Post #35 A comprehensive guide to senior living communities (#5/5 in a series)

Where Baby Boomers can begin in their search for senior living communities

Welcome to Part 5 of our five-part series on getting started in your senior living journey. We’ve come a long way! In parts 1 and 2 we talked about mentally preparing for this journey (posts 28 and 31). In post #33, I gave you an overview of all the Stay-at-Home and Senior Community options - 14 in all! ; Post 34 discussed the seven “Stay-at-Home options in detail; In this post 35, I will discuss the seven Senior community options. Some of these you may know, some you may not. Put this all together, and you will be the senior living expert in your neighborhood!

Senior Living Community Overview

This is a long post – over 4,000 words. However, I wanted you to have everything out there today in one post, so you won’t have to go digging up multiple posts when looking at senior living communities. Think of it as a chapter in a book. You don’t have to read all of it in one sitting – but it is here for your reference.

You may think that you have a decent idea of the senior industry and the choices out there. Most of you know what a nursing home is and probably have been in one, usually as a visitor. Some of you may have had Rehab in one. (I hope it was not too unpleasant!). Many of you have also probably been in an assisted living community, with a parent or relative. Some are OK, and some are very nice. You may be a bit confused about “memory care” communities. Are they a nursing home? An assisted living community? Its own thing? I will explain below. And how about Independent Living? Is it a retirement community? You may have recently heard about “active adult” communities. What the heck is that?

It all will be explained below.

But first I want to say this. For the last 65 years, we have all lived in a world where there even was a thing called senior living. It used to be called “a home.” Nursing homes started in this country around 1960 when for the first time, there was a need to take care for about one million people. However, as I’ve discussed in other posts, it was an institutional model. They used the hospital as the model to build nursing homes. In past posts I’ve described this as “the big mistake.” Who wants to live in a hospital?

Then in 1990, assisted living came along. There were three million people who needed some care at this time. Many of these folks did not need high-level nursing home care - cared for by nurses - as they were frail, but not necessarily medically challenged. They needed personal care by a nurse assistant. So, the assisted living industry was invented for these folks. They also changed the model to be more residential in nature, rather than institutional – fixing the big mistake.

However….despite this being a big improvement over nursing homes, there was and still is a somewhat institutional “feel” in many assisted living communities. In fact, there is what I call an “ick” factor in many senior living communities – of any type. It’s just this queasy feeling one gets – even in the nicest of places – of having a living situation filled with only older seniors. Something about it feels unnatural, and is a turn-off to many Baby Boomers. All of these senior communities were built for the last generation - not us Boomers. Hopefully, with our input, we can start making a difference and creating communities Boomers will feel comfortable in.

I know it’s a bit controversial for me saying this – and I’m in the senior living business! Hopefully, it will not be a deal breaker for you – if and when you feel you need a senior living community instead of a “stay-at-home” option.

Ironically, as time has gone on, things have evolved. Nursing home have almost turned into hospitals, with very high medical acuity. Many assisted living communities have become higher acuity as well – and with the help of technology, some now almost feel like nursing homes. People with a need for “lighter” care can now sometimes live in an “independent living” environment.

As we delve into the weeds below, here are some real basics regarding the three basic types of senior living, their payment and acuity level:

Nursing home: are for those on Medicaid and have run out of funds, or with a very high level of care, and also the place where people go for Rehab – (paid by Medicare) for a few weeks; as well as for high level dementia care.

Assisted living: is private pay – if you have the money, you generally will go to assisted living rather than a nursing home. It is for for light to heavier care. Prices are between $4,000-8,000 per month, the difference being in the amenities and high-end real estate that money can buy.

Memory Care: it has the same license as assisted living – not nursing homes. You will see most memory care “neighborhoods” (wings) in assisted living communities. In fact, if you have been diagnosed with dementia, but are still functioning decently and are in the early stages of dementia, you generally move into an assisted living neighborhood first, then eventually move into the memory care wing. If that is the case, make sure the AL you move into has a MC wing! Some do, some don’t. Memory care is generally about $1,000- 2,000 more than assisted living care, or $5,000-9,000 per month.

