In my last article, I talked about choices for care in the home. What happens if your loved one is no longer able to stay in their home due to safety concerns, a health issue or simply financial constraints? What then are your choices?

Unfortunately, home care in many cases when care needs increase can become more expensive than moving to a community to receive an increased level of care.

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There was the day when the options were limited. Most of us remember when moving from the home meant moving to a nursing home. How many of us have heard from our parents or grandparents: "Promise me you won't put me in a nursing home"?

Times have changed. The options for supported living have increased. Choices range from independent living in a senior community (Continuing Care Retirement Community), assisted living, to the most supported level of skilled nursing care in a long-term care center or nursing home.

Continuing Care Retirement Communities (CCRC) offer what some refer to as a "lifetime of care." Many may enter into the community and live in an independent living residence -- such as a cottage or apartment -- and move through the various levels when there in a change in the level of care required. Some communities are much more accommodating to allow residents to age in place in their cottages or apartments. As an added benefit CCRCs provide a health center for rehabilitation care or long-term care, and this makes a CCRC an attractive option for many.

CCRC living typically includes amenities such as a meal plan (and you can eat in a variety of dining venues), cleaning services, lawn service, activities and religious services all within the community. For many, the move to a CCRC allows for freedom and travel without all of the responsibilities of owning a home.

CCRC living isn't cheap and that's the bad news. Typically, there are buy-in fees, which are unique to each facility. Many will use the sale of a house to buy their new residence in a CCRC. Monthly fees or rent per se include a meal plan and many of the amenities. In most cases, costs increase as the care required increases. There are some communities that have "a la carte" plans, which keep expenses constant over the span.

The advantages of CCRC community living is the peace of mind to know that once you are there you can age in place and take advantage of care provided, should aging or health issues create limitations in the ability to perform self-care or what is referred to as the activities of daily living or ADLs.

If CCRC living is not for you or a loved one, and an increased level of care outside the home is required, another option is assisted living. Assisted living (AL) is an option that many don't realize is out there. Oftentimes I hear "mom needs to go the nursing home because we can't continue to care for her at home." Assisted living can be a wonderful option where comforts of home and independence are combined with care and oversight. Some assisted living facilities can provide care through the end of life in appropriate situations.

ALs provide a room or suite with full amenities: meals, socialization, activities and sometimes, transportation to various activities are included. ALs may be very small with only a few rooms or large communities. Pricing is typically based on size and services available. Assisted living is paid for privately and ranges from $2,000 to $6,500 per month or more for specialized dementia care. There are subsidies for low income and qualified seniors, which can offset a minimal amount. The Medicaid waiver, which unfortunately at this point has a waiting list, aims to keep higher functioning seniors in the AL setting and out of nursing homes. However, once again there is bad news: very few assisted livings accept the waiver. Medicare does not pay for assisted living care.

Finally, when the amount of care required exceeds what may be able to be accommodated in the home or AL, long-term or nursing home care is an option. Nursing home care is appropriate when you or a loved one are no longer able to perform the activities of daily living (ADLs) such as bathing, dressing, toileting, ambulating and or transferring from one place to another. In addition, managing medications, doing housekeeping, laundry, using the telephone and driving are all considered instrumental ADLs and are evaluated in conjunction with the ADLs.

The goal is to have a person living in the most suitable environment for them. As a geriatric care manager, my goal is to keep individuals at their highest level of functioning in the least restrictive environment.

Long-term care is for those with the highest care needs. There are unfortunately some caveats to this philosophy. In the case where a person could potentially be cared for in the home with help or in assisted living, but has no financial resources, it sometimes becomes a necessity to reside in a nursing home to get financial assistance through medical assistance.

It doesn't make sense to place someone in a higher level of care for reimbursement when long-term care is the most expensive care averaging $6,000-$13,000 per month, but it happens. The Medicaid Waiver program, which was originally in place to reimburse for assisted living residences (which are limited), or financial help with home care has been overloaded. Plus, the waiting list remains long -- at times 3-5 years.

The state has added a new program called Community First Choice to move dollars for in-home care to keep individuals in their homes with services. This still does not work for everyone. Services cap out at 12 or often fewer hours per day. For someone who requires 24/7 care, it's just not enough to keep them safe and cared for, and they will require nursing home level of care. Community First Choice is available for those who meet criteria for medical assistance and are currently receiving community medical assistance and show that they have care needs.

The Waiver Program will hopefully open up and move those most in need of assisted living care to the top of the list. At this point, it's based on your waiting spot on the list only. There are criteria for need and one must not have assets that would deem them ineligible for Medical Assistance.

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No matter which option you choose it is important to research your choices, take the time to visit the community and evaluate their ratings on nursing home compare at: http://www.medicare.gov/nursinghomecompare/search.html for nursing homes or go to Maryland Health Care Commission Consumer Guide to Long Term Care at http://mhcc.maryland.gov/consumerinfo/longtermcare/SearchPage.aspx?qs=AL to view a listing of facilities and survey results.

Jill Rosner is a registered nurse, certified geriatric care manager and owner of Rosner Healthcare Navigation. She provides patient advocacy and care management services to clients with health and aging issues. Contact her at JillRosnerRN@aol.com.

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