The “Sandwich Generation”, comprised of mostly middle aged adults in their 40s and 50s, are caught between caring for their aging family members while raising their own children and attempting to build a nest-egg for their future. These days the Sandwich Generation is quickly having to learn about senior care and how to navigate the growing industry as they are faced with tough decisions of how to best provide for the elderly in their lives. This guide helps serve as a starting point on how to navigate the matrix of senior health care.
Making the decision to move a family member into a long-term care facility or nursing home can be a challenging call and a heavy burden on the entire family both emotionally and financially. First the family must determine the best course of action considering the medical condition of the elderly, the potential need for short and long-term care and finally the financial situation of everyone involved.
If time is of the essence, consider the following first:
Often, family members are thrust into a decision after a hospitalization from a minor or major medical issue, forcing family members to quickly determine which nursing home is right as opposed to “if” a nursing home is the right option. For those who need to make an immediate decision, the most important thing to consider is the financial situation. The cost is generally comparable from home to home. However, it is important to determine if the homes you are considering accept medicare or medicaid payments.
For those who have time to evaluate and plan, you need to consider the following three critical factors:
- Short-term and long-term health prognosis. Start by first consulting with the family member’s medical doctor or care team to help determine the short-term and long-term potential needs.
- Evaluate the financial situation of your family member.
- Then begin considering which type of care is best – home health care or nursing home care.
Home Health Care: At its core, home health care is just as it sounds – medical and non-medical care provided in the home. Home health care can include many services provided by skilled medical professionals such as physical therapy and nursing care. Additional support can also include skilled non-medical and companion care to assist with basic needs such as help around the home, help with grooming, cooking and ensuring medication is administered properly. Many families choose this option to prolong the family members time at home in their known environment. Typically speaking, the cost is less than that of a nursing or long term care facility. However, home care support often requires oversight by a family member or friend and might need to be modified as the health condition of the family member evolves. While creature comforts are a major advantage of home health care, it is important to note that social engagements and community support are of critical importance for elderly and often need to be augmented by family members.
COSTING NOTE: Home care tends to be less expensive than nursing care but costs will increase as health deteriorates and additional care is needed. A general guideline on costing is $4,500 – $5,500 per month. IMPORTANT – this is based on U.S. average and can vary greatly per state and need. This should be used as a guideline only.
Nursing Home Care
A nursing home is a facility for the residential care of elderly varying in needs of medical support. Nursing homes can also be known as skilled nursing facilities, long-term care facilities, retirement homes, convalescent homes or group homes. Each may offer slightly different types of support and care. Generally speaking, a nursing home is used by elderly who do not need to be in a hospital, but need additional support from professional nurses and skilled care givers. Nursing homes provide around the clock care and have access to medical professionals in the event a resident needs support. Like home-health care, nursing homes can provide basic support, like administering medication to dementia care and day-to-day grooming support. An additional advantage to a nursing home is the built-in community and social engagement opportunities.
COSTING NOTE: Home care tends to be less expensive than nursing care but cost will increase as health deteriorates and additional care is needed. A general guideline on costing is $6,000 – $7,500 per month. IMPORTANT – this is based on U.S. average and can vary greatly per state and need. This should be used as a guideline only.
How to Select a Nursing Home
CONSIDER THE FOLLOWING:
First, consider what you want and what your family member needs. What is critical and what is nice to have —nursing care, meals, physical therapy, a religious connection, hospice care, or special care units for dementia support, social activities. A few additional questions to consider:
- Does my relative get to choose a roommate?
- Can he/she still have her favorite foods?
- What religious services are provided?
- Who is responsible for laundry and should clothes be labeled?
- What is the distance from your home?
- Do they accept local or federal financial payments, like Medicare or Medicaid?
ASK FOR RECOMMENDATIONS: Talk to friends, family and religious leaders who know your loved one well. Their healthcare providers will also likely have some wonderful suggestions. Talk with friends, relatives, social workers, and religious groups to find out what places they suggest. Check with healthcare providers about which nursing homes they feel provide good care.
ADDITIONAL RESOURCES: Medicare offers a great resource on their Nursing Home Compare website. Their site allows consumers to compare information based on yearly surveys conducted in person by the Department of Public Health according to strict criteria. It contains quality of care information on every Medicare and Medicaid certified nursing home in the country, including over 15,000 nationwide.
