide a little less freedom when it comes to decorating
• Provide communal dining and living areas
• Tend to offer less recreational space
• Serve about 88 residents each day, on average, according to CDC

Cost and Payment Methods

According to Genworth, in 2023, the national median cost was $7,944 per month for a shared room in a nursing home (vs. assisted living costs of $5,628 per month). For a private room in a nursing home, the cost was $8,898 per month. So, although costs vary from facility to facility, assisted living usually costs quite a bit less than nursing home care.

But looking at cost alone doesn’t provide the full picture. That’s because how you pay for services may play a larger role in determining your options. For example, many seniors rely on Medicare and Medicaid, but those government programs don’t always provide the necessary coverage.

When it comes to assisted living:

• Most residents (or families) pay out of their own pockets.
• Some people are covered through private long-term care insurance.
• Many former military members (and/or their spouses) are able to pay using veterans’ benefits.
• Some states provide Medicaid coverage if you meet certain eligibility criteria.

When it comes to nursing home care:

• Most residents, if they are eligible, pay for it with Medicaid.
• Some people pay for it out of pocket or with private long-term care insurance.
• Under certain conditions, some patients receive temporary coverage through Medicare.

Medicare Part A, which is a federal government program, will temporarily cover the costs of care in a skilled nursing facility (SNF) under specific conditions. Medicare.gov says that, in order to qualify, a patient must have spent at least three days in the hospital prior to his or her stay in an SNF. Medicare will then fully cover the costs of care for the first 20 days in the SNF. After that, Medicare will continue to pay a portion of the costs for up to a total of 100 days. (During that time, a patient will need to pay a copay of over $214 per day.) When Medicare coverage runs out, the patient must cover all costs of care in the SNF.

In contrast, Medicaid is often used to pay for extended stays in nursing homes (and, less commonly, in assisted living facilities). Medicaid is a joint program of the federal government and individual state governments. Each state gets to set its own eligibility criteria for Medicaid benefits. As a result, the rules about long-term care coverage vary from state to state.

In general, however, a long-term care resident can often qualify for Medicaid coverage if he or she meets a few basic conditions. First, the long-term care facility must be licensed by the state and accept Medicaid payments. Second, the resident must have proof from his or her doctor that the long-term care is medically necessary. Finally, the resident may have to prove that his or her income and financial assets fall below a specific state-mandated threshold.

By Kathleen Doheny  Wed., Nov. 1, 2023

Your doctor for many years is hanging up his or her stethoscope. How do you find a new doctor and manage the transition? 

You saw the signs. You should have seen it coming. But then, here it is in black-and-white, the letter making the breakup official. “Dr. X regrets to inform you that s/he is retiring after 40 years of practice.  Dr. X is sorry to go, has enjoyed taking care of you and wishes you the best of health moving forward.”

Act Fast

It may leave you in a frantic quandary: How do you find a new doctor, one as good as this beloved primary care doctor (or your favorite specialist)?  Or, alternatively, how you do find a new doctor when you’re dissatisfied with the one you have?

In either case, action immediate action is crucial, according to the experts we interviewed.

“Find your new doctor before exiting your old doctor,” says Trisha Torrey, founder of the Alliance of Professional Healthcare Advocates and, more recently, of Every Patient’s Advocate. She wrote “You Bet Your Life: Mistakes Every Patient Makes.”

Even though your current doctor may not actually exit for a couple months, don’t delay, she says, as the necessary pre-exit actions take time. 

If you are in a large healthcare system, your doctor may refer you to a partner or other colleague. Your insurance provider may also provide you with a list of other doctors in the network, says Caitlin Donovan, senior director of the Patient Advocate Foundation, a nonprofit organization in Hampton, VA, offering case management and financial assistance to those with chronic, life-threatening diseases.

Do Your Research

Still, do some of your own research. Many people ask friends for suggestions, then find out too late that the doctors they suggested don’t accept their insurance. Torrey says, “I say, start with your insurance, and then ask your friends.”