As we move through all seven choices, I will give you a brief synopsis on each one, and then comment on eight characteristics of each so you can have a good perspective of comparison on pricing, food, activities, socialization and overall quality of life.

Moving to a Senior Community

Let’s start with more independent living communities

Active Adult Communities (AA)

Active Adult are a newer type senior communities and the new buzzword in the industry. It is what it sounds like. It is for seniors 55 and up who want an active and maintenance-free lifestyle. From what I have seen it is for people in their sixties and seventies. You usually can purchase a small cottage, or have a one or two bedroom apartment. It is basically your independent retirement home on steroids. There is no personal care in AA communities, but lots of golf, tennis, food and martini’s.

The upside – lots of meals, socialization and things to do; kid-free without having to lift a finger.

The downside – lack of diversity in age and sometimes race, there is no personal care; and is kid-free. It’s not for those who enjoy the diversity of city life.

· care quality - there is no care

· affordability – market driven. Nicer ones cost more

· food choices - most AA communities have pretty good food. That is their main amenity.

· activity choices – great.

· socialization – excellent. This is one of the reasons why you would be there.

· ability to do what you want when you want – Good to great.

· real life vs recreated one – medium. It’s a senior community with all seniors. Some will feel more like “real life” than others.

· overall quality of life - pretty good. Though plan on seeing lots of pictures of grandkids.

Independent Living Community (IL)

Independent Living communities are the newer version of what was once called Retirement Homes. You are “independent” – meaning, that you are not in need of personal care from a caregiver. You generally will have a one or two-bedroom apartment with a full kitchen, receive two to three meals a day, and have an activity program, which can be on the continuum from OK to quite robust. You can purchase housekeeping and laundry, and of course there is no more snow removal and lawn care to worry about. Since there is little or no personal care, these communities are generally NOT licensed by the State. They are apartments on steroids for seniors.

Funny though – many people DO need some level of care. In these cases, the owners of the building/company are generally NOT allowed to provide the care that you may need. However, you can (and many do) purchase your own care from a local home-healthcare provider, just as if you were in your own home.

Sometime, when there are enough people receiving care, there is a homehealth care provider with an office in the building, and you can purchase personal care from them on an a la carte basis. This is convenient and is less costly as usually you can purchase care in smaller increments than the 3-4 hours which is usually the minimum amount of hours you can purchase from a homehealth company.

Many upper scale Independent Living communities have assisted living and memory care neighborhoods in different buildings on the campus, and some have them right in the same building. This can be convenient, knowing that if you become too ill or frail, you can move to the assisted living community on campus. If they have that AND, also have a nursing home as well, then they might be called a Life Plan community – see below.

· care quality - no care in Independent Living, although in some places you can purchase it a la carte. It’s nice to have it available in case you need it.

· affordability – market driven. Nicer ones cost more

· food choices - most IL communities have decent food. That is their main amenity. Some are better than others.

· activity choices – most IL communities have a decent amount of activities. Like food, some are better than others.

· socialization – excellent. This is one of the reasons why you would be there.

· ability to do what you want when you want – Good. It is still independent. However, meals and activities will have times associated with them.

· real life vs recreated one – medium. It’s a senior community with all seniors. Some will feel more like “real life” and some won’t. Each is different. Some could have a bit of the “ick” factor (too many old people around doing old people things).

· overall quality of life – being in independent living can help you live longer. You probably won’t do physical things that you would do at home, which could make you fall and hurt yourself. You’ll have lots of socialization, two to three solid meals a day, and pre-made activities. Not bad. The downside is it’s not really real-life, you aren’t in your own home, it is usually fairly homogeneous and the people you are hanging out with are strangers, at least at the beginning. Like in Active Adult, you’ll see a lot pictures and hear a lot of talk about grandchildren.

