About Assisted Living
by Thomas Day


Assisted living is more of a marketing term referring to a generalized care model then it is a specific form of care delivery. It is an attempt by the industry that offers these services to bring a disparate number of service providers under one umbrella.

Assisted living, also called residential care, is a type of living arrangement in which personal care services such as meals, housekeeping, transportation, and assistance with activities of daily living are available as needed. Also an important aspect of the assisted living model is to provide security, comfort and meaningful activities for residents. But unlike nursing homes, residents in assisted living remain independent, living on their own in a residential setting. Assistance with activities of daily living may include help with bathing, dressing, toileting, diapering, medicating, helping with daily living decisions and moving from one place to another.

The definition of the term assisted living and what it is called in licensing regulations vary from state to state. One of the reasons many terms exist for similar facilities is that each state has its own licensing requirements. Regulations to govern these facilities are not uniform. Allowable services also vary from state to state. Assisted living services allowed in one state may only be available in a nursing home in another state. Recently there is an effort among many state legislatures to unify assisted living licensing provisions based on a common model for all states.

Here are some examples of the titles states use for assisted living:

  • Residential care
  • Personal care
  • Adult congregate living care
  • Board and care
  • Adult living facilitiesSupported care
  • Enhanced care
  • Adult homes
  • Sheltered housing
  • Retirement residences
  • Adult foster care
  • Community based retirement facilities

The difference in licensing is usually based on the size of the facility or the services it can offer.

For example, residential or board and care is usually a converted home or small facility with three to ten beds where the caregiver is a homeowner or single proprietor with little or no support staff. These facilities typically are not allowed to offer much care beyond bathing, dressing, providing meals or helping residents move around. Some of these homes however, may contract with home health agencies, home visiting doctors or nurses to provide care for their residents.

The cost for board and care homes is typically much less than with large, new, apartment-style assisted living facilities. People who operate board and care homes have a love for the elderly and in essence are taking these people into their homes to care for them as if they were family members. Unfortunately because of their small size these operations have little money to advertise and their residents usually come to them from referrals or word of mouth.

Assisted living fills a gap between home care and nursing homes. Years ago, before assisted living, a person needing professional care went to a nursing home even though the care didn't always merit the intensive supervision and control of a nursing home. The fairly new alternative of assisted living provides a more homelike environment for people needing or anticipating help with activities of daily living or incidental activities of daily living but for which 24-hour nursing care is not a necessity.

Instead of the hospital environment of a nursing home, newer assisted living facilities look more like apartment buildings with private rooms or suites and locked doors. Instead of a nurses desk, there is a help desk. And instead of a hospital-like lounge area and sterile cafeteria, assisted living has gathering areas with couches, fireplaces, gardens, atriums, etc. Central dining areas look more like banquet rooms and often offer entertainment during or after mealtimes. Meaningful activities and chats with neighbors in pleasant surroundings, keep residents active and stimulated. Frequent outings are also planned. And transportation is available to residents who can't drive.

Many assisted living facilities allow home health agencies to come in and offer services for residents. Some states may allow facilities to have a resident nurse or therapist to help with minor medical problems. And some states even allow variances for assisted living to offer limited nursing home services.

Some assisted living facilities specialize in the care of Alzheimer's patients. An Alzheimer's patient typically does not require a lot of medical attention but often requires supervision and confinement. Alzheimer's facilities have locked entrance doors to prevent residents from wandering.

Prior to assisted living, many people had to reside in nursing homes but didn't need the level of care provided. Yet there were few options for other living arrangements. With assisted living, these people now have the choice of a more homelike environment at about half the cost of a nursing home. Demonstrating the popularity of ALF's over nursing homes is the fact that the number of nursing home beds in this country has increased only slightly over the last decade to about 1,800,000 beds, whereas assisted living beds have grown from about 600,000 to well over 2,000,000 beds over the same period.

