Chapter 6 - Conducting the Search,
Making the Decision, & Minimizing Regret/Anxiety and Guilt

In 1943, the psychologist Abraham Maslow confirmed what all of us already knew: Shelter is a basic human need, joining such others as air, food, drink, warmth, sex and sleep. Shelter and these biological and physiological needs are so fundamental that they must be met before we can even consider achieving others—safety, law, relationships, self-actualization and many more.

It’s not surprising, then, that basic needs arouse human emotions. The decision to make a housing change, particularly one that requires a move from a treasured home into a seniors’ facility, has profound emotional consequences. There are other practical complications, of course, such as choosing from among several options—an independent-living apartment, an assisted living facility, or a nursing home. Additional decisions—about location preferences, cost limits, available services—have to be made as well.

So: Making the best senior housing choice, given the emotions and practicalities involved, is difficult, and it doesn’t matter whether you live down the block or across the country from your aging parent. If he or she is like most aging Americans, they prefer to stay in their homes as long as possible. They may have done so for the past months or even years, relying on family, friends and in-home health care providers for whatever assistance they may have needed

But now, you realize that it’s time for a change, and you need to make the right decision. Bad decisions mean repeated moves, which can result in emotional damage, not only to the parent but to the entire family as well.

Fortunately, you've got an experienced ally in Great Places. This section of our Toolkit gives you a workbook containing information that will help you to

• Focus on your parent, including their needs, preferences and interests;
• Determine the best housing product type to consider;
• Find and sort through options; and
• Make the optimum choice after narrowing the field.

Let's begin by evaluating the parent's needs, preferences and interests:

• What are their immediate and probable future medical needs?
• How much supervision will be necessary?
• Have they expressed a preference for a particular senior housing product type (e.g., apartment living, assisted living with some services)?
• Would the parent’s preference be appropriate, given their current physical, mental, financial and emotional condition?
• What do you think would be the best option?
• Have you gotten advice from a medical or geriatric professional who is familiar with your parent’s situation? What is it? Is there agreement?
• What activities do they currently enjoy? What did they enjoy in the past?
• Do they want a variety of social interactions or do they prefer privacy? Some balance between the two?
• Do they have friends in similar facilities who have spoken positively or negatively about the transition experience? This can help or complicate your situation.

Begin to compile a list of priorities. You might even give each entry a number or letter. All the “A’s” are the deal breakers. The new home choice must have these qualities, amenities or attributes. The “B’s” are also pretty important, but they’re not absolutes. And the “C’s” are the ones that would be nice to have but your parent can get along without them if they are not available.

Be careful when you assign priorities. Sometimes the smallest item, and one that might be easily overlooked, can actually be a deal breaker for your parent. For example, a 94-year old woman who was moved to skilled nursing care facility did poorly there, not because the care was substandard, but because she couldn’t get any sleep. She had been a night owl most of her life, but the nursing home staff tucked her in just after sunset and got her up at the crack of dawn. Once this disruption in her sleep cycle was noted and she was allowed to return to her old habits she rallied.

The most common concerns that adult children have about their aging parents are these:

• Administration of medication: Taking the right medication at the right time and in the right dosage;
• Diet: Lack of interest or the opportunity or ability to shop for groceries--even the ability to taste and smell—which may result in poor nutrition;
• Memory: Memory loss monitoring and prevention;
• Depression: Loss of friends and vitality frequently result in the onset of depression;
• Lack of socialization: The loss of mobility, hearing and sight may result in a lack of healthy social interactions with friends and family;
• Hygiene: Reduced mobility, memory loss and depression issues can reduce capacity to launder clothing, bathe and perform personal grooming tasks;
• Transportation: Loss of sight, hearing and physical stamina often result in a shrinking world. Others become more responsible for transportation to shopping, medical appointments, and other important places.

Seniors’-Oriented Housing Types

A description of the most common housing types is available in our Toolkit and our homepage. Here are the three most common groupings:

• Independent senior housing is typically an age-restricted apartment community with a few seniors'-oriented services. This is usually the lowest cost product. Meals may be delivered by an outside service and transportation provided by local government resource.


• Assisted living communities are also private apartments but here you may find a wide range of age-related services (e.g., medical and personal care, social activities, minimal meals), with additional services offered at escalating costs (e.g., supplemental meal plans, cleaning, skilled nursing visits).


• Skilled nursing care--nursing homes--often provide private or semi-private rooms with costs based upon levels of care provided.

You may be able to find available housing in a senior apartment community that offers some financial subsidy provided by the local city or county. However, Medicare, Medicaid and private insurance rarely offer coverage for independent- or assisted-living costs, although assistance for care in nursing homes is frequently provided and are expanding for in-home health care.

Narrowing the alternatives

If you need help in determining the type of housing that would be appropriate for your parent, consider the following table. It is intended to correlate the services and levels of care that are available to meet the needs of the aging parent.

