Carol Levine

Article / Updated 09-27-2022

Assisted living is a term that is often used as though everyone understands it in the same way. But that’s not the case. Assisted living is just a generic term like hotel or automobile that covers a lot of options. Before getting into the specifics, here's a simple definition: Assisted living is a residence where groups of people share meals and other activities and where individuals can receive personal assistance to maintain their independence. People who choose assisted living typically would have difficulty living completely on their own but do not require constant medical attention. You can also think about assisted living as an intermediate step in long-term care. It’s in the middle of the spectrum of long-term care, which often goes from independent living to assisted living to nursing-home care. Independent living can be in your own home or the entry level of assisted living or in special housing for older people. About 70 percent of residents in assisted living come to the facility from their own house or apartment. In this section I cover a more formal definition of assisted living, what services are included, which health care options may be provided, and tips for finding a facility to provide a broader understanding of all that assisted living covers. Interpreting industry and government language Most definitions of assisted living come from industry or government sources and emphasize different aspects of this setting. It’s important to keep the source in mind when you gather information. For example, Argentum (formerly the Assisted Living Federation of America), a trade organization, says, “Assisted living is a housing and health care option that combines independence and personal care in a residential setting.” This is a good definition as far as it goes, but it doesn’t tell you what personal care means and what health care services are likely to be offered. The Eldercare Locator, a free service connected with the federal Administration for Community Living (ACL), has an even more specific definition: “Assisted-living facilities offer a housing alternative for older adults who may need help with dressing, bathing, eating, and toileting but do not require the intensive medical and nursing care provided in nursing homes.” This definition, while accurate, doesn’t include younger adults who may want or need the kinds of services available in assisted living. It also underestimates the importance of the social aspects of assisted living. Living with a congenial group of people with whom to share meals, activities, and conversation is a potential benefit, since social connections have been shown to improve health and well-being as well as to reduce medical costs. Keep in mind, though, that it is sometimes hard to make new friends in assisted living because residences experience a lot of turnover. Most people stay in assisted living for only 22 months, according to the 2010 National Survey of Residential Care Facilities. Nearly 60 percent move on to a nursing facility, a third die, and the rest move home or to another location. Note: The 2010 survey has not been updated and has been replaced by a survey with a different name — the National Survey of Long-Term Care Providers. The Centers for Disease Control and Prevention (CDC) website has several recent reports on aspects of assisted living. State governments, which license group residences, call assisted-living facilities by different names. Some examples of state licensing categories are residential care facilities for the elderly (California), residential facilities for groups (Nevada), and personal care homes and assisted-living facilities (Pennsylvania). You may also come across the acronym ALF in your search. It is shorthand for assisted-living facility, not the character in the TV series popular in the 1980s. Similarly, ALP is an abbreviation for assisted-living program, not a mountain. Owners of assisted-living facilities tend to shy away from that term in the name, preferring more appealing names like village, community, manor, or any phrase that evokes a secure and invigorating lifestyle. Your state’s name for assisted living is not as important as its licensing requirements and its monitoring activities. Some states have detailed standards about what counts as assisted living and what must be provided, as well as building and safety regulations. States may require training for staff, background criminal checks, and other safeguards. Regulations in other states are less definitive. The National Center for Assisted Living, a provider organization, has information about state offices and a state regulatory review. Another important publication is the National Center for Assisted Living’s “Guiding Principles for Assisted Living.” This guide offers a good check on the kinds of information that providers should be giving you as a prospective resident, including contracts, finances, and resident transfers. When you check out your state’s regulations, find out whether it has a bill of rights for assisted-living residents. Most states have such a document and generally require facilities to post it and give copies to residents. These documents may be lengthy. Some of the items include the right to privacy, to confidentiality of personal and medical information, to have private communications with a physician or attorney, to practice the religion of one’s choice, and to be given notice about transfers or fee increases. Some are negative rights, such as the right not to be coerced or required to perform work. However, not all the documents tell residents how to complain if they feel their rights have been violated. One way is to contact the state’s long-term care ombudsman, who is responsible for investigating complaints in nursing homes and assisted-care facilities. You can find the ombudsman in your area. Or you can contact the National Consumer Voice for Quality Long-Term Care. What assisted living offers All assisted-living facilities, however defined, offer three main components: Shelter: Residents are given a place to live, usually a private unit or apartment. Meals: Food is provided, although not necessarily three meals a day. Staff: The facility staff provide the assistance that comes with the name. In addition to managers and activity directors, most facilities have aides or attendants to help with bathing, dressing, getting around with a cane or walker, and other daily tasks. When it comes to services provided by staff, you may frequently hear the term ADLs. It stands for activities of daily living, which are the actions people take for granted until they can’t do them by themselves anymore — dressing, bathing, going to the bathroom, and feeding themselves. ADLs have a companion term — IADLs, or instrumental activities of daily living — that includes tasks like making phone calls, managing money, managing medications, shopping, and cooking. People in assisted living may also need help with these responsibilities. Assisted-living facilities may be located in cities and look like ordinary apartment buildings. Some are in suburban locations with lots of open space. There are fewer assisted-living sites in rural areas. Some assisted-living facilities are luxurious and provide a wide range of services and amenities. At the other end of the spectrum, some facilities have small staffs