What Is Assisted Living? (2024)

Key Takeaways

• Assisted living provides older adults with a broader base of support than independent living, but offers less support than a nursing home or memory care facility.
• Medicare will not cover the cost of assisted living or any form of long-term care. Medicaid may pay for specialized care within the assisted living setting and some state-level Medicaid waivers will help the resident cover the cost of room and board, using a combination of the individual’s income and Medicaid funds.
• Not everyone has the financial resources for assisted living. Our Local Care Reviews Team shares tips on how to manage the gap between independent living and a skilled nursing home.

As an older adult—or the caregiver of an older adult—the search for assisted living isn’t just about a place to live. It’s about access to a healthy lifestyle with built-in support.

In our Local Care Reviews Team’s March 2023 survey, 40% of respondents said their search for senior living was prompted by a medical diagnosis or a fall.1 The last thing you need at such a challenging time is another headache, yet 26% of survey respondents said they spent 10–20 hours searching for assisted living and other senior living options, and 24% spent 20–30 hours on their search. If you feel frustrated by a lack of transparent information about senior living, you’re not alone.

Our goal is to provide older adults and their caregivers with an honest, comprehensive guide to assisted living. We want you to feel more informed about your options and more confident about the next steps in your search process.

Why trust our expert review?

Our Local Care Reviews Team works hard to provide clear, transparent information to older adults and their caregivers seeking senior living and home care. To provide you with the best possible information, we have spent more than 250 hours:

• Consulting with our advisory board, which consists of a certified care manager, a board-certified geropyschologist ⓘ,A geropyschologist is a professional psychologist who specializes in the needs and well-being of older adults.
  Source: American Psychological Association (https://www.apa.org/ed/graduate/specialize/geropsychology) and a geriatric nurse practitioner
• Analyzing and synthesizing nationwide data from the Centers for Medicare & Medicaid Services and the National Investment Center for Seniors Housing & Care
• Analyzing and synthesizing state-specific data from government health regulatory agencies
• Surveying 1,000 older adults and their caregivers about their search for senior living and home care options
• Conducting a focus group with caregivers helping older adults find assisted living
• Mystery shopping dozens of brands and facilities associated with long-term care for older adults

How is assisted living different from other senior living options?

Assisted living is a type of residence for older adults who need daily care, but not as much care as a skilled nursing home provides. In an assisted living community, you or your loved one may receive prepared meals, housekeeping, medication management, and personalized help with activities of daily living (ADLs), such as bathing, dressing, or using the bathroom. Because assisted living is regulated at the state level, services available to residents will vary depending on your location.

Here’s an overview of services typically provided in assisted living in comparison to services provided in independent living or a nursing home or memory care facility.

Table 1 Comparison of services provided in senior living facilities

*In a continuing care retirement community, residents can receive all the care services listed in this table, though they may have to move to a different floor or building to receive a higher level of care.

What kind of senior living is right for me?

Names used for senior living facilities may vary from state to state, as might the services offered in each kind of facility. This can make it challenging to determine which type of senior living is a good fit for you or your loved one.

Here’s an overview of the types of senior living as well as names commonly associated with each type of facility. We’ve listed them in the order most people need them.

Independent living

What is it?

Independent living refers to communities of adults 55 and older who live in their own apartments. Benefits may include communal meals, transportation to grocery stores and doctor’s appointments, and daily activities like yoga, movies, gardening, and book clubs.

Who needs it?

Independent living communities are for older adults who do not need daily personal care but no longer want to drive, cook all of their meals, or be entirely responsible for home cleaning and maintenance.

Other common names for independent living include retirement community, retirement home, or active adult community.

Assisted living

What is it?

In assisted living, older adults receive personal care based on their needs. Benefits may include communal meals, a social activities calendar, and as-needed 24/7 care, including medication management and help with ADLs such as bathing and dressing.

Who needs it?

Assisted living communities are for older adults who need help with ADLs but want to live somewhat independently in a home-like setting with their own belongings. People might transition to assisted living after living at home or in an independent living community.

