How to Choose the Best Living Option For Older Adults

While most people would prefer to stay in their own home as they age, sometimes, that simply isn’t possible. This could be for any number of reasons: the inability to find or afford help, a lack of nearby friends or relatives who can assist, or because home has become too difficult to navigate due to fall risks and other hazards.

When staying at home isn’t possible, there are many alternative living options — see our guide for a complete list. As you assess different possibilities, we’ve outlined important tips on how to evaluate each choice.

How To Get Started

Clearly Understand Your Care Needs and How They’re Likely to Increase in the Short and Long Term

Be clear in your own mind as to why you or your loved one are considering this change of living situation. Is it social isolation, or are there needs around safety, supervision, or assistance with daily tasks, like mobility or meal preparation? The reason behind the move can shed light on how needs may increase and help you ensure the facility you choose fits your needs in the short and long term.

Talking with your doctors and other health care professionals about functional prognosis can help you make a better prediction. For example, loss of mobility after a single, unexpected stroke may create disability (like a slow stride) that remains stable for decades. In that situation, an assisted living facility or CCRC may be just fine for months or years if stroke risk factors are controlled.

On the other hand, a patient whose slow stride is a result of a progressive neurological condition (such as Parkinson's Disease) is far more likely to experience gradual worsening of gait over time. If the facility cannot accommodate you in that situation, you could be moving yet again.

While no one has a crystal ball, a perspective like this can and should inform e the way you evaluate a facility and its capabilities. Your doctor is a critical and helpful voice in all of this.

All Things Being Equal, Err on the Side of Selecting Not-for-Profit Facilities

At the end of the day, long-term care facilities are a business, and they want and deserve to make a profit. As with most businesses, one of the best ways to maximize profit is to control costs.

What’s the most expensive cost in long-term care? Staff. And any type of facility — whether it’s assisted living, a nursing home, a life care community, or another — could be made better with more staff. Until every resident has a personal aid, nurse, and physical therapist, there’s always more that could be done.

That is, of course, impossible. But it’s why a mountain of data suggest that, on average, not-for-profit long-term care facilities are higher quality than their for-profit counterparts. “Higher quality” is measured across many metrics: staff turnover, staff to resident ratio, staff salaries, falls, bedsores, state citations for deficiencies, and more.

To be clear, these are average effects measured over thousands of facilities in some studies. There are wonderful for-profit facilities and not-for-profit facilities that are poor quality. And sometimes, there is no choice: Not-for-profit facilities are being converted to for-profit ones at an increasing rate, and there may not be any in your community. But in general, it’s a good thing to keep in mind during your search.

How To Tour Options

• Visit many facilities: Unless you’re in a remote geographic area where there are limited choices, see as many facilities as you can at the care level you or your loved one needs. Explore every practical option.
• Visit at night and on weekends: When you come for the “guided tour,” things tend to be polished. What you want to know is what the facility is like at its most vulnerable times — after hours, when staff are less plentiful and emergencies seem to occur.
• Interact with “frontline staff” in your due diligence process: A facility may tout the five-star chef, the master yoga instructor, or any number of impressive amenities, but those are not the people doing the “heavy lifting” in long-term care. Even if you don’t need help with day-to-day care needs, it’s the frontline staff who will have the most impact on your experience, and you should meet some of them.
  → In home care settings, these are home health attendants; in long-term care facilities, these are typically certified nursing assistants (CNAs). Nearly every medical service field has a category of paramedical assistants, like physical therapy aids (PTAs) or occupational therapy aids (OTAs).
  → A good question to ask is, “How long have you worked here?” High turnover among frontline staff is a sign something may be amiss.

• Ask about access to medical services: One area often overlooked in entering senior housing is the relationship of the facility to medical services (if any). Important questions to ask are:
  → Does the facility have a physician and/or a nurse on site? If so, during what hours?
  → If there is a physician, do you still have the option of seeing your own doctor? Can they visit the facility?
  → What if you need to be hospitalized? Is there an existing relationship with a local hospital, and if so, are you free to use any hospital, or just that one?