and offer limited assistance. When you’re considering an assisted-living facility, be sure to ask about staffing: how many, training, special skills, and background checks. If the management seems evasive, probe further. The response will give you an idea of whether this is a place you want to consider further or avoid. Assisted-living facilities may be large or small. About a third of all facilities are considered large (25 or more beds), but they have more than 80 percent of all assisted-living residents. About 82 percent of all facilities are run by for-profit organizations, some of which are national or regional chains. The rest are run by charitable or religious organizations or by state, city, or local governments. In general, larger facilities have more staff and can offer more activities. This benefit may be offset by frequent staff changes and a more impersonal management style. Your preferences about small-group living versus a large residence should be part of your decision. If you or your parent have always lived in a private house with few close neighbors, it may be difficult to adjust to large-group living, even if you have your own apartment. Or a new environment may be just what you are looking for. A CDC analysis comparing smaller and larger assisted-living facilities found that in 2016, in larger facilities, more residents were age 85 and older, and a higher percentage of people needed personal care assistance. Residents in smaller facilities were also more likely to be receiving Medicaid. The percentage of residents who had fallen in the previous 90 days increased with the bed size of the facilities. Check out health care services The health care services offered in assisted living vary considerably. Most common is assistance with administering medications. Some states require staff with specialized training to help with this task. Some assisted-living facilities have medical staff, usually a nurse, available 24/7 on-site; others have a part-time nurse or someone on call. Compared to practice 20 years ago, assisted-living facilities are now accepting people with more serious chronic conditions. The National Center for Health Statistics, a government agency, reported in 2010 that 82 percent of assisted-living facility residents had Alzheimer’s disease or dementia, high blood pressure, heart disease, or a combination of those conditions. Some assisted-living facilities have adapted to the greater health care and assistance needs of these residents, while others have not. The 2016 CDC survey described in the previous section found that among residents of smaller facilities (4–25 beds), the prevalence of Alzheimer’s disease and depression was higher, but the prevalence of cardiovascular disease was lower. If you have a chronic condition that requires frequent monitoring and checkups, be sure to ask whether you can continue to see your own doctor or what alternatives will be available, especially if you’re moving to a new area. Alzheimer’s disease and other types of dementia are conditions that require specific care and are a huge factor when making a long-term plan. A 2012 MetLife Mature Market Institute survey of long-term care costs found that about half of assisted-living facilities provided Alzheimer’s and dementia care, but 61 percent of them charged an additional fee. Sometimes the special units or programs within a facility are called memory care, perhaps to avoid the stigma of dementia. If memory care is important in your plan, be sure to ask about the staff qualifications and training, types of programs available, and opportunities for interaction with other residents. Also ask whether behavioral interventions are used instead of psychoactive drugs, which should generally be avoided. And care for people with dementia should be more than keeping them from wandering; it should include activities designed to stimulate their minds and keep them active. More information on assisted-living facilities Your goal is finding the right assisted-living situation, one that offers the right balance of independence and privacy with the kinds of assistance you need now and may need later. After you know more about assisted living, you can begin your fact-finding process. You can get information about specific assisted-living facilities from many sources. A lot of marketing information stresses the living aspect of assisted living and glosses over the assisted part. It’s hard to find out how friendly the staff is, whether management is responsive to concerns, and all the other quality-of-life questions that matter so much. You have to ask about and observe these aspects for yourself. But you can learn a lot from some basic resources, including the following: Eldercare Locator: This federal resource is a good place to start. It directs you to your nearest Agency on Aging for assistance. There is also a basic introduction to assisted living. State websites: State websites are important because you can generally find which assisted-living facilities have a lot of health and safety violations or don’t offer what you’re looking for. You can then eliminate these from consideration. Some states also have good consumer information, specific to that state, on their Office of Aging or Health and Human Services websites. Note, though, that these agencies have different names in different states. Your state’s long-term care ombudsman: This individual investigates complaints about assisted-living facilities and nursing homes. Check with that office, usually located in the State’s Office on Aging, to find any complaints about a specific facility and how they’ve been addressed. The Commission on Accreditation of Rehabilitation Facilities: This nonprofit organization lists continuing-care retirement communities that meet its survey standards about business practices, philosophy and physical environment, and some aspects of assisted living. Argentum (formerly the Assisted Living Federation of America): A membership organization of assisted-living providers, you can search for its state partners on its website. Internet sites: When you search on the Internet for “assisted living,” you can find ads for specific facilities as well as companies that offer to help you find a facility in your area. Sometimes these companies are endorsed by celebrities, which isn’t a guarantee of quality. Personal assistance from “care” or “family” advisers may be available. Facilities on these lists typically pay to be included, so not all options may be offered to you. Friends or relatives: People you know who are currently in or have lived in assisted-living facilities are a good resource for information on local facilities. Keep in mind, though, that one person’s good or bad experience may not convey the whole picture. Doctors and other health care professionals: Talk to doctors and nurses with experience in providing care to assisted-living facility residents. Use more than one resource, because no single one is likely to have all the options. Be aware of the criteria for including the assisted-living facilities and the sponsorship of the list. And none of these resources can tell you what it’s really like to live there. You should address questions about quality of life in your visits to various facilities. I suggest some specific questions in the later section “Beyond the Brochure: What to Look For When You Visit.”

