Deciding about Housing

The other day, a friend of mine said “My husband and I are talking about planning a move to assisted living.  I was quite surprised, as she did not appear to me to need any ‘assistance’ in her daily living activities.  However, I have heard this thought expressed frequently, and it seems to me that there is a big lack of understanding about different types of housing for older adults – what they are, and how one determines the level of care needed, if any.

Before we talk about care facilities, we should define ADL’s or the Activities of Daily Living.  It is how the older person scores on these various activities that determines what level of care he or she requires. There are two different screenings:  Activities of Daily Living and Instrumental Activities of Daily Living:

ADLs involve self-care and include the ability to:

Dress oneself

Use the toilet (not incontinent)

Feed oneself

Bathe/ maintain personal hygiene

Ambulate – walk independently or transfer into or out of a car, wheelchair, and bed

IADL’s are those that enable individuals function independently in the community:

Meal preparation



Use transportation (car, public or arranged rides)

Manage medications

Handle money

Communicate – use the telephone

There are several screening instruments that professionals use to evaluate an older person’s needs.   A reduction of ability on one or two points may not indicate a need to move to a care facility if alternative support is available.  For instance, Meals on Wheels may be a substitute for inability to prepare meals.

Care facilities such as assisted living residences and nursing homes use ADL screenings to determine if a potential resident would benefit from their services, and what care level would be required, hence what the fee would be.  Since maintaining ADL levels does not require skilled nursing care, the costs of providing such care are not covered by Medicare.  Medicaid, which is state-based, uses ADL screenings to determine eligibility.  Medicaid has income level criteria.

Here are some examples of screening instruments for ADLs and IADLs

Assisted Living

Assisted living is one form of care facility for people who need help with some of the ADLs or IADLs (often medication management).  Facilities can vary widely from a small board and care home with just a few beds to an elegant facility that looks more like a resort hotel.  The latter can offer a variety of floor plans, including some apartment sized units.  However, since three meals a day are provided, these units usually only have limited kitchen facilities, perhaps only a small refrigerator and a microwave. Residents can bring their own furnishings. Some units may be furnished and offered for temporary respite care or rehab care, and there may be a memory care unit. All housekeeping services are provided, along with a social activities program. Laundry services are available for a separate charge.  A nurse is available to manage medications.  Assisted living facilities fall under much less restrictive state or province licensing requirements than do nursing homes. Note that these regulations vary from state to state. There is no national standard.

Assisted living facilities follow a social model rather than a medical model.  They provide a secure environment with nonmedical services, including personal care, preventive health services, and planned social and recreational activities.

AARP has a checklist to help you evaluate an assisted living facility at

55Plus Independent or Active Senior Living

Independent living is just that – no care services are offered.  The main distinction is that it is age restricted. The senior housing market uses a number of different terms for its offerings. They may be boarding houses, rental apartments, condominiums, townhouses or individual villas or homes.   Costs vary widely, as well as the structure of the fees – flat monthly or fee for service.  Some may offer subsidized housing for those who qualify.

The term Active Adult community may be used for a development that offers a wide range of activities and programs,  including amenities such as swimming pool, exercise facility and classes, tennis courts, and golf course.  There may also be social programs planned by program director or the residents themselves.

Continuing Care Communities CCRC’s or Life Care Communities

These include multiple levels of independent living and care facilities such as assisted living, nursing care and memory units. The amenities mentioned above are offered.  Residents pay an upfront fee which can be substantial, and a monthly service fee, a portion of which is applied if or when the resident must move from an independent living unit to a care facility.

Hope this clears things up.


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