Concern	Independent	Assisted Living	Skilled Nursing
Medications	Self administers	May need reminders or monitoring system	Requires medical personnel to administer and monitor
Nutrition	Prepares and eats meals without assistance	Requires one daily meal prepared by others	Requires all meals prepared by others and/or may require assistance eating
Memory	Seems fine although may exhibit occasional forgetfulness	Seems normal  most of the time but has bouts of confusion or disorientation	Exhibits poor judgment, has increased memory lapses, is unable to follow directions without guidance
Housekeeping	Makes beds, vacuums and does dishes consistently	Requires some assistance with home upkeep	Needs others to perform housekeeping  tasks
Dressing	Is able to make appropriate clothing choices and dress self	May have some difficulty with closure devices (zippers, shoelaces, buttons	Needs assistance getting dressed
Getting around	Is able to get around (even with a cane, walker or scooter), ask directions and respond appropriately in an emergency situation	May need occasional assistance getting around, or getting out of bed, a chair or on and off a toilet.	Requires full assistance from others
Hygiene	Can  perform bathing, grooming, shaving tasks without assistance	May require some assistance or reminders to perform daily tasks	Requires the assistance of others for most personal hygiene tasks
Toilet needs	Is totally continent or incontinent, has a colostomy or catheter but is able to handle all hygiene issues independently	May have difficulty maintaining good hygiene while coping with incontinence, a colostomy, catheter or other eliminatory assistance device.	Needs care and assistance with toileting
Behavior	Behaves normally in social situations.	May have  difficulty with stress, controlling emotions or coping with daily life	Potentially poses threat to themselves due to inability to cope or control emotions.  Requires constant monitoring

Many people who choose assisted living facilities may not have any of the problems that are listed in the columns above; instead, they make this housing choice for other reasons. Perhaps they have friends already living in the community. Maybe they like the social environment and activities. Some are planning for their future when they anticipate the need for some care. Your visits to the property will be a good learning experience. You may learn that your parent isn’t as independent as you thought and that assisted living is a better choice. Or you may learn that assisted living cannot provide the level of care that is necessary, and a nursing facility is the better choice.

If you are starting from scratch you will need to find sources that list the potential properties or in-home healthcare services and then sort them according to how well they match the needs, wants and interests of your parent.

The first search is often for some type of in-home health care. Dad may be able to return home if his doctor prescribes skilled nursing visits and/or visits from a physical therapist. In addition to nurses and therapists, home-health aid services to handle bathing, dressing, meal preparation and the like are necessary and are usually covered by Medicare.

To search for licensed service providers go to www.medicare.gov, scroll down and click on Compare Home Health Care Agencies in Your Area. You will then be asked to select the city, county or zip code in which you wish to search. Then you are asked what type of health care you seek (nursing, a variety of therapists or home health aid). Once you have focused your search you will receive the names of the service providers in the area you have designated and which of the services they provide. From this list you are now able to select up to 10 companies for which you can view data.

For example, you are able to compare the percentage of patients whose wounds improved or healed, the percentage who had less pain moving around or perhaps more tellingly, and such statistics as the percentage of their patients who had to be admitted to the hospital or who needed urgent, unplanned medical care.

You will need to check boxes at the left to select which companies you wish to compare; then hit “next step” to proceed. The site will show you all of the criteria that are measured. Again, you will need to go to the bottom of the page and hit “Compare Quality Measures.” This will take you to the graphs which appear to be the easiest to read. They compare all of the companies you have selected against not only each other, but also the state and national average. In our sample searches we found that these graphs particularly useful in helping us to quantify the quality issues that were most important to us.

Sorting through the product

Medicare also provides helpful information regarding licensed nursing homes. Many seniors experience their first stay in a skilled nursing facility after a health episode that renders them unable to return to their home. This type of care is most often called “short-term nursing care” or “transitional care” and can be found in a nursing home or CCRC (continuing care retirement community). If this is the type of facility that will best serve your parent’s needs, the first decision to be made is where the facility should be located--the city or suburb where you will start your search.

Most important: Where does your parent want to live? It may be the one with which they are most familiar. But, there may more critical considerations, such as the proximity of family or even a medical specialist. So, start with the geography. This is how you would begin:

www.medicare.gov offers a section called Compare Nursing Homes In Your Area. You will then be taken through a series of questions that will focus your search. You can search by city, county, zip code or name. For example, if Dad wishes to remain in a particular city, you would enter the name of the city and state. You get some choices as to how far you wish the search to extend (e.g., in the city itself, 10 miles, 25 miles, etc.). You will then hit the search button and receive a list of all of the licensed homes or health care providers that are available.

