Longterm Care, Part 2: Assisted Living

I’m wrapping up my birthday month growing old and aging series with the second part of my three-part series on longterm care options for the aging and elderly in society. Today we look at Assisted Living.

Assisted Living Facilities (ALF) are growing in popularity with about 1/2 a million aging adults choosing this option in the past few years. The number of people choosing to age in ALFs where residents can receive some level of care and assistance with activities of daily living if required is growing every year. ALFs do not provide and are not licensed to provide around the clock nursing care provided by federally-licensed long-term nursing homes and are licensed by the state instead.

The advantage of many ALFs is that residents still maintain some level of independence usually having their own apartment or room inside a larger facility or campus that provides care on in a group-like setting. For instance, most ALFs offer staff availability 24-hours a day, although that may mean staff is on-call or at another location on campus and not necessarily “in-house” 24 hours a day. Nursing and medical care are generally available on short-notice, though, if required at any time of day or night.

Assisted Living Facilities also offer some sort of social services and often programming and activity directors, to keep residents socially engaged and to monitor for changes in mental or cognitive or financial capacity. Residents may engage in activities scheduled on campus or be provided with transportation to off-site activities, and cooks in kitchens or cafeterias provide meals three days a week for residents without kitchens or who cannot prepare foods for themselves. Assisted Living Facilities also offer housekeeping and laundry services and other assistance with activities of daily living. And sometimes nursing staff or caregivers provide help with medication management and other light duty nursing, monitoring and health checks.

Photo by Georg Arthur Pflueger on Unsplash

People can choose different levels or types of assisted living such as group homes, shelter in a private-home type setting, continuing care retirement communities or even adult foster-care. In a group-home, residents share a living and dining area and meals are provided by the staff. Residents only have a bedroom of their own. Generally, a small staff of nurses or CNAs are on-site 24 hours a day, but the number of residents to staff can be high. Some group homes may offer memory/dementia/Alzheimer’s care and other more long-term and severe medical care, but others do not.

I volunteer as a companion at one such group home in my area. Just last week, residents were provided with an animal parade and petting zoo put on by local 4-H students. They were often are visited by singers and entertainers before COVID and some of that programming is returning due to vaccinations, including laughter yoga exercises I will be leading in the coming weeks.

“Goat” the sheep at a petting zoo at the Bee Hive Group Home last week

Adult foster care provides adults with the chance to live in a home setting and to be cared for by paid foster families or caregivers. Adult foster care is not available in all states, and the rules and regulations also vary from state to state. Adult foster care programs help not only the aging and elderly in the community but also those with disabilities that require some sort of assistance with daily living of any age over 18. Because Medicaid, through several different programs, pays for foster care, it cannot be used for room and board or food, so often times, the foster adult receives increased social security and disability insurance to cover those costs in a foster setting.

Under the Aged and Disabled Waiver, Indiana Medicaid offers a benefit called Structured Family Caregiving.  This benefit covers services provided in private homes, essentially adult foster care.


Adult foster care in Kentucky is defined as a home providing care to between one and three persons unrelated to the homeowners. The state’s Medicaid program, under the Waiver for the Aged, allows for consumer direction. This means participants can choose their caregivers and the location in which they receive care.


Sheltered housing is similar to foster care in that it provides home care to seniors in a home owned by someone else. These private home situations usually consist of a few boarding-style rooms with assistance provided for activities of daily living, housekeeping and meals. These homes may also provide social services and activity coordination for additional fees. There is little to no “medical” care provided in this style of care home, and the cost is usually calculated on a sliding scale based on income, generally coming in at around 30% of income.

I also visit residents at a shelter-housing community that consists of a few veterans that share a large home with a private full-time caregiver, a retired veteran, who provides housekeeping, meals and assistance with daily living. Two of the residents are receiving at-home care through hospice currently, which can provide care in any of these situations as residents approach end of life.

Continuing Care Retirement Communities (CCRC) are what comes to mind for most of us when discussing assisted living. These communities generally include several large buildings on a campus where each building houses a different sort of apartment or care. There may also be a fully-medical long-term nursing home on the campus and some sort of memory care facility as well. The idea of of continuing care in CCRC refers to the many different levels of care available in “one-place” meaning the resident does not really have to move, except perhaps to a different area of the building or campus, when the level of care needed changes as they grow older.

Nurse holding hands with senior woman sitting in wheelchair in garden of retirement home

This type of ALF covers the entire gamut of care needs provided by other ALF situations, but is not in any way covered by Medicaid services. Residents may start by paying a monthly rent-style fee, based on the amount of services being provided. Rates will increase as the need for care increases. Only the beds and care in the nursing home facility are covered by insurance, in most cases. Needless to say, the cost of living in these type of facilities can be high and prohibitive for many.

Through hospice, I visited with a woman who was in the long-term nursing home wing of such a residence. Her husband would visit her from his apartment on the other side of the facility. When he first moved into the facility, she was well enough to spend part of her days with him in the apartment as well, so they were able to be together in a way that would not have been possible if he remained at home once she needed full-time nursing care.

Lastly, memory-care ALFs exist to provide assistance to people with memory issues, such as traumatic brain injury, dementia or Alzheimer’s disease. This type of care is the most expensive as it requires strenuous safety and security measures and a high-level of assistive care. The amount of staffing and medical care necessary means these facilities are staffed and often operated similarly to long-term nursing facilities, but, again, may not be covered by Medicaid and insurance meaning the costs are the greatest for residents: easily $5,000 or more per month, and sometimes per resident. All of these diseases can last for decades meaning that care in facilities such as these is prohibitively expensive for most people. Because the cost is so high, people with memory and cognition issues are generally cared for at home until that care becomes an impossible burden for family caregivers, who then have to send their loved one to a long-term nursing home facility.

Assisted living offers some solutions to elders who want to maintain some level of independence and who may not require continuous health and medical care. However, as their physicality and health continues to deteriorate, ALFs, even if they can provide the care, are most times too expensive to be a feasible alternative to traditional long term nursing homes, which we’ll explore in Part 3.

Published by MKChurchman

Certified Care Consultant and End of Life Doula Specialist. I offer assistance with end of life planning, elder care, end of life and after death care through my practice Shoji Bridge Departure Doula. My passion is to bring death into the light and inspire my community to be more comfortable with and compassionate to people who are dying. My mission is to be a guide to help people pass through the final barrier on this plane of existence and move gently onto the path to the next.

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