Read one family’s personal account of dealing with making the move into assisted living…

In 2001, Gail Heimberg says she had to make one of the most difficult decisions of her life. Her 88-year-old mother–a sharp, independent woman who had lived alone in Brooklyn, New York, for most of the latter part of her life–was quickly growing frail. While she used to walk from her home to the neighborhood bakery with ease, navigating the stairs of her circa-1920 apartment building had become a daily battle. “She couldn’t walk very well,” remembers Heimberg. “And her emphysema had worsened.”

Heimberg knew the discussion she needed to have with her mother, yet like many adult children who were thinking of moving elderly parents, the three words ” assisted living facility” seemed foreign, cold and impossible to utter.

Time is of the Essence – Having That Tough Conversation

A few months passed, and Heimberg got a disturbing call. Her mother had suffered a mild heart attack and had been taken to the hospital. Heimberg used the opportunity to share her concerns with her mother. But when the subject came to moving her mother away from her home, she was met with sharp resistance. “No,” said her mother firmly. “I’m not moving.”

Those can be the most difficult words a concerned child may hear their elderly parent say. So how does a worried family member convince a recalcitrant parent that moving to a long-term care facility is in their best interest?

Tips From The Experts

When it comes to moving elderly parents and broaching the “nursing home” or “assisted living” conversation, experts like Stella Henry, R.N., author of The Eldercare Handbook(HarperCollins, 2006) say “this is probably one of the hardest decisions a child will ever have to make.” Henry, an eldercare specialist who has been featured in Time, The New York Times and The Wall Street Journal, says many seniors “unrealistically believe they can take care of themselves for the rest of their lives.” And that’s where their children or other family members can be instrumental in identifying the problem and instigating change.

No matter what the age of your parent, Henry and other experts say now is the time to begin communicating about the future. If you open the lines of communication early on, she says, words like “nursing home” lose their sting later on. That’s important, considering that most of Henry’s clients approach her with little communication groundwork laid.

“Ninety-five percent of my clients come to me in crisis situations,” says Henry. The result? Confused elders, disorganized yet well-meaning children, and a family in chaos.

The Importance of Regular Conversations

Avoid these unnecessary results by having regular conversations with your parent about what the future holds. “Make it your problem instead of your parent’s problem,” adds Henry. “If you say ‘you have to do this, or do that, ‘you’ll lose them. Instead say something like, ‘Mom, I’m concerned about you; it makes me worried to see you like this.’”

That’s the approach Heimberg ended up taking with her mother. After sharing her serious concerns about her mother’s health and safety, the elderly woman slowly came around. “She finally said yes,” says Heimberg.

Nine out of ten parents, says Henry, don’t want to burden their children, and they will often respond to this sort of honest communication. “Parents sometimes hide things from their adult children because they don’t want to scare them,” she says. Yet, if you show them that you are trying to be their advocate, adds Henry, and that you are genuinely concerned about their wellbeing, it can make all the difference.

The Resistant Parent – What to Do

Barry Jacobs, PsyD, a psychologist who has counseled many people in the situation of moving elderly parents, knows how difficult it can be when a parent in need of aging parent care refuses to leave his or her home. While he’s quick to say there are no magic strategies or tricks for persuading an elder to move, he suggests that adult children ask their parent to “indulge” them by visiting an assisted living facility.

“Most of us are more likely to change our position and lifestyle if such a transformation is of our own choosing,” writes Jacobs in his book, The Emotional Survival Guide for Caregivers  (Guilford Press, 2006). “Placed under duress to change, we typically resist, regardless of the soundness of the other person’s arguments.”

And when a parent continually refuses to entertain the idea of moving? “The child needs to back off for the time being,” advises Jacobs. But don’t give up, he adds, “seek other openings to raise the issue again.”

“What I tell adult children is that, unfortunately, sometimes things have to get worse to get better,” he says. ”It may take the parent falling or being spooked by burglars or having the electricity turned off because he forgot to pay the bills for the realization to dawn that the parent can no longer safely reside in the home. Even then, it may take the strong urgings of health care providers and extended family members for the parent to accept the inevitable.”

If the parent begins to show signs of warming up to the topic, “the child needs to emphasize the parent’s right of self-determination but also urge action,” adds Jacobs. He suggests structuring the conversation in the following way: “Tell your parent: ‘I can’t make decisions about how you should run your life. It would make me feel better, though, if we could go together to look at some possible assisted living facilities so that you’re better informed about what choices are available. Would you be willing to humor me in that way?’”