Not all residents of ALF's need significant care or assistance. Many are there because they want a simpler lifestyle without the worry of maintaining a home and they seek the companionship of other people their own age. They also may have chosen assisted living over an independent retirement community because they may need some minor help such as taking medications or they desire a secure environment or they may require some minor supervision. They may be able to get this help other places but they anticipate a time when they may need the more intensive care available only with an assisted living facility. Source for below: National Center for Assisted Living, 2001



A Difficult Decision

By Paulette Kaufman

The decision to place a loved one in an assisted living facility is a difficult but frequently unavoidable one. Even though the choice may be absolutely necessary, the person forced to make the decision for their spouse or parent often feels an overwhelming sense of guilt.

When the time came for me to decide to place my mother, who suffers from Parkinson's disease, into assisted living, I knew as a nurse that it was the best decision for both my mother and me. All the same, I felt an enormous amount of guilt, and when I came home after helping my mother move into her new community; I broke down, sobbing.

Today I work as a marketing counselor for the facility where my mother lives - so I see her every day and know firsthand that she receives excellent care - yet there are still times when I fail to hold back the tears.

Many caretakers who decide to put their loved one in an assisted living facility think they have failed them somehow, even if they have already spent years caring for them and simply cannot do so any more. I had been taking care of my mother for three years before bringing her to live in a long-term care community, helping her with daily tasks and spending every other night at her house. I even managed to make it a family effort, with my son easing much of the burden during his summers home from college. My mother did not want to leave her home, and I did all I could to see that she would not have to leave.

But eventually that time came. In a fall my mother broke her foot, but she hid the injury from me. A fall like my mother's is especially worrisome because Parkinson's is an incurable disease which progressively and inevitably gets worse. Patients are often able to minimize the ill effects of the disease for a time, but eventually they will require frequent or constant assistance from a caregiver.

My mother's fall was a sure sign that she could no longer live on her own. When her doctor discovered that her foot was broken, he told her this in no uncertain terms. Now it became my responsibility to help her find a new home, and though part of me wanted to take care of her just as she had taken care of me as a child, I knew that I did not have the capability to care for her as her Parkinson's progressed.

In some respects my mother and I have been fortunate, in that she was aware of her doctor's instruction and conscious of the reasons for entering an assisted living facility. Children and spouses of Alzheimer's patients, on the other hand, must bear the full weight of responsibility when choosing the option of assisted living, though many spend months or even years denying this fact. Usually, when it comes time to seek out an assisted living facility for an Alzheimer's patient, that patient has already reached an advanced stage of the disease and likely exhibits a number of disturbing symptoms.

If the caregiver has decided that it is time to consider assisted living, the patient may already be in need of help with dressing, shaving, eating, and even using the bathroom. Perhaps the patient has become delusional, convinced for instance that the caregiver wishes to harm them. These are all common symptoms of Alzheimer's disease, and, like Parkinson's, such symptoms will only get progressively worse.

Recognizing that a patient whose Alzheimer's has reached such a stage and may need to enter an assisted living facility is positive. Unfortunately, I have met many people who think they can convince their parent or spouse of their need to enter an assisted living community, when in fact it is only the children or spouse of Alzheimer's patients who can ultimately make the decision.

Compounding the grief is that patients who have reached an advanced stage of Alzheimer's often lose awareness of recent experiences and surroundings, and may even lose recognition of their caregiver and other loved ones. Because of this, the patient will probably be confused by the move and unaware of the suffering of the child or spouse responsible for placing them in assisted living. Like I did, people begin to cry at times. Depression and anxiety, caused by guilt, sometimes become acute.

But there are a number of things that one can do to diminish feelings of guilt. In my case, besides visiting my mother every day, I always make sure that she has fresh flowers in her room. When she was able to, she spent a lot of time in her garden, and the flowers help her to experience a bit of the garden all the time.

On Sundays, I spend the day with my mother in my home, picking her up early in the morning and taking her back to her assisted living facility in the evening. I try never to miss a week.

