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In-Home Care or Assisted Living: How Do You Decide?

When your aging parent begins to seem frail, forgetful, confused, or less able to take care of herself, unfortunately one of the main decisions you are going to face is whether to help her "age in place" so she can continue living in the home with the help of in-home care, or whether it would be a better idea for her to move into an assisted care facility.

It comes to no surprise that the first choice of the majority of older adults is to age in place. However it may not always be the best, safest, or most cost-effective option. In fact, one of the many surprising discoveries that adult children often make is that as time goes on, in-home care can become as expensive if not more expensive than residential care in some circumstances.

Having dealt with this situation personally, this is not an easy decision since there are many good reasons for older adults to remain in their homes, and many good reasons to move. It is a huge commitment to care for an aging parent. If your parent needs 24 hour care think how hard it will be to find consistent, trusted three caregivers a day for 5 days a week and then another three caregivers per day for the weekend.

So how do you evaluate your aging parent's needs and compare the various options available? To help you navigate this process here are some insights from into the factors to consider when comparing assisted living with in-home care.

Advantages to Assisted Living

Flexibility to adapt to changing needs

Things can change quickly as an older adult's health declines and many adult children are caught by surprise. Talking with others who have been caregivers most have underestimated the time involved with in-home care, the mental and physical stress involved, additional responsibilities family members take on and the problem of family dynamics.

"The very essence of aging is that it's degenerative," says Mary Kay Buysse, executive director of the American Association of Senior Move Managers. "So the way things are now is not how they're going to be. You can buy yourself some time, but eventually big decisions have to be made."

You do not want to be making these decisions in a hurry, warns Maria Basso Lipani, a licensed clinical social worker in New York who runs "For adult children, it's like they are standing on the edge of a pool and they don't know it," says Lipani. "They're about to get shoved in, and they don't have a bathing suit or water shoes or a towel -- they're totally unprepared for what's to come." With the flexibility of multiple levels of care, assisted living offers you a variety of options so your family is not caught unprepared in a crisis.

Availability of expert assessment

"Is Mom and/or Dad really OK?" It is the most common question experts hear from adult children and one that is not easy to answer without careful assessment. Unfortunately, family members may have trouble getting an accurate picture of an older adult's true situation, especially if they are primarily seeing their loved one during short social visits. "You have to look for red flags such as not eating well, financial issues, or no longer being able to drive safely," says Bunni Dybnis, a Los Angeles-based geriatric care manager and spokesperson for the National Association of Professional Geriatric Care Managers.

Even when you identify causes for concern, it is not easy for adult children to confront their parents about such private matters. "It's a huge change psychologically to try to take control when your parent was always the one taking care of you," says Dybnis. "There can be a great deal of fear about changing the family system." A professional evaluation, on the other hand, looks at how well your loved one is coping with the activities of daily living (ADLs), so you know how much care your parent really needs.

Specialization in dealing with Alzheimer’s and dementia

Alzheimer’s and dementia cause not only memory issues but for some it causes extreme changes in personality and behavior. A facility that specializes in Alzheimer's or dementia care will typically have staff with specialized training in handling behaviors associated with dementia, such as Sundowner's syndrome or combativeness.

According to the AARP, newer facilities have special features for Alzheimer's patients. Safety features, noise-reduction features and better lighting help to decrease the effects of sun-downing -- an increase in restlessness, agitation, disorientation and other behaviors that become worse at the end of the day. Outdoor courtyards with shrubs and other natural barriers allow wandering without obvious restriction, and alarm systems monitor exits from the facility. Memory cues such as color-coding in the hallways help patients to navigate, and memory boxes with pictures and mementos help them to find their rooms.

Many facilities will have appropriate activities help to keep residents active and appropriately engaged such as arts and crafts, looking through scrapbooks and photo albums, exercise programs, singing, dancing, and listening to music. Nursing homes often hire occupational therapists or other professionals to design and lead activities for residents suffering from dementia.


Unlike licensed nursing facilities, which are regulated by state and federal law, home care is basically an unregulated industry. If no family members are near to monitor an agency's staff, individuals who live alone are more vulnerable to potential abuse and neglect by caregivers.

Accommodations to the home, which can be costly, may be needed if falling danger is high or physical mobility is limited. In some situations, assisted living may be the most practical and safest solution if your loved one needs someone with them overnight.

No need for home maintenance

One factor families often forget to factor in, senior experts say, is the cost of maintaining the home. As people get older, often they cannot do even routine household tasks, much less repairs, yard work, or serious cleaning.

Access to long term insurance and government assistance benefits

If your family member is lucky enough to have long term care insurance, many assisted living communities have financial specialists who will help you with the claim process or even do it for you which may result in your family member receiving more benefits.

On the other hand if your family member is eligible for financial assistance, such as Medicaid or veterans' benefits, moving to assisted living or a skilled nursing facility may offer access to significant financial benefits, some of which are not available for home care. Having gone through the veterans benefit application and approval process believe me it is quite complicated and you can use all the help you can get.

Disadvantages to Assisted Living

High cost of personal care

One factor to realize is that most assisted living facilities do not include personal care in their basic fees but treat it as an add-on for an additional cost, says Dybnis. So while the facility's starting bill of $4,000 to $6,000 a month might seem reasonable, those costs can mount quickly as you add hours of special care assistance.

Underestimating growing costs

Assisted living communities periodically reassess the needs of residents to determine whether they need more assistance, and as a result they may require a move to a higher, more expensive tier of care. If families are not prepared for these rising costs, says Lipani, they may find they can no longer afford a living situation that they intended to be permanent. Some assisted living facilities offer a dementia care option, but many do not. Facilities that do provide specialized dementia care; there are typically higher charges due to the need of expertise and security.

Problems adjusting to group living

Many seniors want to stay in their homes, pure and simple, says Mary Kay Buysse of the American Association of Senior Move Managers. They are so strongly set against moving to assisted living that adjustment would be difficult. "They just want to be in their own bed, in their own house, and nothing is going to change their minds." In other cases, an older adult may have personality, behavior, or health issues that would make it difficult for them to assimilate to or be accepted into assisted living.

Cost Considerations

For most adults, the most affordable option is to live independently, as long as they are able to care for themselves or can get by with family help or a few hours a day of paid help. According to calculations by some senior care experts, once your family member needs full-time daily care, and especially continuous 24-hour care, the cost comparison between aging in place with an in-home caregiver and moving to an assisted living facility or nursing home becomes more equivalent. This is especially true if you live in an area where in-home care costs are higher, such as in or near a big city or on either of the coasts.

"Depending where your parent lives, the cost for 12 hours per day of a home health aide and the cost of an assisted living facility may be about the same," says Lipani.

In urban areas, home care can easily run you at least $20 an hour, says Lipani, which adds up to $240 for a 12-hour day or $7,200 for a 30-day month. Many adult children think of care on a 40-hour-a-week basis, do not forget about weekends and evenings. Compare that with assisted living, which would cost somewhere between $4,000 and $8,000 a month, depending on the level of care your parent needs.

With aging parents living longer, most of us are not prepared. The best advice I can offer is to educate yourself on the alternatives, be realistic in assessing your and other family members’ time, energy, financial resources and responsibilities. Contact us if you need help. We help our clients develop a financial plan that is not for just the conditions today but for the future as well.