The site contains the following information: The name address and phone number for the facility and whether it accepts Medicare and Medicaid; the number of certified beds; the type of ownership; whether there is a hospital on the premises; whether the facility is a part of a continuing care retirement community; and whether there are active resident and/or family councils that assist in the governance of the facility.

You can take this search a bit further. As you review the list, check boxes on the left of as many as 10 facilities and you will be able to compare them based on some quality criteria.

The next page contains a wealth of information. You are now just a few clicks away from being able to compare your selected facilities based on Quality Measures and Health and Fire Code Deficiencies. Some of the quality criteria that the site compares are these: Presence of pressure sores in patients; increases in patient depression; the percentage of residents who spend most of their time in a bed or chair; and the percentage of patients whose ability to move in and around their room got worse. The facility scores are displayed against the average for your state, the national average and each other.

Perhaps one of the most telling statistics is the average number of hours per patient per day that a skilled nurse and a certified nursing assistant are available to spend with each patient. Quality is such an important issue in nursing home care we would like to offer another resource for your consideration. We find www.aarp.org a bit cumbersome to navigate, but the AARP Bulletin offers a state to state guide on nursing home performance data. The bulletin also lets you know which states have published nursing home “report cards”. Each state has an ombudsman office which serves as a resource providing information about complaints received on senior facilities. For contact information refer to the Toolkit Resource Directory.

Also, all states have websites dedicated to services for the elderly. Some states provide senior housing directories. The Toolkit Resource Directory defines which states provide these housing guides. If you are unable to locate a list of facilities using your state website, we suggest you visit www.eldercarelinkdirectory.com.

We assume that you will make an initial determination of the property type and then compile a list of potential facilities or services before you call them or physically visit with their staff. If you are dealing with directories, scroll through the properties or companies that are listed and eliminate any that don’t meet your basic criteria. Then sort them according to what you learn about their quality.

If you fail to find any candidates, you will need to broaden your geographic search. This takes a bit of research but you should be able to compile a list of choices. Now, you will need to make some phone calls. Introduce yourself and describe your situation. This call is intended to learn if there are vacancies and if this might be a good match for your parent. Don’t be discouraged by waiting lists. Units open fairly frequently and are often awarded to anyone on the list who is able to make a quick decision.

Making the Selection

The initial search is just the beginning. Now you will need to gather information and sort through it to make the best informed decision you can. Here are some questions that you might use as talking points on the phone and in person to elicit the kind of information you need:

In-Home Health Care

• How long has the business existed?
• Is it licensed, and if so, in what states?
• Have you ever had a complaint lodged with the state? What was the nature of the complaint? How was it resolved? (Verify the information received with your state ombudsman.)
• Have you ever been sued?

Skilled Nursing Home Facilities

• Medicare/Medicaid certified?
• How is level of care determined?
• What are the costs at each level?
• Inquire about how the facility would provide assistance to meet the special needs of your parent (e.g., Alzheimer’s, rehabilitation. Incontinence).
• During the personal visit: Is there any unpleasant smell present? Do you observe kind and caring interaction between staff and patients? Are there any patients that appear to need attention? Do you encounter staff performing patient-focused tasks? Are staff uniformed and wearing name tags? Are residents called by name? Do staff members show respect by knocking on doors before entering patients’ rooms? Does the staff engage the patients in interesting conversation? What do you hear when you visit? Is the atmosphere punctuated with cries or the pleasant sounds of conversation and laughter? What is the atmosphere (e.g., good lighting? Comfortable temperature? Homelike furnishings? Smoking?
• How is the patient’s care plan developed, executed and monitored? How often is the plan revised? Who is involved in the planning
• What are the nursing and staff/patient ratios? Can you verify how many hours are allotted per patient per staff member
• Is there a team approach? If so, how long do teams work together?
• Is there a full-time registered nurse on staff 24 hours each day? Is there a full-time doctor on staff that is there daily and easily reached at all other times? Is there preventive care in place (e.g., vaccinations for flu and pneumonia? Are there any health deficiencies that have been noted in the past two years? Ask to see certification that these have been remedied.

Assisted Living, CCRCs and other campus based facilities

After you've narrowed these options, your first contact with the property will most likely be a manager or marketing representative. Remember that this person's job is to sell you and your parent on the idea of moving into their facility, but he or she will probably have little involvement with your parent after the contract is signed. Depending on the size of the facility there will be a cast of other players whom you may wish to interview before making your decision. Here are a few of the people you will encounter in an assisted-living community and some questions you might ask them:

Executive director

• How many staff are employed and in what capacities?
• What background checks—specifically, regarding past employment and criminal histories--do you perform before you make your hiring decision?
• What kinds of training do your employees receive? Are there training programs in place for each position? Are employees trained on listening and care standards? Are these standards in writing?
• What kind of staff turnover does the community experience? Are there frequent vacancies? Is the facility often understaffed?
• What language do staff members speak?
• What is the availability of skilled nursing staff (e.g., 24/7? Or specific hours per week?)
• Is there a full-time maintenance staff? How are requests for maintenance handled?
• Is there a full-time activities director?
• How frequently do you survey your residents and their families regarding quality and customer satisfaction?
• How are questions, concerns or complaints handled?