Beyond that, it helps to remind oneself of the advantages that an assisted living facility affords. Working in the community where my mother resides provides me with some added insight into those advantages, for which I am grateful. Besides the obvious - the physical aspect of care - there is the always-important social aspect of continuing care communities. My mother, even before entering the facility, was very antisocial, and I even made a friendly bet with the staff that they would not be able to get her out of her room. For three and a half years I was winning that bet, but six months ago, after much persistence on the staff's part, they finally got her to participate in the events.

One day recently, while I was with my mother, she took out a quarter from a drawer in her room. Though Parkinson's makes it difficult for her to speak, she managed to say, "cards" - my mother had won the quarter playing cards. She never used to play cards.

Despite moments like these, which remind me of all that an assisted living facility offers that I alone could not, the guilt and the grief never entirely go away. But I know my decision was the right one, and I know that I am not alone in feeling involuntary pangs of guilt. My hope is that others in my position share these same realizations.

Paulette Kaufman is currently Director of Sales at Keswick Pines, a Lifecare Center in New Jersey , which offers assisted living and comprehensive health care programs to residents, providing personal assistance, nursing care, pain management, and memory impairment support. Ms. Kaufman's mother has been a resident of Keswick Pines for four years.  


A 1999 survey done by the National Council For Assisted Living e stimates the average length of stay in an assisted living facility ranges from approximately 2.5 to 3 years. Residents who leave typically do so because they need to move to a nursing home for more care or because of death. A 2000 study found that, among those who moved to another setting, the need for more care was the most commonly cited reason for leaving



In most cases residents pay a regular monthly rent to include meals and housekeeping and the care services are added as extra cost as needed. In smaller facilities the entire cost includes room and board as well as care services. Some facilities provide levels of care based on need and charges are uniform for each level. For instance a level or grade 1 care might cost an additional $400.00 a month. A second level or grade 2 might cost $800.00 a month and so on.

A rule of thumb estimate is that assisted living costs about 60% of the cost of a nursing home. In many areas of the country this might price assisted living at about $2,400.00 a month. It should be noted that this would typically be the charge for newer apartment style complexes. So-called Board-and-Care homes which are typically individual residences converted to accommodate a small number of residents are going to be considerably less in cost. For example a board and care where two people are sharing the same room might cost about $1,000.00 a month.

There are also assisted living facilities that cater to people with money. These facilities would be more like living in a high-rise condominium but having in addition long-term care, housekeeping, meals, planned activities and transportation included in the package. Obviously facilities like this are going to cost a great deal of money.

A common and growing trend is for care providers to integrate care systems in one complex or in close proximity to each other. For example, a nursing home may have an assisted living wing along with an adult day center and an in house home health agency. These could be in the same building or in buildings on a common campus.

There are at least three advantages to this arrangement. One is, as the need for care progresses the care facility can retain a paying client by providing higher levels of care and not losing the client to a competitor. A second reason is that residents who have formed friendships or who have a spouse in one area of the care facility can maintain those relationships by moving to another area that is virtually in the same place. A third reason is that the care facility may have been chosen due to its proximity to the family. Keeping their loved one in the same place as the need for care escalates can be very valuable to the family.  


In 2002, Medicaid helped pay for services for approximately 11% of assisted living residents in 41 states. It should be noted that Medicaid typically only pays for care costs in assisted living and does not pay for room and board. Also a person receiving Medicaid can have no assets exceeding $2,000.00. As a percentage of the cost of total assisted living care the Medicaid portion would be considerably less than 11%. Based on care costs alone Medicaid might only pay about 5% of the total cost of assisted living.

Medicare does not pay for assisted living. About 75% of all costs are paid by residents out of personal funds or family assistance. SSI (supplemental security income) pays for 14% and 2% is covered by long-term care insurance. It should also be noted that the majority of SSI payments for assisted living are for specialized units for mentally retarded and developmentally disabled individuals. These units are maintained and staffed on behalf of state welfare programs. These would not be your typical apartment style assisted living complexes. This means that for the general public--excluding those on SSI welfare payments--more than 90% of the cost of assisted living is paid by individuals or families out of pocket.