Assisted living community (AL)

This is where you go when you need not only personal care, but also 24-hour supervision. That is hard to get at home and too expensive. It was a positive evolution from the nursing home. Some AL’s have nurses, some do not, but all have personal caregivers 24/7. This is mostly for the “frail” elderly, although as the years have gone on, some AL’s now take higher acuity residents. The real nice ones can be beautiful, but if the acuity is too high, it can feel like a “dolled-up” nursing home – which can be OK, as you are there because you need the care. There is strict programming on meal times, and in nicer communities the food is generally pretty good. There are mostly large group activities throughout the day, which you may or may not like. It’s great if you need a lot of personal care, and is much better than a nursing home – if you can afford it. They are generally month-to-month leases ranging from $4,000-8,000 per month depending on how upscale it is, where it is located, and how much care you need. Average prices in Michigan are $4,500 - $5,500. They is similar in care to the small group homes described below. Most AL’s have between 20-60 people. Many have a memory care neighborhoods as well.

care quality - generally good, some excellent, but market driven (you get what you pay for). This is the primary reason you are there. Like all senior communities, some have staffing issues which can make you wait for care sometimes. A good staffing ratio is from 6-1 up to 8-1 ( people per caregiver) in daytime hours, double that at night. Be careful if the ratio’s are higher than that. Smaller group homes have a ration of 3-1, which is great. Nursing homes generally have higher ratios 10-1 or even 15-1. Watch out for that.

food choices - generally mediocre, and market-driven. The more you pay, usually the better the food. I’d try the food before moving in. They almost always invite you to lunch if you ask. Most have options where you can get a salad, soup or sandwich at any meal if you don’t like what they are serving that day.

activity choices – again, market driven – higher priced ones have more activities with better quality. Most have group activities throughout the day, which may or may not be for you. Better ones will have more small groups, which will give you more of a chance of doing things you like to do.

socialization – there are plenty of people around. That is another reason you are there. However, many of the people may have some dementia or be quite physically limited, so even if there are twenty or thirty people there, you may not find that many people you can be friends with, but there usually is one or two persons you can connect with.

Real life versus re-created one: this is the re-created version of life. Not much real life here - in terms of social life. They are kind of making it up for you. However, there is plenty of real-life drama, especially with your health.

overall quality of life – it can go either way. Market and mission driven.

Small group home (3-6 people)

This can be a viable alternative for people who can’t or don’t want to stay home, but also don’t want to move into a larger assisted living community. It’s like deciding which high school or college to go to – The larger ones have better amenities, but the smaller ones have more intimacy. Small group homes have better resident assistant to resident ration’s, 3-1 and 4-1. Usually the food is not as good as in a larger communities, as it is not provided by a professional cook. But it could be homey if you get lucky with a good, natural cook. In general, the larger places have more “professionalism” with higher paid administrators and department heads, and sometimes that translates into better food, care and activities. But sometimes it doesn’t. If you need a lot of personal care and are not going to be very active, this could be a good choice for you.

care quality - generally good with low resident-staff ratio’s. However, not much backup and if someone calls off, it can be difficult.

food choices - generally mediocre food made by the staff. The larger places will have more variety and usually better food, unless you get lucky, and one of the caregivers is a good cook.

activity choices – larger communities will have more choices and variety. This is usually the weakest part of a smaller home. They usually don’t hire a dedicated activities staff so the activities are done by the caregivers, who generally are not that interested in the activity side of their job. Small group homes have lots of crafts, card games and TV.

socialization – there are less people around, and hopefully you will find one person to be friends with. But maybe not. For real extroverts, larger communities will probably be a better fit. Introverts may like the smaller ones.

real life vs recreated one – it’s real. 6 people who need personal care living together in one small, single-family home. There aren’t many places to go or things to do. But that may be OK.

overall quality of life – it can go either way depending on them and on you.

Memory care (dementia) community (MC)

Memory care communities are usually in an assisted living community. They usually have the same license as an AL. They are there for people with moderate to severe dementia. The truth of the matter is that most MC communities are not very good, even in the best of places. They may have fancy lobbies and common areas, and provide reasonable personal care, decent meals and some activities, but unfortunately, most of the nurse assistants will have minimal training in how to care for and maximize the quality of life for someone with dementia. It takes a real specialist to understand all the different behaviors within dementia. There are seven primary dementia’s with Alzheimer’s Disease being the most prevalent among people, with over fifty percent of all diagnosis.

