There are many options today for senior living. When facility care becomes necessary, it is important to understand the difference between an assisted living facility and a nursing home in terms of the types of care provided, the degree of regulation, and the payment options. Generally, assisted living facilities are considered less expensive and homier than nursing homes; nursing homes generally are considered more expensive and are more hospital-like. While both types of facilities are regulated, nursing homes are much more highly regulated. For patients with dementia, a memory care unit at an assisted living facility is often the top choice if the patient can privately pay. Veterans (or their widows) who can qualify for aid and attendance benefits can get help from the Veterans Administration with assisted living costs, but long term care Medicaid does not pay for assisted living in Virginia.

It can be a very difficult process for family members to choose a nursing home or assisted living facility. Often the choice of a nursing home comes at a time of crisis and stress, possibly following a hospitalization for a medical crisis of some sort – a stroke, for example, or hip fracture that required hospitalization and that will require some period of rehabilitation after the hospital stay or may require long-term care for the foreseeable future.  Families are often caught in the dilemma of having to make such decisions among limited options within a few days. In these circumstances, hospital social workers and discharge planners can be a help in identifying possible nursing homes with available beds, but cannot necessarily recommend a specific nursing home.  It's really up to families to do the homework. For this reason, it is wise for families with elderly members to do their research well in advance of a crisis situation whenever possible. It also is important for people to be aware that there are often a number of alternatives to nursing home placement, depending on the individual's condition, preferences, resources, etc.  Home care, adult day care, assisted living, or some combination of services, may be options.

Assisted Living Facilities (ALF) are primarily residential settings which offer varying degrees of supportive services for people who are able to live fairly independently but need some assistance with medications, activities of daily living (e.g., bathing, dressing, toileting), and/or meals.  Unlike a nursing home, an assisted living facility is not primarily medical and provides less intensive nursing and medical supportive services than does a nursing home.  Even where more care is needed than the assisted living facility provides, assisted living residents may also privately pay to bring in additional professional care at the facility.  An ALF may be a good option for someone who is not safe or comfortable living alone in the community, even with in-home services, but who does not yet need nursing home care.  Many ALF’s have memory care units for persons with dementia.  Neither Medicare nor Medicaid cover assisted living care, but someone with limited income may qualify for an Auxiliary Grant (application through the local Department of Social Services) to supplement her monthly income to help pay the monthly ALF fee.  Many ALFs, however, do not accept Auxiliary Grant payments and may only accept private pay residents.  

In searching for the right nursing home for you or your loved one, it is important first to identify any specific needs your loved one has.  For example, if there is a need for short term rehabilitation, e.g. physical and speech therapy following a stroke, you will want to check out the quality of the therapy services offered and consider where the patient would go after rehabilitation.  If the prospective resident has dementia, the quality of the staff's training and the overall assisted living or nursing home program and services related to this kind of care will be critically important.  Some assisted living facilities and nursing homes have separate dementia or Alzheimer's units that are designed to prevent residents from wandering out of the unit. For some patients a locked ward is necessary.

It is also important to consider payment issues.  What will be the method of paying for care?  If the resident will be covered by Medicare or Medicaid, you must choose a nursing home that is "certified" to receive Medicare or Medicaid payment.  Medicare will generally only pay for skilled care – most often for a limited period of time following a hospital stay.  If the resident will be covered by Medicaid, he must be in a Medicaid-certified bed. Obtaining admission to a nursing home which has Medicaid beds can be challenging where the individual does not have the ability to privately pay for about six months. If the resident is likely to be Medicaid-eligible within six months of entering the nursing home, she will need to be pre-screened to make sure she meets the functional and medical needs criteria for nursing home care.  If you are working with a hospital discharge planner, he or she will be familiar with what nursing homes take Medicare or Medicaid, and what nursing homes have beds available.

Location of the nursing home is another key issue.  Finding a nursing home that is in close proximity to enable regular visits by family and friends is an important consideration, as this can have a major impact on the quality of life as well as the quality of care the resident experiences.  For a married individual, it is important to consider whether the spouse will remain at home or will go to the facility with the applicant.

Facilities may be for profit or not for profit. Some for profit facilities have Samaritan funds that can help an individual pay for care when money runs out.

Once you have considered these key factors and narrowed the choices of facilities, you want to broaden the sources of information you tap to compare facilities.  First, ask around – ask neighbors, friends, physicians, clergy, the local long term care ombudsman, and citizen and family groups.  If a facility has a reputation in the community as good or bad, that is an important factor to consider.