Article / Updated 09-20-2020

When you’ve completed a safety checklist on your home and made all the easy fixes and repairs, you may find that problem areas still exist for safely aging in place. Some problems may be unsafe conditions, but others may be barriers that make it difficult for you or your relative to move about freely and to enjoy the comforts of home that make him want to stay put in the first place. This article covers modifications that can be made to an aging person’s current home to allow him to continue his present living arrangement. For more information on this topic, check out the AARP HomeFit Guide Downloads, Worksheets, and Resources. Categorizing types of home modifications Many houses and apartment buildings were constructed before universal design features were common or in some cases required by guidelines for remodeling and new construction under the Americans with Disabilities Act (ADA), passed in 1990. Ramps in public places, doors marked for wheelchair entrance, and buses with lifts and special seating for people with disabilities have become so common that they are scarcely noticed (unless of course you’re the person with a disability who needs these accommodations). Yet the need for similar accommodations in private homes is less visible although equally important. The Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) puts home modifications into three categories: Accessibility: Accessibility modifications allow a person in a wheelchair or with disabilities to move easily throughout a structure, such as with widened doorways, lowered countertops and sinks, grab bars in the tub or shower, and light switches and electrical outlets at waist height. Adaptability: Adaptability covers changes that can be made more quickly, without having to completely redesign the home or use different materials for essential fixtures. Universal design: These features are usually built into a home, including appliances, floor plans, and fixtures that are flexible, sturdy, reliable, and easy for all people to use. These categories are important because they involve different levels of planning, implementation, and cost. For example, adapting a home is the least complicated type of modification. Grab bars and outdoor ramps are examples. Making a home accessible, however, may involve structural changes and complying with building code and ADA requirements. Universal design may come into play when you are completely remodeling a home or building a new space. Checking out accessibility General home safety issues (see the earlier section “Dealing with Two Major Hazards”) are important for all older people living on their own. But other specific features can make the home easy to use — or not — for people who have disabilities or are aging. Start in the kitchen and bathroom and think about the particular problems you or your parent may face in accessibility: Are cabinet knobs or pulls easy to use? Pulls are generally considered easier to use than knobs. Are stove controls easy to use and clearly marked? Are faucets easy to use? Universal design faucets have one lever, not two knobs to turn. This makes mixing hot and cold water easier. Can the oven and refrigerator doors be opened easily? Is the freezer easy to reach? Is the kitchen counter height and depth convenient? Most kitchen counters are too high for a person in a wheelchair. Is there room to move around the bathroom and a place to put towels and shampoo in easy reach? Is the shower faucet easy to use? Turning on the shower and getting the right temperature can be difficult. A new showerhead or faucets may be needed. Does the height of the toilet seat make getting up difficult? A raised seat may help. In closets and storage spaces, check the following: Does the closet contain items that have just been put there to get them out of sight? Move them so that the closet is easier to access for coats, hats, umbrellas, and boots. Can items in the closet, like a coat on a hanger, be removed and replaced easily? Can the use of storage space be improved with closet shelf systems? Doors and windows may need the following updates: Are the doors wide enough to accommodate a walker or wheelchair? The standard for a wheelchair is 36 inches. Most door openings are narrower. Are the doors and windows easy to open and close? Are the door locks sturdy and easy to operate? Evaluate the electrical outlets and safety devices: Are electrical outlets easy to reach? Is the area around outlets free of clutter? Are the outlets properly grounded to prevent shock? Can you hear the doorbell in every room? Is the telephone readily available for emergencies? A land line may be more reliable in an emergency than a cellphone. Is there an alarm system? If so, is it easy to use? If not, consider whether one is needed. The preceding information is only a partial list. The University of Southern California Leonard Davis School of Gerontology has an extensive resource list. Also see the AARP HomeFit Guide for a questionnaire to help you plan when you remodel. One part of the HomeFit guide has suggestions for remodeling for people with vision, strength, and mobility problems. Some items that need correcting can be done by you or a friend or family member, but if you have determined that major changes are necessary — for example, widening doorways or replacing kitchen cabinets or appliances — you probably need to find a contractor to tackle the modifications. Head to the next section for advice on finding the right person for the job. Remodeling is a messy and often frustrating experience. The first phase, demolition — even if it’s limited to one room or area — is unsettling. Delays are common. It may be a good idea to move your relative to another setting while the work is being done, especially if you expect a lot of dust, noise, and disruption. Finding a contractor How do you find a reliable and knowledgeable contractor? If you have already worked with a contractor and were pleased with the results, then you have a head start. Ask this person to go over the problem areas with you, suggest fixes, estimate the cost, and tell you how long it will take to do the work. Most people with accessible homes have neither built their own houses nor undergone extensive remodeling. Ask for recommendations from friends or neighbors who have had similar work done. Check online referral sites for recommendations. Then ask a few contractors for estimates and for people to call for references. Some home builders work with certified aging-in-place specialists, a program developed in partnership with AARP. Visit the AARP's website for worksheets and more information. Before hiring a contractor, check with the local Chamber of Commerce or other agency to see whether any complaints have been filed against the company. Make sure the contractor is licensed to perform the work and can obtain any building permits required. Finally, ask for a written agreement that stipulates a small down payment and schedule of payments, with the final payment to be made only when the work is completed and approved. A frequent scam carried out against older people occurs when a “contractor” scans a neighborhood for a likely target and offers to do needed (or unneeded) repairs or home modifications. The person asks for a large down payment and either disappears or does only a token amount of work. If you’re thinking of home modifications for older relatives, be sure to warn them about this scam. Attempting any major repairs, especially if they involve climbing ladders or using power tools, is dangerous. Some people want to save a few bucks by doing the jobs themselves, but they need to be reminded that the cost upfront is much less than the aftereffects of being injured. If you or your relative lives in an apartment building or housing complex, you need to contact the management to make some changes, particularly in corridors and stairways and even within the apartment itself. Co-op or condo residents may be required to obtain approval from their governing board too. Getting help paying for home modifications Many home modifications, such as ramps and lighting replacements, are relatively inexpensive. But when you start widening doors and installing new kitchen equipment like a refrigerator with side-by-side doors, the costs add up. In the bathroom, installing a roll-in shower can be costly although important for someone who cannot move from wheelchair to tub. Eldercare Locator, a federal agency funded by the Administration for Aging (AoA), suggests these resources for financial assistance: Some funds for home repair may be available through Title III of the Older Americans Act. They are distributed through the local Area Agency on Aging (AAA). You can find your nearest AAA by calling Eldercare Locator at 800-677-1116 or going online. These funds are likely to be limited, however, and best suited for relatively small jobs. Rebuilding Together, Inc., a national volunteer organization dedicated to assisting low-income seniors, may be able to direct you to a local affiliate. Some types of home modification — those determined to be medically necessary — may be covered by Medicaid (for eligible low-income people), depending on the state you live in. For example, a roll-in bathtub or shower for a person in a wheelchair may be covered. A doctor’s order may be required, and some Medicaid programs limit eligibility to certain diagnoses or ages. Check with your state’s Medicaid office for details. If the home is mortgaged and has substantial equity, a home equity loan may be available from the bank. However, this loan will increase the mortgage payment. Whether major improvements and their associated costs will substantially improve your or your relative’s safety and quality of life is a personal decision. You may decide that aging in place is not really feasible after all and that a move to assisted living or another setting is the best choice. If you do decide to stay, going through the important process of evaluating the home and making those small changes that can prevent accidents will make it much safer.