Try and find a place that has true passion for caring for people with dementia. Ask who the Memory Care Director is. Ask about their credentials. Ask what the training is. Ask them to prove to you the caregivers know what they are doing when it comes to understanding the disease, and especially the dementia that your loved one may have. I would ask the caregivers themselves if they know the difference between Alzheimer’s, Lewis-body, Parkinson’s and Frontal Lobe dementia (google about dementia and get a quick understanding yourself).

In reality, most MC communities provide what we call “custodial” care. In other words, they take care of the personal care, meals, and offer some activities, but they really do not have a true, memory care program. They do their best to keep people comfortable.

The costs of MC are generally $1,000 to $2,000 more than assisted living, or somewhere between $5,000 and 9,000 per month. The average price in Michigan is about $6,500.

Most MC communities categorize people with dementia as having early stage, moderate stage, or later stages. Most people with early stage dementia who do not display negative behaviors can live in the assisted living neighborhood. It is when someone starts displaying negative behaviors and has moderate to severe dementia when they may suggest a move to the memory care neighborhood. Also, not all places take people with later stages. Sometimes only a nursing home may take these people.

It’s a sad disease. Your loved one may eventually not know you, and not know who they are and where they are. Try to find a place as loving and gentle as possible, who will make your loved and you, feel as comfortable as possible.

care quality - generally ok depending on resident-staff ratio’s. Generally, the more you pay, the better the ratio’s and the care.

food choices - generally fairly mediocre food. However, depending on a person’s cognitive level, this may not be a priority. The larger places will have more variety and usually have better food.

activity choices – this will depend upon the acuity of the person. Most MC communities have activities throughout the day. However, unless the staff is highly trained, they usually are lower-level versions of what they are doing in assisted living that day. There will be lots of crafts, card games and TV. The better places have “sensory” programs, which focus on providing one-on-one activities that activate the each of the senses.

socialization – there are usually lots of people around. However, they may or may not be able to socialize, depending on the level of dementia of each person.

real life vs re-created one – it is real life; dementia can do that to you. It is a re-created one as well. In MC, not having a “real-life” environment is not the issue like it is in AL. We are looking for compassion, safety, and comfort here.

overall quality of life – again, this depends on the level of dementia each person has, and the community’s ability to create a program that fits for that person.

Nursing Homes

This was the first senior living with care in this country, starting in 1960. It is an institutional model and quite frankly, is obsolete. Unfortunately, because you need a special license to be a nursing home, and the State allocates only so many per region, not many new nursing homes have been built. So, most nursing homes are 30-60 years old.

Almost 95% of people in nursing homes are on Medicaid and are there because they don’t have the funds for assisted living. Or, they are there for a few weeks in Rehab, paid for by Medicare. Very few people pay private pay anymore, because if you have the money, you will go to an assisted living community. Occasionally, even if you have the funds, you will need a nursing home if you have severe physical needs such as a trach, catheter, IV or need other medical interventions. Nursing homes are staffed with nurses and half nursing assistants, where most assisted living communities are predominately staffed with nurse assistants only. Some AL’s may have one nurse manager.

Nursing homes were built from a hospital model, so most have two people in a room like a hospital. Generally, the food is lousy, and the activities are large, group activities like bingo, current events, or some music.

I wish I had better things to say about nursing homes. The people who work there are generally great, and many have a true passion for people. But with the physical buildings being what they are, it is hard to have a good quality of life there. You go to a nursing home when it is your last resort.

Private pay is huge, at $9,000 per month, but few pay that amount. Generally, Medicaid picks up the bill.

care quality - this can vary upon the community. Some Medicaid homes have very high staff ratio’s – 10-1 to 15-1. With higher staff ratio’s come less time with each person and lesser quality of care. In general AL communities have better staff ratio’s and subsequently better personal care.

food choices - generally not that great in nursing homes. It’s like hospital food.

activity choices – not much choice in a nursing home. They will have a few group activities during the day which the person may or may not like or be able to do. Expect lots of crafts, card games and TV.

socialization – there are people around. Whether you can form a relationship with them will depend on how cognizant each person is. It’s lucky if you find a friend.

real life vs recreated one – this is as far from independent living as possible. This is institutional living. The better ones try to bring in pets and have some intergenerational programming to break things up overall quality of life – you are in a nursing home because you need a high level of care, and/or you have run out of private pay funds to pay for assisted living. It is hard to have good quality of life in an institutional setting.