If there is a willingness on the parent’s part to visit a senior housing facility, says Jacobs, “the child should proceed post-haste to set up visits at local facilities and point out that most of these facilities will allow an aged individual to try living in them for a week or a month before the person has to decide whether to sell his house and stay in the facility or return home.” Experts say that can be the extra bit of comfort that can make the difference for many hesitant seniors.

Reprinted with permission from A Place for Mom

No one likes to admit it, but we are all getting older. We are watching our parents, grandparents and other relatives age, as well. Watching them age and seeing them become more dependent on others for various things such as their safety and well-being can be difficult for the entire family. There may come a time when you realize that your loved one is going to need a higher level of help in order to maintain their safety. This may be achieved by things such as improving exercise, changing medications and in some cases by moving into an assisted living community.

As people age, their balance and spatial awareness tend to decrease. Their muscles and bones become weaker and they can become dizzy more easily. They also tend to decrease their physical activity. All of these factors can lead to an increase in safety concerns and an increased risk of falling, especially in the home where seniors spend a majority of their time. About one third of the population over 65 years of age and over half of those over 80 will experience at least one fall annually. These statistics are startling, and in fact may be low as many falls go unreported.

Home safety for seniors is a very important topic for families to discuss. To help improve their safety, seniors should attempt to maintain some physical activity, as approved by their physician. Even something as simple as regular walks in the mall can help to decrease the risk of falls and keep a senior safer in their home. Taking vitamin D and calcium supplements and receiving regular vision and hearing screenings can also help. Seniors should discuss their medications with their pharmacist and physician to see if any can cause side effects that can lead to falling. Additionally, flat, non-skid shoes or slippers can help reduce the risk of falling.

Even with all of these added precautions, you and your loved one may not feel like they are completely safe at home alone. It can be a hard decision to leave your home and move into an assisted living community, but there are many benefits in assisted living, including increased safety. In an assisted living community, residents are checked on frequently.
This means if they do fall, immediate access to help is always available. Many assisted living facilities also provide emergency pendants that can be worn around their neck or wrist. In an emergency they can press the button and help will come to them right away. Assisted living communities also offer help with dressing, bathing, and other activities of daily living in which seniors are prone to fall. Assisted living facilities are also equipped with many safety features such as higher toilet seats, safety railings in hallways and bathrooms, and shower seats.

If you have safety concerns for seniors in your life, it is probably time to discuss it with them. Together you can decide the best ways to keep them safe, whether it is modifying their lifestyle at home, or having them move to experience the many amenities and safety benefits of assisted living. Once the necessary changes have been made you can both rest easier at night.

During the process of normal or “healthy” aging, there are natural changes that take place if one is free of any disease. Dementia, on the other hand, is not a normal outcome of aging. Being able to recognize the difference between normal aging and dementia in you or a loved one can assist you in determining when additional help or evaluation is needed.

Normal Aging
In normal aging, you can expect a number of skills and abilities to remain intact or only slightly different. You will continue to be independent in what are often referred to as daily living activities. These activities include bathing, dressing, driving, preparing meals, managing finances and working. You may notice that sometimes you forget things, but you will be able to give details about those incidents of forgetfulness. This occasional forgetfulness may concern you, but may not be noticed by friends or family. Despite these occasional lapses of forgetfulness, your memory for recent events and your ability to hold a conversation will remain robust. Although you may notice occasional difficulty finding the specific word to use, your vocabulary will still be as extensive as it always was. It is also “normal aging” when you get lost in a familiar place, forget where you put your keys, or forget birthdays or anniversaries. You may have to give yourself a few moments to remember these things, but you WILL remember. As you age, you will also continue to learn new things, if you are open to learning.
Lifestyle factors that contribute to healthy aging include: not smoking, moderate alcohol consumption, healthy social activity, physical exercise that promotes flexibility, strength, and mood, routine medical care to maintain good health, and keeping your mind stimulated through activities such as reading, crossword puzzles, or new hobbies.

Dementia
Now, contrast the abilities and skills of normal aging stated above with what you can expect with dementia. A person with dementia depends on others for those daily activities that will keep them independent. He or she will not be able to recall incidents of memory loss and may only complain about memory problems if specifically asked. These more frequent occasions of memory loss will become most obvious to close family members. In addition, there may be a noticeable decline in memory for recent events or the ability to maintain a conversation. A person with dementia has considerable difficulty finding and using the right word. The person may use substitutions for the word he/she wants or may use a description instead of the actual word. Word finding continues to decline in dementia. The person may lose his/her way in what was very familiar territory and sometimes may take hours to find their way back. Also, a person who has even early dementia will not be able to learn new things or may take extensive repetitions to remember the sequence of new events. Factors that can lead to decline and possible dementia include: untreated high blood pressure or diabetes, poor nutrition, heart disease, stress, depression, social isolation or a family history of dementia.