Article / Updated 06-03-2020

Falls and burns aren’t the only sources of injury at home when you or a loved one is aging in place, but if you address them, you’ll likely prevent other kinds of injury as well. An important first step in deciding whether staying in the same home can work is taking a hard look at the home. Looking past a cherished home’s attractive features and focusing on its flaws and hazards can be hard to do. Having someone with fresh eyes with you as you survey the premises can be helpful, preferably someone with experience in home modification for older people, such as a physical or occupational therapist, a geriatric care manager, or a contractor who has done similar jobs. If you’re trying to improve the home for a relative, be aware that older people often downplay concerns about safety and resist change. Be tactful but firm. Safety is not the only issue, but it is a prerequisite for enjoying a good quality of life. Preventing falls Your first priority should be preventing falls. Falls are among the most common accidents in homes. Older people are at risk for falls because keeping your balance as you age is more difficult, and it’s harder to readjust your feet to regain your balance if you slip. Arthritis can limit your range of motion. Many older people suffer bone loss, or osteoporosis. Hips are the most likely joints to be injured because people tend to fall on their sides. Falls are often the first step in a cascade of decline that ends up with a hospital stay and eventual placement in a nursing home or death. Fortunately, many fall-prevention measures are easy to take and are not expensive. Here’s a checklist for falls prevention adapted from the National Center for Injury Prevention and Control, a division of the CDC. Another valuable CDC publication is available for family caregivers. Floors: When you walk through a room, do you have to walk around furniture? If so, make a clear path by moving the furniture. Are there throw rugs on the floor? If so, remove them or use double-sided tape or a nonslip backing. Are there papers, books, towels, shoes, magazines, boxes, or blankets on the floor? Pick them up and keep them off the floor. Do you have to walk over or around wires or cords (like lamp, telephone, or extension cords)? Coil or tape cords and wires next to the wall. You may need an electrician to put in another outlet. Stairs and steps: Are shoes, papers, or other objects on the stairs? Remove them. Are some steps broken or uneven? Have them repaired. Does the stairway have a light? An electrician should install an overhead light and light switch at the top and bottom of the stairs. (Use an energy-saving type of light bulb so it doesn’t need to be changed as often.) If there’s carpet on the stairs, make sure it’s firmly attached to every step. Make sure that handrails are not loose or broken and that they’re on both sides of the stairs. To make seeing the stairs easier, paint a contrasting color on the top edge of all the steps. For example, use a light color paint on dark wood. Kitchen: Are often-used items on high shelves? Move them to lower shelves (about waist level). Is your step stool unsteady? If you must use a step stool, get one with a bar for support. Never use a chair as a step stool. Bathroom: Tubs and shower floors are often slippery. Put a nonslip rubber mat or self-stick strips on the floor. Install grab bars inside the tub and next to the toilet. Make sure you have this done by someone who knows how to place them correctly and securely. The screws should be installed in the studs in the wall, not in the tiles, or the grab bar will pull loose. Bedroom: Is the light near the bed hard to reach? Make sure a sturdy lamp is close to the bed. Is the path from the bed to the bathroom dark? Put in a night-light, preferably one that turns itself on after dark. Handling clutter and hoarding Your survey of the home may have uncovered an unpleasant secret. Perhaps unread newspapers and magazines have accumulated, the refrigerator is full of rotting food, or the cats have taken over the bathroom. This behavior is not just difficult to look at, but it also can be a fire and safety hazard. Some of this accumulation is clutter. Bending down to pick up papers may be difficult for a person with arthritis, or a person with vision problems may not be able to read the sell-by date on foods. But sometimes the accumulation of stuff rises to the level of hoarding, which is a more serious problem. Hoarding interferes with ordinary life by making it impossible to use the space as intended and impedes access in an emergency. You may be tempted to overlook the problem because one good cleaning would get rid of the worst of the mess. But it’s not something that should be ignored, and if you get rid of the piles of what you call junk and your relative considers priceless, he or she will only refill the space as quickly as possible. There are many theories about what causes this kind of behavior, which may be related to depression, anxiety, prior losses, or other mental-health issues. Hoarding is one manifestation of obsessive compulsive disorder (OCD). Dealing with hoarding requires consultation with experienced mental-health and home-organizing professionals who can negotiate the cleanup in nonjudgmental ways. A useful article prepared by the University of California-San Francisco is available. Another resource is the International OCD Foundation. Preventing burns Burns are a common problem in the home. Even a minor burn can lead to infection and serious consequences. Older people literally have thinner skin that’s more susceptible to scalding from hot water or burns from electrical appliances. To keep older people safe from burns at home, make sure that you: Replace electrical cords that are broken or cracked. Replace electronic devices, heaters, or appliances that overheat, spark, or smoke. Use a power strip rather than an extension cord. Keep electrical appliances away from water. Unplug small appliances such as toaster ovens and coffeepots when not in use. Keep a three-foot zone of safety around the stove, oven, and microwave. Use microwave-safe cookware. Set the water temperature to a maximum of 120 degrees Fahrenheit (this may be a job for a plumber or apartment building staff). Use a humidifier that sprays cool mist rather than hot steam. Have smoke alarms installed and change the batteries twice a year. You can use changes to and from daylight saving time as your reminder. Smoking in bed is still a common cause of fires. Do everything you can to prevent this dangerous habit. A comprehensive brochure with guidelines for preventing burns from the Hearst Burn Center at New York Presbyterian Hospital is available.

