What Are the Best Assisted Living Alternatives?

Updated

Certified Care Manager, Aging Life Care Professional, and National Master Guardian Emeritus

As our population ages, older adults are looking for alternatives to the traditional model of assisted living. These other housing choices are sometimes less expensive, and more flexible. Financial considerations and a desire for greater choice have driven the senior housing market in new and creative ways.

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But for many people, assisted living can be a viable choice as they age. Assisted living provides nursing, aide service, housekeeping, transportation, and activities. Others may find the cost of assisted living less appealing and not the right choice. In addition, residents do not get to choose their neighbors, as the social makeup is predetermined.

Below, we'll explain common alternatives to assisted living, who they're right for, and more.

1. In-Home Care

As an alternative to assisted living, in-home care can be a viable option for people who want to stay at home for as long as possible. Survey after survey shows that most people say they prefer to age in place. In-home care makes that possible if you can afford it. But of course, with any senior living option, in-home care has its advantages and disadvantages.

Unless you have long term care insurance or Medicaid, in-home care is an out-of-pocket cost. That hourly cost can vary by agency, as well as the state you live in. The national monthly average in 2019 for homemaker services was $4,290. The average will vary depending on the number of hours per day and per week requested. As this cost climbs, it can easily exceed the cost of staying in assisted living.

In-home care is very flexible. Caregivers adjust their hours based on what the client needs. For example, you may have a family member that has recently returned home from a rehab stay due to an accident or illness. The initial hours required might be greater in the beginning until your family member is stronger and able to function more independently.

Caregiver turnover in the home care industry is estimated at 82 percent. What does this mean for you? Sadly, if you find a caregiver you really like, they may leave. High caregiver turnover can be disruptive to your loved one and frustrating for you.

Although an agency will manage caregivers in the home, you will still need to monitor your loved one’s care. A proactive approach will make certain that the plan of care is followed and that you and your family member are happy with the care staff.

Pros and cons of in-home care

Unless you go through life aging with few problems, in-home care might be inevitable if your plan is to age in place. Full-time caregiving by family members is a possibility, but the stress, strain, and economic consequences of caring for a loved one can be significant. As with any choice, there are pros and cons to in-home care. 

Pros

  • You get to stay in your familiar surroundings, close to your neighborhood friends, grocery stores, and place of worship.
  • As the consumer, you can choose the caregivers you like.
  • Hours and days are flexible and can be changed with very little notice.

Cons

  • At some point, the cost of in-home care might get too expensive.
  • Your needs can exceed what an in-home caregiver is allowed to provide in your state. 
  • As mentioned, you may have an abrupt change in your caregiver(s) due to staff turnover.

How does in-home care compare to assisted living?

Comparing in-home care to assisted living has as much to do with perception as reality. Many older adults still have a negative image of assisted living associating it with nursing home care. In addition, there is the illusion that if you are in assisted living, you have become too frail to live at home when the reality is it takes significant caregiving to keep someone at home.

Although in-home care allows someone to age in place, it does so without the stimulation and activities afforded by assisted living. With in-home care, you do have strangers coming into your home to care for you. The same may be true of assisted living, but you do have a great deal of privacy in assisted living and can come and go as you please.

There is no one-size-fits-all. Some people have clear preferences for in-home care over assisted living and vice versa. The most important thing in deciding between the two is to review the pros and cons of each so that your decision is an informed one.

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2. Independent Senior Living

Independent senior living can appeal to older adults thanks to the opportunities for community and socialization. For many older adults, living in their own home is isolating and lonely. They want and need other people while remaining independent.  

  • Independent senior living can be a congregate setting with multiple apartments. This could be a high rise or even smaller single homes in a group setting. 
  • Independent senior living apartments can also be part of a “continuum of care.” An example would be a community that has independent, assisted, and memory care apartments all in one building or on the same campus. They may also have support groups for aging adults as well.
  • Independent usually means that there is no help from aides for tasks such as bathing, grooming, and transfers. Nursing is not available although in some communities on-site physician services can be arranged. If someone wants to stay in independent living but needs help, they can hire private caregivers through an agency.
  • Medications are not managed or dispensed. Taking medications is the responsibility of the resident.
  • Amenities can include weekly housekeeping, laundry, transportation to medical appointments, and all meals and snacks. Daily activities are also included.
  • Independent senior living eliminates the headaches of homeownership such as yard care and home maintenance 
  • Pets of a certain size are allowed in most independent living as long as the resident can care for that pet.
  • Just as with in-home care, the cost depends on the state where you live. Costs may also vary within a state depending upon whether you are in an urban or rural area. You can look up what the average costs are for all senior care options across the country.