NARROW YOUR FOCUS:
Call every facility on your recommendation list and ask the critical questions from above along with key details like:
- Average cost per month
- Resident to care provider ratio
- Advanced support (e.g., hospice – should it be necessary)
NOTE: Facilities can range from small independent homes to large corporate backed homes, each offering pros and cons. Don’t rule one out based solely on size.
Once you have selected a few facilities that fit your needs, prepare to visit each home. It is important to meet the facility director as well as the nursing director. Medicare has provided the following home checklist: Medicare Nursing Home Checklist (PDF, 178K) for additional ideas like:
- Medicare and Medicaid certification
- Handicap access
- Residents who look well cared for
- Warm interaction between staff and residents
During your visit, be sure to ask lots of questions such as schedules, approach to senior care, tenure, turn-over rate, etc. Once you have your top 2, plan for a follow-up visit on a different time or day of the week to see different activities, meal services and procedures.
Paying for Nursing Home Care
If independent funds are unavailable, limited federal or state support might be available. Unfortunately, the supplemental support varies greatly per state and will require additional research.
IMPORTANT NOTE: Definitions and terminology can also change – for example Nursing home vs. Assisted living home can have different meanings
The 2019 State Medicaid Assisted Living Benefits guide has a wonderful recap with more links and information.
|State||Medicaid Policies and Programs for Assisted Living|
|Alabama||Alabama has several Medicaid programs that help individuals remain living in their homes, but does not currently provide assistance for those in assisted living.|
|Alaska||The state of Alaska will pay for assisted living or “Residential Supported Living Services” through the Alaskans Living Independently Waiver, as well as Adults with Physical Disabilities Waiver. Enrollment may be capped, and therefore, waiting lists for services may exist.|
|Arizona||Arizona, through the Arizona Long Term Care System (ALTCS) will pay for services for individuals residing in an assisted living community, provided there is space available in the program. Self Directed Attendant Care offers ALTCS program participants the option to choose their own care providers|
|Arkansas||Arkansas now offers two options that help pay for assisted living for Medicaid beneficiaries. The specifically designed Living Choices Assisted Living Waiver is a great option. Personal Care under the state’s regular Medicaid program can be provided to assisted living residents, and via this program, program participants can self-direct their own care through the Independent Choices Program.|
|California||Medi-Cal (California Medicaid) pays for assisted living via the Assisted Living Waiver (ALW). This waiver is not available statewide, and as of 2019, assisted living residences are available in only 15 counties. However, persons not living in those counties can choose assisted living residences in those counties.|
|Colorado||Colorado has an Elderly, Blind and Disabled Waiver (EBD) that allows program participants to receive care services in an assisted living residence. Be aware that assisted living is referred to alternative care facilities. Via the Consumer Directed Attendant Support Services (CDASS) option, EBD program participants can choose and hire their own care providers.|
|Connecticut||Medicaid in CT pays for care in assisted living (which it calls congregate housing) through the Home Care Program for the Elderly (CHCPE). The Connecticut Assisted Living Program further explains the assisted living services under CHCPE. Adult Family Living is another option, although it is analogous to adult foster care, not assisted living.|
|Delaware||Through the Diamond State Health Plan Plus program Delaware provides assistance to individuals in assisted living.|
|D.C.||The District of Columbia Medicaid program offers the Elderly and Persons with Disabilities Waiver which now covers assisted living in limited situations.|
|Florida||Florida has eliminated its HCBS Waivers and now covers assisted living through the Statewide Managed Medicaid Care – Long Term Care.|
|Georgia||Under Georgia’s Community Care Services Program, assisted living services, also referred to as alternative living services, are provided. The Georgia SOURCE Waiver also includes this benefit|
|Hawaii||Hawaii offers Med-QUEST (Medicaid managed care), which will pay for an individual’s nursing services in assisted living residences. Another option is Adult Foster Care which provides assisted living type services in small home-like environments.|
|Idaho||Idaho Medicaid provides three programs that pay for participants’ personal care regardless of the location in which they reside (at home or in assisted living) provided they do not live in a nursing home. These programs are the HCBS Aged & Disabled Waiver, Personal Care Services Program and the Idaho Medicare Medicaid Coordinated Plan.|
|Illinois||Illinois offers the HCBS Waiver for Supportive Living Facilities. While there is an enrollment cap on the program, the state does offer a large number of slots and has many more residences under development.|
