Compare and Contrast Nursing Home Alternatives

Introduction

Most aging Americans today wish to avoid placement in a nursing home for long-term care. The good news is that the number of options that serve as alternatives to nursing homes has never been greater. Even better news is that the primary payer of nursing homes, the federal government, wants the same thing as most seniors, to reduce the number of Americans living in nursing homes. The best news of all is that the US government has a variety of different methods of providing financial assistance to help seniors avoid living out their later years in a nursing home.

In this article, we will describe what nursing home alternatives exist, the level of care they offer, their costs, financial assistance, and other options available to cover the costs.

Are We in Denial?  Only 14% of working Americans believe they will need ongoing daily assistance at some point during retirement, yet 66% of us actually will. 

 

Nursing Home Alternatives Summary

We have identified 5 viable options to nursing home placement. Each option is explored in greater detail further down this page.

1) Assisted Living - a group residence where residents live in private apartments, share meals, participate in activities and day trips and receive personal care assistance, medication reminders and have 24 hour on call assistance.  Though still a group living environment, assisted living is vastly different from nursing home care with consideration to the quality of life of the resident. 

2) Medicare PACE Programs - for Medicare beneficiaries, PACE (Program of All-Inclusive Care for the Elderly) programs offer a combination of services to individuals who would otherwise require nursing home care. This allows them to remain living in their homes or in the homes of family members. 

3) Medicaid HCBS Waivers - for Medicaid beneficiaries, HCBS (Home and Community Based Services) Waivers provide a variety of care services and non-medical support for the elderly and their caregivers. These services are specifically intended to prevent nursing home placement and allow seniors to live at home or in the homes of their caregivers.

4) Adult Foster Care - is offered in private residences, usually family homes, where 1 - 3 seniors live and receive personal care, share meals and assistance with their activities of daily living.  Compared with nursing home care, adult foster care offers a family-oriented living experience. 

5) Eden Alternative - Not as much an alternative to a nursing home as a philosophy for significantly improving the nursing home experience for residents.

 

Quick Comparison Chart

 This chart provides an easy way to compare nursing homes against the alternatives however readers should be aware that these are not all equal nor do they all offer a complete substitute for nursing home care.

  Assisted Living PACE Programs HCBS Waivers Adult Foster Homes Eden Alt. Nursing Homes Traditional Nursing Home
# of Residents 10 - 100 (31 on average) 1 (at home) 1 (at home) 1-3 Estimated at 50 - 100 50 - 200 (109 on average)

Types of Non-Care Services -Meals
-Activities
-Homemaker
-Meals (in adult day care)
-Activities (in adult day care)
-Meals
-Homemaker
-Chore
-Transportation
-Meals
-Homemaker
-Some activities
-Meals
-Activities
-Pets
-Gardens
-Children's playgrounds
-Meals
-Limited activities
Types of Care -Personal
-Medication Help
-Alzheimer's
-Adult Day
-Medication Help
-Personal
-Nursing
-Medical
-Personal
-Medication Help
-Adult Day
-Alzheimer's
-Nursing
-Medical
-Personal
-Medication Help
-Full range of care -Full range of care
Family Expected to Provide Some Care No Yes Yes No No No
Cost $2,500 - $5,000 / month.  National average is $3,600 No additional costs over Medicare No additional costs over Medicaid

$1,500 - $3,500 / month $4,000 - $12,000 / month.  National average is $6,360 $4,000 - $12,000 / month.  National average is $6,800
Funding Sources -Medicaid
-State Assistance
-SSI
-VA
-Private Pay
-Medicare -Medicaid -Medicaid
-Private Pay
-SSI
-VA
-Medicaid
-Private Pay
-SSI
-VA
-Medicaid
-Private Pay
-SSI
-VA




Program Details

Assisted Living

These group residences accommodate between 5 - 100 seniors. Residents live in private or shared apartments, enjoy optional group dining, participate in activities and day trips, and receive personal care assistance, medication reminders, and have 24 hour on call assistance. The level of care available varies with needs from no care to almost nursing home level care. Many residences have "Memory Care" divisions with increased supervision for persons with Alzheimer's or dementia who would otherwise require nursing home care.