Pros and cons of independent senior living

Independent living has advantages and disadvantages, depending on the type and location. Some people like the idea of being “independent” but having some of the amenities of assisted living. In some developments, independent senior living means separate dwellings within a community of 55+ residents. In these communities, you can expect to arrange any support services yourself, such as in-home care.

Pros

  • For independent living in a community that offers assisted living, you can likely have all meals, transportation, access to activities, and other amenities included in your monthly rent.
  • The opportunity for social engagement is one of the main reasons people choose independent senior living.
  • For some, independent living is a transition to assisted living should they need it. 

Cons

  • With independent senior living, there is no personal care provided. 
  • If you are interested in independent senior living, there may be limited availability in your area.
  • You may have to move to assisted living from independent senior living at some point.

How does independent senior living compare to assisted living?

Independent senior living can give someone all of the amenities of assisted living at a lower cost than assisted living. For someone who is healthy and functioning well, independent senior living can offer the opportunity to connect with other seniors and find a supportive community.

However, if you expect that everyone is entirely independent, you might be surprised. It is not unusual to find people with walkers and even wheelchairs in independent senior living.

Assisted living is for seniors who definitely require help with bathing, dressing, medication management, and other activities of daily living. Each state has regulatory programs that dictate rules for assisted living.

In general, most assisted living communities can provide significant assistance to residents. With that said, they tend to draw the line at two-person transfers or providing for complex medical needs. 

3. Cohousing

Independent living may also encompass community formats like cohousing. Cohousing is similar to independent senior living, but it features several residences on one piece of property where common space is shared.

Although this model appeals to seniors, some cohousing communities may be multi-generational and others may be for seniors only. Features of cohousing can include the following:

  • With cohousing, you buy your property, but also requires you to have equity in the home you live in so you can buy within a co-housing community. 
  • Cohousing communities are independent. Some are in cities, but many are in more rural locations.
  • Cohousing is similar to a homeowner’s association. Decisions are made as a group and follow a consensus model of governance.
  • There is an emphasis on the sharing of chores, responsibilities, and activities.  Cohousing residents are expected to be active participants in the community. There are no support services available except for those that you arrange.
  •  In multigenerational co-housing developments, there is an opportunity for seniors to be around children and families.

Pros and cons of cohousing

Cohousing has great appeal for people who have the funds and choices of communities to choose from. One of the challenges of developing cohousing communities is the availability of land. In more urban settings, land can be very expensive, so some developers move to more rural areas to build cohousing communities. 

Pros

  • Cohousing is a true community with shared decision-making and shared responsibilities. This is very appealing to many people.
  • The intergenerational nature of many co-housing communities provides a diverse experience that is hard to find in any other senior living situation.
  • Although you have the benefit of socialization, you can retreat to the privacy of your own home when you want to.

Cons

  • The cost of buying into a cohousing community may be prohibitive for some. 
  • If your cohousing community is in a more rural area, access to medical facilities could be limited. 
  • Not everyone likes the idea of a consensus model of decision-making and shared responsibilities. 

How does cohousing compare to assisted living?

Cohousing is completely independent living in the true sense of the term. It’s as if you are in a neighborhood of like-minded people but have your separate home. There is a sense of shared responsibility and support, but that support does not include help with functional activities.

If you need medical assistance or in-home care, you will be responsible for arranging and paying for that. It is possible at some point that if you need assisted living, you will have to sell your home and move.

Assisted living is congregate living in most places. It is like living in an apartment building where the level of support is individualized. With that, costs will go up depending on the amount of care you require. In-house caregivers are available to assist with activities of daily living, and a nurse manages basic medical needs and medications. Memory care units are also under the assisted living umbrella, so transitioning from assisted living to memory care is possible. 

4. Continuing Care Retirement Communities (CCRC)

Continuing Care Retirement Communities (CCRC) offer peace of mind and security for many people. CCRCs give seniors the option of living within the same community throughout the rest of their lives. The appeal is pretty straightforward.

With a CCRC, you can opt in not having to worry about where to go if you need more care. They include independent, assisted living, memory care, and skilled nursing all in one location. Some may have individual homes, condominiums, or apartments with assisted living and nursing care on the same campus. Most people move to CCRCs when they are independent.

Many CCRCs vary in terms of their structure and buy-in options. They can be costly, as CCRCs require a significant upfront investment. By contrast, most traditional independent, assisted living, and memory care communities are paid for month to month, and you can cancel with advance notice. 

