Long-Term Care

Checklist for Selecting a Long-Term Care Facility

Moving a loved one with Alzheimer’s disease or a related dementia to a long-term care facility is often a complicated and difficult decision—and one that is intensely personal. If possible, families should try to plan for long-term care early on. Doing so may provide some comfort, knowing that a loved one with the brain disorder was able to contribute to the conversation. Consider the following:

Note that one size does not necessarily fit all, and become familiar with the different types of care available. The two most common are assisted living residences and nursing homes/skilled nursing facilities.

  • Assisted living residences provide private living spaces and services such as selected meals, housekeeping, laundry and transportation. Many also offer hands-on help with activities of daily living. Most do not provide skilled nursing care, though they can provide help with medication management. In addition, individuals may choose to hire a private home health aide. Almost all assisted living facilities are private-pay only. Each state sets its own requirements regarding licensure.
  • Nursing homes offer a great deal of skilled care, including round the clock nursing care and physical, speech and occupational therapy, as well as assistance with the activities of daily living (i.e., bathing, dressing, toileting, eating). Medicaid typically pays for skilled nursing care, and private-pay arrangements also can be made. Nursing homes are state-licensed, regulated and regularly inspected to determine whether they meet Medicare and Medicaid quality and performance standards.

Take stock of available financial resources, including personal assets, to pay for long-term care. Most assisted living facilities do not accept Medicaid, whereas nursing homes do. Medicare covers skilled needs (nursing care/rehabilitation services/related health services), but only for 100 days. Most private and HMO insurance plans follow the same rules as Medicare when it comes to long-term care. Long-term care insurance may be a viable option for helping to offset these costs; however, an individual may not be able to obtain a policy if Alzheimer’s disease or a related illness has already been diagnosed. Also be aware of extra costs; for example, a private room costs more than a semi-private room, and assistance with activities of daily living carry a price tag.

Understand your loved one’s care needs. Often, an individual’s physician can provide input. A registered nurse, social worker or geriatric care manager may also be able to conduct an assessment. A skilled nursing facility may be more appropriate if someone’s needs are greater.

  • Does the person with the disease need assistance—especially from more than one caregiver—with activities of daily living?
  • What is the person’s physical condition (i.e., other chronic conditions, mobility impairment)?
  • Does the person require therapy (i.e., occupational, speech)?
  • What type of behaviors does the individual exhibit (i.e., wandering, agitation)?
  • What medications does the person take? Does the individual need cueing, supervision or someone to provide medication?

Check whether the facility caters to people with dementia. An increasing number of facilities are dementia-specific or house specialized memory care or dementia units. Characteristics typically include staff with specific training in dementia care and higher staff-to-resident ratios; more secure environments, including safety features to help prevent wandering; and activities specifically designed to provide mental and physical stimulation to people in various stages of the disease. Be sure to find out if your loved one can remain in the facility as the disease progresses and more assistance is required with activities of daily living, or behavior problems emerge.

Know what questions to ask.

    • May I see your last inspection report? State health departments annually inspect nursing homes that receive Medicare or Medicaid funding, and more often, as needed, if they receive complaints. Facilities should be willing to share the reports, which may also be available online. Pay attention to, and ask about, any deficiencies and if there is a plan of correction in the works. Steer clear of facilities in “immediate jeopardy”—indicative of a serious lack of care.
    • What is the ratio of staff to residents each shift? This ratio speaks to the ability to provide quality care. What is staff turnover? Does staff receive ongoing training? Are medical professionals, such as doctors, pharmacists and social workers, on call or on site?
    • What is the facility’s policy on the use of antipsychotic drugs to manage residents’ behavior?
    • If hospitalization is required, will your loved one be able to return to the facility?
    • How are hospice services delivered?
    • Is there a bed available? If not, how long is the waiting list?

See it with your own eyes. Stop by the facility, without an appointment, at different times of day as well as on weekdays and weekends. If possible, bring your loved one on at least one of the visits.

    • Look at the overall space. Does it look attractive and home-like? Is it clean and free of clutter? Excessive clutter can increase the risk of falls. Are there safety features, such as hallway railings, bathroom grab bars, door alarms, call buttons, video monitoring? Is it dementia-friendly (i.e., non-patterned carpets, contrasting floors/walls)? Do residents have privacy? Are there extras—like a barber shop, outdoor garden, chapel, movie theatre?
    • Use your senses. Are there any odors? Scents such as lavender can be calming. Does the facility minimize unpleasant sounds? Is the lighting adequate?
    • Observe the residents’ appearance: Are they well-groomed? Is their clothing clean and appropriate for the current weather? Are their faces and fingernails clean from dirt and food deposits?
    • Spend some time near the nurses’ station. How quickly do staff respond to call bells?
    • Observe the staff. Are they professional, yet caring and calm? Are residents treated with dignity and respect? Do employees appear to “know” the residents—greet them by name, and know their likes, dislikes, life history?
    • Speak with residents’ family members. How would they rate their experience with the facility? Are administrators available to discuss needs or situations as they arise?
    • Check out the meals. Does the dining environment encourage eating? Does the menu provide adequate hydration and nutrition, and offer variety? Are the aides interacting with or assisting the residents? Speak with a nutritionist at the facility to get a sense of accommodations for special needs; for example, as functional abilities decline, residents might need more finger foods or pureed foods.
    • Take note of the available recreational activities. Are there specific activities or therapies for individuals with Alzheimer’s disease, such as physical exercise, art or music therapy, pet visits or intergenerational activities? Are residents engaged? Does the recreational staff have specific dementia care training?

Get a sense of the home’s “welcome mat.” From a logistical standpoint, it is important for you to judge whether the facility is close enough to home/work for you or other family members to have desired visitation levels.

  • Are there visitation limits, particularly during the period following move-in?
  • Is there a dining room available for private family functions?
  • Are there regular meetings between staff and family members?
  • Is the residence child-friendly, pet-friendly?
  • Are private, live-in aides allowed?
  • Are there support services for family members, such as educational workshops or support groups?

Finally, residents have rights! The federal government as well as many state governments mandate minimum standards for nursing home residents. Family members are the strongest advocates for their loved ones, so be vocal. If you have concerns, immediately share them with the appropriate administrator. And, if the issues are not addressed in a timely or effective manner, know your options: contact the state long-term care ombudsman program, available in every state to address residents’ complaints; notify licensing authorities; and/or transfer your loved one to another facility.

Research Resources  

Assisted Living Federation of Americawww.alfa.org 703.894.1805

The Centers for Medicare & Medicaid Services (CMS)— www.medicare.gov 800.633.4227

Eldercare Locatorwww.eldercare.gov 800.677.1116

Excellence in Carewww.excellenceincare.org 866.232.8484

Nursing Home Compare—http://1.usa.gov/138fqkE 800.633.4227

The National Consumer Voice for Quality Long-Term Care— www.theconsumervoice.org 202.332.227

Alzheimer's Foundation of America  866.232.8484