As you’re working your way through the list of potentials, be sure you can get access to your medical records so they can be transferred. Sometimes a letter telling you about the retirement or move will include an authorization form you can return to them for release of medical records.

Transferring records seems simple in this digital world, but it’s not always, Torrey says. Her suggestions: work ahead; get a thumb drive and take it to your retiring doctor’s office and ask them to download it. “Keep your own copies, too,” Donovan says, once you’ve transferred them.

As you narrow down the list of candidates, what else?

• Study the reviews. Torrey suggests scrutinizing them in a way that might be new to you. “You’re not looking for someone who is nice,” she notes.  “Nice doesn’t always equal competent.”  If a doctor got 5 stars – for what? Office cleanliness? Friendly staff? What about the quality of patient care, callback times, and other crucial information?
• Read the negative ones, too. Donovan was searching for a new doctor and found a negative view that sealed the deal for her. “A disgruntled patient was complaining she didn’t want to take the COVID vaccine,” she remembers, and this doctor wouldn’t give her an exemption. Donovan read further and found out the patient was a hospital nurse and had offered no reason she couldn’t get the vaccine. The doctor’s refusal to grant an exemption convinced Donovan this doctor shared her views.
• Be aware of the shortage. According to the Association of American Medical Colleges, by 2034, there may be up to 124,000 fewer doctors available. Pandemic burnout took its toll. A survey of more than 3,500 doctors by the Physician Foundation found that 8% closed their practices due to COVID. So the doctor you want may not be accepting new patients. If that’s the case, Torrey suggests: Contact your previous doctor, if possible, and see if he or she will ask the new doctor to accept you as an exception.
• Think about the practical aspects, Donovan says. For her, proximity is important, as she doesn’t have time to drive 45 minutes to an appointment.
• Ask the questions important to you: How does your office communicate between appointments? Is it possible to email questions between appointments? Do you offer virtual appointments? What is the doctor’s approach to medical conditions – treat quickly with medication or try lifestyle or other approaches first? How do you handle prescription refills?
• At the First appointment: Notice if your styles mesh. Donovan says she likes a no-nonsense approach, but also likes ‘’someone who will get chatty with me.” Others may need the opposite, perhaps a little coddling but no small talk.

It’s very likely that all of us, at some future point, will get a farewell letter from our long-time medical professional.  Acting quickly, obtaining records, and doing research are key to a smooth transition.

The patient moved into a large assisted living facility in Raleigh, N.C., in 2003. She was younger than most residents, just 73, but her daughter thought it a safer option than remaining in her own home.

The woman had been falling so frequently that “she was ending up in the emergency room almost every month,” said Dr. Shohreh Taavoni, the internist who became her primary care physician. “She didn’t know why she was falling. She didn’t feel dizzy — she’d just find herself on the floor.” At least in a facility, her daughter told Dr. Taavoni, people would be around to help.

As the falls continued, two more in her first three months in assisted living, administrators followed the policy most such communities use: The staff called an ambulance to take the resident to the emergency room. There, “they would do a CT scan and some blood work,” Dr. Taavoni said. “Everything was O.K., so they’d send her back.”

Such ping-ponging occurs commonly in the nation’s nearly 30,000 assisted living facilities, a catchall category that includes everything from small family-operated homes to campuses owned by national chains. It’s an expensive, disruptive response to problems that often could be handled in the building, if health care professionals were more available to assess residents and provide treatment when needed.

But most assisted living facilities have no doctors on site or on call; only about half have nurses on staff or on call. Thus, many symptoms trigger a trip to an outside doctor or, in too many cases, an ambulance ride, perhaps followed by a hospital stay. Twenty years after the initial boom in assisted living — which now houses more than 800,000 people — that approach may be shifting.

Early on, assisted living companies planned to serve fairly healthy retirees, offering meals, social activities and freedom from home maintenance and housekeeping — the so-called hospitality model.  But from the start, the assisted living population was older and sicker than expected. Now, most residents are over age 85, according to government data. About two-thirds need help with bathing, half with dressing, 20 percent with eating.