If you are noting memory changes in yourself or a loved one that you think might be dementia, make an appointment with your doctor. He or she can assess your health and answer any questions you may have. If you or your doctor believes that staying at home is not an option, then independent senior living or assisted living communities may be an opportunity for you to get the care you need.

As a resident in assisted living, the adjustment to congregate living during the first few days or even over a couple of months can prompt an adjustment in the expectation about the intensity of care. You and your parent may have questions regarding how and when the care is provided. You may have a different perception than the assisted living community about the services available. Knowing what to reasonably expect about the care can improve the quality of life in assisted living.

Since assisted living regulations vary by state, and the operations of each community vary depending on the type and size of the facility, we’ll narrow our focus, somewhat, to Virginia assisted living regulations and the operations of the communities of Retirement Unlimited, Inc. However, the perceptions are universal and the expectations can serve as a guideline for you as you navigate through assisted living.

Intensity of Care – The Expectation

Living independently in one’s home or having in-home assistance by a personal caregiver is very different than living in an assisted living community. At home, you make choices based on your own preferences with little or no input from someone else. An in-home aide can provide personal care and focus only on your needs. You or someone else may have prepared meals and snacks, spent time with you playing cards or reading, or just being there to make sure you were safe. You may have spent unlimited time bathing, grooming, styling your hair and dressing. You may have had someone to run errands to the dry cleaners, grocery store or pharmacy. You or a family member may have cared for a pet, cleaned daily, completed minor repairs and such. The care provided in an assisted living community cannot compare with independent living.

Intensity of Care – The Reality

The Virginia state regulations require an assisted living community to complete a face-to-face assessment with a prospective resident prior to admission and throughout one’s tenure to determine the care needed. In addition, the state expects that the community will provide written documentation about how that care is provided, by whom, and the cost of those services. In Retirement Unlimited, Inc. communities this information is provided in our lease agreement, individual service plan and other documents.

Due to the number of residents cared for in assisted living communities, the differing levels of care required by each resident, and the numbers of staff available, no facility can provide close, personal supervision or care to any single resident on a regular basis. The nature and intent of “assisted” living means that the resident is an active participant in his or her own care. Situations do arise, however, where a resident may require or request additional or more intensive services. In these cases, communities may provide the services for an additional fee. However, if any resident requires continuous or one-on-one supervision on a regular basis, this type of service is, by definition, provided in a nursing home, not in an assisted living community.

Of course, it is important to understand the costs involved in assisted living. The majority of assisted living communities are private pay meaning that the resident is fully responsible for the cost. While Medicare and Medicaid do not usually cover the cost of assisted living services, long term care insurance does. Veterans and their spouses should also ask about VA Aid and Attendance.

Ask, up front, about how costs are paid at the assisted living you or a loved one are considering. Look beyond the glossy brochures and ask specific questions about the cost of living there. A reputable community will always have a written contract, so ask to see one. Be sure that they clearly differentiate between the cost of the apartment and the cost of any services provided.

It may be a good idea to have a calculator with you when you tour so that you can have a running total of the costs. Find out if services are bundled or itemized, when provided. Ask for a listing of any other fees that might be assessed. Assisted living communities vary greatly with regard to the amount of the security deposit, “buy-in” fee, endowment fee, or move-in fee that might be assessed. Also, there can be variance in the timing of rent and fee charges. So, be sure to ask about each of these cost items.

Leaving the home you have been in for years is difficult. However, if an assisted living facility provides a variety of services and amenities, it can significantly help the transition to a new environment. The key is to match your loved one’s current personality and interests to the services that would be most beneficial. For example, an assisted living community offering a pool, tennis courts, or a community center will only benefit you or your loved one if you actually swim, play tennis, or throw parties.

Conversely, if you or your loved one no longer drive, then an assisted living community with transportation to medical appointments, shopping, and excursions would be very useful. So, with respect to services and amenties, consider a wide array of possibilities including activities, opportunities for socialization, visiting hours and policies, dining options, housekeeping and maintenance services, transportation, safety, and “special touches.”