Other common names for assisted living include residential care, long-term care, supportive living, or an extra-care community.

Skilled rehabilitation center

What is it?

A skilled rehabilitation center is a temporary residence with 24/7 skilled medical care paid through Medicare or Medicare Advantage insurance. The benefits of skilled rehab include dedicated therapies and medical care for acute health conditions following at least three nights of hospitalization.

Who needs it?

Skilled rehab is for people who need care for an acute condition. For example, someone who experienced a fall, broke their hip, and underwent surgery might temporarily move to a skilled rehab facility to receive physical and occupational therapy. According to research by the Kaiser Family Foundation (KFF), the average skilled rehab stay is 26.3 days.2 People often transition from skilled rehab to assisted living or a nursing home. If the person receiving care is aging in place, they can transition back to their home after home care support has been arranged.

Other common names for a skilled rehabilitation center include skilled nursing home or transitional nursing care facility.

Nursing home

What is it?

A nursing home is a permanent residence with 24/7 personal and medical care. Benefits of nursing homes include nutrition support, social activities, and skilled medical care.

Who needs it?

Nursing homes are for older adults with chronic diseases that require ongoing, skilled care, such as Alzheimer’s disease, congestive heart failure, or other conditions that have worsened near the end of life. People might move to a nursing home from an assisted living community or from a home setting where they were being cared for by family.

Other common names for a nursing home include long-term care and skilled nursing care.

Memory care

What is it?

Memory care is long-term care specifically for people with memory loss caused by Alzheimer’s disease or another form of dementia. Memory care may be embedded in an assisted living or nursing facility, but it is a separate kind of care. Benefits of memory care include help with ADLs and a safe, regulated environment that minimizes confusion.

Who needs it?

Memory care facilities are for people with memory loss that interferes with their ability to live independently. Because of the focus on routine, memory care can reduce anxiety, a common symptom for people with memory loss and/or cognitive impairment. Memory care facilities are also designed to safeguard against wandering, a common risk for anyone living with Alzheimer’s disease or other dementia.3

Other common names for memory care include dementia care or a special-care unit.

Continuing care retirement community (CCRC)

What is it?

CCRCs offer all levels of care at one location with each level of care typically delivered in a different building or on different floors within a building. Residents can move from one level of care to another as their needs change.

Who needs it?

CCRCs accommodate older adults needing any level of care, but CCRC entrance fees and monthly costs can be prohibitive. According to the Internal Revenue Service, CCRC entrance fees can range from $50,000 to $450,000.4

Other common names for CCRCs include retirement communities and life plan communities.

What are the pros and cons of assisted living?

Types of assisted living available to you or your loved one will vary depending on the state where you or they live. In most cases, assisted living refers to a residential setting where managed care is provided alongside a healthy social environment.

Benefits of assisted living

The structured setting of assisted living allows older adults to maintain some independence while also receiving personalized care. The around-the-clock presence of caregivers and certified nursing assistants helps provide older adults and their caregivers with peace of mind.

Here are some of the other benefits of assisted living:

• Older adults in assisted living receive individualized help with ADLs such as bathing, dressing, and grooming.
• On-site physical therapy, occupational therapy, and speech therapy are often available to residents of assisted living. These therapies are not included in the room and board fee, but they are usually covered by Medicare.
• Medication management services are typically available to assisted living residents, ranging from medication reminders to medication administration and full pharmacy services.
• Social activities, including communal meals, are standard in assisted living facilities. As research from the American Sociological Association shows, the physical and cognitive health of older adults is improved by social engagement.5
• Private or semi-private apartments offer residents privacy and a degree of autonomy.
• Residents do not have to grocery shop, cook their own meals, or clean their apartments. Housekeeping, laundry, and regular meals and snacks are often included.

In most assisted living facilities, a medical alert system is located in each resident’s apartment, allowing for 24/7 emergency care.

Assisted living facilities have several benefits for older adults and their caregivers.

Drawbacks of assisted living

While the peace of mind provided by an assisted living facility can benefit families, this type of care isn’t ideal for everyone.

