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No one wants to face the inevitable decline of their parents, but if we're fortunate, they will have already made plans for a retirement community, and have the resources to afford it. For the rest of us, it may involve persuading them to start researching options while they're still in good health, or, in the worst-case scenario, scrambling to find a place after an unexpected event like a fall or stroke. In either situation, locating the right facility can be difficult, particularly when you're pressed for both time and money. To help get started, I consulted David Hackerstick, a former director of the Lancaster County, Pennsylvania Office of Aging and administrator of several senior care homes, now serving as a consultant.
Understanding the Different Facility Types
When it comes to care options, there are three primary categories: independent living (often part of a continuing care retirement community or a life plan community), assisted living (which offers help with daily activities like dressing, bathing, eating, medication management), and skilled nursing (providing full-time nursing care). According to Haverstick, "The move to skilled nursing is typically associated with incontinence"—if your parent struggles with bladder or bowel control, it's time to consider skilled nursing.
How to Find a Local Facility
Nursing homes are often something you don’t think about until the need arises, so you may not be aware of the options available in your area. According to Haverstick, "Every part of the U.S. has an Area Agency on Aging, often referred to as 'offices on aging.' In more populated states, there may be five or six, while in rural states, there could be just one. Their job is to provide information to help people make decisions and navigate the process, whether it’s about keeping a parent at home or finding a suitable facility. Most aging offices have a strong information and referral program." Look up your local office online and contact them for a list of facilities in your area.
If your parent is in the hospital, the social worker there can assist by providing a list of nearby facilities. However, Haverstick points out that hospitals prioritize discharging patients quickly, not necessarily assisting with finding the most suitable facility for your loved one.
Another alternative, if you're willing to pay, is hiring a geriatric care manager. This is a social worker who specializes in elderly care and can help ensure your parent receives the appropriate services. Haverstick notes that this option is more common when parents and their children live in different locations. You can find one by searching for 'geriatric care manager' along with your state, and ensure they are accredited. The New York Times article further explains the role of geriatric care managers, the certifying organizations, and typical fees (though the information may be outdated).
Finally, Nursing Home Compare is a valuable resource that can connect you with skilled nursing facilities in your area that accept Medicare and Medicaid. Simply enter your zip code, and a list of available facilities will be displayed. Facilities are rated on a 1-5 star scale, with Haverstick advising, "Facilities rated three stars or higher are generally considered good, while those with one or two stars should be approached with caution."
What You’ll Be Paying
According to Haverstick, "Care isn’t cheap. Assisted living in the Northeast or Mid-Atlantic region can cost about $150 per day, while skilled nursing care runs around $300 a day." Assisted living is typically paid for out of pocket: "There aren’t any government programs to assist with this (though some states may offer subsidy programs, while others don’t), so patients must handle the expenses themselves."
Long-term care insurance is an option, but Haverstick warns that these policies can be unreliable due to insurers going out of business or premiums rising unexpectedly. For skilled care, Medicare can cover the costs if your parent meets certain criteria: the condition must be treatable through rehabilitation, your parent must have had a three-night stay in the hospital for that condition, and the care must be provided at a Medicare-certified community. However, even with Medicare, the coverage is "time-defined": only up to 100 days per incident. If your parent’s condition doesn’t qualify, you’ll be responsible for out-of-pocket expenses. "There’s little assistance for assisted living," says Haverstick. "The assumption is that care can be provided at home to avoid placement."
Haverstick explains, "Another option is medical assistance, a federal program managed by individual states, for those who require long-term care but lack financial means. Typically, skilled nursing facilities will first require proof of substantial financial resources—often demanding that you demonstrate having, for example, $200,000. Once those resources are spent down over time, the facility transitions the payment responsibility to medical assistance, which will continue to provide care."
If your parent has no financial resources to begin with, they may qualify for medical assistance right away, but not all care communities participate in the program. Moreover, facilities primarily funded by medical assistance tend to be of lower quality than private-pay options. Haverstick notes, "These are usually one- or two-star communities."
Preparing in Advance
If you're starting early, Haverstick recommends consulting with an eldercare attorney alongside your parent to help them organize their finances for what lies ahead. He also advises visiting various facilities with your parent. "For those who plan ahead, a continuing care retirement community can be a great option. You can explore local communities, assess their offerings, and decide what’s covered or not—and these choices are not just for those with significant wealth." If your parents are in their late 60s or early 70s, "now is the time to begin this journey," says Haverstick.
Making the Final Decision
When it comes to selecting a facility, Haverstick admits his personal preference leans toward not-for-profit, mission-driven (often religious) organizations, as he believes they tend to offer a higher level of care compared to for-profit facilities. "While these businesses often claim to prioritize care, at their core, they’re businesses. This can lead to significant frustration for families," he explains.
Haverstick recommends paying attention to these potential warning signs and positive indicators when touring and interviewing care facilities:
Facility size. "Smaller facilities are generally preferred," Haverstick explains. "They offer more personalized care and feel less like an institution. These are often referred to as ‘green houses’ or follow a ‘household model.’ Larger medical-assistance facilities tend to be more institutional in nature."
Person-centered care. Is there individualized care for activities? Do they accommodate food preferences? Are residents allowed to wake up when they wish? This is a crucial consideration: If staff insists on waking your parent at 4 or 5 AM, it can disrupt their well-being.
Connection with the outside world. Is there a sense of continuity with your parent’s previous life? Look for activities or events that help residents feel connected to their past life: speakers, hobbies, etc. Check the activities calendar: Would your parent enjoy these? Also, observe if residents are mainly gathered around the TV or the nurses’ station, which could indicate a lack of diverse activities.
Staffing ratio. What is the staff-to-resident ratio? How large is the unit? Haverstick suggests, "If there’s one aide for ten residents, that’s too much. Five is typical, and two or three is exceptional. While the second and night shifts will have fewer staff, there should still be enough to ensure that residents are well-cared for and not left in wet diapers." If possible, observe all three shifts.
It’s an undeniable fact that this is a painful journey for both parents and children, and if you’re in the midst of it, it may feel like you’re reinventing an exhausting process. The key takeaway here is simple: Start planning as soon as possible—it will significantly improve your parent’s quality of life, and your own as well.
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