Assisted Living Overview

assisted-living facility
Assisted-living facilities come in all shapes and sizes.

Home, sweet home. You can spend a lifetime saving up for a house and then renovating it, decorating it, making memories in it and getting it to the perfect intersection of function, comfort and appearance. Home is a place to invite friends and loved ones, but it's also a place to retreat from friends and loved ones. Living independently in your own home -- be it a rented apartment, condominium or house -- may be the most fundamental expression of personal freedom. None of us want to get to the point in life when we can't take care of ourselves.

As a person gets older, family members, friends and neighbors begin dropping by to check on him or her to see if help is needed. Maybe a slip on wet bathroom tile or a medical emergency will worry loved ones -- not to mention the person in question -- even further. A family member may move in, but over time that arrangement often stops being a good one for either party. The at-risk family member is accustomed to freedom; the caregiving family member has a life of his or her own that needs attention.


­The family starts talking about care options, but none of them seem appealing at first. As time passes, the elderly relative needs more and more attention -- more, frankly, than family members know how to give. And while the care isn't constant (the relative still gets around, after all -- it's just that she gets, well, forgetful sometimes), it is consistent day to day. She needs help getting dressed, or he needs help getting safely in and out of the tub. Also, cooking is becoming more difficult, but after the relative is clean, dressed and fed, all parties involved would like some private time until lunch. The thing is, if you step out to run some errands, who will know if your older loved one has taken a fall down a set of stairs while you're gone? Even though you're not needed all the time, a sense of "nearness" is. Your loved one doesn't need to be laid up in a nursing home (not to mention the expense!), but something different from the status quo is called for.

The answer may be assisted living. Assisted living facilities provide a step between fully independent living and around-the-clock care. It's for people who value their independence, yet need some help with life's daily chores and necessities.


Assisted Living Basics

older woman with a walker
She can still get around pretty well on her own.

­About one in every 300 Americans lives in an assisted-living facility [source: Assisted Living Federation of America]. Assisted-living facilities are designed to help the infirm, disabled or elderly with tasks such as dressing or bathing while also helping that person maintain maximum personal independence and self-reliance. The facility is designed (and appropriately equipped) to help residents primarily with the daily challenges of living that many of us are able to take for granted: reading small medication labels, preparing and eating meals, and keeping up with housekeeping and laundry.

There seem to be about twice as many descriptive terms for assisted living facilities: "residential care," "retirement residences," "personal care," "enriched housing program" and "adult foster care," just to name a few. When looking for assisted living options, be sure that what's being described is what you're looking for. Often, these terms are somewhat interchangeable with other types of personal care, such as nursing homes.


Assisted-living homes aren't nursing homes -- just because your balance isn't what it used to be doesn't mean you're ready (or welcome) to receive bedside care and near-constant supervision. Assisted-living facilities don't provide around-the-clock care -- nursing homes do. But a person who no longer is fully able to take care of himself or herself (or be given a regular helping hand by a friend or relative) may be appalled at the thought of going into the "old folks' home." Assisted living also enables people who are in earlier stages of Alzheimer's or age-related dementia to receive care as needed, and not around the clock.

With more than 20,000 different assisted-living facilities in the United States, there is no universal "look" or design [source: Assisted Living Federation of America]. There could be on-site beauty salons and barbershops, horse stables, or swimming pools. Or, the facilities could have none of those amenities. However, they do share common caregiving features. So while one facility may have rooms that resemble those of the Chelsea Hotel and another facility has rooms that are actually large multi-roomed condominiums, both will offer services -- like laundry or meal preparation -- on a per-fee basis.

We'll discuss what type of care is provided through assisted living in the next section.


Assisted Living Services

What type of care is provided at assisted living homes? All homes are different, as are individual needs and service contracts (which we'll talk more about later). Generally, assisted living arrangements involve help with the following:

  • Laundry. This includes the washing and changing of bedding and clothing, as well as ironing.
  • Meal preparation, service and assistance. While some assisted living quarters may include kitchenettes to provide more independent residents with the option of continuing to cook their own meals, most offer regular daily meals prepared and served in common areas. Assistance may also be provided to those who are no longer able to feed themselves.
  • Help getting dressed. Injuries or infirmity may make getting dressed and undressed a difficult and even dangerous daily task for some residents.
  • Bathing. Decreased mobility and risk of falling means some people -- who otherwise may be perfectly able to feed themselves or get dressed -- need help bathing or just getting in and out of the bathtub.
  • Daily medications. Physically able residents may have cognitive difficulties caused by Alzheimer's or other conditions that make it difficult to keep up with medication schedules. While assisted living environments typically have limited health care options, most are able to make sure that residents are taking the appropriate meds on schedule.
  • Social and recreational planning. Assisted living homes typically have an events coordinator who is responsible for making sure entertainment, social gatherings such as dances and stimulating activities like book clubs are a daily part of residential life.

