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Senior Living: What Are Your Options?

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When I started this blog at age 51 about twelve years ago, topics such as Social Security and Medicare were distant on the horizon. My focus back then was on living frugally and managing our investments intelligently so that our savings would last through a long retirement. We had too many plans for our newfound freedom to think further about the issues we’d face in our 60s and 70s.

Well, Social Security and Medicare have arrived for us. Caroline has started both. I’ll be on Medicare within two years, and taking Social Security by age 70. Meanwhile, we’ve been heavily involved with caring for our mothers this past year. That’s given us a close-up preview of housing options for our senior years.

In terms of finances or lifestyle, senior living is probably the next big change on our radar. With luck that could be a decade or more off. But maybe not. If our health should fail before then, or if high-quality senior living options don’t expand in our area, we may feel pressure to act sooner. We might want to lock in a comfortable living situation for our final years while we still have good options.

In this article I’ll explore what I’ve learned on the topic of senior living and continuing care retirement communities based on our experience of caring for two mothers who each took their own paths through senior living, assisted living, and nursing care.

Stages of Senior Living

We all would like to live independently as long as possible. That’s the ideal. But the vast majority of people will need physical assistance at some point in their later years. That’s just the reality. I’ve seen it personally for all the elders in my own family.

But, just as individuals pass through different stages in earlier years of life, senior living is not a fixed state. Rather it is a series of progressively more extensive, and expensive, services:

55+ Communities

55+ Communitites are retirement living for mature adults who don’t need much in the way of extra care yet and want to live in a community of their peers. These developments typically might feature smaller, stand-alone housing with nearby amenities such as shopping and restaurants and a dedicated transportation system. Outside home maintenance is likely provided through an HOA-like mechanism. In these communities, or any independent retirement living, you’d expect to see a variety of group activities offered: sports, reading groups, hobbies, etc.

Independent living

Independent living is the normal, independent lifestyle most of us are able to lead into our 60s and 70s. However, in the context of senior living, the term usually identifies the entrance stage at a facility with additional services. Independent living typically features a private apartment of one or two bedrooms. At this point people are healthy enough to provide their own personal care, though they may appreciate having their apartments cleaned or taking one or more meals daily at a communal dining room.

Assisted Living

Assisted living is the next step up from independent living. It typically features a smaller private apartment with a nursing station nearby on the same floor. Residents can expect regular help as needed with dressing, bathroom, transferring between bed and chair, etc. Meals are usually served in a communal dining room, though some residents may keep small kitchens, while others take meals in their apartment.

Board and care

Board and care is another form of assisted living. These are smaller, more home-like facilities. Many are family-operated, and sometimes the caregivers live on-site. The rates can be very reasonable. One elderly man who needed only light personal care was able to live very comfortably in his private bedroom with all meals provided in one of these facilities for only $2,000 per month. But such low rates aren’t a given. And licensing and inspection standards may vary by state, so beware.

Memory care

Memory care is dedicated housing for those suffering from Alzheimer’s or dementia. Residents with mild dementia can be managed by the staff in assisted living, as long as they aren’t a danger to themselves or others. But when dementia progresses to the point that residents become disoriented or agitated, they may need the additional attention of memory care. For the safety of all, this is likely to involve controls on freedom of movement such as locked exit doors.

Skilled Nursing

Skilled nursing care is for mostly bedridden residents who need an extra level of medical care while recovering from sickness or injury, or nearing the end of life. This means nurses are available for 24/7 monitoring and to administer medications. Though it is still not the level of care a hospital would deliver. Doctor visits may be included or might need to be arranged privately. Since these facilities are oriented to long-term medical care, they may or may not be the best place to spend your final days.

Hospice

Hospice facilities are dedicated to palliative care for residents approaching the end of life. Rather than trying to heal or fix people, the focus is on providing comfort, relieving pain, and offering a peaceful, home-like atmosphere for the final stages of life. The staff is trained and experienced in how to care for dying patients and also oriented to providing a peaceful and supportive environment for family members. In my experience, hospice staff have been highly responsive, but not intrusive. It’s the best of both worlds, with skilled care readily available, but out of sight when not needed.

You might notice a clear progression in these levels of senior living. The real estate market has jumped at this business opportunity. The result has been the growth of “Continuing Care Retirement Communities” (CCRCs) that package all or most of these stages into one institution with increasing levels of care available as needed, all managed under a single umbrella. A single entrance process and fee structure gives you access to the entire package of services up to the end of your life.

What about Aging at Home?

Dying is a natural process over which bystanders have little control. It’s difficult, personal, and unpredictable. There is no solution that can alleviate all the pain and sadness.