Do your due diligence and make sure you understand the long-term consequences of the investment you are making. You may want to consider meeting with a financial advisor to do an estate plan.

People who choose CCRCs say they like not having to worry about where they will go when more care is needed. Although the upfront investment takes care of you all the way through nursing home care, there may also be additional monthly fees. Amenities can be extensive. Some CCRC have pools, pickleball courts, and clubs.

Pros and cons of CCRCs

CCRCs are gaining a larger and larger share of the senior living sector with a slightly higher percentage than assisted living. Some CCRCs are private, and others are faith-based non-profits. One is not necessarily better than the other, but a non-profit might be more affordable. In either case, there could be a substantial financial investment so you will want to be careful in making a decision.

Pros

  • CCRCs are designed to take care of you all the way through nursing home care if you need it. You don’t have to decide where to go since each level of care is provided. 
  • Many CCRCs have built-in health care systems with in-house home health and in-home care.
  • The amenities in CCRCs can be extensive. Some have swimming pools, pickleball courts, and state-of-the-art gyms.

Cons

  • Make sure to read the fine print. Some CCRCs will return a portion of your buy-in cost if you leave, and others won’t. 
  • The cost of CCRCs can be high. In addition to buy-in costs that can be two or three hundred thousand dollars or more, you have monthly fees as well.
  • What if the community isn’t what you expected? The independent section may be fine, but you move to assisted living and don’t like it. At this point, you are faced with a decision about whether to stay or move and try to recoup your investment. 

How do CCRCs compare to assisted living?

The majority of CCRCs have assisted living as part of their community. That is the idea— you have everything you need without deciding on which assisted living community to choose should you need it.

The main difference between a CCRC and assisted living is financial flexibility. Most assisted living communities are pay as you go- you have monthly fees and can give notice at any time to move. A CCRC has a much more complicated financial involvement that could be challenging to extricate yourself from.

The bottom line decision for you might be comfort level and peace of mind with each of these choices. A faith-based option could be the deciding factor for you and your family due to shared values and costs. 

5. Board and Care Homes

Board and care homes go by several different names: residential care home, group home, V.A. foster home program, adult foster home, or senior group home.

Board and care homes can be found in residential neighborhoods, often in someone’s home. Most houses can have anywhere between 2 and 10 residents. Services provided are very similar to assisted living and include meals, help with grooming and hygiene, medication management, and recreation activities. Nursing may be limited.

Some folks like board and care homes because they are smaller and more intimate. This also allows for more oversight by staff since there are fewer residents. Rooms are often shared.

Pros and cons of board and care

Board and care homes may not even be an option in your community, but if they are, they could be worth looking into especially if finances are limited. But, as with any senior living option, do your due diligence and look carefully at accessibility, ownership, and resident makeup.

Pros

  • Board and care homes have a more home-like feel since most are in residential neighborhoods. 
  • A smaller number of residents allows for more individualized attention.
  • The cost of board and care can be significantly lower than assisted living due to fewer amenities.

Cons

  • Depending on where you live, board and care homes might have lax oversight.
  • Assistance for medical conditions or help with activities of daily living could be limited.
  • Privacy could be a concern since meals and common spaces are shared. In some board and care communities, bathrooms are also shared. 

How does board and care compare to assisted living?

A board and care home can have many advantages for an older adult who prefers an intimate and home-like environment. A residential neighborhood also has great appeal since it more closely resembles the home they may have left.

However, the downside is that activities and amenities are limited and won’t include a gym, a theatre, or other offerings that assisted living has. If you have a loved one with cognitive impairment, the open design of board and care might not be best since residents can come and go. 

For some, assisted living feels like apartment living which can be positive or a draw back. But, if you need help, assisted living communities are designed to provide that. Depending on the level of support you require, and where you live, costs in assisted living could escalate over time. 

6. Program of All-Inclusive Care for the Elderly (PACE) 

PACE is a program administered by the Center for Medicare and Medicaid Services for frail older adults who live in the community. Most of the recipients are eligible for both Medicare and Medicaid.

The purpose of the program is to provide support services to keep people in their homes, as not everyone can afford other alternatives to assisted living.

In addition to all of the resources available through Medicare and Medicaid, a team of specialists can care for the following tasks:

  • Dietician
  • Driver
  • Home care liaison
  • Nurse
  • Occupational therapist
  • PACE center supervisor
  • Personal care attendants
  • Physical therapist
  • Primary care physician
  • A recreational therapist or activity coordinator
  • Social worker

Pros and cons of PACE

As with most federal and state programs that assist older adults, the PACE program is a good model for care but has some red tape to go through. But, if you feel there is any chance you or your loved one might qualify it is well worth it to apply.