Because the government participates little in the cost of assisted living for the non - SSI public, individuals anticipating a future need for assisted living would do well to consider the purchase of long-term care insurance. All modern comprehensive policies cover assisted living. You must, however, qualify for benefits under the policy. Some in assisted living may not need long-term care and until the need for care comes about the policy would not pay.

Insurance is certainly more cost-effective than paying out-of-pocket and may make assisted living a possible living arrangement where otherwise it would not have worked. Depending on your age, 20 years worth of premiums, as an example, might only cost 3% to 8% of the actual amount the insurance policy would pay for a 3 year stay. That's a lot cheaper than paying 100% out-of-pocket.

Buying and paying for a policy before retirement might mean that assisted living would be an alternative with a retirement income that otherwise could not afford assisted living. For example, one could leverage a $3,000.00 per month assisted living cost with a $100.00 a month long term care insurance premium.



Choosing an Assisted Living Facility

An ALF staff worker can tell you whether or not you or a loved one will qualify for assisted living. But you may be forced to choose a nursing home instead because the level of care that an ALF can offer is dictated by the licensing provisions of that particular facility. In the event that you are turned down for care by one ALF, it is very important to get evaluations from other facilities. Many ALFs have found ways to stretch eligibility and you shouldn't give up after one try.

Below is a copy of a reprinted article from the Assisted Living Federation of America's Assisted Living Today Magazine, copyright 1999, ALFA. This article is found on-line at


How to Choose a Residence

Making the right choice is easier when you thoroughly evaluate residences using these criteria - By Elizabeth Parker Welton MSW, LCSW

Assisted living residences, in both rural and urban areas, allow today's consumers to be highly discriminating in their choice of a residence. A wide range of choices, however, may produce confusion and anxiety. With choice often comes the implied responsibility for making the 'right choice.' Family members engaged in this search sometimes feel like they're looking for a needle in a haystack without the benefit of a map.

ALFA has developed a complete checklist to be used in the evaluation and selection process. Consider the following elements when searching for that needle in a haystack.

Atmosphere: Family members involved in the selection process must look at the residences they visit through the eyes of the person who will be living there. When touring facilities, family members often comment, 'I could imagine myself living here.' Although that is a positive reaction, what is truly relevant is whether they can imagine their loved one living in that setting.

How does the prospective resident react when he or she meets the staff and other residents? Is the decor welcoming and homelike? Do the current residents appear to be compatible with your loved one? Will the particular personality and culture of that setting support the physical, emotional, mental, and spiritual needs of the prospective resident? The answer to that question is critical in determining the success of your and your loved one's choice.

Make several return visits to the residence on the top of your list to experience staff and residents in a variety of situations. Although crisis sometimes necessitates a more immediate choice, it is always ideal to take the time to make a slower and more informed decision guided by as much information as you can gather.

Physical Features: A residence that is modern and tastefully decorated almost always creates an initial favorable impression. However, an aesthetically pleasing setting that is not designed to maximize comfort and ease in functioning may not be a particularly wise choice. For example, a beautifully decorated unit that does not have doorways wide enough to easily accommodate a wheelchair does not allow for ease and comfort in movement. A bathroom that is too small to permit a wheelchair or walker to enter without precise maneuvering also reflects poor design. Hallways that are long and/or poorly lit without handrails may confuse and overwhelm elderly residents.

It can be extremely helpful to choose a potential unit and have the future resident move about in that space as if he or she is already in residence there. It gives you an excellent opportunity to evaluate how well the space is designed to promote both comfort and ease in movement as well as how it supports independent functioning.

Needs Assessment, Contracts, Costs, and Finances: Assessing the fairness and comprehensiveness of the contractual agreement is important. Most people are accustomed to evaluating and signing contracts fairly routinely. But it will be important to understand any future costs for increased levels of care and service should the resident's physical and/or cognitive functioning decline. It is reasonable to expect costs will increase over time as independent or minimally assisted functioning declines. Being prepared for that eventuality will help you decide whether that particular residence is financially feasible. Visit ALFA's Web site ( to view a standard 'Consumer Information Statement' or disclosure form, which identifies questions you should ask specific to fees and services.