|Indiana||Indiana includes assisted living as a benefit under its Aged and Disabled Waiver (A&D) provided participants reside in Medicaid approved assisted living communities. The waiver also offers an alternative to assisted living called Structured Family Caregiving.|
|Iowa||Iowa allows residents to consumer direct their attendant care. Attendant or personal care can be provided at home or in assisted living. The HCBS Elderly Waiver is the name of the program that provides funding. Another option for adults under 65 is the Health and Disability Waiver.|
|Kansas||Medicaid in Kansas (KanCare) offers payment for nursing services regardless of the location in which an individual resides, be that at home or in assisted living. Funding is provided by the HCBS/ FE Waiver.|
|Kentucky||Kentucky Medicaid has the Supports for Community Living Waiver, which covers adult foster care. However, it is not available to most seniors as it is for persons whose intellectual or developmental challenges developed prior to the age of 22.|
|Louisiana||Louisiana Medicaid does not currently provide assistance to individuals to help with the cost of assisted living. However, under the Community Choices Waiver, there is a benefit called Monitored In-Home Caregiving, which is similar to adult foster care.|
|Maine||MaineCare (Medicaid’s name in Maine) offers two Medicaid programs that help persons remain living in their homes, but does not currently provide assistance for those residing in assisted living facilities.|
|Maryland||For Medicaid (called Medical Assistance in Maryland) eligible individuals who are assessed as requiring a higher level of care, but do not have a need so great that it would be less expensive for them to live in nursing home, Maryland Medicaid will pay for assisted living under the Community Options Waiver (formerly the Waiver for Older Adults). Another option with different eligibility criteria is the Increased Community Services (ICS) Program. Finally, Community First Choice, under the state Medicaid plan, will provide care services in assisted living.|
|Massachusetts||In Massachusetts, Medicaid is called MassHealth. MassHealth pays for personal care for individuals living in assisted living through the Personal Care Attendant program. Massachusetts also has a program called Caregiver Homes in which participants receive a similar level of 24/7 care as they do in assisted living but instead live in the private homes of caregivers. Finally, Group Adult Foster Care covers personal care but not rent.|
|Michigan||Through the Michigan Choice Waiver Program, the state will pay for assisted living. However, the state may refer to it as adult foster care or homes for the aged. Another option is Health Link.|
|Minnesota||Minnesota pays for assisted living through the Medicaid Waiver called the Elderly Waiver. As with most waivers, participation is limited. A second option is the Community Access for Disability Inclusion (CADI) Waiver. A third option is the state’s Medicaid managed care program called MSC+ & MSHO is available via all programs above.|
|Mississippi||Mississippi has a Medicaid Waiver specifically designed to help individuals reside in assisted living residences. Read more about the Assisted Living Waiver.|
|Missouri||Missouri Medicaid covers the cost of personal care for qualified individuals through its Aged and Disabled Waiver. The waiver does not specifically designate the residential location of the care recipient other than to exclude personal care from being provided in a nursing home. The same rules apply to the State Plan Personal Care option. The Supplemental Nursing Care Assistance Program also offer financial assistance for both assisted living and nursing home care. Finally, Medicaid Care Options provides long-term care services in assisted living.|
|Montana||The Montana Home and Community Based Services Medicaid Waiver will cover the cost of care services in assisted living for its participants. Note that this waiver refers to assisted living as Adult Residential Living.|
|Nebraska||Nebraska offers residents the Aged and Disabled Medicaid Waiver. Under this waiver, assisted living is an included benefit.|
|Nevada||Nevada HCBS Waiver covers “augmented personal care” or in more common language, the program covers personal care in assisted living residences. Another option for disabled adults of any age is the WIN Waiver.|
|New Hampshire||New Hampshire, through the Choices For Independence Medicaid program pays for assisted living. However, it is referred to as adult family care in the list of the program’s benefits.|
|New Mexico||New Mexico now has a managed Medicaid program for long term care. Under this program, titled Centennial Care Community Benefit, assisted living is an included benefit.|
|New Jersey||New Jersey has a Medicaid managed care program called Managed Long Term Services and Supports (MLTSS), which includes assisted living as an option.|
|New York||New York offers the Assisted Living Program (ALP), which provides approximately 4,200 units statewide in licensed assisted living communities. However, this program is not strictly open to Medicaid participants. Personal care provided under Managed Long Term Care can be provide to persons residing in assisted living, as can the Consumer Directed Personal Assistance program.|