Here are some of the drawbacks of assisted living:

• The national median rate for assisted living is $4,000 monthly, not including fees for additional services like medication management and help with bathing. For many older adults and their caregivers, this cost is prohibitive.6
• Assisted living facilities are not required to have registered nurses (RNs) on staff. Care is typically provided by licensed professional nurses (LPNs), certified nursing assistants (CNAs), and other non-licensed personnel. For this reason, assisted living is not ideal for older adults with advanced chronic diseases like Alzheimer’s, congestive heart failure, or stroke. But it’s important to note that staffing will vary by facility. When you tour assisted living facilities, ask whether the nursing staff is available and, if so, when they are on site.

• Staffing shortages can impact the quality of care provided to older adults in assisted living facilities. Since 2020, assisted living facilities have seen significant reductions in staff, according to Federal Reserve Economic Data.7 Even when positions are filled quickly, staff turnover can lead to inconsistent care.

To ensure you or your loved one will receive timely and consistent care, ask about both the staff turnover rate and the caregiver-to-resident ratio at the assisted living facilities you tour. If you live in one of the 12 states with minimum staffing ratios for assisted living facilities, ask the communities you tour if they are meeting that standard.8

If your state does not have minimum staffing ratios, Payne recommends talking to as many caregivers and residents as possible when you tour facilities. “Look for positive interactions between residents and caregivers, as well as a sense of community within the facility,” she said. “These are good indicators that caregivers are regularly engaged with residents and that they’ve been on staff long enough to form positive relationships with residents.”

Who lives in assisted living facilities?

According to the American Health Care Association’s National Center for Assisted Living (AHCA/NCAL), about 55% of residents in assisted living communities are 85 or older, and 26% are between the ages of 75 and 84.9

Still, age alone is not a determining factor when it comes to assisted living. More important than age is the degree to which someone needs assistance with ADLs or care for chronic disease.

According to a 2021 report by the National Center for Health Statistics, 61% of assisted living residents need help with three or more ADLs. According to the same report, 34% were living with Alzheimer’s disease or another form of dementia.10

What are the qualifications for assisted living?

Assisted living facilities have guidelines to ensure they will be able to meet the needs of future residents. In most assisted living facilities, residents:

• Need help with ADLs, like bathing, grooming, toileting, and eating
• Are ambulatory (meaning they can get around mostly without assistance from another person) but may need the assistance of a cane or walker
• Can transfer in and out of bed without assistance
• Do not have medical needs that require skilled nursing, such as advanced Alzheimer’s or dementia, tracheostomiesⓘ,A tracheostomy is an incision in the windpipe (trachea) that provides an alternate airway for people with vocal cord paralysis, throat cancer, or other neurological or medical conditions.
  Source: Mayo Clinic (https://www.mayoclinic.org/tests-procedures/tracheostomy/about/pac-20384673)insulin pumps, or feeding tubes

What are the requirements for moving into assisted living?

Before you move into assisted living, you’ll need to provide the facility with a few important documents. These documents will vary by facility, but the list below covers the items most assisted living facilities require upon move-in.

• Most assisted living communities will ask for some kind of health care provider evaluation before placing an older adult in their facility, usually on a state-approved form. The name of this form will vary by state, but it typically includes information about the level of care you or your loved one needs, including diagnoses, current medications, and immunizations. In North Carolina, it’s called an FL-2 form; in Alabama, it’s called a 704 form. Check with your primary care physician about the form used in your state.
• You’ll need to provide proof of a recent tuberculosis (TB) test ⓘ,Administered as a skin or blood test, a TB test checks to see if you have been infected with Mycobacterium tuberculosis complex, the bacteria that causes tuberculosis (TB).
  Source: Centers for Disease Control (https://www.cdc.gov/tb/topic/basics/default.htm) which can be completed at many pharmacies.
• Though legal documents may not be required by the assisted living facility, it’s a good idea to have power of attorney, a living will, and advance directives on file. These documents help caregivers know how to handle medical or financial matters when older adults cannot make decisions on their own.
• Have your insurance information ready on move-in day. If you’re using Medicare or Medicaid to pay for any services received in assisted living, be prepared to provide your Medicare and Medicaid identification numbers.