Assisted living is not the right choice for everyone. Also, assisted living isn't generally made available to those who need special care outside of that which a facility can provide. The following are care options not provided or medical situations that don't qualify for assisted living care:


  • Use of restraints or physical confinement. Assisted living is designed for those who still have considerable freedom and independence, and such care providers aren't equipped or trained to handle residents who need restraints or have restricted mobility.
  • Care for chronic health conditions. People who require regular care for a health condition such as lung or kidney failure will need advanced care that assisted living can't provide.
  • Severe cognitive impairment. Those who are in advanced stages of dementia aren't adequate prospects for assisted living. Assisted living depends on a resident's ability to dictate the terms of their own individual care.


What to Look for When You're Choosing Assisted Living

older woman with dog
Can't bear to leave your dog behind? Some assisted-living facilities allow pets.

­When choosing an assisted-living facility for yourself or a loved one, it's important to know what to look for and what questions to ask when visiting different homes. As we've learned, assisted living comes in many different forms, and, like about everything else in life, some are better than others.

Some questions to ask yourself or your guide when visiting:


  • Do the residents seem happy? The faces of the residents will be the best advertisement for a good, attentive and well-run facility. If residents seem withdrawn, forlorn or antisocial (or too social, depending on your personality), that facility may not be the one for you.
  • Is the residence clean, neat, secure and well designed? Again, it will only take a cursory examination to learn a lot about the maintenance and professionalism of the home. Are hallways and stairways easy to navigate and well lit? Are there handrails in the bathrooms? All of these factors will affect safety and comfort, especially considering your stay may last many years.
  • Are pets allowed? Some homes may allow residents in private rooms to keep fish, birds, cats or dogs.
  • How many common areas are there? If there are few places to mingle, there may be few chances to form new relationships.
  • Is transportation available to residents? Make sure you know whether the home has a shuttle or is near a bus line. Some assisted living homes charge parking fees for residents and visitors. Others provide (sometimes at a charge) transportation to and from religious services.
  • What is the facility's policy on what personal belongings the resident can bring? In some cases, residents may be able to bring household furniture such as chairs, sofas or bookshelves, while in other cases the living quarters may be furnished or too small for bulky items. Many times, on-site storage is available for any items that won't fit in the room.

If you're considering a roommate so that you can cut costs (or simply for the camaraderie), check the size of the rooms and the design of the living arrangements. It'll be harder to get off on the right foot with your new roommate if you're constantly stepping on his or her toes.

Think about these matters before you start your search, and you'll be more likely to know you've found the right facility when you see it.


Assisted Living Contracts

If you think haggling over the contract for a new car is stressful, imagine signing a contract that determines how much you'll pay for your loved one to receive specific caregiving services. You'll definitely want to go into the contract phase of entering assisted living with a clear idea of what you want and what you can expect.

Many assisted living residences are for-profit businesses, and even nonprofits need to delegate their resources carefully. What this means to you or your loved one is that every service requested on top of the basic package included in the base monthly housing payment will have a cost attached. Some facilities may include laundry and meals in the base rate, and others may not.


Contracts tend to fall into three categories:

  • Extensive. This type of contract agreement includes a fixed monthly rate for unlimited lifetime assisted care. Since the payments will be higher up front, it's a more expensive option right out of the gate. As time passes and care needs increase (as they often will, due to declining health), that fixed monthly rate will become a better and better deal.
  • Modified. This contract also has a fixed rate, but it's only good for a set length of time. This means you'll pay less per month than you would with an extensive contract, but that when you or your loved one outlives the contract, a new (and more expensive) contract will need to be established.
  • Fee-for-service. This third type of contract works exactly like it sounds: The resident pays by the day and for each individual service. There is no protection or provision that accounts for rising health care costs or needs -- when the resident needs more, the resident will have to dig deeper into his or her pocket. However, because future costs aren't figured into the contract, this is the most affordable contract in the short term. Also, assisted living isn't as expensive as a full-care nursing home that provides 24-hour nursing and observation. A person who just needs to be in a safe environment and needs only a little help could pay as little as $60 a day [source: Medicare]. That comes to about $12,000 a year, compared to around $50,000 a year on average for nursing home care [source: AARP].


Assisted Living Costs

older woman looking over contracts
Planning how you'll pay for long-term is a good idea, as it can get very expensive.

There are typically three different ways to pay for assisted living care: Medicaid, long-term care insurance and out of pocket. Medicare won't cover the cost of care facilities unless the care is medically necessary. Usually, assisted living situations aren't medically necessary, in that the type of help provided in assisted-living situations is considered "custodial care."

Most facilities in the United States do accept Medicaid. Medicaid is government assistance for health costs that is available to limited-income or asset-depleted elderly Americans. Regulations for Medicaid's payment for assisted living vary from state to state, but more than 100,000 people receive Medicaid assistance toward the cost of assisted living [source: National Center for Assisted Living].