• Ask for a copy of the assisted living’s activity calendar.
• Find out how often the activities change or how the community incorporates resident suggestions into the activities.
• Does the community offer both onsite and offsite activities?
• Do the activities address your social, emotional, physical, and spiritual needs?
• Do volunteers or family members get involved in running some activities?
• What are the policies regarding visitors?
• Can you have guests in your apartment and for what length of stay?
• Can you and your guests use the common areas in addition to your apartment to socialize?
• What times of day or night can you receive visitors?
• Does the assisted living facility have a process for checking visitors who come and go a the community?

You should expect the care provided in assisted living will meet your needs or those of your loved ones and be provided in a timely manner.

When touring an assisted living facility, you should find out about assessments, planning for your care, and the processes for care change, handling emergencies and discharges from the assisted living community. Ask how the initial assessment of your level of care is completed. In Virginia, it is a requirement that an assessment be completed prior to your admission to an assisted living facility. Who will do the assessment and how will you be told of the outcome? If you do not agree with the assessment, what recourse do you have?

Once the assisted living facility has determined that it can meet your needs or those of a loved one.

• Ask how the plan for that care is implemented?
• How soon after you move in will the plan be in place?
• Who has input in the plan?
• How often is the plan reviewed and modified?

When you decide to move to an assisted living community and your care needs change, ask in advance what happens when you need more care.

• Can you stay in your apartment or do you need to move to somewhere else in the building or somewhere else on campus?
• How does the assisted living facility handle emergencies?
• Under what circumstances can the resident refuse service?

Most importantly, you need to know before you decide what process the community has in place for discharves.

• Is this process in writing?
• You will want to know if the community will inform you prior to issuing a discharge and if so, how far in advance? All of these questions will provide a complete picture of the type of care you can reasonably expect in assisted living.

As you tour different communities, understanding differences in staffing is an important factor. After all, it is the staff that provide the care for you or your loved one.

First, ask about the nursing staff since staffing requirements vary among communities and may be regulated by the state. You will want to know how many nursing staff are scheduled for each shift. You should reasonably expect that the higher the level of care offered the more staff are available.

Find out how many hours per day a nurse (LPN or RN) is scheduled on-site. This will give you an idea of the level of supervision provided.

It is also important to know that if your doctor calls to change a medicine or the type of care, there is someone at the community who can respond to the doctor’s orders. Ask who is responsible for administering medications and completing care assessments.

Also, you will want to know about the turnover rate for staff and the tenure of key employees. Besides the nursing staff, find out what other support staff are available and what their responsibilities are. Does the community have dedicated staff to implement activities, provide dining services, complete housekeeping and laundry chores, and do routine maintenance or do staff take on multiple responsibilities?

Note how all staff interacts with residents. Do they greet residents by name and seem to know about their level of care? Ask how staff is assigned to care for residents and who supervises what care is given. Be sure you are comfortable with the staffing before deciding on which assisted living community you choose.

Assisted living residences vary dramatically in size. You can find small, home based living housing only a few residents to large campuses housing thousands. Each type will have different options in size of living space as well.

You’ll first need to consider the size of facility that you or your parent or loved one would be most comfortable in. A larger community may offer more socialization, but that aspect would not interest someone who has been an introvert with a small, close group of friends. Larger residences may offer care in different buildings. If so, ask about when and how a resident moves from one level of care to another.

Many residences only offer rooms, while some offer private condos or apartments. Some have shared living areas where 2 or more residents may sleep or live. You may find apartments or living spaces that are furnished. In this case, you can personalize the living space to make it feel more like “home”. Sizes are definitely a personal matter, but remember that bigger is not necessarily better and smaller does not guarantee more care.

Quality can be determined by a number of factors. Having information about each can give you a picture of the total quality that a community provides. Therefore, find out about licensure, length of stay, complaint resolution, and support services. Every state has different regulations governing assisted living communities.

In Virginia, all assisted living communities are licensed by the Department of Social Services. One determinant of quality care is the type or length of the license, but quality extends much further beyond.

You should also find out how long an average resident stays at the community and why. Short term stays can be indicative of a community that accepts more frail residents who move on quickly to higher levels of care. Or, a short stay may mean that the facility accommodates residents who only need services temporarily until they are strong enough to go back home.

Complaints are inevitable any time a group of diverse people are living together. The key to a quality assisted living community is their ability to resolve disputes. Ask for a copy of a grievance procedure or inquire specifically about how complaints are resolved.

Finally, high quality assisted living communities have access to support services such as rehabilitation, specialized medical services, and multi-denominational clergy, to name a few. Find out which services the assisted living you are considering provides.