Another way to determine the viability of a particular residence is to learn whether each resident has a written care plan. Without such a tool, it's possible the care needs of residents will be unrecognized and therefore unmet. A comprehensive care plan should be created with the help and input of the resident, all available family members, the family physician, and any staff members who will have direct contact with the resident. This care plan must be reviewed and updated as the resident's needs change. The process of developing a care plan allows the resident to feel that all of his needs are both recognized and important to those around him. This frequently allays much of the anxiety associated with such a major life change.

Education and Health Care: The majority of people entering an assisted living residence are on at least two daily medications. Many choose this type of setting because medication self administration, among other things, has become difficult. Understand what specific policies are in place for giving medication as well as for any medical emergency that may arise.

Is a licensed nurse available to residents and staff in a full-time capacity? If the prospective resident has chronic hypertension, can you be confident his blood pressure will be taken and recorded on a frequent basis? Does a staff person arrange for visits from a physical therapist, occupational therapist, hospice nurse, etc.? The coordination of services with agencies in the community allows for a full continuum of care to be provided. It not only significantly benefits the health and well being of residents but also establishes the residence as a true member of the outside community. The relationship between the residence and the local community will support the resident in not feeling isolated or sequestered.

Services: Determining as specifically as possible the prospective resident's daily care needs is a critical step in choosing a residence. Make a detailed list of the type of assistance that will be required with each activity of daily living. For example, will this resident require assistance in dressing and undressing? If so, what specific type of assistance will be required? If her clothes are laid out for her, can she dress herself or will she require assistance in the actual dressing process? Does the staffing pattern allow residents who are wheelchair bound to receive help quickly if they need toileting? Inquire about the staff/resident ratio on all shifts. This information will give some indication of how quickly staff can be available to assist residents.

The ease and availability of transportation to shopping, the hairdresser, and other community activities also is important information. The ability to move relatively effortlessly between the residence and the community is another significant way the resident's autonomy and independence are valued and encouraged. Transportation provided by the residence may or may not represent an additional monthly charge.

Cognitively impaired adults may need a different type of assistance in their daily functioning. Are safety measures in place to contain possible wandering? Is the staff trained in techniques important to the care and comfort of mentally confused residents? Are specific areas and/or units designed to provide specialized care and programming for those who are cognitively impaired?

Individual Unit Features: Nurturing the spirit and individuality of residents as they move from their home into a residence is both challenging and achievable. The opportunity to have a choice in one's living space is an important way to achieve this goal. Some people value their privacy and don't thrive in double-occupancy units. Others may feel too isolated in a unit by themselves and will welcome a roommate.

Bringing some treasured pieces of furniture and pictures from home will greatly facilitate the transition and should be encouraged. The presence of a kitchen area in each unit allows for maximum choice and autonomy. Although most prospective residents will acknowledge that they are excited at the prospect of not cooking, the ability to prepare snacks or even a light meal is an important option. One of the fundamental goals of an assisted living residence is to provide comprehensive care to older adults while preserving their ability to be independent and have as many choices in their environment as is feasible. A future resident's participation in the choice of a residence, and the various options available within that residence, will have a direct and vital effect on the quality of that resident's adjustment to his new home.

Social and Recreational Activities: A diverse program of planned activities both within the residence and the community is vital to the happiness and contentment of residents. Does a staff member have sole responsibility to plan and direct social events? Do residents have a voice in planning activities both within and outside the residence? Does the selection of activities reflect the interests and lifestyle of the residents in an appropriate and satisfying way? Are residents who are less social encouraged to participate in activities? Are activities designed to not only nurture the spirit but challenge the intellect? Are activities in the residence consistently well attended by residents?

