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Nursing Home Alternatives

10 Surprising Ways to Avoid Nursing Home Care

By , Caring.com Expert
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happy mom and daughter

Although many nursing homes today offer wonderful care, most of us would prefer to live out our lives in the comfort of home.

For any number of reasons, though -- from physical or mental health issues to dwindling finances -- staying at home doesn't always seem possible. If someone close to you appears to be headed for a nursing home, there are alternatives that can -- sometimes indefinitely -- forestall the need for such a move.

Here are ten ideas for keeping your loved one at home:"ƒ

1. Share care

As an older adult's need for in-home care begins to mushroom, even the combination of paid and family caregiving may quickly become too expensive, too time-consuming and exhausting, or both. Many people discover they're able to share caregiving (and its costs) by pooling their resources. Examples include:

  • Moving in with a relative, friend, or neighbor. Living alone significantly increases the need for caregiving. Many older adults address this problem by sharing their living space with someone else who's in similar circumstances. This might mean sharing one or the other's existing home, or getting a new place together. The roommates can then help support each other while sharing some family and paid caregiving, reducing both the burden and the cost.

  • Simultaneous family-and-paid caregiving shared with a neighbor. There may be someone who lives in the same building or on the same block as the person you're caring for who also needs regular in-home care. If so, and assuming that the two of them get along and accept the idea, it may be possible for them to share some in-home caregiving. One of them could be taken to the other's home -- and, if both physical setups allow, this could alternate between the two places -- and be cared for there for a day or a few hours, either by a paid or family caregiver. A comfortable chair or bed could be added to one or both places to make this more workable.

How Relocating Can Help You Avoid Nursing Home Care

2. Move to a less expensive area

If in-home care gets too expensive, consider moving your loved one to a different, less costly, location. The cost of living -- including both the regular expenses of daily life (housing, food, utilities) and the cost of an in-home caregiver -- varies substantially in different areas of the country. For example:

  • Urban areas tend to be more expensive than rural ones.

  • Both coasts are generally more expensive than the South, the Southwest, and much of the Great Plains and Rocky Mountains.

By reducing costs, it may be possible to afford considerably more in-home care in a new, less expensive location. When making such a move, consider:

  • Moving your loved one near a family caregiver. Making a major move may be most sensible if it's to a place near one or more family members who will be involved with caregiving. Even if most in-home caregiving continues to be paid, having a nearby family member who's responsible for overseeing that care and for providing extra care and other assistance when needed will further reduce costs.

  • Consider a move out of the country. Entire retirement communities that cater to older Americans have sprung up in a number of countries, such as Mexico, where the cost of in-home care is much lower. Even if you're caring for someone with family or friends who've made such a move, be sure to thoroughly investigate these costs before relocating. Be aware, too, that there may be local immigration restrictions on moving to certain other countries. Equally important: Medicare provides no health insurance coverage outside the U.S., so some alternative medical insurance program would need to be available.

Try Adult Daycare to Avoid Nursing Home Care

3. Use adult daycare

One way to make in-home care work -- both in terms of cost and preventing family caregiver burnout -- is to supplement it with adult daycare. Your loved one can spend from a few hours to a full day at an adult daycare center while the primary in-home caregiver sees to other matters or simply gets a break from caregiving.

The benefits of adult daycare aren't just for the caregivers. Adult daycare centers typically offer meals, activities, exercise, and transportation, providing the person in your care a change from the isolation of home, socialization with others, and activities he or she might not otherwise participate in. Many adult daycare centers accept, and have special services for, people with mild to moderate Alzheimer's or other forms of dementia.

Adult daycare centers charge considerably less per hour than in-home caregivers -- $25 to $75 for a full day, depending on location and services provided. Also, many centers offer sliding-scale fees.

Neither Medicare nor other health insurance pays for adult daycare, but long-term care insurance does, as do many state Medicaid programs. Also, the Department of Veterans Affairs (VA) operates its own adult daycare centers for veterans who qualify.

There are more than 3,500 adult daycare centers currently operating in the United States; probably at least some are centers close to you.

How Low-Cost or Free Companion Care Can Help You Avoid a Nursing Home

4. Hire free or low-cost companion care

Skilled in-home care can cost $20 to $30 an hour -- and even more. If the number of hours needed for care begins to mount, consider what type of help is actually necessary. Can your loved one get by with skilled in-home assistance for only a small part of the day (first thing in the morning, for example, or at bedtime), and for most of the day have a nonprofessional caregiver who simply provides companionship, helps with small household chores, and provides a presence for safety and security?

If lower-cost (or free) "companion care" is workable for your family member, here are some sources of such help:

  • Senior-to-senior programs. In some areas, local government or nonprofit organizations operate an agency or referral service that connects local senior volunteers with other seniors in need of companion care. To learn about whether such a senior-to-senior program exists near you, check the Eldercare Locator or call toll-free at 800-677-1116.