How do I know it’s time for assisted living?

“Every single person will at some point in their life care for someone or need to receive care from another,” said Certified Life Care Manager Carla Payne, founder of Aging Care Matters. She recommends starting conversations early with your loved ones and discussing your wishes and priorities so you’re prepared when the time comes for assistance.

Honest conversations with loved ones can help determine the next level of care for older adults. In March 2023, our Local Care Reviews Team organized a focus group of six caregivers of older adults to understand their experiences with searching for senior living options. More than one participant shared that the older adult they cared for sometimes found it difficult to have honest conversations with their children or other family members about their needs.11 It might be helpful to ask a doctor or certified care manager to be present for this discussion.

Here are some questions for older adults to help them and their families decide when it’s time for assisted living:

• Do you feel lonely or depressed?
• Are you having trouble getting around your house or apartment?
• Do you feel overwhelmed by everyday tasks, like getting groceries, preparing meals, or cleaning?
• Is it difficult to dress, bathe, or go to the bathroom without help?
• Do you sometimes forget to take necessary medications?

Here are some questions for caregivers to help them decide when it’s time to talk to their loved one about assisted living:

• Have you noticed that your loved one seems depressed or lonely?
• Has your loved one experienced any falls or near-falls?
• Have you noticed a change in your loved one’s personal or home hygiene?
• Is your loved one getting enough healthy food to eat?
• Is your loved one having trouble with medication management?
• Are you feeling overwhelmed by your loved one’s level of need?

If you or your loved one answer yes to one or more of these questions, it might be time to start talking about assisted living options.12

How much does assisted living cost?

On average, assisted living costs about $4,000 per month for room and board, according to the AHCA/NCAL. This fee usually covers the cost of a shared or private apartment, Wi-Fi and cable, regular housekeeping and laundry services, and three meals per day.

In some cases, sharing an apartment with another resident can reduce the cost of room and board. One assisted living facility we researched in Fort Collins, Colorado, offered shared suites for $3,550 per resident, whereas the monthly cost for a private studio was $4,550.

What additional fees are associated with assisted living?

Additional fees could increase the monthly assisted living facility bill by hundreds or thousands of dollars each month. For example:

• You may need to pay extra for medical and personal care services provided in assisted living. As one of our March 2023 focus group participants shared, “You can get anything you want; you just have to pay more.”13

Most assisted living facilities will do a clinical services evaluation of the resident before or at the time of move-in to assess this. Based on this assessment, the resident will be placed in a certain level of care, each with a corresponding additional fee per month.

One facility we researched in Chapel Hill, North Carolina, had four levels of care, with Level One needing the least amount of hourly care and Level Four needing the most. For Level One care, residents paid an additional $400 per month; for Level Four care, an additional $1,250.

Another facility in Fort Collins, Colorado, had four levels of care ranging in cost from $700 to $1,700 per month. This facility also charged a $300 fee for medication management, regardless of the resident’s level of care.

In both of these facilities, Level One care included help once or twice per day with a few ADLs, such as showering and dressing. In Level Four care, residents needed help throughout the day with ADLs, medication management, escorts to and from the dining room, and transferring in and out of bed in the morning and at night.14

• Upon move-in, many assisted living facilities require the first month’s rent and a community fee, which, when combined, can range from $7,000 to $16,000.12

• As not all assisted living facilities have fully furnished apartments; you may need to provide furniture for yourself or your loved one.

Long Term Care Insurance Providers

Does Medicare pay for assisted living?

Medicare pays for short-term rehabilitation, but it does not pay for any form of long-term care, including assisted living.

Medicare may pay for selected services older adults receive while they are assisted living residents, such as physical therapy or preventive health services.

To find out what you qualify for, get in touch with a Medicare advisor or use BenefitsCheckUp.15

Does Medicaid pay for assisted living?