Those who don't qualify for Medicaid are in danger of outliving their resources (and eventually qualifying for Medicaid). Those who don't actually outlive their funds end up spending so much on their ongoing care later that they have little if any to bequeath to surviving family members, churches or charitable causes when they die.

Long-term care insurance works like other forms of insurance: You qualify for it, pay for it before you need it, and it pays for your needs when they arise. If you wait until your health is beginning to give way, you may find it is too late to qualify for this type of insurance. Insurers know how much long-term care costs can accumulate and won't put themselves on the line for a high-risk applicant. Of course, you don't want to get prematurely insured and pay years and years of premiums for a policy you may not ultimately even need. The premiums aren't cheap -- a retiree who applies for long-term care insurance at age 65 may pay as much as $3,000 a year on premiums [source: AARP]. Some premiums will increase according to inflation or a pre-arranged staggered payment schedule that increases after a set number of years. The upside is that this insurance kicks in before you need to move to a facility, as it oftentimes will cover at least part of the costs of adult day-care or home-based care in the form of visiting nurses.

The benefits (or payout) of long-term care insurance may be calculated on a per-day or per-month basis. Once that amount is reached in your care, additional costs won't be the responsibility of the insurer.

Veterans and military personnel should contact their nearest Veterans Affairs (VA) hospital to find out if free assisted living will be available to them at a VA facility.


Getting In Assisted Living -- and Getting Out of It

Prior to being admitted by an assisted living facility, potential residents will be required to have a medical examination and other assessments. The physical exam will serve to establish that the applicant's needs can be met by the facility. People with serious health problems won't be admitted.

Additionally, people at the facility will assess the resident's ability for himself (or herself). This helps determine what services the resident may need and which ones are unnecessary. Behavioral screening may be provided to guarantee that extreme cognitive issues commonly associated with dementia, such as violent outbursts or confused wandering, aren't present.


While in care, residents may have regular checkups (how often this occurs varies state by state, and even within states). If these exams uncover new or advancing health issues, the resident may be required to leave and seek more advanced care elsewhere.

Residents must also frequently update their service contracts. This may occur once every three, six or 12 months, depending on the facility. If a physical exam reveals the resident will need a greater level of care, the contract must be reassessed to reflect the change in circumstances.

Assisted living care is rarely a permanent living situation. Most residents, as they age, will need higher levels of care. Many facilities are grouped together on a shared campus with nursing homes and independent retirement communities so the transition from one care provider to another will be as easy as possible.

These are known as continuing care retirement communities, or CCRCs. By grouping these facilities, residents are able to remain in the same location for the latter stages of life instead of moving from one part of town to another. CCRCs allow the retirement community resident to switch to a different level of care. Many CCRCs are maintained or operated by nonprofit organizations, such as religious groups.

Other times, a resident or the resident's family may run out of money to pay for care, requiring the resident to leave. When the decision isn't the patient's, state laws determine the amount of notice and method of notification needed to "evict" a resident. Typically, a 30-, 60- or 90-day notice must be given in writing, to both the resident and to the resident's family contact listed on the contract. If a resident becomes a danger to himself or others, the notification period of imminent eviction may be as short as three days.

Once a family or individual is satisfied that the right assisted-living arrangement is available, there are steps that must be taken to place a person in that facility's care.

For more articles on aging, try the links on the next page.


Lots More Information

­­Related HowStuffWorks Articles

  • AA­RP. "Assisted Living: What to Ask." (March 9, 2009) ­­
  • AARP. "Long-term Care Insurance." (March 7, 2009)
  • Administration on Aging. "Housing." June 2, 2008. ­
  • Arizona Department of Health Services. "Assisted Living Homes/Centers, Adult Foster Care Homes & ­Adult Day Health Care Facilities." (March 9, 2009)
  • Assisted Living Federation of America. (March 8, 2009) ­
  • Consumer Consortium on Assisted Living. (March 9, 2009)
  • Haywood Lodge and Retirement Center. "Payment Options." (March 8, 2009)
  • Medicare. "Nursing Homes." U.S. Dept. of Health & Human Services.
  • Medicare. "Paying for Long-Term Care." U.S. Dept. of Health & Human Services. (March 6, 2009)
  • Medicare. "Types of Long-term Care." U.S. Dept. of Health & Human Services. (March 8, 2009)
  • MedlinePlus. "Assisted Living." U.S. National Library of Medicine and the National Institutes of Health. Feb. 3, 2009. (March 8, 2009)
  • National Association for Home Care & Hospice. "Regulatory Affairs." (March 7, 2009) ­
  • National Center for Assisted Living. "Assisted Living State Regulatory Review 2008." March 2008.
  • (March 9, 2009)