For most of human history, people aged and died at home. If you can get some support from family members, perhaps with assistance from part-time home health care aides, it’s still possible to spend your final days at home. This can be one of the cheapest options and potentially the most comfortable, if your medical situation is not complex. However the toll on family members if care is required beyond a few months can be heavy.

But staying at home simply may not be practical. An InvestmentNews article reported on a financial planner whose parents spent $125,000 in home repairs to make it senior-friendly, only to move to a care facility two years later because of health issues.

For those who can afford the high expense, it might seem that dying at home with all care delegated to private duty nurses or aides would be ideal. But I’m not so certain. You would likely need two nurses on duty for transporting tasks. And they would spend much of their days idly waiting to be needed. A hospice or nursing facility with trained staff down the hallway, not hovering nearby, might be less intrusive for family, and certainly more economical.

So, institutional options for end-of-life care may be desirable or necessary. But, no matter what environment an individual is in while dying, the involvement of caring family is critical. As good as they might be, professional staff won’t have the same time or commitment as a family member. Without family monitoring your care, it will be suboptimal in even the very best facilities.

Finances

In the locations where we’ve shopped for retirement communities, availability was tight.

And because that availability depends on the unpredictable lifespan of previous residents, plus your own life trajectory, it’s very difficult to make senior housing decisions far in advance. Typically there are waiting lists and units are snatched up as soon as they become available.

The administration of those waiting lists varies by facility, but it’s possible that you will have to make a deposit to get on the list initially. Then you may only be able to stay on the list a limited time, especially if you refuse a unit that has become available.

Facilities offer different fee structures too. A simple monthly rate is common. But we’ve also encountered six-digit buy-in fees, which act as a kind of long term care insurance. Those buy-in fees might be on a graduated scale that dictates the size of required monthly payments. And a prorated portion of the fee might be refundable if you die or leave in the initial years.

Important related financial questions to explore before signing a contract include the financial health of the facility, its history of fee increases, and what happens if you outlive your assets. In that case, will the facility accept Medicaid in payment for your expenses or will you be forced to move?

Example Costs

We have specific experience with two senior care scenarios. One played out in the relatively economical Midwest, the other on high-priced Cape Cod. So, I’ll offer a few numbers from our own experience to give you an idea of the potential price range. Just be advised that these numbers might vary widely from what’s available in your area.

In Lincoln, Nebraska a facility charged an entrance fee for independent living of $201K non-refundable, or $363K with up to 80% potentially refundable on a sliding scale over the first four years.

The contract was for lifetime care, even if assets ran out. And the facility only required that you have 1.5x in assets of the buy-in fee. So that fee functioned as a form of long term care insurance.

The monthly charge for independent living was then $2,900, projected to increase about 3-5% every year. Assisted living cost about $4,600/month. And skilled nursing care in a separate, attached facility was $320/day.

By contrast on Cape Cod, an independent living situation without available assisted living, had a buy-in for a two-bedroom apartment of about $240K and monthly fees of about $2,800. But the apartment was fully owned by the resident and could be re-sold on their passing.

A higher-end CCRC there charged about $7,500 monthly for assisted living but had no buy-in fee. And a small but nicer nursing home there charged $480 daily or over $14K monthly for a private room.

Alternatively, trying to care for a mother at home with the help of a home health care aide at $35/hour for about four hours daily cost more than $4,000 additional monthly. And that didn’t count the financial, physical, and mental cost to family members who had to be on duty almost 24/7.

Long Term Care Insurance

What about the potential of long term care insurance (LTCI) to reduce these costs? In years past, I wrote extensively about the bad deal offered by long term care insurance and why we weren’t buying it.

Nowadays, long term care policies are increasingly difficult or impossible to get. Even though both our mothers carried LTCI, nothing about our recent experiences has changed my opinion on this kind of insurance.

An Unnecessary Policy

One mother paid premiums on two LTCI policies for decades. She passed away never having used either. Instead of making claims against her LTCI, she had life care from her CCRC. This was a far superior solution both logistically and financially. Very little paperwork was involved. And the coverage was in full to the end of her life, with no daily maximums or time limit.

Now we are working to claim a return of premium for modest end of life expenses. Even if we get some of her premium back, the insurance company had use of those assets for years—a big win for them.

Hassling Over Claims

Another mother also carried a LTCI policy for decades. Here we are at least getting a benefit, with about 50% reimbursement for up to four years in an expensive nursing home. However those reimbursements come at high cost: countless hours my wife has spent navigating the insurance company’s byzantine processes to file claims.

Remember that insurance companies are in the business of taking in more assets than they pay out. There is little incentive for them to facilitate the claims process with efficient customer service. Rather, what we have found dealing with insurance companies in recent years is inconsistently motivated and trained employees, and brittle, antiquated systems—usually paper-driven—that have not transitioned into the digital age.