The cost and financial assistance available for care vary significantly by state. Between $2,500 - $5,000 / month should be expected. Alzheimer's units typically charge an additional $1,000 / month. While this may seem high, it is significantly less expensive than nursing home care. Some individuals who could thrive in assisted living end up in nursing homes because Medicaid is more likely to cover that cost. Medicaid hopes to prevent this and is increasingly helping with the cost of assisted living, both to save money and to improve the quality of life for residents. Other financial assistance comes from Supplemental Security Income (SSI), state specific programs, and the Department of Veterans Affairs (VA). Private pay still makes up the majority of assisted living costs.  A complete review of the financial assistance options and state by state costs is available here

 

Medicare PACE Programs

For Medicare beneficiaries, PACE programs offer a combination of services to individuals who would otherwise require nursing home care. Thereby enabling them to remain living in their homes or in the homes of family members. While medical care and some personal care are provided, family members are expected to provide caregiving as well. These programs do not pay for 24/7 personal care and supervision. However, their great benefit is helping the elderly remain in an environment with which they are familiar and comfortable.

Some drawbacks associated with PACE Programs (also called LIFE Programs in some states), include the fact that care services come from a limited number of providers and the program participants have very little, if any, choice of who provides them with assistance. Another factor limiting participation is the geographic availability of PACE Programs. They are not available in every state nor in every county of those states in which they are available. Participants may have to travel great distances to receive care.

There is no additional cost for PACE beyond the normal Medicare costs.  Participants elect to receive all their care services from a limited group of providers and Medicare pays for those services.  Therefore financial assistance is not available, nor is it really relevant.   More information.

 

Medicaid HCBS Waivers

For Medicaid beneficiaries, HCBS (Home and Community Based Services) Waivers provide a variety of care services and non-medical support for the elderly and their caregivers specifically intended to prevent nursing home placement and allow seniors to live at home or in the homes of their caregivers.  Typical services provided under a waiver include adult day care, personal care at home, chore assistance, personal emergency response services (PERS) and often times support for home modifications that increase independence or safety.  Some of these services can be "participant directed" meaning the care recipient chooses their care providers.  In some states, family members can be hired as care providers. 

Drawbacks associated with these Medicaid waivers include limited enrollment.  Waivers have a defined number of "slots" and frequently there are waiting lists.  Medicaid (and therefore HCBS Waivers) are intended for low income seniors with limited financial assets, so unfortunately many seniors who cannot afford their cost of care still are not financially eligible for Medicaid waivers.

There are no costs associated with participation in a HCBS Waiver above and beyond normal Medicaid co-payments or spend-down. They are a form of financial assistance which helps families care for loved ones at home instead of in a Medicaid funded nursing home. 

 

Adult Foster Care

Personal care, supervision and meals are provided in a family home.  Some homes care for just a single senior and others may care for 2 or 3 seniors.  Compared to nursing home care, adult foster care offers a family oriented living experience.  Some seniors prefer this while others prefer the greater social interactions available in assisted living.  Assistance with medications, toileting and bathing are provided, but medical care is not.  Adult foster care providers are regulated by their states or counties and one is usually introduced through working with a state agency. 

Adult foster care is significantly less expensive than nursing home care or assisted living. Nationwide costs range from $1,500 - $3,500 / month.  Payments options include assistance from state programs, Medicaid and SSI.  Some states run structured Adult Foster Care Programs and others leave residents to find and manage their own arrangements. 

 

Eden Alternative

The Eden Alternative (and the closely related Green House Project) are not as much alternatives to nursing homes as an alternative approach or philosophy to creating a nursing home environment. If one has determined a nursing home is essential for their loved one, they would be well advised to find a nursing home that adheres to the Eden Alternative approach. In summary, the Eden Alternative works to create an environment in which the care recipient is the decision maker, both in their care services and in their lifestyle choices. This results in aging environments where seniors are much more engaged, valued, respected, and frankly, happier.

Physically, Eden Alternative homes tend to be spacious, with gardens, animals, and even playgrounds for visiting children. Residents are engaged with their care, as well as their living community and each other.

There are no additional consumer costs for nursing homes that adhere to the Eden Alternative philosophy. Funding comes from the same sources that pay for traditional nursing homes, largely Medicaid and private pay. One can learn more about the Eden Alternative here or search for aging locations that adhere to their philosophy here.