Life Plan Community (formerly called CCRC)

This is the type of senior community where you have ALL of the levels of care we have talked about above on one campus – IL, AL, MC, and NH, although most of the people are in Independent Living. In these settings, you generally pay a large up-front fee, anywhere from $50,000 to $500,000, which you can all or mostly back upon leaving (you know that that means). Most people like Life Plan communities for two reasons - in theory, you get first priority if you have to move from Independent Living to Assisted Living or to the nursing home. Second, you don’t have to worry about where you will move to when you may eventually need those services. In other words, it’s your last stop. You still will pay a fairly decent monthly fee, but it will be only slightly less than the IL, AL, or MC, fees in the stand-alone communities mentioned in 5,6 and 7 above.

People are generally happy in Life Plan communities. They are usually moderately to extremely upscale, as you have paid a good amount of money to be there. The food is generally pretty good, as they have the funds to pay decent salaries. There are plenty of activities and lots of socialization. The personal care in the AL’s, MC’s and NH’s are generally equal to or above the stand-alone communities mentioned above as again, they pay a competitive wage. And again, it gives people good amount of peace of mind knowing they will not have to move off campus if they need AL, MC or NH care in the future.

The downside- you are living with hundreds and hundreds of older people.

care quality - usually pretty good, if you need it.

food choices - usually pretty good in the Independent Living area, which is for most of the people.

activity choices – again, pretty good. When you have hundreds of people in Independent living, there is the budget to have a lot of activities.

socialization – If you like older people, this is the place to be.

real life vs recreated one – It can feel a little artificial here. No one really has any responsibilities. Everything is done for everyone. It is maintenance-free living. Some people like that. Some don’t.

overall quality of life – you generally will live longer if you live in a LifePlan community. You won’t hurt yourself changing a light bulb or getting on a ladder like you may at home. Again, most people who move to LifePlan communities are the people who like that lifestyle. So, they are happy.

Note: There have been recent articles of a few Life Plan Communities which have gone out of business. In that case, people lost all their deposit money! (This isn’t relevant in the other senior living communities as mostly they are month-to-month rentals). This has only been in a small percentage of communities, but since you are putting down a large amount of money – possibly most of your estate – do your due diligence and research on any community you are thinking of moving into.

Rehab - (short-term)

At some point, if you fall, have an accident, a hip replacement, or are recovering from a procedure, you may need “Rehab.” Rehab is paid for by Medicare and is a short-term stay while you are mending from whatever you are recovering from. Medicare pays up to 100 days, but only 100% for 20 days, and then 80% for the remaining 80 days. What most people don’t know is that most Rehabs are in nursing homes. This is where the nursing home makes most of their money. Most rehab stays are under 20 days. They “kick you out” when you are no longer making progress. Rehab used to be longer, but since the advent of Medicare Advantage Plans, they have shortened the time they allow you to stay. There are some nursing homes that do NOT take Medicaid and were built recently just for Rehab. They will have a nursing home license, but are not really a nursing home. Try to find one of them if you need Rehab!

I hope this guide on Senior Living Communities was helpful. If you have any questions, please do not hesitate to communicate with me. We’d be happy to help.

Stay tuned!

Dean Solden is the founder and owner of Creative Senior Solutions (CSS), a management, development and consulting company specializing in senior living. (www.creativeseniorsolutions.com).

Subscribe to this blog at BabyBoomerBlog.substack.com which is a discussion with readers about how Baby Boomers are aging and navigating the world of senior living.

You can reach Dean at (734) 260-3600 or dean@creativeseniorsolutions.com.

If you like music, check out Dean’s music at deansoldenmusic.com for some jazz, blues, and funky piano/vocal tunes

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