  • Churches. Some churches have programs in which congregation members volunteer to provide free in-home care for older adults. These programs usually provide only a few hours of help a week, but even that can make a big difference to a family caregiver and to overall costs. If you or your loved one belongs to a local church, find out if it has such a program, or if it knows of congregation members who provide this kind of unofficial help on their own.

  • Local high schools and colleges. Many high schools and colleges offer community service programs in which students volunteer to provide free local services, such as in-home care for older adults. Student volunteers aren't usually capable of providing extensive care (such as managing medicines or bathing), but often they can run errands, perform household chores, and provide companionship for an older adult for several hours a week. Also, many colleges have student employment centers where students list their availability to provide care for pay, usually at rates considerably lower than those of professional caregivers.

  • In-home care agencies. Most in-home care agencies offer different levels of care, including lower-cost companion care. Here's one way to find out about and compare in-home care agencies near you.

How an ECHO Backyard Cottage Can Help You Avoid a Nursing Home

5. Check out your own backyard

For some people, having a loved one move in with them would make providing care much easier -- in fact, it could eliminate the need to move to a nursing home. But lack of space and the intrusion on the privacy of both the family and the person being cared for often make such a move impractical.

One solution is the addition of a small, separate living unit in the backyard or other open space at a family home. The space, sometimes called an ECHO -- Elder Housing Cottage Opportunity -- unit or accessory dwelling unit (ADU), may be temporary or permanent and can be fitted with special features (safety rails or an easy-access shower, for example) designed for older adults.

The addition of a separate living unit is neither simple nor cheap. There may be zoning issues, and the cost can run between $25,000 and $75,000 to purchase the unit, or between $1,000 and $3,000 per month to lease it. Still, these costs are considerably less than even one year in most nursing homes. Also, once the unit is no longer needed, it can either be removed or kept and used for other purposes.

Although several companies, such as MedCottage and PALS, operate multistate businesses that build these units, finding a company that sells and installs them near the person you're caring for may not be easy. You'll need to search online using the keywords ECHO housing, accessory dwelling, or backyard housing to find local sources. "ƒ

6. Get creative with financial tools

If lack of cash is the reason your loved one can't remain at home, and you think you've exhausted all possibilities for raising funds, consider two often-overlooked sources:

  • Reverse mortgage. If your loved one owns the home he or she lives in, a reverse mortgage might raise enough money to pay for a considerable amount of in-home care. Unlike a conventional mortgage, none of the reverse mortgage loan amount has to be repaid until the homeowner dies or permanently leaves the home. This means that all the money from a reverse mortgage is available to pay for in-home care, or for any other expenses, as long as the homeowner continues to live in the home.

  • Cash for life insurance. Certain life insurance policies can be cashed in with the insurance company itself for 50 to 75 percent of the policy's face value. Some policies permit these "accelerated benefits" or "living benefits," as they're called, only if the policyholder is terminally ill. A "life settlement" (also called a "senior settlement") may also be possible, which involves selling the policy to a life settlement company for a lump sum. The amount of the settlement -- 50 to 75 percent of the policy's face value -- depends on the policy benefit amounts, the policy's monthly premiums, and the policy holder's age and health. The settlement company pays the policy's premiums until the person dies, and then it collects the life insurance benefits.

How VA Benefits Can Help You Avoid a Nursing Home

7. Investigate the Department of Veterans Affairs (VA) Benefits

If your family member is a veteran, or a spouse or surviving spouse of a veteran, he or she may be able to qualify for a number of different VA benefits that will enable him or her to remain at home instead of entering a nursing home. These benefits include:

  • In-home care and adult daycare programs provided by the VA. The VA refers to a number of long-term in-home and community care programs as "extended care." These programs offer nonmedical assistance to help certain veterans maintain their independence. Extended care is available to a veteran with a service-connected disability or to any veteran who has very low income and needs long-term care. Extended care can include:

  • In-home health aides and homemaker services.

  • Adult daycare, which provides health maintenance and rehabilitative services to veterans in a group setting during daytime hours, either at a VA or community facility.

  • Community living centers, which offer short-term residential and ongoing community care for veterans with chronic stable conditions (including dementia) and veterans needing rehabilitation or short-term special services.

  • Home modification grants, since being able to remain at home sometimes depends on the physical configuration of a person's living space. The VA offers several types of cash grants to help a veteran modify his home in order to remove barriers and to make it safer.

  • Cash benefits, depending on the individual situation. Eligibility and amounts for veterans and their spouses vary depending on the nature of military service, existence of a service-connected disability, and income. Some of the benefits include:

    • VA pension benefit, which is for veterans who served at least 90 days of active military service (24 months for those who entered after September 7, 1980), at least one day of which was during an official period of war; has low income; and is age 65 or older or permanently and totally disabled (the disability does not need to be service-related). The pension can be as much as about $1,000 per month (more for a couple) and depends on the veteran's income.

    • VA service-connected disability compensation, which pays monthly benefits to veterans with a physical or mental-emotional condition that affects the vet's ability to perform the activities of daily life. The condition must have resulted from, or have been aggravated by, injuries or diseases that struck while the veteran was on active duty. The amount of compensation -- from $123 to $2,673 per month -- depends on the seriousness of the disability and whether there's a dependent spouse.