• Take a test drive: Whether it’s something as simple as coming to the facility to share a meal with existing residents, or even spending a few nights there to see how it feels, getting as much experience as possible with the facility in making your decision is a good thing. Many programs offer respite services and other short stays that could be used to test drive or acclimate to a facility before committing. In the case of nursing home care, patients and families who have previously used a facility for subacute rehabilitation have a bird’s eye view of how the facility operates and feels. Other services offered by nursing homes, such as adult day care, also provide a view into the facility.

How to Assess the Quality of a Facility

• Look at state survey results and complaint logs: Nursing homes (and in some states, assisted living facilities) are required to undergo a survey process annually or when a complaint is logged by a patient or family. Typically, these have to be posted for public inspection. Summaries or prior surveys are often available to the public on Medicare’s Care Compare site. While the survey process can be arbitrary in some states, a history of chronic problems in one or many areas should raise questions. This doesn’t necessarily disqualify a facility, but should have you asking questions of its leadership.
• Understand who you’re doing business with: It’s critical that you understand the expertise and history of the owner and operator of the facility you’re about to enter into an agreement with. Some key questions to get answers to are:
  → How old is the facility?
  → How many of these facilities does the management own or run?
  → How long have you been in business?

In the case of a CCRC arrangement where you’re paying a fixed fee for care for the remainder of your life in the facility, you’re actually buying two things: a place to live and a form of insurance, insulating yourself against downstream health care costs that you may or may not be able to anticipate. As you evaluate facilities, you want as much detailed information as possible around the financial health of the entity. Think about it: If this were any other form of insurance, you’d want to know about the financial solvency of the company issuing the policy.

• Get references: In the same way you’d get references for a contractor renovating your kitchen or a babysitter taking care of your kids, it’s also important to get feedback from people who are actually living in the facility you’re evaluating. Speak to them (and their family members, if possible) and ask specific and probing questions about what they like and what they don’t like. Share your concerns with them. Ask about other facilities they may have looked at and how they came to this choice. In the case of assisted living facilities or life care communities, it can also be helpful to ask if people have opted in for higher-level amenities (like more assistance, more housekeeping) and if they’re actually using them.
• Avoid commercial referral sources: There are dozens of heavily-marketed businesses that purport to have vetted each and every facility. This is usually not the case; most are simply brokers who get a piece of the pie when someone moves in. Over the years, some have even been investigated for misleading claims. Nothing can substitute for your own due diligence.

What To Consider When You're Narrowing In

• Understand how the decision to transition to another care level is made and your participation in it: One of the most difficult issues in long-term care is deciding when frailty has created care needs that exceed the facility’s ability to provide a safe level of services. If and when this happens, there may be a disagreement between the facility and the resident, which can produce difficult consequences. It’s important to understand exactly how these types of decisions are made up front. Who decides when additional care is needed? How is the facility set up to provide that care? Run through as many scenarios as possible. In some cases, facilities are quick to send residents away so that staff are not taxed; in other situations, facilities may keep residents too long relative to their capabilities.
• Understand exactly what you’re buying: It’s critical to know exactly what you’re paying for, from meals to medical services. Medicare and Medicaid may supplement some costs (such as doctor’s visits and ambulance rides), especially in a nursing home, but you need to identify everything the facility says it’s going to provide for your money. Are you getting a double room or a single room? Are there transportation services, and if so, who pays? Who’s responsible for housekeeping? Who manages medications? Be as thorough as possible to identify potential gaps in services and clarify how they are covered.
• Consider getting a lawyer for complicated contracts, especially equity deals: Some facilities require a substantial upfront payment and then a monthly fee for ongoing service, with the promise they will care for you no matter what happens — unless you develop a disability. If this is the case, you should have an eldercare lawyer look at your contract, especially as it relates to questions of what constitutes a disability or needing more care.
• Have an exit strategy: Even with the best due diligence, sometimes you find yourself in a facility that just isn’t the right fit. Before committing to a facility, you should know the repercussions if it doesn’t work out. In a pure rental model, you should be able to walk away without any financial encumbrances, but this is more challenging in a long-term care situation where you have paid money upfront to secure a lifetime spot. What happens there? Does your “investment” have value that can be bought and sold to the next customer? Some families choose to hold on to an older adult’s previous home for several months before their loved one has definitely “settled in.”