Article / Updated 08-12-2019

Planning should be a dynamic process. Where you want to live in your 60s may look very different from where you’ll want to be in your 80s. Your needs change based on your finances, family circumstances, health, and more. Someone considering moving from a single-family house to an apartment or assisted-living facility should think about whether this is a move that can satisfy future needs as well as immediate ones. Not everyone moves though the spectrum of needs at the same pace, or even goes through all the same stages. The needs of a person with mild cognitive impairment, for instance, are very different from the needs of a person with advanced dementia. As another example, someone diagnosed with diabetes needs chronic care — that is, doctor or nurse visits; ongoing monitoring, including blood tests; medications; and foot and vision exams. If the diabetic condition deteriorates to the point where the person is unable to walk or perform daily activities independently, then significant changes need to be made. Some future needs can be anticipated, and others cannot. The goal is not to have a detailed plan for every possible contingency but a general idea of what can reasonably be anticipated and planned for. Location, location, location The well-worn real estate adage of choosing a home based on location applies to this stage of your life as well. In this case, location is not so much an economic asset (although in some cases it can be) as a symbol of personal comfort and satisfaction and, often, being near family and close friends. Consider how you will meet all your needs — including the social and emotional aspects. Many people just say, “I want to stay in my own home!” And indeed, that’s a reasonable short-term goal, but it may not be feasible in the long run. Beyond their initial statement, many people just stop thinking about it or assume that their children (or more likely, a particular child) will say, “I’ll move in with you so you can stay at home.” Maybe that will happen, and maybe it won’t. But it certainly requires an explicit understanding, not just an assumption. In thinking about location, you want to consider: Family: Moving to another community to be nearer children, often at their urging, may be an option. You should consider what you may lose and what you may gain. Someone with strong ties to a particular community — for example, a faith community or club or other group — may miss that connection. On the other hand, you may be able to re-create those ties in another setting. A lot depends on the type of community you would move to, whether you have spent enough time there to be confident you would like it, and whether you will have to depend on your children for transportation and other needs. Visiting your children as a guest and participating in their activities is different from being a permanent resident. Some social groups welcome newcomers, but others closed their ranks a long time ago. Climate: It’s almost a stereotype that older people want to move to warmer places, but in fact that is one main reason people do relocate. There may be health reasons to move to a different climate, or the upkeep on a house and car in a winter zone may be too onerous to sustain. But not everyone adjusts easily to a more or less constant temperature, especially if it’s very hot. And although blizzards can create dangerous situations for someone living alone, so can hurricanes and tornados, which generally occur in warmer areas. Cost of living: Different regions of the country are more or less expensive places to live. This applies to costs of housing, medical care, food, personal care services, transportation, and other items that will figure into your plan as well as independent or assisted living. An extended visit to a community you’re considering is a good way to find out whether you like it or not. Before or after your visit, you can look online to get an idea of prices for everything from groceries to rentals. You’ll also see what social, sporting, and cultural events are featured. Think about what you most like to do now and what you would like to be able to do in a new location. Timing and flexibility If you’re going to make a change, when is the best time to do it? I can’t give you the perfect answer. Still, if you’re planning to stay where you are for the immediate future, you should start now to reassess your home for safety and accessibility. The mostly minor modifications you can make now will help prevent falls, which are the most common reason for a need for more intense long-term care services. Even if you don’t expect to stay in this location permanently, the modifications will add value to your home because they will also make it safer for others, including families with young children. At the same time, you should begin to investigate alternatives. Without the pressure of family members or doctors insisting that you make a change, you can think about what matters most to you and what you have become used to but can live without. If a change does fit into your plan, allow enough time to make all the arrangements and consider all the pieces that need to be reassembled in a new location, whether that is independent living, assisted living, or another option. Downsizing and moving is one of life’s most stressful events, even if it is well-planned and desired. Take your time. You may not have enough space in your new location for the lifetime of memorabilia and objects you have collected. You may have to donate or sell some possessions. If you’re moving from a big house to a smaller house, apartment, or condo, you may have to decide what furniture to keep and what won’t work in the new setting. This process — with the emotional impact of dealing with so many memories at once — stops many people from moving forward. But if you enlist help from family, friends, and, if need be, from professional organizers, it can be liberating. Be flexible. Even if you aren’t moving to a different location or a different community, you’re entering a new stage of life. Change can be stimulating but also disorienting. Paradoxically, remaining independent often means asking for help. Asking for and accepting help is often a major hurdle in any future plan. Being willing to acknowledge that you can’t do everything alone (and probably you never really did) is the first step toward a person-centered plan. Family and friends are your first sources of help, but they are not the only ones. Neighbors, volunteers from community groups, building contractors, home care aides, and transportation services can all play a part in helping you achieve your goals.

