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    Dementia Symptoms & Caregiver Strategies: Residential Care Options for Cognitively Impaired Adults

    If a cognitively impaired adult prefers a communal living environment or needs more care than can be provided at home, a residential facility may be the best option. Different types of facilities provide different levels of care, depending on the individual's needs.

    Types of Residential Care

    A good long-term care facility should feel comfortable and homelike; offering privacy and providing opportunities to meet with other residents. Listed below are the different types of residential care to help you determine which one would be the best fit for the person you are caring for.

    • Retirement housing
      Retirement housing may be appropriate for individuals with mild cognitive impairment who are still able to care for themselves independently. A person may be able to live alone safely, but has difficulty managing an entire house. Generally, this type of housing provides limited supervision and may offer opportunities for social activities, transportation and other amenities.
    • Assisted living (also called board and care, adult living, supported care)
      Assisted living bridges the gap between living independently and living in a nursing home. Assisted living typically offers a combination of housing, meals, supportive services and health care. Assisted living residences generally provide 24-hour staff, recreational activities, housekeeping, laundry and transportation. Residents may choose which services they receive from the facility such as help with bathing, dressing, eating, or medication reminders. Costs vary depending on the services provided. The federal government does not regulate assisted living and definitions of assisted living vary from state to state. Assisted living facilities may or may not offer services specifically designed for people with cognitive impairment, so it is important to ask.
    • Nursing homes (also called skilled nursing facilities, long-term care facilities, custodial care)
      Nursing homes provide round-the-clock care and long-term medical treatment. Most nursing homes have services and staff to address issues such as nutrition, care planning, recreation, spirituality and medical care. Different nursing homes have different staff-to-resident ratios. Also, the staff at one nursing home may have more experience or training with cognitive impairment than the staff at another. Nursing homes are usually licensed by the state and regulated by the federal government.
    • Memory care units (also called special care units or SCUs)
      SCUs are designed to meet the specific needs of individuals who have dementia. SCUs can take many forms and exist within various types of residential care. Such units most often are cluster settings in which persons with dementia are grouped together on a floor or a unit within a larger residential care facility. Some states have legislation requiring nursing homes and assisted living residences to tell exactly what specialized services their SCU provides, including a trained staff, specialized activities, ability of staff to care for residents with behavioral needs and fees. When you visit a facility, ask for their Special Care Unit Disclosure form.
    • Continuing care retirement communities (CCRC)
      CCRCs provide different levels of care (independent, assisted living and nursing home) based on individual needs. A resident is able to move throughout the different levels of care within the community if his or her needs change. Payment for these types of facilities can include an initial entry fee with subsequent monthly fees or payment may be based solely on monthly fees.
    There may come a time when the person with cognitive impairment will need more care than can be provided at home. With certain types of cognitive deficits it becomes necessary to provide 24-hour supervision to keep the person safe. Making the decision to move into a residential care facility may be very difficult, but it is not always possible to continue providing the level of care needed at home.

    The questions below may helpful when determining if a move to residential care a good option:
    • Is the person with cognitive impairment becoming unsafe in their current home?
    • Is the health of the person or my health as a caregiver at risk?
    • Are the person's care needs beyond my physical abilities?
    • Am I becoming a stressed, irritable and impatient caregiver?
    • Am I neglecting work responsibilities, my family and myself?
    • Would the structure and social interaction at a care facility benefit the individual?
    Even if you planned ahead with the person for a move, making this transition can be a stressful experience. You may feel guilty and wonder if you are doing the right thing. These feelings are are common. Families that have been through the process tell us that it is best to gather information and move forward. Keep in mind, that regardless of where the care takes place, the decision is about making sure the person receives the care needed.

