What is the Difference Between a Nursing Home and Assisted Living?

Sheila lives with her son, his wife, and her grandchildren in their home, and has been there for 3 years since her Parkinson’s started getting worse. They enjoy having her with them, but as her needs are becoming greater, they think she may need more support than they can provide. They have heard from some friends in similar situations that they should start looking into an assisted living facility for Sheila, while others have suggested that a nursing home may be the best option. They are confused about these options and which one would be a better choice. They are also surprised to see that nursing homes are regulated by the federal government, while assisted living facilities are not.

Similar to the family in our example, the time may come when you can no longer care for a loved one at home. These scenarios are quite common: In fact, 70% of people currently age 65 or older will need some kind of long-term care, according to The Centers for Medicare & Medicaid Services (CMS). Assisted living can be a good option for seniors who need extra support or who need assistance with day-to-day tasks. A nursing home, by contrast, offers more comprehensive support to seniors with extensive medical needs.

Level of Care Elder Care Facilities Offer Can Vary Significantly

Assisted living facilities and nursing homes are two of the most common types of facilities for long-term care. Many people use the terms assisted living and nursing home interchangeably, without understanding that these types of facilities differ in many ways. The main differences are is in how the facilities are licensed and in the level of care each can provide. Here’s what you need to know:

Assisted Living:

  • Assisted living is for people who need some help with daily care, but not as much as what nursing homes offer;
  • Assisted living is generally for individuals who can still take care of themselves to some extent, but need assistance with some or all daily nonmedical needs and activities such as:
    • Bathing or showering;
    • Cooking;
    • Day-to-day housekeeping duties and chores;
    • Laundry;
    • Medication management;
    • Transportation to medical appointments or stores.
  • Assisted living communities are not healthcare facilities. They are not required to have any nurses or doctors on staff or to offer any medical services, although many assisted living communities do have a nurse on staff, and many do offer some medical services, especially help with diet and nutrition issues;
  • In most assisted living facilities, 4 or 5 “levels of care” are offered, with residents paying more for higher levels of care. At most assisted living communities, the highest level of care is memory care, where services are offered for those with Alzheimer’s disease and other forms of dementia;
  • Some assisted living residents have their own apartments, while others share a room;
  • Assisted living has many amenities for residents. Residents typically have access to common areas like a dining room, gym, and community rooms. Most offer three meals a day for those who prefer not to cook, 24-hour supervision, security, and housekeeping services. They also typically provide opportunities for socializing and recreational activities with other residents.  Many assisted living communities even allow pets;
  • Medicaid does NOT cover assisted living in Virginia or Maryland, whereas Medicaid can cover the cost of assisted living in DC under some very limited circumstances (applicants must have a very low income and need the nursing home level of care);
  • Assisted living can be a viable option when a person can no longer live alone, but such facilities come with a steep price. If you are still young enough and healthy enough to afford it, you should consider getting a long-term care insurance policy (whether traditional long-term care insurance or a hybrid long-term care insurance policy) to help pay for assisted living, as described in my article, “How to Afford Assisted Living.”

Nursing Homes:

  • Nursing Homes are also known as skilled nursing facilities. As that name implies, they’re able to offer a higher level of daily care, including medical care that assisted living facilities aren’t equipped to handle and aren’t allowed to handle, but the reality is that most people in a skilled nursing facility do not receiving skilled nursing care, as most people in nursing homes simply need custodial care, also known as long-term care;
  • Nursing homes are more appropriate for seniors who are mostly bedridden or wheelchair-bound or need round-the-clock medical care and/or supervision for conditions such as dementia or the after effects of a major stroke;
  • Nursing homes can offer skilled nursing care. This means that nursing homes can provide medically-necessary care that can only be provided by skilled or licensed medical personnel. Examples of skilled nursing care include: intravenous injections, managing a feeding tube, wound care, tracheotomy care, colostomy care, and catheter care;
  • Nursing homes offer rehabilitation services (typically only after a qualifying three-day stay in a hospital), such as physical therapy, occupational therapy, and speech therapy;
  • Nursing homes also offer aid getting dressed, getting in and out of bed, and daily medical management for chronic conditions;
  • All nursing homes offer care for patients suffering from Alzheimer’s disease or other forms of dementia, but not all nursing homes have a locked-down memory care unit specifically for people suffering from these conditions;
  • Some people require rehabilitation in a nursing home for only a short period, often after being in the hospital, and go home once they recover. But most nursing home residents have physical or mental health conditions that require them to be cared for and supervised for the rest of their lives.
  • The cost of nursing home care in the DC Metro area (including Northern Virginia and suburban Maryland) is around $12,000- $15,000 a month. Medicare will pay for short-term rehabilitation that takes place in a nursing home or rehab center following a hospital inpatient stay that covers at least three midnights. But Medicare does not pay anything for long-term care;
  • Medicaid is the single largest payor of nursing home care costs because so many people can’t afford to cover the costs themselves. However, Medicaid eligibility is the most complex area law in existence, and has complex income and asset and functional capacity requirements, making it extremely difficult to qualify, so the help of an experienced elder law attorney, such as myself, is absolutely essential.

