Understanding Residential Care Options
My remarkable mother in law is in her 90’s and still living at home on her own. She is able to do so with the help of some limited in home supportive services that are being coordinated by a care manager. She lives in another state far away from my wife, who is her only child. The assistance of the local care manager has been invaluable in this situation.
So far my mother in law has been able to remain in her comfortable home where she has lived for many years. But we all recognize that a day will likely arrive when a residential care facility with 24 hour on premises support will become a more appropriate housing choice. So, recently the care manager, my wife and I took my mother in law to visit several care homes in her hometown.
As we were exploring the options, I was struck by how confusing the terminology is for consumers who are trying to make a decision: Assisted Living, Independent Living, Board and Care Homes, Domiciliary Care, Continuing Care Communities, Life Care, Nursing Care Facilities, Veterans Homes. What are the differences? And how do you know what is the best choice when Mom can’t live at home anymore?
It is difficult to navigate this terrain. Fortunately, I’m an elder law attorney and we had the able assistance of the local geriatric care manager to help inform and guide us. Even with this professional expertise, the choices are difficult. But, we did succeed. My mother in law has chosen a place she feels in right for her, and we all agree with her decision.
But what are families to do if they are without this kind of expert assistance? It is difficult to get detailed information about all of the programs and options. And if you decide to try to stay at home for the time being, you have to deal with an additional overwhelming number of choices and programs – it’s way more difficult than it should be.
A confusing multiplicity of care options certainly exists in Pennsylvania. So, I thought, it might help some families if I wrote an article describing some of residential facility housing options that are available here in Pennsylvania. My focus is on the options most often utilized by older adults in Pennsylvania. I hope this information will be of value to you. I’ll save the also complicated topic of options for care in your own home for future articles.
In Pennsylvania, there are a number of options available to families seeking residential care for an aging family member. These include domiciliary care homes, personal care homes, assisted living residences, nursing care facilities, veterans homes, and continuing care retirement communities. Note that if you reside in a state other than Pennsylvania, these terms may have different meanings.
DOMICILIARY CARE. Dom Care services are provided in the care provider’s home. Dom Care residents are matched to homes that best meet their special needs, preferences, and interests. Dom Care homes are smaller than the traditional personal care home. Providers care for no more than three Dom Care residents.
Dom Care homes are inspected annually to ensure they meet health and safety standards. If the home and provider passes this inspection, they become “Certified.” Dom Care is regulated by the Department of Aging. Regulations are located at PA Code Title 6, Aging, Chapter 21 Domiciliary Care. To view a video on Domiciliary Care click here.
PERSONAL CARE HOMES (PCH). Personal care homes are residential facilities that offer personal care services, assistance and supervision to four or more persons. Larger PCHs may have more than 100 residents. Sometimes they are advertised as “retirement homes” or “boarding homes.” In February 2015 there were 46,522 residents in PA’s 1,224 personal care homes.
PCHs provide shelter, meals, supervision and assistance with personal care tasks. Other services available vary with the PCH but typically include laundry, making and keeping doctor’s appointments, using the telephone, social activities and some assistance with activities of daily living including bathing, dressing or going to the bathroom.
Personal Care Homes are inspected and licensed by the Pennsylvania Department of Human Services (DHS) under the requirements contained in 55 Pa.Code Chapter 2600. They are usually for profit-privately-owned, although some are operated by local governments or non-profit agencies.
Personal Care Homes are not covered by Medicare or Medicaid. Payment sources include private payment, SSI, the State SSI Supplement, and long term care insurance. Some personal care homes accept residents of low income who receive Supplemental Security Income (SSI). To find information on a Personal Care Home near you see the DHS Personal Care Home Directory.
ASSISTED LIVING RESIDENCES (ALRs). ALRs provide an apartment like setting for residents and include services such as meals, laundry, housekeeping, and transportation. ALRs also provide assistance with activities of daily living and cognitive support, generally on a fee for service basis. In addition ALRs are able to provide or arrange for types of care such as home health, skilled nursing, occupational and physical therapy, and specialized cognitive support that Personal Care Homes and Dom Care homes may not provide directly. See PA Department of Human Services Regulatory Compliance Guide, March 1, 2015.
ALRs are regulated under the provisions set forth in 55 Pa.Code Chapter 2800. As of February 2015 there were only 34 licensed ALRs in Pennsylvania. Payment sources include private payment, SSI, and long term care insurance.
NURSING CARE FACILITIES. These are sometimes referred to as skilled nursing facilities or simply as nursing homes. Nursing Care Facilities are licensed medical facilities that are inspected and licensed by the Pennsylvania Department of Health. They must meet both state and federal regulations.
Nursing Care Facilities provide 24-hour health care services including basic and skilled nursing care, rehabilitation, and a full range of other programs, treatments and therapies such as occupational therapy and physical therapy. They may also manage complex medical needs that require equipment, such as ventilators and IV lines. They can provide a higher level of care than is available in Assisted Living Residences and Personal Care Homes.
