If your attention has been drawn to this article, you are probably already the carer of a friend or relative. Possibly, you have a colleague or employee who is a carer whose divided loyalties you share. Most of the statistics concerning caring are based on the iconic age of 65 – the median age at which most Americans plan to retire and the age at which they become eligible for Medicaid. The real problem for actual or potential carers begins twenty to twenty-five years earlier. How much and what sort of care will an individual need in the years ahead?
- Who will provide the care?
- What will be the cost?
- Who will pay?
Let us consider today’s outlook for someone who has recently turned sixty-five or is shortly about to do so.
About 70% of Americans turning sixty-five can expect to develop a long-term care need in their lifetime, and nearly half of these will need some form of paid long-term services (LongTermCare.gov.) Aging is a natural process that inevitably decreases our ability to do things that seemed effortless earlier in life. The effects of aging vary from person to person in terms of the time of onset, severity, and rate of advancement. However late symptoms present themselves; the consequences of aging will eventually affect the ability to perform the activities of daily living without help.
Activities of Daily Living (ADLs)
Long-term care is a term used to describe the range of support and services needed by those who cannot care for themselves. Most commonly, the need for long-term care will be due to age-related conditions that affect the ability to perform the Activities of Daily Living (ADLs).
- Movement (walking, the ability to change positions)
- Personal hygiene (bathing, brushing teeth, shaving, nail care)
- Dressing
- Eating (not including cooking/preparation)
- Toileting (continence, safe and hygienic use of toilet)
These are examples of the regular, daily living activities for which older adults may need help in varying degrees, from none or minor to moderate or full help when someone does the task for you.
Instrumental Activities of Daily Living (IADLs)
In addition to the ADLs, many other activities may determine the nature and degree of assistance an individual may need. These activities/skills (IADLs) are not necessarily required daily but are instrumental in enabling older people to live independently. Typical IADLs involve more planning and organizational skills.
- Managing finances, e.g., using online banking facilities, paying bills, planning expense
- Transportation and shopping
- Meal preparation
- Managing communications, e.g., the use of phones (landline or mobile), the internet or email
- Home maintenance and house cleaning
- Managing medications, e.g., the ability to obtain the appropriate medication and prescription drugs and self-administer according to the instructions.
Why are ADLs and IADLs important?
You might be an older adult looking at your or your spouse’s ability to care for yourselves. Partners often compensate for each other’s difficulties in managing their physical and cognitive welfare. You might be an adult child concerned with an older family member’s ability to care for themselves and live safely.
ADL and IADL assessments are indicators of an individual’s ability to live independently and safely. Identifying and recording them is essential in securing medical aids such as mobility devices and specialized therapies (occupational, physical, and speech). They can also be the basis for discussing or agreeing on a care plan with your healthcare provider, including the longer-term use of care facilities.
What are the options?
The need for long-term care generally develops gradually. A heart attack, stroke, or significant traumatic event are exceptions. The consequences of aging are progressive, and although therapy and healthy lifestyle choices (Discuss your medical history and lifestyle with your healthcare provider) may slow the process, they will eventually affect the ability to perform the activities of daily living without help.
Home-based
Very often, and in the early stages of need, long-term care is “Home-based,” spontaneous, and provided by spouses, partners, family members, or friends. Most likely, this care is related to the “activities of daily living” described above and, most importantly, to the safety of the individual (e.g., house modification.)
It is common, and in some cases, essential that Home-based care is formalized and supplemented by trained/qualified caregivers, e.g., nurses, healthcare aides, therapists, and other professionals. These home care health services are charged by the hour. Medicare offers only limited support for these services and only when Medicare-certified agencies provide them,
Most areas have adult/senior daycare centers offering meals, mobile or static exercise, personal care, transportation, and, most importantly, social activities.
There comes a point at which an older person or someone with a degenerative medical condition can no longer live safely in their own home. While moving in or finding some way to share with family or friends may seem natural, this is only sometimes practical. The alternative is to move to a residential (live-in) facility.
Residential facilities come in various categories, specializations, and service levels. They can broadly be described as follows: –
Board and care homes
Also referred to as residential care facilities or group homes, these are small private establishments with communities of twenty or fewer residents in shared or single rooms. They offer an agreed level of personal care, meals, and staff available 24/7. These organizations do not usually provide on-site nursing and medical care but may have an arrangement with local providers.
Nursing homes
In addition to the facilities provided by Board and Care facilities, Nursing homes (skilled nursing facilities) offer specialized medical care, including 24-hour supervision and rehabilitation services – therapies such as speech, occupational, and physical.
Assisted Living (AL) and Continuing Care Retirement Communities (CCRC)
Many seniors need help with daily care but do not need a nursing home’s medical or nursing skills. Assisted Living enables individuals (or couples) to live in self-contained apartments, sharing common facilities such as recreation areas (indoor/outdoor) and dining rooms and entertainment. Residents may have access to personal services such as social and recreational activities, assistance with medication, housekeeping, and laundry.
As the name suggests, Continuing Care Retirement Communities offer various accommodations and care services on a single campus. They will often provide a choice ranging from homecare in independent housing to Assisted Living and, if needed, to the CCRC’s nursing home.
What is the cost of long-term care?
The cost of long-term care can only be expressed in terms of averages in each of the categories described above. The cost to individuals will depend on location, personal choices, medical necessities, and duration. The following guideline figures are based on data provided by the federal government’s Administration for Community Living.
| Type of care | Average cost without insurance |
| A semi-private room in a nursing home | $6,844 per month |
| Private room in a nursing home | $7,698 per month |
| Assisted living facility, one bedroom (excluding nursing and medical services) | $3,628 per month |
| Health aide | $20.50 per hour |
| Homemaker services | $20.00m per hour |
| Adult daycare center | $68 per day |
Who pays?
The government’s health insurance program, Medicare, helps pay some medical costs for individuals 65 and older. The services covered extend to hospital stays, doctor visits, limited home health care, hospice care, and certain preventive services, e.g., vaccinations. Medicare does not cover long-term home care, assisted living, or skilled nursing. On average, men need 2.2 years of long-term care, women need about 3.7 years.
The cost of long-term care is the responsibility of the individual. In the early stages, family and friends can often provide the necessary personal care and services, such as transportation, for free. As needs increase, paid services, homemakers, and daycare, for example, inevitably become unavoidable. The result is a drain on personal resources such as retirement income, investments, or proceeds from the sale of a home.
For most of us, there is no way of completely avoiding the cost of long-term care. We can, however, plan for it. In that way, we can spread the financial impact over longer than the 2-4 years of unaffordable outgoings of unplanned long-term care expenses.
We normally associate ‘health insurance’ with Open Enrollment, but we can initiate long-term plans at any time. Such plans may not be subsidized by your state or federal government, but they may be income tax-free if the accumulated income is spent on medical or healthcare expenses.
When you talk to your insurance adviser, ask about the many options you have of protecting yourself or your loved ones from the cost of caring.