There are some specific resources which can be helpful to a prospective resident or family member in trying to make a good choice of nursing home.  The Local Long-Term Care Ombudsman is an excellent source of information. What is an Ombudsman?  Long-term Care Ombudsmen serve as advocates for older persons receiving long-term care services.  Ombudsmen provide older Virginians and their families with information, advocacy, complaint counseling, and assistance in resolving care problems.  They are generally housed at the local area agency on aging.

The Center for Medicare and Medicaid Services (CMS) has the Nursing Home Compare website on which provides some basic data about nursing homes including overall ratings, health inspections, staffing, quality measures and distance.

Remember that Nursing Home Compare is just a starting point.  It does not include detailed information on inspection results or information about nursing home ownership.  State nursing home inspection reports, which must be made available upon request by the nursing home, can also be helpful in evaluating the care provided by that nursing home.   You can also talk with the local ombudsman and ask about complaints that have been filed about that facility.

It is critical that a prospective resident or a family member visit the facility beforehand.  Here are some suggestions of particular things to look for or times of day to visit:
• You may want to visit the nursing home several times if possible.  At least one of those times should be unannounced.
• Use all of the senses - -Pay attention to the smells, the way staff interacts with residents (Do they treat residents with kindness and respect? Do they seem to know the residents they are caring for?)
• Are residents lined up in hallways, seeming to be restrained or over-medicated? OR are they involved in meaningful activities, pleasant interactions with staff and other residents, enjoying time out of doors?
• Visit during meal times – Does food look and smell appetizing?  Are residents being assisted?
• Does the group dining experience seem to be pleasant and relaxed?

Ask Questions of Staff Members
Questions to ask the Nursing Home Administrator:
• Can residents bring their own belongings to the home?
• What is the nursing home's policy on visiting?
• What does the nursing home do to ensure that a new resident is made to feel comfortable and at ease?
• If your review of the most recent survey report gives you concern, ask the administrator to tell you more about the problems referenced there, and how the nursing home has corrected those problems.
• How many residents is each nursing assistant responsible for?  Is staffing at the same level at night as during the day shifts?  Are the same staff assigned regularly to the same group of residents ("consistent staffing") so that they know and understand the residents' needs?
• How long has the Administrator been there?  How long has the Director of Nursing been at the nursing home?

You should also talk to other residents and family members.  For example:
• Ask residents and family members about their experience there. Ask them if there are there things they wish were different.  Ask them what they like best and least about the nursing home?
• Ask residents how staff members treat them, whether they are treated with respect, whether their particular interests and schedules are honored.

Once a resident is admitted to a facility, the family should anticipate that there may be a period of adjustment by the resident which might include some changes in the resident's behaviors.  Reactions will be as different as residents are different, but there often is some adjustment period.  It is not unusual for residents to have some anxiety or sadness; even depression can result.  For residents with dementia, an adjustment to a new and unfamiliar setting, with unfamiliar routines and people, can be particularly stressful and disorienting.  Families need to be aware of this, and to expect that residents may be more agitated, emotional, etc.  Hopefully, if the resident is dealing with dementia issues, the facility of choice has trained its staff well in understanding these behaviors and how best to respond.  The family can help by explaining what the resident's normal patterns are, particular triggers that create fear or anxiety in the resident, and approaches that seem to work to reassure and calm the resident when upset. 

The family can help their loved one adjust to life in the facility by helping the staff to understand as much as possible about the resident – his or her preferences, interests, patterns of eating, sleeping, interacting, assistance needs, etc.  The more the family can share that helps the staff get to know the resident as a full human being with needs beyond clinical needs, ideas and preferences, loved ones, a history of accomplishments and memories, the better the foundation for that resident to receive good and sensitive care.  Visiting is important at all times, but especially so in the early part of the resident's stay – before the resident has had a chance to make connections with people in the new surroundings and to feel comfortable with a setting and routine that are not "home"--- a time when, in a very real sense, the resident is in a grieving process for what has been lost in terms of the life that was familiar to him or to her up until that point as well as the loss of a certain amount of independence that is almost inevitable in any move to a facility setting, no matter how individualized the care may be.  Visiting regularly and being present to the resident during this difficult time may be the single most important way to help him or her to adjust.