While Medicaid does cover the skilled nursing provided in a nursing home, it usually does not help pay for the room and board costs associated with an assisted living facility.

Medicaid may pay for selected services that Medicaid-eligible older adults receive while they are assisted living residents, such as physical therapy, personal care services, case management, transportation to doctor’s appointments, and personal medical alert systems.

Sometimes, a Medicaid waiver can help Medicaid-eligible seniors cover the cost of assisted living. Medicaid 1915(c) Home & Community-Based Services (HCBS) waivers have broad federal guidelines that states can tailor to meet the needs of residents in their state. Currently, there are 300 HCBS waiver programs across the United States.16

Though all Medicaid programs have federal oversight, each state runs its own Medicaid program. So, Medicaid rules and regulations will vary from state to state. For example, some states will provide additional medical and personal care services to residents of assisted living facilities. Others will only provide those services for in-home care.

To get answers about your Medicaid coverage, contact your state’s Medicaid office, find a Medicaid advisor through your local senior center, or consult BenefitsCheckUp.17

How can I pay for assisted living?

Table 2 How to pay for assisted living

How do I choose an assisted living facility?

You’re not alone in your search for assisted living. Currently, more than 800,000 people reside in senior care facilities in America, and that number will continue to grow as the population ages.18

Our research shows many people begin the search for assisted living when their loved one is already in crisis. This can make the search feel even more overwhelming. Knowing where to look and what questions to ask can help you make an informed decision, even if you’re in a hurry. When researching your options, consider the following tips:

• Ask your friends. In our 2023 Local Care Survey, 63% of respondents cited “friends and family” as a primary source of information on senior living options.
• Make a list of assisted living facilities. Decide on the geographical parameters for your search and make a list of facilities you can visit within those parameters.If you’re willing to drive 20–30 miles outside of your immediate area, you may have more options. That said, as a caregiver, you’ll need to balance the length of the drive with the number of times per week you want to visit your loved one.

• Take as many tours as you can in the time you have. If you can, divide and conquer by enlisting family members to tour facilities. Then, compare notes. After you’ve narrowed your top few choices, visit again unannounced and, if possible, chat with a few residents about their experience. This will give you a more accurate view of the assisted living community.
• Make the most of your visit. Here are a few tips:
  • Start taking notes the moment you arrive at the facility.
  • Don’t be afraid to ask a lot of questions, and take detailed notes of the responses. As you tour, take notes specific to each facility, as they may start to blend together in your recollections.
  • Talk to everyone you encounter during your tour, from administrators to caregivers to residents.
  • Look beyond aesthetics and remember that how you see the community is not how your loved one may see or experience it. Some of the less modern facilities might still have excellent staff and quality of care.
  • Do a gut check—how does the place make you feel?

Alternatives to assisted living

In most cases, Medicaid will pay for nursing home care but not for assisted living. For low- and middle-income older adults, this means assisted living may not be financially feasible. This presents a new challenge: managing the gap between independent living and a nursing home.

For older adults aging at home: Consider goods and services that make it possible to safely continue living at home or in an independent living community, for example:

• Look into hiring companion care for you or your loved one. With an average cost of $25-$38 per hour, companion care is less expensive than skilled nursing care and can provide social engagement, light housekeeping, and meal preparation.12
• Use programs within your community, such as area agencies on aging, senior centers, libraries, and places of worship that might offer helpful services like meal delivery or transportation to doctor’s appointments.
• Invest in a medical alert system. These systems, which connect people with help in an emergency, cost about $20–$30 per month. A medical alert system can provide peace of mind for older adults aging at home, as well as their caregivers.

For caregivers of older adults: Often, caregivers are juggling so much more than just caring for an aging loved one, including full-time jobs and raising young children. Consider programs that help you to care for your loved one at home, for example:

• Consider adult day services. Adult day centers provide a coordinated program of social and some health services for adults who need supervised care outside the home during the day. These community-based group programs offer professional, compassionate care while also affording caregivers respite from the responsibilities of caregiving. Adult day centers usually operate during normal business hours five days per week, and some programs offer services in the evenings and on weekends.
• Use respite care, a temporary residence for older adults. Respite care is ideal for times when you need to travel or just need a break from caregiving.