Like most older Americans, they also generally contend with chronic illnesses and take long lists of prescription drugs — and more than 80 percent need help taking them correctly. Moreover, “these places became the primary residential setting for people with dementia,” said Sheryl Zimmerman, an expert on assisted living at the University of North Carolina at Chapel Hill. 

About 70 percent of residents have some degree of cognitive impairment, her studies have found. So residents can find it difficult to coordinate medical appointments and tests, and to travel to offices and labs, even when facilities provide a van.

“The assisted living industry has to recognize that the model of residents going out to see their own doctors hasn’t worked for a long time,” said Christopher Laxton, executive director of AMDA, a society that represents health care professionals in nursing homes and assisted living.

His recent editorial in McKnight’s Senior Living, an industry publication, was pointedly headlined: “It’s time we integrate medical care into assisted living.” AMDA is considering developing model agreements. “There has to be more attention to medical and mental health care in assisted living,” Dr. Zimmerman agreed. “Does everyone who falls really need to go to an emergency department?”

Lindsay Schwartz, an executive at the National Center for Assisted Living, a trade association, said in an email that “assisted living has certainly expanded its role in providing medical care over the years by adding nursing staff and partnering with other health care providers, among other ways.”

But persuading most operators to provide medical care likely won’t happen without a fight. They’ve built their marketing strategies on looking and feeling different from the dreaded nursing home, and they object to “medicalizing” their communities. “They don’t want the liability,” said Dr. Alan Kronhaus, an internist who, with Dr. Taavoni (they are married), started a practice called Doctors Making Housecalls in 2002. 

The facilities also “live in mortal fear of bringing down heavy-handed federal regulation,” he said. That can happen when Medicare and Medicaid, which cover most residents’ health care, get involved. Doctors Making Housecalls provides one example of how assisted living can offer medical care. The practice dispatches 120 clinicians — 60 doctors, plus nurse-practitioners, physician assistants and social workers — to about 400 assisted living facilities in North Carolina.

“We see patients often, at length and in detail, to keep them on an even keel,” Dr. Kronhaus said. By contracting with labs, imaging companies and pharmacies, the practice can provide most of the medical care for more than 8,000 residents, on site and around the clock.  Working with a local emergency medical service, he and his colleagues reported in a 2017 study that the practice could reduce emergency room transfers by two-thirds. The Lott Assisted Living Residence in Manhattan, on the other hand, relies on a single geriatrician, Dr. Alec Pruchnicki, to provide medical care for most of its 127 or so residents.

If they’re feeling sick, a family member calls or the resident just knocks on the door of “Dr. P’s” basement office. “Sometimes it’s just a cold — chicken soup,” Dr. Pruchnicki said. “But this winter we had a few cases of flu and pneumonia, things you need to treat.” Nearby Mount Sinai Hospital employs him and provides emergency services when needed. Often, they’re not. In 2005, Dr. Pruchnicki reported at medical conferences, he decreased hospitalizations by a third. “I can’t be in the only place in the country where this would work,” he said.

Spending time in emergency rooms and hospitals often takes a toll on residents, even if their ailments can be treated. They get exposed to infections and develop delirium; they lose strength from days spent in bed. Perhaps that contributes to short stays in assisted living. Adult children often see these facilities as their parents’ final homes, but residents stay just 27 months on average, after which many move on to nursing homes.

Adding doctors to assisted living could also cause problems, advocates acknowledge; in particular, it might increase the already high fees facilities charge. But something has clearly got to give. “There can be health care in assisted living without making it feel like a nursing home,” Dr. Zimmerman said.

Family members tell of frightened and confused residents arriving unaccompanied at emergency rooms, unable to give clear accounts of their problems. Dr. Kronhaus recalls a resident with dementia taken to the local E.R. by ambulance; discharged, she was sent home by taxi. The address she gave the driver was her former home, where neighbors spotted her and called the police.