Article / Updated 04-16-2019

If you were born after 1940, you probably grew up in a nuclear family: mother, father, 2.3 children. Maybe grandparents or other relatives lived nearby but not under the same roof. Although the nuclear family seemed the norm for middle-class Americans, it was actually an aberration lasting only a few decades. For most of human history, family members of all ages lived together, and they continue to do so in much of the world. In the United States, large social and economic changes have not only redefined family — think of blended families, same-sex marriages, and children born to surrogate mothers — but have also revived multigenerational living with some modern adaptations. Why different generations are living together Each family is different and has its own story, but several reasons contribute to the appeal of generations living together. Economics is probably the major driver of multigenerational living. Unemployment, loss of housing, credit card debt — all the uncertainties of a changing economy have driven many families together to share resources and space. Another reason to share a home is the changing needs of aging relatives. Living together can alleviate the strain on family caregivers who must maintain their own home and that of a parent or other relative. The needs of older people who can’t live safely by themselves often can be addressed more easily and economically in a shared household than if they lived in a separate home. And as an advantage for the younger generations in the home, older people can contribute to the household economy and help with some tasks, particularly child care. These arrangements may especially benefit children as they get to know their grandparents intimately and not just on holidays and visits. The whole family may grow much closer as a result of the shared experiences. But these positive outcomes are not guaranteed and do require effort and patience. On the flip side, prolonged education and poor job prospects have created the Boomerang Generation, young people who have not established households of their own and have returned to feather their parents’ formerly empty nest. This generation includes those who have married and divorced, or who had children while unmarried, and move home with the grandchildren in tow. This way, younger people have a place to live, can establish themselves financially, and can help their aging parents at the same time. Defining family households by generation The Pew Research Center, which studies social and demographic trends, identifies several different types of households. Which one describes your family now and which one would describe it if you all lived together? One generation: A one-generation household consists of people of the same age group: a married or cohabiting couple, a single person, siblings, or roommates. These people are not necessarily young. A married couple may be in their 80s, and older siblings may live together. Two generations: A two-generation family household includes a parent or parents and their child or children under age 25. It may include stepchildren from different marriages. A two-generation household can also be made up of a person over 60 and a parent in his or her 80s or 90s. Multigenerational: A multigenerational household can include Two generations: Parents or in-laws and adult children (or children-in-law) age 25 and older; either generation can “head” the household. Three generations: Parents or in-laws, adult children (and spouse or children-in-law), and grandchildren. Skipped generations: Grandparents and grandchildren whose parents are dead or unable to care for them. These are sometimes called “grandfamilies.” More than three generations: The ages in the household can range from infancy to extreme old age. The more generations living together, the greater the opportunities for sharing knowledge and history. Many families find that they enter the arrangement for economic or caregiving reasons but remain in it because they enjoy the closeness of family interactions. But possibilities for friction and dissension also exist. The multigenerational households of older times were not necessarily happy with the arrangement or unaffected by intergenerational or interpersonal strife. The topic of who inherited the family farm in 19th-century America can be just as contentious as current disputes over homes and other assets. Addressing early on the ways in which everyone’s needs will be met and clearly stating everyone’s responsibilities will go a long way toward ensuring a cooperative arrangement. In later sections I suggest specific ways to accomplish this. In 1940, one quarter of Americans lived in households with at least two adult generations, usually parents and grandparents, as well as minor children. By 1980, that share had declined to 12 percent — the intervening decades were the high point of the nuclear family. But in 1980, that trend started to reverse, and since then the share of all Americans living in two-generation households has continued to increase. According to the Pew Research Center, in 2014 an estimated 60.6 million Americans, or 19 percent of the total U.S. population, lived in a household that contains at least two adult generations or a grandparent and at least one other generation. The Pew Center attributes this growth to the rising share of immigrants in the population and the rising median age of first marriage. Although this shift affects all ages, it is particularly significant for older adults and 25- to 34-year-olds. In a broader age group — 18–34 — living with parents was more common than other arrangements for the first time in 130 years. Another measure of this change: In 1900, only 6 percent of people 65 and older lived alone, whereas 27 percent currently do. However, people are living much longer than they used to but with many chronic health conditions. Older people who live alone are less healthy and often feel more depressed than their counterparts who live with a spouse or others. Consider family reactions before making a decision A move to intergenerational living typically involves the entire family. If you’re planning to combine households, think of how the other people in your life — spouse, children, siblings — are affected by this decision. Having an in-law, a grandparent, or grown children living in your home is not the same as having them visit. Whether you are having an aging parent move in with you or you are the older person about to move into your child’s home, ask yourself the following questions: Will the other people in my life have to give up space to accommodate another person? Will children still feel free to bring friends home? Will family members have additional responsibilities? If you’re considering bringing a parent into your home, how your siblings react is a particularly sensitive issue. A lot depends on your prior relationship and their relationship with your parent. One sister may feel relieved not to have to take on the responsibility; a brother may worry that being in your home may undermine his relationship with your parent. Money is often a contentious issue between siblings. When dealing with siblings, consider the following questions: Who is going to be financially responsible? If the person you’re bringing into your home plans to contribute to the household and then retires or suddenly can’t contribute for other reasons, will the financial responsibilities change? Will a parent’s contribution to buying a home or supporting a household take money away from an expected inheritance? If the move involves the sale of the parent’s home, how will the proceeds be used? These issues are all best addressed at the outset, although they may have to be revisited as circumstances change. If you’re the older person moving in with an adult child, ask yourself the following: What are my main concerns? Will constantly being around grandchildren and their behavior annoy me? Will I be able to accept the help that is part of the package? Am I concerned that my son or daughter has never been a good money manager and may not use my financial contribution wisely? These issues are best discussed before you make a move. The following is perhaps the most important question you need to ask yourself before going further in your fact-finding: Is this something I want to do or something I feel I should do? If it’s something you want to do, and the primary person you’re concerned about also wants to do it, then you have a good beginning. If it’s something you feel you should do, that doesn’t mean it’s a bad idea. Just take a good look at your worries and negative feelings. You may be making some assumptions about what it will be like that won’t be borne out. Talk to others in this situation to see how they have handled the changes. A trusted family friend or counselor may be able to help you sort out your feelings and to help allay your concerns. But if this honest appraisal results in increasing rather than relieving your anxiety, this may be the time to acknowledge that the arrangement isn’t going to be successful.