Pros

  • The PACE program is designed to keep people out of nursing homes and in their communities. This saves the federal and state governments money and keeps people where they would rather be - in their homes.
  • The PACE program provides members with a team of professionals to manage their care. At PACE centers (usually in adult day care centers), there is a wide range of services available, but you can qualify for healthcare providers to come to you if you are home-bound.
  • Since Medicare and Medicaid fund the PACE program if a participant has both Medicaid and Medicare, they do not have to pay for the long-term care portion of the program.

Cons

  • Even if you qualify, there may not be a program in your area.
  • You may qualify but don’t have the funds to pay your portion of the care costs.
  • You may not be able to live safely in your home even with PACE program participation. In that case, nursing home care might be your only option.

How does PACE compare to assisted living?

The PACE program is for people who would otherwise qualify for a nursing home or a high level of care in assisted living. If you are eligible for Medicaid and Medicare, most of the costs of all the care and services you receive will be paid for. Keep in mind that the team of providers may be located at a PACE center, or some can come to your home.

Medicare never pays for assisted living, and Medicaid only pays under certain circumstances. You might be in a position where paying for assisted living is unaffordable. On the other hand, if you can pay for assisted living, you may prefer to have all services and activities centrally located. 

7. Home Sharing

Home sharing is gaining in popularity and for good reason. It is very affordable. The fact is, more and more people can’t afford traditional assisted living or continuing care retirement communities. Home sharing can be a creative way to address affordability and the need for socialization.

Let’s look at the ways people are making this work for everyone:

  • You own a home and need extra income. Let’s say that a single or married couple find themselves in a home that is too large for their current situation. The kids have grown and gone. More and more people are looking at this as an opportunity to share their space while getting extra income. Especially single or widowed women. 
  • You will likely share a bathroom and kitchen. Also, someone needs to establish lease arrangements and rules of the house.
  • Downsizing may mean moving. Some friends are considering a home purchase together. This way everyone eliminates the need for their single-family home and does a group purchase with room for everyone.
  • All household costs are shared. This includes utilities, maintenance, and taxes.
  • There is ample opportunity for socialization and sharing of activities.
  • A supportive atmosphere where residents can help one another.
  • Living with people provides more security than living alone.
  • Home sharing is not for everyone. The legal arrangements and close quarters are less appealing to people who value their privacy.

Pros and cons of home sharing

Home sharing is a viable and workable option for people who live in an area where there are some choices. As more companies get into the business of pairing people together in home sharing situations, confidence in the process will grow. Homeowners and renters want protection and assurances. 

Pros

  • Financial flexibility for both parties is a big benefit of home sharing. The owner collects rent, and the tenant or home investor spends less to live.
  • If you like a home atmosphere with other people with whom you share meals and household duties, home sharing is for you.
  • Another benefit is the support and security of living with other people. You can share tasks, transportation, cooking, and shopping.

Cons

  • You may move in and not get along with one or more of the other home sharing residents. Too much togetherness and lack of privacy might be a problem for you.
  • If you develop serious health problems, the home you live in may not be ideal for aging in place due to stairs or other accessibility problems.
  • Rules, lease agreements and sharing of household duties might not appeal to you.

How does home sharing compare to assisted living?

Home sharing is much closer to independent living than to assisted living. You are basically in a home with other people and there are no amenities, support services, or aides to assist you. The affordability of this arrangement may make up for any potential deficits. You can always qualify for home health or pay for private in-home care if you need it. 

In assisted living, you can count on help with almost any personal care needs that you have. But, you will pay a price for that help, and for many, the cost is prohibitive. Home-sharing is a viable short term and even possibly long term solution for social connection. And if you can contract a company that will vet either the homeowner or renter, you can have a measure of confidence in the people you choose.

Alternatives to Assisted Living: Your Choice, Your Life

As you look to your future or that of an aging parent, you have more choices than ever before. Finding the best fit can take time, but your efforts will yield some ideas you may have never considered. Assisted living is not your only option, and that is as it should be. 


Sources

  1. “Cost of Care Survey.” Genworth. genworth.com
  2. “Home Care Industry Turnover Reaches All-Time High of 82%” Home Healthcare News. homehealthcarenews.com
  3. “What is Co-Housing?” The Co-housing Association of America. cohousing.org
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