By contrast, the North Carolina woman with a history of falls is doing well. Dr. Taavoni discovered that her hypertension medications were causing such low blood pressure that she fainted. Reducing the dose and discontinuing a diuretic, Dr. Taavoni also weaned the patient off an anti-anxiety drug she suspected was causing problems, substituting a low dose of an antidepressant instead. The falls and the related emergency room visits stopped. Doctors Making House calls is still caring for her, and for most of the neighbors in her assisted living facility.

March 26, 2019

By Lois A. Bowers– Mcknight’s Senior Living

Almost one-fourth (24.5%) of private long-term care insurance claims began in assisted living in 2018, and two percent more (26.5%) ended there, according to new data from the Los Angeles-based American Association for Long-Term Care Insurance.

The steadiness reflects trends across all settings where private long-term care insurance is used — most claims end where they first began, according to AALTCI Director Jesse Slome.

“For the most part, people with long-term care insurance begin care in a specific setting — typically their home — and that’s where the claims ends due to death, recovery or the exhaustion of policy benefits,” he said.

In 2018, 72.5% of all long-term care insurance claims ended because of death, 14% ended because of recovery and 13.5% of claims ended because benefits were exhausted, the AATLCI found in a January study, for which the association gathered data from seven national long-term care insurance companies.

“There are many misperceptions about long-term care insurance, and we conduct these studies to provide consumers with current and relevant insights,” Slome said. “For example, most consumers associate long-term care insurance with nursing home care. Less than one in four new LTC claims begin with someone receiving care in a nursing home.”

More than half (51.5%) of claims began in home settings in 2018, and 43% ended there, according to the association. By comparison, 23% began in nursing homes and 29.5% ended there. One percent of claims began and ended elsewhere.

Long-term care insurance companies paid out a record $10.3 billion in claims in 2018, according to the American Association for Long-Term Care Insurance.

“The industry passed the $10 billion mark for the first time,” American Association for Long Term Care Insurance Director Jesse Slome said.

Benefits were paid on more than 303,000 traditional, health-based long-term care insurance policies, which represent the majority of policies. “Traditional long-term care insurance pays when care is needed at home, in assisted living communities or in a skilled nursing home environment,” Slome said.

The 2018 totals compares with total claims amounting to $9.2 billion paid to approximately 295,000 people in 2017, according to the advocacy organization.

The AALTCI expects claimants paid in 2019 to exceed 303,000.

Greg Says believes there is a need for more education regarding long-term care insurance. There are now several approaches to this valuable coverage besides the traditional long-term care insurance policy which is cost-prohibitive for many people today.  One approach that’s gaining popularity is a life insurance policy that includes a living benefits rider.

Premiums for tax-qualified LTC insurance policies are considered a medical expense.

By Marlene Satter| November 19, 2018 | ThinkAdvisor

Traditional tax-qualified long-term care insurance policies now have new tax deductibility limits, according to the IRS.

Premiums for tax-qualified long-term care insurance policies are considered a medical expense, according to the American Association for Long-Term Care Insurance, and for an individual who itemizes tax deductions, medical expenses are deductible to the extent that they exceed the current amount required to meet the individual’s adjusted gross income (AGI).

Neither hybrid nor linked benefit (life plus LTC or annuity plus LTC) policies qualify for the deductions. However, individual taxpayers can treat premiums paid for tax-qualified long-term care insurance for themselves, their spouse or any tax dependents (such as parents) as a personal medical expense.

The new 2019 limits for traditional LTC insurance premiums (that can be included as “medical care”) are as follows: If the policyholder’s attained age before the close of the taxable year is 40 or younger, $420 in premiums are deductible, unchanged from 2018. For policyholders 41 to 50, the limit is $790, versus $780 in 2018.

For those 51 to 60, the limit is $1,580, up from $1,560 in 2018, while for those 61 to 70, the limit is $4,220, up from $4,160. The largest deduction, for those more than 70 years old, is $5,270, up from $5,200.

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‘Greg Says’ believes this is good news for older policy holders who can benefit from the potential of a $5,270 qualifying expense (deduction) for a single person, or up to a $10,540 expense for a couple where one spouse now has big medical/dental/vision bills.