Article / Updated 02-19-2019

Copyright © 2014 AARP. All rights reserved. Assisted living as pertaining to long-term care for the elderly is a term that is often used as though everyone understands it in the same way. But that's not the case. Assisted living is just a generic term like hotel or automobile that covers a lot of options. Before getting into the specifics, start with a simple definition: Assisted living is a residence where groups of people share meals and other activities and where individuals can receive personal assistance to maintain their independence. People who choose assisted living typically would have difficulty living completely on their own but do not require constant medical attention. You can also think about assisted living as an intermediate step in long-term care. It is in the middle of the spectrum of long-term care, which often goes from independent living to assisted living to nursing-home care. Independent living can be in your own home, or the entry level of assisted living or in special housing for older people. About 70 percent of residents in assisted living come to the facility from their own home or apartment. Most definitions of assisted living come from industry or government sources and emphasize different aspects of this long-term care setting. It's important to keep the source in mind when you gather information. For example, the Assisted Living Federation of America, a trade organization, says: “Assisted living is a housing and health-care option that combines independence and personal care in a residential setting.” The Eldercare Locator, a free service connected with the federal Administration on Aging (AoA), has an even more specific definition: “Assisted-living facilities offer a housing alternative for older adults who may need help with dressing, bathing, eating and toileting but do not require the intensive medical and nursing care provided in nursing homes.” Living with a congenial group of people with whom to share meals, activities, and conversation is a potential benefit. Remember, though, that it is sometimes hard to make new friends in assisted living because they see a lot of turnover. According to the 2010 National Survey of Residential Care Facilities (assisted-living facilities), most people stay in assisted living for only 22 months. Nearly 60 percent move on to a nursing facility, a third die, and the rest move home or to another location. State governments, which license group residences, call assisted-living facilities by different names. Some examples of the state licensing categories are residential care facilities for the elderly (California), residential facilities for groups (Nevada), and personal care homes – assisted-living facilities (Pennsylvania). You may also come across the acronym ALF in your search. It is shorthand for assisted-living facility, not the old TV character. Similarly, ALP is assisted-living program, not a mountain. Owners of assisted-living facilities tend to shy away from that term in the name, preferring more appealing names like village, community, manor, or any phrase that evokes a secure and invigorating lifestyle. Your state's name for assisted living is not as important as its licensing requirements and its monitoring activities. Some states have detailed standards about what counts as assisted living and what must be provided, as well as building and safety regulations. When you check out your state's regulations, find out whether it has a bill of rights for assisted-living residents. Most states have such a document and generally require facilities to post it and give copies to residents. These documents may be lengthy.

Article / Updated 12-31-2018

Most of the work of downsizing involves sorting, organizing, decision making, and disposing of the things you no longer need or want. Hard enough, but unless you recognize the emotional toll this process can take, it will be even more difficult. It’s not just the items with obvious personal history such as wedding photos or grandparents’ silverware; it’s often ordinary items that bring back memories of childhood or places that you visited. Allow some time to reflect on these memories before deciding whether the items they are attached to stay or go. Some people attach emotional value to items that represent unfulfilled goals. The sewing machine reminds Mom of the projects that she never got started and Dad the expensive woodworking tools that he can never figure out how to use. These lost opportunities may loom larger than items that are attached to completed projects. People who experienced hard financial times may collect things that once were hard to come by but have no real use now such as monogrammed towels or heavy suitcases. While you’re going through items, think about who in your family would want them. If there is conflict about distribution, it may be time for a family meeting led by a trusted friend or professional. The positive side to downsizing can’t be overlooked. In the newly streamlined space, you can reposition furniture, highlight items you value highly, and in general make an old space both familiar and new. And there’s the practical benefit of making it easier to clean and to find things that always seem to be missing — your glasses or keys, for example. In the award-winning AARP’s Downsizing the Family Home (Sterling), home and lifestyle columnist Marni Jameson offers helpful advice on both the practical aspects of downsizing and the emotional impact of the process. She and her brother managed their parents’ move from a family home laden with 50 years of memories to an assisted-living apartment. Her expertise and experience can be useful for someone planning to stay or move. One way to keep memories alive is to take photos of objects that you don’t want to keep but don’t want to lose altogether. The photos can be put into digital form and shared with family and friends. Perhaps a young techie in your family can take on this task, or you can use a commercial service. If the home is filled with garbage, piles of papers and bags, evidence of pest infestation, animal waste, unworkable toilets, or unsafe stairs, this is not ordinary clutter. It is likely a case of hoarding, which requires expert mental health attention as well as organizational assistance. According to the Mayo Clinic, “A hoarding disorder is a persistent difficulty discarding or parting with possessions because of a perceived need to save them… . Hoarding often creates such cramped living conditions that homes may be filled to capacity, with only narrow pathways winding through stacks of clutter… . People with hoarding disorder may not see it as a problem, making treatment challenging. But intensive treatment can help people with hoarding disorder understand how their beliefs and behaviors can be changed so that they can live safer, more enjoyable lives.” Hoarding is difficult to address because the person is often dealing with loss, trauma, and long-buried issues. A useful article prepared by the University of California-San Francisco is available. Another resource is the International OCD Foundation.

Article / Updated 12-31-2018

Help at home is probably the most-often-needed service for an older adult, and it’s the area where Medicare coverage is weakest and private costs are highest. Medicare does pay for some home healthcare services, however, under these conditions: A doctor confirms in writing that he or she has examined the person within 30 days and that the patient needs skilled nursing care, such as care provided by a registered nurse or physical therapist. Without this signed paper, the home healthcare agency cannot “open the case” (begin treating the person). The doctor can be a hospitalist or an emergency department doctor (employed by the hospital) or a community-based doctor. The visit must be face-to-face, not a phone conversation or a report from a nurse. If there is a documented need for skilled care, the person may also receive some home care aide services, although usually for a few hours a day or a few days a week. The person is homebound (meaning that leaving the house is hard). The person needs only short-term or part-time skilled services. The services are provided by a Medicare-approved home health agency (HHA). The HHA may have its own home health aides or contract with licensed agencies to provide these workers, but Medicare will not pay for services provided only by licensed agencies or companion agencies. The so-called “improvement standard” (denial of physical or occupational therapy because the Medicare beneficiary is no longer making improvements) no longer exists (it was never a regulation even though it was commonly used). As a result of a lawsuit (Jimmo v. Sebelius) filed by the Medicare Advocacy Center, CMS has officially ended this practice. See the agency’s statement. The cap on reimbursement for these services has also been lifted, although providers are subject to a review of their fees if they reach a threshold of $3,000. You can find more information from Medicare.