Assisted Living Facilities Don’t Have the Same Protections or Regulations as Nursing Homes

When it comes to protections, a recent article in Virginia Mercury discusses what happens when someone gets evicted from assisted living. It is very eye-opening when it comes to the protections residents have in nursing homes that they don’t have in assisted living facilities. As the article explains, nursing homes, almost all of which accept Medicaid, are subject to an appeals process through the Virginia Department of Medical Assistance Services (DMAS), which can overturn discharges if a hearing officer finds a resident was removed inappropriately; at the Farr Law Firm, we routinely file (and win) appeals with DMAS challenging what we believe to be a wrongfully-threatened nursing home discharge. Assisted living facilities in Virginia don’t have any such protections. Virginia’s Landlord and Tenant Act, which spells out specific rights and restrictions when it comes to eviction, does not apply to assisted living facilities because Virginia code section 55.1-1201 States that the protections of the act do not apply to people residing at a private institution that provide “geriatric services.” And while  residents of an assisted living facility who believe they are being improperly discharged can file a licensure complaint against an assisted living facility with the state’s Department of Social Services, the agency can’t require facilities to keep or readmit a patient. This lack of protection is particularly detrimental given the vulnerability of so many residents in assisted living communities.

When it comes to regulations, individual states — not the federal government — regulate assisted living facilities. CMS is the federal agency that regulates and provides ratings for nursing homes, but there are generally no state agencies that provide ratings for assisted living communities. While there is a national website (Nursing Home Compare) to view the audit and licensing history of Medicare-approved nursing homes, and that rates nursing homes according to a five star scale, no such national website exists for assisted living communities, which are regulated by individual states.

Here are the regulatory agency links for Virginia, Maryland, and DC:

Virginia:

Virginia conducts inspections annually and can fine communities for violations or for being found in non-compliance. Search for Virginia assisted living facilities here.

Other Helpful Virginia Links

Maryland:

Maryland conducts inspections every 15 months and can fine facilities for violations. Search for Maryland assisted living facilities here.

Other Helpful Maryland Links

District of Columbia

DC conducts inspections every 12 months and is able to fine facilities. Search for DC assisted living provider here, but please note that this list is not searchable and not updated with any regular frequency. DC provides information about inspections, complaints, and survey results for each facility here.

Sources and Links

Not Sure if Assisted Living or a Nursing Home is a Better Option?

Still need help deciding? The Farr Law Firm can assist you as part of our Level 4 Planning services. The lines are often very blurred between the need for assisted living and the need for nursing home level care, and many people could do well in either setting depending upon their condition. Many residents in assisted living can and should should be in a nursing home, but many people resist putting a loved one into a nursing home because of of the perceived stigma of nursing homes, and because most people think that nursing homes are more expensive than assisted living facilities. But the ironic surprise to most people is that nursing home care is much more affordable because it can be paid for in large part by Medicaid, whereas Medicaid as a general rule does not pay for assisted living.

Start Planning for Long-term Care As Soon as Possible

When it comes to planning for long-term care, Medicaid Asset Protection Planning can be started while your loved one is still able to make legal and financial decisions, or can be initiated by an adult child acting as agent under a properly-drafted Power of Attorney, even if your loved one is already in a nursing home or receiving other long-term care. In fact, the majority of our Lifecare Planning and Medicaid Asset Protection Planning clients come to us when nursing home care is already in place or is imminent. Generally, the earlier someone plans for long-term care needs, the better. But, fortunately, it is never too late to begin your planning.

To afford the catastrophic costs of long-term care without depleting all of your loved one’s hard-earned assets, you should begin Long-Term Care Planning as soon as possible. You should also do Incapacity Planning and Estate Planning, if you haven’t done so already. We offer a no-cost initial consultation for most potential new matters:

Elder Care Fairfax: 703-691-1888
Elder Care Fredericksburg: 540-479-1435
Elder Care Rockville: 301-519-8041
Elder Care DC: 202-587-2797

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About Evan H Farr, CELA, CAP

Evan H. Farr is a 4-time Best-Selling author in the field of Elder Law and Estate Planning. In addition to being one of approximately 500 Certified Elder Law Attorneys in the Country, Evan is one of approximately 100 members of the Council of Advanced Practitioners of the National Academy of Elder Law Attorneys and is a Charter Member of the Academy of Special Needs Planners.

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