Home, Assisted Living, or Nursing Home: 5 Things to Consider

Families whose loved ones need long-term care are often overwhelmed and confused about what level of care is most appropriate. As a social worker, I assess the client in their home gaining important insights into this decision. Each client is different so there is no “right answer” as to when to choose home care versus assisted living or nursing home, but there are generally five factors that should be considered.

1. Personality: If your loved one has been a loner for his/her whole life, it is unlikely that placement in an Assisted Living Facility (ALF) or Nursing Home (NH) will change that personality. Someone who prefers a quiet life may have a better quality of life staying at home with a caregiver despite what the family thinks is “best.” Conversely, a social person may have a better quality of life in an ALF or NH rather than staying at home isolated with one caregiver. In addition, all ALFs and NHs have their own distinct personality. Some have a younger, more lively and independent population, while some have an older and more dependent population. Remember, you need to focus on where your loved one fits best, not where you fit best!
2. Cost: It is unfortunate, but the amount of money your loved one has available to pay for care generally determines whether home care or ALF is an option. Medicaid, which picks up the cost of care when medical and financial criteria are met, usually does not pay for enough homecare hours to be a long-term option in New Jersey. Also, you will have few choices of facilities when the assets are depleted. Most ALFs require sufficient assets to pay privately for care for 1-3 years ($100,000-$400,000). While most ALFs participate in the NJ Medicaid program, they usually have only a small percentage of Medicaid eligible beds. Most ALFs will not guarantee Medicaid bed availability and is possible that your loved one will have to leave the ALF once assets are spent down if no Medicaid bed is available. There is much more variability in the number of assets needed to spend down in an NH, varying from straight Medicaid to $40,000 to several years of private pay. Unlike ALFs, NH beds are all Medicaid certified so you are guaranteed a bed if you are Medicaid eligible.
3. Care needs: There is a lot of overlap between the care offered by ALFs and NHs. Generally, ALFs cannot manage residents who require the assistance of 2 to transfer, have a feeding tube or catheter, or have extensive wounds. The ALF can require a resident to leave if the care needs cannot be met. It is important to consider your loved one’s diagnosis and prognosis when deciding which level of care is best. Some people are comfortable choosing an ALF knowing that their loved one may need to transfer to an NH in the future while others choose NH care so that their loved one will not have to be moved.
4. Location: It is essential that family be able to visit their loved one on a regular basis. This not only provides emotional support but also allows the family to oversee the care. Even the “best” facilities make mistakes and it is important to monitor to ensure that your loved one is receiving the care he/she needs.
5. Dementia: If your loved one has dementia, placement in an ALF or NH with a designated Memory Care unit is usually preferred. This can be a hard decision for families, especially if their loved one is in the earlier stages of dementia. Generally, there is more structure in a Memory Care unit and the staff is specially trained to provide behavioral interventions to manage the varied manifestations of the disease. This is especially important in an ALF because the expectation is that the resident can get to the dining room and call for help if needed -- tasks that can easily overwhelm a resident with cognitive impairment.