Oct 25, 2017

What is the Difference Between a Nursing Home and an Assisted Living Facility?

How is a nursing home different from an assisted living? What in the world is “Memory Care Facility”? How can I figure out which is best for my loved one? How are they different?

Assisted living facilities are rapidly replacing nursing homes as the preferred setting for residential long-term care for persons with dementia.
By Rita Jablonski
Alzheimer's Reading Room

Families who are searching for the optimal place for their loved ones with dementia now have an almost overwhelming set of choices.

Assisted living facilities are generally described as congregate residential settings that provide 24-hour supervision, at least 2 meals daily, and an array of personal and health-related services.

Fifty-nine percent of assisted living facilities provide skilled nursing services, defined as medical activities that must be legally performed by a registered or licensed practical nurse.

Assisted living facilities are licensed by individual states, meaning that there are NO CONSISTENT REQUIREMENTS FOR THE QUANTITY AND QUALITY OF CAREGIVING PERSONNEL.

  • Assisted living facilities are rapidly replacing nursing homes as the preferred setting for residential long-term care for persons with dementia.
Nationally, 1 million older adults reside in one of the 30,200 assisted living facilitiesNational Study of Long-Term Care Providers - 89% of these residents are living with dementia.

In contrast, 1.6 million people live in one of 16,000 nursing homes, Nursing Home Data Compendium 2015 Edition - 61% of these residents are living with dementia.
  • Nursing homes are generally settings that provide much closer supervision and tend to be more aligned with a hospital or medical model (although that is rapidly changing as nursing homes become more “home” and less “medical”). 
All meals and medications are provided. 24/7 licensed nurse supervision is available. And, nursing homes are regulated by Medicare and have “certified” Medicare beds.

They are differenences in how nursing homes and assisted living facilities are inspected and monitored (oversight).
  • Nursing homes are inspected every year by surveyors who check to see if the facilities are following the rules—including rules about prescribing drugs often used to reduce or stop behaviors in persons with dementia
They are “under the microscope” and are expected to handle behaviors, like yelling or wandering, using non-drug approaches.
  • Assisted living facilities, on the other hand, are inspected by the health department, and inspections may vary. Often, the assisted living facility is inspected when it first opens and only afterwards if there are complaints.
Nursing homes are held to specific rules and standards, which may limit how “homelike” a room may be or prevent the kitchen from serving soft-boiled eggs. However, a nursing home rarely “kicks out” a person with dementia who shows difficult or challenging behaviors.

Assisted living facilities, on the other hand, will “involuntarily discharge” someone with the same behaviors…or insist that the family hire 24/7 “sitters” (which if the family could afford in the first place, the person would not be in the assisted living facility).

What does this mean for the caregiver? 

Which one is the best option for my loved one? One very important driver is cost. In some states, assisted living facilities accept Medicaid. This is great for seniors with very limited financial resources. The assisted living option would be more financially feasible than a nursing home option.

However, if your loved one is in the hospital for 3 or more CONTINUOUS nights and meets strict Medicare requirements (such as needing physical, occupational, speech therapy), you will need to find a rehabilitation facility, often a nursing home with a “short stay” unit. This is because Medicare pays for 100 days of skilled nursing and therapeutic care (physical therapy, occupational therapy, speech therapy) for CERTIFIED FACILITIES ONLY.

Medicare Part A covers all costs for the first 20 days of rehab stay, then charges the beneficiary $165 co-insurance each day until day 100 (assuming that the person is still receiving the services and making progress).

There are Medigap policies that cover the co-insurance. I would recommend speaking with the hospital social worker and the facility social worker and getting this information in writing.
  • Assisted living facilities are not certified by Medicare, even if they offer identical services. Medicare will not pay for post-hospital care in an assisted living facility, and most major health insurance companies follow Medicare’s lead.
What is Memory Care?

There are no standards for “Memory Care.”

In some states, like Alabama, any assisted living facility who admits persons with dementia must be licensed as a “specialty care assisted living facility” or SCALF.
  • SCALF’s are locked (secured) facilities and staff having direct resident contact are mandated by the Dementia Education and Training Act (DETA) to receive very specific dementia training.
Unfortunately, the training materials were developed in 1997 and last updated in 2008. Some of the content is frankly wrong (e.g., “Psychiatric symptoms usually respond to medication”) and insulting (“Fifty to sixty percent of all nursing home residents are demented”).

Search the Alzheimer's Reading Room for Answers to Your Questions, and Solutions to Problems

While Alabama is held up as a good example and model for SCALFs because “mandatory dementia training” looks great on paper, the reality is much different. See 5 Critical Questions to Ask When Selecting a Memory Care Facility .

Bottom Line: You can obtain information about nursing homes using the “Nursing Home Compare” website that contains important Medicare information and results inspections.

The information is a couple of years behind, but you can see trends with items like staffing, infections, and bedsores.

There are no sites like this for assisted living facilities.

I would recommend going to your state’s health department web site and seeing if there is information posted there.

Talk to health care providers, especially nurses, who usually know a lot of “behind the scenes” information.

Rita Jablonski, PhD CRNP is an internationally recognized expert in dementia behaviors. She is tenured professor at the University of Alabama at Birmingham and a funded researcher, with over 50 publications and book chapters to her credit. She is a nurse practitioner in a Memory Disorders Clinic, where she helps people with dementia and their care partners. She shares her wisdom on her blog, Make Dementia Your B*tch.

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