For older adults and their caregivers: Work together to learn your options and find the solution that works best for your family, for example:

• Find a geriatric social worker through your local area agency on aging or senior center and schedule a meeting. They can help you find resources in your community. Use the Eldercare Locator to find your local aging organization.
• Hire a certified care manager to help you understand your benefits, navigate the health care system, connect with community resources, and find a long-term care solution for your family.

Have questions about this article? Email us at reviewsteam@ncoa.org.

Sources

1. Local Care Reviews Team survey. 1,000 respondents. Conducted using Pollfish. Launched March 2023.
2. Kaiser Family Foundation (KFF). Amid the COVID-19 Pandemic, Medicare Spending on Skilled Nursing Facilities Increased More than 4% Despite an Overall Decline in Utilization. June 2022. Found on the internet at https://www.kff.org/medicare/issue-brief/amid-the-covid-19-pandemic-medicare-spending-on-skilled-nursing-facilities-increased-more-than-4-despite-an-overall-decline-in-utilization/
3. Alzheimer’s Association. Stages and Behaviors: Wandering. Found on the internet at https://www.alz.org/help-support/caregiving/stages-behaviors/wandering
4. Internal Revenue Service (IRS). Elderly Housing Report. 2004. Found on the internet at https://www.irs.gov/pub/irs-tege/eotopicg04.pdf
5. Thomas, Patricia. Trajectories of Social Engagement and Limitations in Late Life. Journal of Health and Social Behavior. American Sociological Association. Dec. 2011. Found on the internet at https://journals.sagepub.com/doi/10.1177/0022146511411922
6. American Health Care Association / National Center for Assisted Living (AHCA/NCAL). Assisted Living Facts and Figures. Found on the internet at https://www.ahcancal.org/Assisted-Living/Facts-and-Figures/Pages/default.aspx
7. Federal Reserve Economic Data. All Employees, Nursing and Residential Care Facilities. Found on the internet at https://fred.stlouisfed.org/series/CEU6562300001
8. Long Term Care Community Coalition. Assisted Living Fact Sheet: Staffing Ratios. Found on the internet at https://nursinghome411.org/wp-content/uploads/2019/01/LTCCC-Assisted-Living-Fact-Sheet-Safe-Staffing.pdf
9. American Health Care Association’s National Center for Assisted Living (AHCA/NCAL). Assisted Living Facts and Figures. Found on the internet at https://www.ahcancal.org/Assisted-Living/Facts-and-Figures/Pages/default.aspx
10. Caffrey Christine, et al. Residential care community resident characteristics: United States, 2018. National Center for Health Statistics (U.S.). Division of Health Care Statistics. Long-Term Care Statistics Branch. Sept. 2021. Found on the internet at https://stacks.cdc.gov/view/cdc/103826
11. Local Care Reviews Team Focus Group for Caregivers. 6 participants. Conducted Using Google Meet. March 2023.
12. Interview with Carla Payne, Certified Life Care Manager. Conducted using Google Meet. March 2023.
13. Local Care Reviews Team Focus Group for Caregivers. 6 participants. Conducted Using Google Meet. March 8, 2023.
14. Mystery shopping at assisted living facilities in North Carolina, Colorado, Michigan, and Alabama. March 2023.
15. Medicare.gov. Contact Medicare. Found on the internet at https://www.medicare.gov/talk-to-someone
16. Medicaid.gov. Home & Community-Based Services 1915(c). Found on the internet at https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/home-community-based-services-1915c/index.html
17. Medicaid.gov. State Medicaid Links. Found on the internet at https://www.medicaid.gov/about-us/beneficiary-resources/index.html#when2contactstate
18. American Health Care Association’s National Center for Assisted Living (AHCA/NCAL). Assisted Living Facts and Figures. Found on the internet at https://www.ahcancal.org/Assisted-Living/Facts-and-Figures/Pages/default.aspx