How to Choose Between Home Health Care, Assisted Living, and a Nursing Home

Caring for someone can be time-consuming and exhausting—for you and your bank account. Family and friends can step in to assist, of course, but there may come a point when your loved one needs professional care. Here are some basic options to consider.

Home sweet home
In-home health aides average $19 an hour, and hired companions who don't provide health care are slightly less expensive. Do the math and you'll see that for round-the-clock assistance, the tab can run as high as $170,000 a year, making home care a very costly option.

"It's so expensive because people are basically trying to recreate the nursing facility at home," says Chris Cooper, a certified financial planner and social gerontologist in Toledo. Medicare and private insurance generally do not cover long-term in-home care. So unless you have a long-term-care insurance policy, the cost must be paid out-of-pocket, which may mean liquidating assets or applying for a reverse mortgage.

Despite the expense, "most people try to do what they can to stay at home before placement in a facility," says Nancy Wexler, a Los Angeles–based geriatric care manager and author of Mama Can't Remember Anymore: Care Management of Aging Parents and Loved Ones. The good news is that many people don't need 24-hour care, at least not right away. Someone with a chronic condition like heart disease, for instance, might only need help with specific tasks, like meal preparation or bathing.

To find an in-home aide, ask others who have used one or consult a geriatric care manager. It might cost more to employ an aide through an agency, but if any sort of problem arises, the agency will furnish a replacement quickly. That beats spending stressful days trying to find aides and conducting background checks.

Assisted living
"Assisted living is not as institutional and depressing as many nursing homes," says Joseph L. Matthews, the author of Long-Term Care: How to Plan & Pay for It. "It allows you to have your own living space, but it provides a level of monitoring that most can't afford at home."

A key benefit of an assisted-living community is that, should your loved one's health deteriorate, services are already in place to provide extra care in the same facility. He or she can start with a basic apartment and live independently, with services such as cleaning, meals, and transportation taken care of. If additional assistance is needed—with dressing, bathing, or walking, for example—that help is available. The level of medical care depends on the facility, but most can’t offer the kind of round-the-clock professional medical attention that's common in a nursing home. The average cost for assisted-living facilities in the United States is just under $3,000 per month (more than $35,000 per year), according to a 2007 market survey conducted by MetLife. In a growing number of states, at least some assisted-living services are covered under Medicaid, the government health-care program for low-income people, but most people pay for it themselves or through a long-term-care insurance policy.

When researching assisted-living facilities, be sure to read the fine print. "As soon as you need something more than the basics, they raise the rate considerably," cautions Wexler. Also, you can't assume the facility will automatically up the level of care when your loved one’s health situation changes, warns Matthews. You'll need to monitor the situation to make sure he or she is getting the proper treatment.

Nursing home
A nursing home is a last resort for most people, who often end up there after a hospital stay or severe illness. For example, a heart attack might put someone into a rehab facility and leave him too ill to return home. Or a person's health might deteriorate to the point where so much care is needed at home that it's no longer financially feasible.

"If you need a lot of care, and you don't have family who can help, a nursing home is the most practical choice," says Matthews. Annual costs range from less than $50,000 to nearly $200,000 a year—a fortune, but potentially less expensive than hiring home health aides. If your loved one spends down all his or her assets, Medicaid will pay for most nursing-home care at a facility that accepts the plan. Don’t bother giving away all your parents' assets a month before moving them into a facility, however. Federal law now requires a five-year look-back period to prevent just this type of activity.

When you choose a nursing home, look for the signs of a good facility.

• Don't take the staff's word for how great things are. Talk to residents and their families. The staff should willingly put you in touch with some contacts. This is one of the best ways to evaluate any facility.
• Evaluate with your nose. If it doesn't smell good, follow your nose elsewhere. After visiting a few, you will be able to tell the difference.
• Sample some meals. "When you become old and sick, a lot of your life revolves around meals," says Matthews, "so make sure the food is good." Meals also are an excellent opportunity to observe the nature of the interactions between the staff and residents, he says.
• Find out the staff-to-resident ratio. This can be tricky to uncover, cautions Wexler. You might be told one thing by the facility's honchos, but nursing homes are chronically understaffed and there's a tendency to stretch staff-to-resident ratios beyond what's reasonable. Casually ask a low-level staffer how many nurses there are. A ratio of 1 registered nurse for every 15 residents is the national average, according to the Centers for Disease Control and Prevention’s National Nursing Home Survey, but many facilities routinely go above that.
• Pay attention to detail. According to Cooper, you can tell a lot about a facility and the attentiveness of its staff by looking for small signs. Is the piano tuned? Is the air conditioner humming well? If the staff is taking care of small details, they're also taking care of big ones.
• Get a recommendation from the pros. Your local Area Agency on Aging is a good resource and will know about nursing homes that accept Medicaid. Geriatric care managers are often very familiar with private nursing homes. They do a lot of due diligence on them and over the years develop a sense of what makes a good nursing home and what doesn't.
• Check that the nursing home is accredited by the Joint Commission, a nonprofit organization that certifies health-care organizations and programs. Once you've narrowed your choices down, contact your local Better Business Bureau to see if the facility has drawn any complaints or government actions.
• Ask to see the results of the home's latest inspection.
• For a fee, companies such as CareScout can provide ratings of facilities.

Remember, even after choosing a facility, your loved one will only get the best care if you make yourself visible and stay involved.