    • VA aid and attendance benefit, available to a veteran who's also eligible for a VA pension or to a veteran's survivor who's collecting a VA death pension (see above). Aid and attendance benefits can add up to about $700 per month extra to a veteran's VA pension, and about $500 per month extra to a survivor's VA death pension. To receive an aid and attendance benefit, the veteran or surviving spouse must either require regular assistance to safely perform activities of daily living, be bedridden, or be blind.

    • VA housebound benefit, for a veteran who's receiving a VA pension or a survivor receiving a VA death pension. Such a veteran may also be eligible for housebound benefits if he or she has a 100 percent-rated (by the VA) disability that substantially confines him or her to home.

To get free information or assistance regarding any VA benefit, contact one of the VA's Vet Centers, which are located in every state. You can also get assistance by contacting the VA's Veterans Benefits Administration office nearest you. The VA's toll-free telephone help line, at 800-827-1000, is also available for any questions. "ƒ

How Assisted Living Can Help You Avoid Nursing Home Care

8. Consider assisted living

Even though assisted-living facilities are sprouting up everywhere, many older adults and their caregivers don't realize that an assisted-living facility -- usually far less costly and less institutional than a nursing home -- may be right around the corner. Or there may be assisted-living facilities near a family member who can provide regular companionship and extra support beyond what the facility offers.

If your loved one needs regular monitoring but not round-the-clock supervision, and assistance with some but not all aspects of daily living (such as bathing, eating, walking, getting in and out of bed, using the toilet), then it may pay to look into an assisted-living facility. Some things to know:

  • Assisted-living facilities offer a separate, private living space -- from a single room to a one- or two-bedroom apartment, usually with kitchen facilities -- in a building of 20 to 150 units that house other older adults.

  • Assisted-living facilities offer basic supervision and services -- meals in a common dining area, housekeeping, help with activities of daily living, monitoring of medication, transportation, and social and wellness activities.

  • Many assisted-living facilities provide specialized care and services for people with Alzheimer's or other forms of dementia.

  • Assisted-living facility costs vary by area, size of the individual unit, and level of services, but they generally range from about $2,000 to $7,000 a month.

What are the advantages of assisted living facilities over nursing homes?

  • More privacy. Because each assisted-living facility resident has an individual living unit, there's much more privacy than in a nursing home.

  • Greater independence. Assisted-living facility residents come and go as they please, can choose to join others for a common meal and social activity, or instead have their meals and socialize privately in their own units. They may also have outside visitors in their private residences.

  • Less institutional. Many nursing homes tend to look and feel like hospitals. Assisted-living facilities are much more homelike, both in the common areas and in the private units, where residents can have some or all of their own furnishings.

  • Cost. Assisted-living facilities tend to cost a third to a half less than nursing homes in the same geographic area.

Find out about and compare assisted-living facilities in your area.

How Home- and Community-Based Services Can Help You Avoid Nursing Home Care

9. Look Into Medicaid

Medicaid (the medical insurance program for people with very low incomes and few assets) does not include nonmedical, long-term, in-home care as a standard part of its coverage. But for those who qualify for Medicaid, the program has begun to recognize that the alternative to unaffordable in-home care is entry into a nursing home, which Medicaid does pay for. So, as a way of allowing Medicaid recipients to remain at home -- and thereby saving Medicaid the cost of full nursing home coverage -- some state Medicaid programs have established what's called Home & Community Based Services (HCBS).

HCBS programs offer Medicaid coverage for a limited amount of in-home care and adult daycare. These programs only operate in some states, and the eligibility and benefits rules vary from program to program.

To find out more about the availability of an HCBS program where your loved one lives, contact a local Medicaid office at Benefits.gov.

10. Ask about the PACE program

If you're caring for someone with low income and few assets other than the home he or she lives in, and who needs more in-home care than you can provide or pay for, it's worth looking into the Program of All-Inclusive Care for the Elderly (PACE).

  • Benefits: The PACE program provides full medical coverage plus comprehensive community care -- mostly at adult daycare centers but also in-home care, transportation, meals, social services, and so on -- for frail older adults who would otherwise need to be in a nursing home. If someone is accepted into PACE, a program team will assess his or her specific care needs, develop a care plan, and be responsible for providing all medical and other care services.

  • Eligibility: PACE is only available in certain areas, and eligibility is restricted to low-income adults over age 55, usually those eligible for Medicare. Some PACE programs are limited to people who are eligible for Medicaid, and for these enrollees, the program is entirely free. Other PACE programs also accept some people whose income or assets are slightly too high for Medicaid eligibility, and in these cases there is a monthly premium for medical care.

To learn more about the PACE program, see the Centers for Medicaid and Medicare Services information sheet Quick Facts About Programs of All-Inclusive Care for the Elderly -- PACE. To learn whether there's a PACE program operating where you live, and, if so, how to contact the program, see the Medicare official website list of PACE programs.