    First Steps:
    • Plan on visiting several care facilities. Take a look around and talk with the staff, as well as residents and families.
    • When you visit a care facility, ask to see the latest survey/inspection report and Special Care Unit Disclosure form. Facilities are required to provide these. The report and the disclosure form can give you a picture of the facility's services.
    • Visit the facilities at different times of the day, including meal times.
    • Ask the care facility about room availability, cost and participation in Medicare or Medicaid. Consider placing your name on a waiting list even if you are not ready to make a decision about a move.
    • If you will be paying for the facility out of pocket, ask what happens if the person runs out of money. Some facilities will accept Medicaid; others may not.

    Care Facility Checklist

    When choosing a care facility, there are a number of factors to consider, including the staff, the facility, the programs and the type of treatment residents receive. Use this checklist when considering a facility:

    Family Involvement
    • Families are encouraged to participate in care planning
    • Families are informed of changes in resident's condition and care needs
    • Families are encouraged to communicate with staff
    Staffing
    • Medical care is provided
    • Personal care and assistance is provided
    • Staff recognize persons with cognitive challenges as unique individuals, and care is personalized to meet specific needs, abilities and interests
    • Staff is trained in dementia care if appropriate
    Programs and Services
    • Appropriate services and programming based on specific health and behavioral care needs are available
    • Planned activities take place (ask to see activity schedule; note if the activity listed at the time of your visit is occurring)
    • Activities are available on the weekends or during evenings
    • Activities are designed to meet specific needs, interests and abilities
    • Transportation is available for medical appointments and shopping for personal items
    • Care planning sessions are held regularly
    Residents
    • Personal care is done with respect and dignity
    • Residents are comfortable, relaxed and involved in activities
    • Residents are well-groomed, clean and dressed appropriately
    Environment
    • Indoor space allows for freedom of movement and promotes independence
    • Indoor and outdoor areas are safe and secure
    • The facility is easy to navigate
    • There is a designated family visiting area
    • Resident rooms are clean and spacious
    • Residents are allowed to bring familiar items with them, such as photos, bedding, a favorite chair, etc.
    Meals
    • There are regular meal and snack times
    • Food is appetizing (ask to see the weekly menu and come for a meal)
    • The dining environment is pleasant
    • Family and friends are able to join at mealtime
    • Staff have a plan for monitoring adequate nutrition
    • Staff are able to provide for any special dietary needs
    • Staff provide appropriate assistance based on person's abilities (for example, encouragement during meals or assisted feeding in advanced stages)
    • There are no environmental distractions during meal time (noisy TV etc.)
    Policies and Procedures
    • Family and friends able to participate in care
    • Visiting hours work for the family
    • Discharge policy has been discussed (learn about any situation or condition that would lead to a discharge from the facility, such as change in behavior or financial circumstances)

    Costs

    The cost for care varies widely depending on the type of facility. The national average cost for basic services in an assisted living facility is $41,724 per year*. In a nursing home, it's $78,110 per year for a semi-private room* and $87, 235 per year for a private room.* Costs in the Bay Area tend to be higher.

    *Source: MetLife Mature Market Institute. Market Survey of Long-Term Care Costs: The 2011 MetLife Market Survey of Nursing Home, Assisted Living, Adult Day Services, and Home Care Costs. New York, N.Y.: Metropolitan Life Insurance Company, 2011.

    Most families pay for residential care costs out of their own pockets. Types of benefits that may cover nursing care include long-term care insurance (check the policy as certain requirements may need to be met before receiving benefits), Veterans benefits and Medicaid.
    Medicare does not cover the cost of long-term care in a care facility. Medicare only covers short-term skilled care after a hospital stay.

    Finding an Appropriate Residential Facility



    Cognitive Impairment can have many causes. The patient’s doctor should be consulted to determine a specific diagnosis and treatment options. But whatever the cause, the symptoms are often alike, and the Caregiver Strategies are often similar.

    The information in the resources listed above was compiled by the Ray Dolby Brain Health Center through clinical experience and commonly available published materials. For information on additional Caregiver Strategies, go to: cpmc.org/brainhealth.