When an insurance salesman paints a picture of your easy life after buying a policy, understand that your problems may only begin when you have to file a claim. The process is so tortuous that, without a healthy family member with free time available to take on the task, you’re unlikely ever to collect!

Quality of Life

We’ve touched on the logistical and financial aspects of senior living. But once you’ve moved into a facility, your concerns will center on the quality of life you can live there. This will be impacted by a number of factors.

Ownership/Mission

For starters, who owns the facility and what is their core mission? Is it a nonprofit, faith-affiliated, or a for-profit? You might assume that nonprofits are more compassionate and that for-profits are more efficient. But it would be smart to test those assumptions.

Caregivers

Much of your quality of life in assisted living will be dictated by the staff, especially the nursing staff. What is the resident-to-staff ratio? How many are licensed nurses and how many have different certifications?

Nurses are incredible, committed people in my experience. If you ever get down on humanity and need a boost, meet some hospice nurses. They are some of the most courageous and compassionate people I’ve ever encountered.

But personalities vary and everybody has good days and bad days. One of my mom’s favorite nurses was too aggressive in helping her at first, and they got off to a rocky start, but eventually became very close. What are the facility’s procedures for changing caregivers if that becomes necessary?

Social workers are a lesser-known and underappreciated resource. Not preoccupied with daily care, they are there to advocate for and educate residents and families. In our experience their understanding of the logistics of modern health care systems is invaluable. 

Day to Day Life

Food is extremely important. In later years taking meals might be one of the remaining pleasures in life. Having a variety of healthy, high-quality eating options can make each day more pleasant. So talk to other residents if possible, and explore the available meal plans. Also ask about getting meals brought to your apartment if necessary.

Regarding your apartment, what are the provisions for maintenance, cleaning, and laundry? How often will these services be provided? And how about technical help? More and more seniors will be relying on their computers and devices to stay connected to the world. Can you get assistance when a battery goes dead or your internet connection goes down?

Lastly, if it’s important to you, what is the noise level during the day and night? My mom’s facility pitched us on the modern new addition they were building, including a bistro and pool. But it turned out that the construction went on right outside her window for more than a year.

Activities

When planning for senior living, think about indispensable daily activities and how you’ll accomplish them: haircuts, manicures, banking, grocery shopping. Obviously it’s best if these services are nearby, or even on-site at the facility. If not, is a bus or limo provided with service to a commercial district? How often does it run? How comfortable is it?

Recreation and fitness will be an important part of any senior life well-lived, just as in early years. Does the facility have a fitness center? How well equipped is it? Is physical therapy offered on-site? I’ve yet to be impressed by the fitness facilities provided for the previous generation. I suspect these facilities will get an upgrade for my own fitness-obsessed boomer generation.

Walking is central to many seniors’ fitness regimen. Are there walking paths outdoors that you can reach without needing transportation? Is there a walking route available inside the facility for use during inclement weather? These items are critical in my opinion. Your quality of life is likely to rapidly erode if you can’t keep up your walking strength.

What kinds of group activities are provided and how often: movies, shows, classes, church services?

Is there a library, a public living area, a party room for social events?

Lastly, how does the facility provide for visitors—family or friends who want to see you? Is there a private dining area? Are rooms available for overnight stays at reasonable cost, or is lodging nearby?

Decision Time

So we’ve looked at the logistics and finances of senior living, but what is right for you or your family? And when should you move?

For me, aging at home does not make sense past a certain point. Without a large family to care for us, we will be happier and more comfortable in a community of like individuals with staff that has a professional commitment to care for us.

I’ve seen elders in my family who delayed moving to senior living struggle with loneliness and making new friends. The relocation process just takes longer as we age. In two cases, elders moved to different regions of the country to be closer to children but found less in common with the population there. This was another barrier to making social connections.

I’m going to guess that I’ll be actively investigating senior living by my early-70s. But there is no telling how I’ll feel then, or how the senior living landscape might have changed.

And how about you? What are your preferences for living arrangements in your later years. What lessons have you learned caring for seniors in your family?

*Special thanks to the late Valerie Joiner, my mother, whose notes on this topic provided some of the structure for this article.

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[The founder of CanIRetireYet.com, Darrow Kirkpatrick relied on a modest lifestyle, high savings rate, and simple passive index investing to retire at age 50 from a career as a civil and software engineer. He has been quoted or published in The Wall Street Journal, MarketWatch, Kiplinger, The Huffington Post, Consumer Reports, and Money Magazine among others. His books include Retiring Sooner: How to Accelerate Your Financial Independence and Can I Retire Yet? How to Make the Biggest Financial Decision of the Rest of Your Life.]

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