Article / Updated 12-31-2018

Another program worth investigating is the Program of All-Inclusive Care for the Elderly (PACE). Although supported by both Medicare and Medicaid, participants do not have to be dually eligible for both programs. However, according to the National PACE Association, more than 90 percent of participants are dually eligible. PACE programs have been in operation since the 1970s. The first program was created in San Francisco’s Chinatown. The original program, called On Lok (Cantonese for “peaceful, happy abode”), served families whose elderly relatives had immigrated from China, Italy, and the Philippines. In 1990, the first programs received Medicare and Medicaid waivers to support their efforts. As of 2018, 124 PACE nonprofit programs operated 255 centers and were operating in 31 states. PACE programs serve individuals who are 55 or older (and eligible for Medicare based on disability, ALS, or end-stage renal disease), are certified by their state to be eligible for nursing-home care, can live safely in the community at the time of enrollment, and live in a PACE service area. Because the PACE programs offer comprehensive services, a PACE participant may not be enrolled in any other Medicare Advantage plan, Medicare prescription drug plan, Medicaid prepayment plan, or optional benefit, such as a 1915c Home and Community Based services waiver. It is important to note that PACE participants are also not eligible for the Medicare hospice benefit. See PACE Services for a list of services provided in the PACE program. When needed, PACE (with funding from Medicare and Medicaid) pays for hospital or home care, prescription drugs, and other medical services. Services in the adult daycare setting include physical and occupational therapy, recreation therapy, nutritional counseling, transportation, and social-work counseling. Adult daycare also includes meals, social work, and personal care. All prescription drugs are provided. People who have Medicare but not Medicaid can pay a monthly premium for the long-term care portion of the PACE benefit. There is no deductible or copayment for any drugs or services that the PACE healthcare team approves. Why aren’t there more PACE programs? The business model is difficult to sustain as aging clients need more extensive services. Participation of a multidisciplinary team is essential but may be difficult to organize in some locations. And in some locations, there may not be a sufficient population of eligible older adults to support the program over time. Some policymakers have suggested lowering or removing the entry age to allow for a larger pool of clients.

Article / Updated 12-31-2018

You’ve decided. Multigenerational living, with its pros and cons, is a good solution to your needs. You’ve done all the planning, designing, remodeling, and negotiating. Now it’s time for the move. Moving is one of life’s major stressors, way up there with illness and divorce, so take time to organize this event. The Family Caregiver Alliance has a helpful and exhaustive checklist for downsizing a home in preparation for a move. Also look at AARP’s Downsizing the Family Home, and the accompanying workbook, to walk you through the process. But in the following sections I cover some key points. Note: If you or your parent has accumulated lots of stuff over the years and is determined to keep it, you may have to deal with a hoarding problem. Most of the moving process consists of the same steps you would go through if you were moving to a new home, new town, or even overseas. Moving from a familiar place to the unknown, and giving up all the familiar surroundings, can be hard, even if the move is welcomed and appreciated. Be patient and sensitive to feelings of sadness and the memories associated with the home and its contents. Allow time to do things right. Getting started Start the process of decluttering well ahead of the move. Doing it in small steps — a few hours a day — makes it less upsetting and reduces the chances that important items will be discarded by mistake. Do the following to make the process go smoothly: Shred canceled checks and other unneeded papers that have personal information. Check with an accountant about what records need to be retained. Toss outdated food. Take unused or expired medications to a pharmacy for instructions on safe disposal. Some pharmacies have postage-paid bags you can use to mail the drugs for proper disposal. Donate clothes or household items that won’t be needed in the new home. Collect all important papers and keep them in one place. These may be deeds, wills, birth certificates, passports, discharge papers from the military, or other legal documents. These are hard to replace and may be necessary to obtain benefits or for other reasons. If children, siblings, or others have used the home as a storage unit for their high school or college textbooks, memorabilia, and other items with meaning only to them, ask them to reclaim and remove them. They may decide that these things are not so valuable after all and add them to the discard list, or they may be thrilled to have them back again. Planning ahead The more you do ahead of time, the easier the transition will be down the road. Be sure to Start a notebook or computer file folder for the move. Include to-do lists, phone numbers, appointment times — anything that you may forget but will need at some point. Get estimates from moving companies. Better rates are available for nonpeak times (the middle of the month, for example). Make a floor plan of the new home, with accurate measurements and placement of doors and windows, so that you know exactly how much space there will be. Measure any big pieces of furniture (bed, chest of drawers, tables) and decide where they should be placed by the movers. Make plans for pets to be moved and accommodated in the new home. Refill prescriptions in advance. Obtain or order any medical equipment that will be needed so that it is delivered and in place when the move happens. Sorting and packing Use these tips to help make the packing stage of the move easier and quicker: Go through one room at a time, starting with the easiest. Sort the items into piles: definitely save, possibly save, donate, and discard. You and your relative may have disagreements about what goes where. Try to compromise, but make sure that all truly unneeded and unusable items are discarded. Make packing an event to bring family and friends together. Having a group together takes away some of the anxiety and creates a positive atmosphere. Label everything with its destination. Make sure you keep all the items needed during the move in one place: keys, medications, clothing, legal documents, checkbook, cellphone, first-aid kit, cash, and your moving notebook (which I recommend in the preceding section). Settling in New connections will have to be made: membership in a new congregation, and a new doctor, dentist, dry cleaner, and barber or hair stylist are all important to feeling at home. Introduce your parent or child to neighbors and friends. Tour the community together to check out shops, libraries, and other services. After all the boxes have been unpacked and the furniture rearranged, take some time to get accustomed to the new arrangement. What didn’t work out exactly as planned? What adjustments need to be made? Don’t try to do everything at once.