Question: A year after our mother died, we saw Dad become more unsteady on his feet, and he needed help remembering to take his medications. He wanted to stay at home, but we finally talked him into entering an assisted living facility where he has lived for 18 months except for visits with my family and my siblings. Although the monthly fees began at $2,100 per month including meals, the cost has now risen to than $3,500 per month. The director tells us that Dad requires more care and assistance, thus the higher bills. We have noticed that he has become more and more frail lately. Is it time to seek a residential care facility or a nursing home? Does Medicaid cover residential care if we keep him there because his money is running out?

Answer: Residential care facilities (RCF’s), which are synonymous with what you have called assisted living facilities, are special living environments for elderly persons who, although generally in good health, need assistance with certain activities of daily life or other functions. Generally, assisted living facilities provide a room or apartment, meals, housekeeping, medication management, assistance with personal hygiene, activities, and transportation. These facilities range in size from two unrelated persons to hundreds of residents.

Assisted living could be needed after an independent living situation and before institutionalization in a nursing home, where a higher level of supervision and care is necessary.

Over the past several years, assisted living facilities have been overbuilt in some parts of the United States. Although regulated and licensed by each state, generally speaking, anyone can build a residential care facility. A nursing facility, however, can be built only after securing a certificate of need from the appropriate state agency.

Although subject to state regulations, an assisted living facility is not a medical facility and does not offer continuous resident supervision or skilled nursing care. Generally, state regulations require that these facilities have a written plan of care for each resident.

Despite their stated purpose, for economic reasons some assisted living facilities have increased their fees and services as they try to retain sicker residents, thereby, in effect, competing with nursing homes. To increase their fees for sicker residents, some assisted living facilities use the “point” system – that is, a charge is made for each and every type of assistance given to a resident. The cost of each “point” can range from seventy-five cents to as much as $2. If your father needs help remembering to take his medication four times a day, he might be charged an additional $8 per day – or $240 per month – for that service alone.

While we believe that assisted living facilities certainly have their place, we have seen and heard horror stories where sick residents were retained without being given the appropriate care. We believe that all residents of assisted living facilities should be closely monitored by family members to make sure the needed level of care is being provided. We believe that geriatric care managers should be engaged by family members to review their loved one’s records on a regular basis. We believe that facilities that take on the care of sick people without the proper staffing or regulatory authority are dangerous to the residents.

Medicaid does not directly cover residential care unless there is an optional state supplement program in your state of residence. This program provides a supplement to lower-income individuals that allows them to stay in those facilities that participate in the program. To find out more, contact your local state agency.

Taking the NextStep: With charges approaching $120 per day, we think it’s time to have a geriatric care manager independently assess your father to determine his actual care needs. While assisted living facilities provide assessments, sometimes these can be self-serving and not in the best interests of the resident. For more information, you can check out www.caremanager.org.