Resident Services Director

• Is there a care plan established for each resident? How is it created, executed and monitored for accuracy?

Move-in Coordinator

• What is the assessment process that assures that the community is a good match for the needs and preferences of each resident?

Director of Dining Services

• How many balanced meals are served each day?
• Does a dietician plan and approve all meals and menus?
• How many meals are included in the monthly payment? What is the cost of additional meal plans?
• Is there restaurant-style dining? Are there seating assignments?
• Are snacks and beverages available 24 hours a day?
• What is the policy regarding guests at meals?

If possible, sample the food and have your parent do so as well. Review weekly menus for variety and ask current residents to rate the food service.

Director of Nursing

• What are the credentials of the nursing staff (e.g., RNs, LPNs, etc.)?
• How many are on the staff?
• What hours are they available?
• How long have they worked with this community?
• What services are provided by the nursing staff? What are the costs for these services?

Director of Maintenance

• Is there a 24-hour emergency call system in place in each unit and/or bathroom?
• What security is in place at the entrances and how is it monitored?
• Does the building currently meet all government code and safety requirements? (Request a copy of the most recent inspection.)
• How are maintenance requests handled? What is the response time?

Director of Social Services

• Are there special programs for memory impairment? What are they and how are they administered?
• What level of memory impairment is the community able to provide?
• How is the safety assured for a memory-impaired resident?
• How are the care and satisfaction of each resident monitored?
• What is the availability of laundry and housekeeping services and what costs are involved?
• What is the availability of transportation, including medical appointments, shopping, visits to friends and relatives? What radius is covered, and is there an additional cost? How is this transportation arranged for by the resident?

Director of Activities

• Ask for a calendar of scheduled events.
• Evaluate whether there is a match between what is offered and the interests of your parents. For example, we have found that many assisted-living residents enjoy outings to the local casino and happy hour gatherings, neither of which is mentioned in the brochure or provided at the property.
• What kinds of wellness programs are provided? How regularly are exercise programs offered? What kind of exercise facility and equipment, if any, is available? How does this program interface with the care plan for each resident?

Questions the claims made on their websites, advertisements and brochures. We found that things changed or claims are more “puffing” than reality. Focus your questions around the particular concerns of your parent. Your situation is probably not unique but it is to you and your family.

You will probably “click” with one or more of these individuals. This may lead to a positive impression of the community and could factor favorably in your decision.

Comparing Senior Housing Developments

Once you have narrowed the search, here is a checklist to use when comparing the communities:

• Does your parent like the neighborhood? Is the location convenient to the things they enjoy? Is the location convenient to friends and family members who will visit and provide ongoing support?
• How does the building look and feel? Are the common areas well maintained, both exterior and interior? Do you get the impressions that the staff cares about the condition of the facility?
• What were the interactions between staff members, between staff members and residents, and between residents? Did the employees address the residents in a warm, friendly tone? Did they do so by name? Were staff members actively and positively involved in resident or patient issues, or were they speaking about their dissatisfaction with their jobs or negatively referencing any resident? Was there laughter and the buzz of conversation between residents as you walked through the common areas?
• What did your senses tell you? Was there anything you encountered during your tour of the facility that concerned you? What did you hear, smell, see or feel as you walked around?

As we’ve seen, the initial decision to make a change in housing has emotional consequences. Adding to the challenge is the variety of housing options that are available, and the practicalities that are involved which impact the location of the housing, its cost and the services that are necessary for the aging parent. Although Great Places cannot solve these problems, we’ve provided a straightforward way to consider them, together with some guidance to resolve them.

Finally, it’s important to keep in mind that there are certain common emotional reactions—guilt and anxiety--to putting parents in some type of senior housing project. Virginia Morris in her book, Caring for Aging Parents offers a poignant but somewhat humorous look at the 10 most common feelings that plague adult children who place their parent in a nursing home:

• Guilt you’re not doing enough for your parent;
• Anxiety the nursing staff will not do enough for your parent;
• Guilt that your parent isn’t in a nicer, more expensive place;
• Anxiety over the high cost of the place;
• Guilt that you don’t visit more often or anxiety because you have to visit so often;
• Guilt feeling relief that your parent is living in a nursing home;
• Anxiety that the living situation won’t work and you will have to devise another plan;
• Guilt because you promised you would never put them in a nursing home; and
• Anxiety about whether you, too, will end up in a nursing home one day.

The accommodations have gotten better as the choices have increased. There is a wealth of wonderful care available and Great Places will do all we can to help you find the perfect choice for your parent and family.