Residential Care

Board-and-care facilities provide care for older adults who cannot live independently but who do not need the constant supervision provided in nursing homes. Board-and-care facilities (also called rest homes or residential care for older adults) typically provide the following:

• A room

• Meals in a communal dining room

• Housekeeping services (eg, laundry, cleaning)

• Minimal assistance with personal care

• Sometimes supervision of medication administration

The number of board-and-care facilities is increasing because they offer an economic means of accommodating the increasing number of older adults who would otherwise require nursing home care paid for with state Medicaid funds.

Minimally regulated and sometimes unlicensed, these facilities principally serve 2 groups, often cared for together—older adults and the deinstitutionalized mentally ill. Although excellent homes exist, some facilities tend to warehouse the disabled in substandard buildings and to employ few skilled staff members.

Physicians should try to ensure that their patients in board-and-care facilities are safe and are receiving appropriate care. Physicians may need to visit the facility or send a nurse or social worker to evaluate it.

Assisted-living facilities enable residents who have problems doing activities of daily living to maintain their independence in personalized settings. Assisted-living programs typically provide assistance with the following:

• Meals

• Health care

• Personal care and other supportive services, such as housekeeping

• Transportation

• 24-hour oversight if needed

The cost of assisted living facilities in the United States was about $119 a day or $3,628 per month for a one-bedroom unit in 2016 (1), but costs vary widely by state. These facilities are paid for by private funds, long-term care insurance, community-based charity organizations, or church groups. Some states provide some waivers to help cover services in these settings.

Life-care communities offer a contract intended to remain in effect for the resident’s lifetime and, at a minimum, to guarantee shelter and access to various health care services.

Life-care communities (continuing care retirement communities) offer different levels of care:

• For people who can live independently

• For those who need assistance

• For those who need skilled nursing care

Generally, people pay a substantial entrance fee ($50,000 to $500,000) when moving to the community and monthly fees thereafter. In some communities, residents pay only a monthly fee for rent plus service or health packages. In others, residents can purchase a condominium, cooperative, or membership; service or health packages are purchased separately.

There are 3 main types of communities:

• Those covered by an all-inclusive contract

• Those covered by a modified contract limiting the amount of long-term care provided before the monthly fee is increased

• Those covered by a fee-for-service contract with billing for health services as they are used

If well-financed and well-managed, life-care communities provide a broad range of housing, social, supportive, and health services that enable their residents to live comfortably. However, some communities are not well-regulated; in some, residents’ assets have been wiped out because of unscrupulous real estate dealers or well-intentioned but inept management.

Communities may occupy a single building or be spread across multiacre campuses with housing options ranging from efficiency apartments to cottages with several rooms. Many have community buildings for organized social events, dining rooms, clubs, sports facilities, planned outings, and vacation options. Access to physicians is usually provided, and most programs are affiliated with local acute care facilities.

Medicare and Medicaid usually do not pay for residence in a life-care community but may help pay for skilled nursing care when it is needed. Long-term care insurance may reimburse residents for monthly fees as well as personal care services.