Nursing Care Facilities may be stand-alone or they may be part of a hospital or of a Continuing Care Retirement Community. As of June 30, 2012, there were 713 nursing facilities in Pennsylvania with a total bed capacity of over 88,000. They are regulated by the Pennsylvania Department of Health. Most, but not all, facilities accept Medicare and Medicaid for those who qualify. (Some Nursing Care Facilities do not accept Medicaid – you need to check in advance). Other sources of payment include private payment, long term care insurance, and VA benefits.
The Pennsylvania Department of Health has a Nursing Care Facility Locator Page: http://app2.health.state.pa.us/commonpoc/nhlocatorie.asp.
VETERANS HOMES. Pennsylvania offers its veterans six extended care facilities throughout the state. The facilities are operated by the Pennsylvania Department of Military and Veterans Affairs. All levels of care are provided including: personal care, skilled nursing care, domiciliary care, and dementia care. Care is provided to honorably discharged Pennsylvania veterans and their spouses on a first-come, first-served basis.
As of 2014, these veteran’s facilities had a combined capacity of 1,554 beds: 1,160 licensed nursing facility beds and 394 licensed domiciliary/personal care beds. For more information visit the Department of Military and Veterans Affairs at http://www.dmva.state.pa.us/portal/server.pt/community/state_veterans_home_system/11925
CONTINUING CARE RETIREMENT COMMUNITIES (CCRC). A CCRC, sometimes called a “Life Care Community,” is an “aging in place” housing option that may be appropriate for some older Pennsylvania residents. A continuing care retirement community offers independent living, usually in an apartment or cottage, and access to a higher level of care such as personal care or a nursing facility. Residents move between levels of care as their needs change. Services, such as meals, medical care, social and recreational activities, are provided through a contractual arrangement for the lifetime of the resident.
Residents usually pay an entrance fee and a monthly charge. Additional services may be provided on a fee-for-service basis.
Generally, the fees paid by residents cover residential accommodations and may include: utilities (electricity, heating, air conditioning and water); housekeeping; meals; outside maintenance; linens; and major appliance repair.
Pennsylvania has more than 220 CCRCs. The Pennsylvania Insurance Department has a CCRC locator page http://www.insurance.state.pa.us/dsf/ccfsearch.html or you can call (877) 881-6388. The Department has also created a booklet on Choosing a Continuing Care Community.
Pennsylvania CCRC’s are given only loose oversight with the regulatory emphasis being on disclosure.
Potential residents must try to evaluate the CCRC’s financial strength and viability as best they can. Residents’ entrance deposits and fees can be at risk in the event of financial failure of the community. Several Pennsylvania CCRC’s have gone into bankruptcy with residents losing the right to their “refundable deposits” in one case. See Will Continuing Care Retirement Communities Continue? A Pennsylvania Law Update, Katherine C. Pearson, Joshua R. Wilkins, 77 PA. BAR Q. 69 (April 2011).
A few Pennsylvania CCRCs subject themselves to voluntary accreditation by The Commission on Accreditation of Rehabilitation Facilities (CARF) an independent, nonprofit accreditor. And some information on financial examinations of newer PA CCRCs may be found on the Insurance Department website.
Regarding the financial risks for residents you may want to review the 2010 United States Government Accountability Office Report: “Continuing Care Retirement Communities Can Provide Benefits, but Not Without Some Risk.”
HOSPICE. The term “Hospice” generally refers to a coordinated program of palliative and supportive care for those with a limited life expectancy. Hospice services can be provided in a stand-alone facility or in a hospital, nursing home, assisted living residence, personal care home, or an individual’s home. For more information on the hospice option, see the PA Department of Health website.
My bottom line: If you are struggling to determine what is the best housing option for your aging parent do what my wife and I did. Hire a local geriatric care manager to help you through the maze. If you live in Northcentral or Northeast Pennsylvania, you can contact one of the care managers at Marshall, Parker and Weber.
Here are links to some other sources of information:
Continuing Care Retirement Communities, State Regulation and the Growing Importance of Counsel for Residents and their Families, Katherine C. Pearson, 77 PA. BAR Q. 172 (No.4, 2006).
Will Continuing Care Retirement Communities Continue? A Pennsylvania Law Update, Katherine C. Pearson, Joshua R. Wilkins, 77 PA. BAR Q. 69 (April 2011).
US Government Accountability Office Report: “Continuing Care Retirement Communities Can Provide Benefits, but Not Without Some Risk.”
Pennsylvania Health Care Association, All About Long-Term Care:Long-Term Care in Pennsylvania
PA Long Term Care Statistics, Pennsylvania Health Care Association (last access, 28March15)
The Pennsylvania Alliance of Retirement Community Residents (PARCR) is a voluntary statewide organization of residents of retirement communities. Full membership is open to resident councils of CCRCs and associate memberships are open to individual residents. A related national organization: the National Continuing Care Residents Association (NaCCRA) has a more robust website.