A well-balanced coordination of activities both within the residence and in the community allows the resident to feel a sense of belonging in both places. Activities are an important way in which social and emotional connections are made in a new setting.

In addition, research shows that the presence of animals in the lives of older adults is another important way of nurturing the spirit. However important and necessary the move to an assisted living residence might be, it involves significant losses. A residence that has a dog or cat viewed as the house pet can provide opportunity for constancy and daily love for someone who may be feeling a sense of loss. Many residences allow a small animal to accompany its owner in the move. When discussing this option with the staff, gain a full understanding of how the animal will be cared for.

Food Service: Food is a significant part of life. We look forward to meals and savor not only the food that we eat but the ambiance in which the food is served. If you polled assisted living residents about what contributes most to their customer satisfaction, food would rank high on their list. One of the universally significant ways in which people feel nurtured is through the food they eat. Keeping that in mind, food preparation should include fresh, diverse, and interesting ingredients.

At each meal, residents should have a choice of entree and dessert. Because individuals' tastes in food differ, no one offering can possibly please everyone. Resident input in the menu selection is another important way of promoting choice and respecting individual tastes.

The kitchen's capacity to provide for special diets that are medically mandated is another critical piece of information to gather. If a resident is feeling too ill to come to the dining room for a meal, can food be delivered to his room?

Is the dining room visually appealing to encourage residents to linger over their meals there? One of the most important avenues for socialization is dining with other people. It represents a natural opportunity to gather and share the events of the day and sometimes a lifetime.

In addition to using the guidelines ALFA has developed for choosing a residence, use your own knowledge of the prospective resident as a guide in making your choice. In what setting will he or she feel most supported and at the same time be able to function most independently? What are the particular and unique physical, mental, emotional, and spiritual needs of this person and in what setting are those needs most likely to be recognized and met?

The goal you set in choosing a residence should not be considered met until a setting has been selected in which the prospective resident can feel physically cared for and can thrive emotionally. Many older adults who are living independently, but struggling each day with physical and/or cognitive disabilities, are isolated and afraid. Moving into the appropriate assisted living residence can relieve the daily struggle to function and release the energy to fully and joyfully engage in life again.

Elizabeth Parker Welton MSW, LCSW is a psychotherapist in private practice in Arlington, VA. She can be reached at 703/524-3169.Be Informed, Be Prepared, Be Thoughtful


Be Informed:

  • Learn about assisted living. Find out what services are provided by the residences in your area. Keep in mind that residences can vary greatly.
  • Shop around. Finding a new home takes time. Plan ahead to visit as many residences as you can. Know what services you need and what to shop for. Make an appointment to meet with staff.
  • Visit and revisit. Once you've decided on your top choices, revisit each facility at least one more time and at different times during the day. Talk to staff, residents, other family members, and the local long-term care ombudsman.
  • Ask for written material. Information is essential. Review marketing material, consumer information brochures, the resident contract agreement, and state survey information about the residence. Consider having an elder law attorney review the resident contract agreement. Read the fine print.
  • You're doing business so ask the right questions. Find out about prices and what initiates a price increase. How much do the extras cost? Find out how each resident's needs are assessed and monitored. Inquire about policies on refunds, transfers, and discharges. What will happen if the facility closes? Is there an appeals plan for dissatisfied residents?

Be Prepared:

    Know the costs. Assisted living can be expensive. Be familiar with what each facility charges for each level of care, plus the charges for extra services beyond the monthly rate.

Examine your finances. Monthly rates vary. Determine the affordable price range and shop accordingly. Will family members contribute and how much?

Be Thoughtful:

In most cases, adult children play a major role in helping a parent secure an assisted living residence. Respect the interests, needs, and wishes of your loved one. Although many assisted living facilities offer a lifestyle that preserves autonomy and dignity, moving from home to a new place can be a difficult transition. Work together to make plans and decisions. Don't exclude your parent from the process.

From Sen. Charles Grassley (R-IA), chairman of the Senate Special Committee on Aging

Home | Back to Top Copyright 2002, Assisted Living Federation of America.