|North Carolina||North Carolina’s Medicaid State Plan Personal Care option provides personal care assistance in assisted living.|
|North Dakota||North Dakota’s State Plan Personal Care is provided regardless of the living situation (excluding nursing homes).|
|Ohio||Ohio offers a Medicaid waiver specifically for assisted living called the Assisted Living Waiver Program. This program pays for care services in residential care communities but does not pay for the room and board cost. There are a limited number of slots available and participants must select from approved providers. In certain counties, for persons eligible for both Medicaid and Medicare, the AL Waiver has been replaced with a Managed Medicaid program called MyCare Ohio.|
|Oklahoma||Through Oklahoma Medicaid’s ADvantage Program Waiver, services in assisted living communities are covered. Under the Medicaid State Plan Personal Care can also be provided to persons living in assisted living.|
|Oregon||Oregon, under the K Plan (part of the Community First Choice state plan option), offers attendant care services as a benefit regardless of the location in which the beneficiary lives (except for nursing homes). Eligible locations include at home, in adult foster care, independent living or assisted living communities.|
|Pennsylvania||Pennsylvania does not provide financial assistance or care services funded by Medicaid to residents that live in assisted living communitie. However, the Department of Aging Waiver does provide personal care assistance in domiciliary care homes, which can be thought of as adult foster care. There is also the Community HealthChoices Program, a managed care program, which provides personal care assistance in domiciliary care homes. Additionally, PA offers a supplement to Supplemental Security Income (SSI) to persons who are living in non-nursing residential care.|
|Rhode Island||Rhode Island has a program called SSI Enhanced Assisted Living that provides up to approximately $1,500 / month to be put toward the cost of assisted living. However, this is not a Medicaid program. RI does have a Medicaid program called RIte @ Home, which offers 24/7 personal care in a caregiver’s home, but not in assisted living communities. Finally, the state’s Global Consumer Choice Compact Waiver covers supported services in assisted living.|
|South Carolina||South Carolina Medicaid under the Community Choices Waiver includes assisted living as a benefit.|
|South Dakota||Under South Dakota’s HCBS Waiver for the Elderly, (now called the HOPE Waiver) services in assisted living communities are covered.|
|Tennessee||TennCare CHOICES in Long-Term Care Program helps participants that wish to reside in assisted living communities by paying for nursing and personal care services in those communities. Room and board however are not considered eligible expenses for the Medicaid Waiver.|
|Texas||Texas Medicaid will cover the cost of services provided in an assisted living community through the state’s STAR PLUS program. The cost of room and board is not included.|
|Utah||Utah Medicaid pays for services in assisted living residences via the New Choices Waiver.|
|Vermont||Vermont’s Choices for Care Medicaid Waiver operates under the Global Commitment to Health Waiver and continues to pay for services in non-nursing home, residential care facilities. Another Medicaid option is Assistive Community Care Services. Finally, there is the Attendant Services program.|
|Virginia||Virginia does not currently have a Medicaid program that helps to pay for assisted living. However, while the VA Adult Services program does not provide care services in assisted living, it does provide assisted living assessments.|
|Washington||Washington has Medicaid waivers and programs that provide help for residents in assisted living or adult family care. Two of the options, the Medicaid Personal Care program and the Community First Choice program, are state plan options that provide care assistance. The COPES Program also has an assisted living option, as does the New Freedom Program. Finally, the Nurse Delegation Program is a unique program that trains non-medical caregivers to assist with some medical related tasks|
|West Virginia||West Virginia, through its Medicaid Personal Care option will pay for personal care for state residents if they live at home or in assisted living, but does not cover rent.|
|Wisconsin||Wisconsin, in a limited capacity, provides services to state residents that live in assisted living communities through Family Care program which is designed to replace COP-W. Another option is Personal Care, provided under the general Medicaid program. Finally, persons can receive care assistance in assisted living residences via IRIS.|
|Wyoming||Wyoming Medicaid offers the Community Choices Waiver. This program will pay for a variety of personal care and nursing services for residents in assisted living, but notably does not pay for their room and board costs.|
While the process can seem daunting at times, researching and planning for the future of your beloved senior will help ease the transition for all.