Care Arrangement: Continuing Care Retirement Community

The entry/admission requirements will be different from center to center. Most CCRCs require residents to be in good health, be able to live independently when entering the facility and be within minimum and maximum age limits.

As a prerequisite to admission, facilities may also require both Medicare Part A and Part B, and perhaps Medigap coverage as well. Because the financial requirements for residence are fairly strict and the costs are relatively high, very few CCRC residents are eligible for Medicaid. A few CCRCs now even require long-term care coverage as a way of keeping fees down. 

Many continuing care retirement communities will not admit a new resident into the independent living section if they have been diagnosed with Alzheimer's disease or another type of dementia. Though, some CCRCs may admit new residents with a diagnosis of Alzheimer's disease directly into the assisted living or nursing care sections, as these areas have staff trained to assist individuals with such conditions, but openings tend to be scarce.

Some allow you to hire your own home health care services while you live in an independent living unit. Others require you to be fully independent while staying in independent living unit. They may require that you have a health screening before you can move into the independent living unit.

There are a number of CCRCs that are affiliated with a specific religious, ethnic or fraternal order and membership in these groups may be a requirement. Of course, applicants will have to demonstrate that they have the means to meet the required fees. You may be placed on a waiting list since CCRCs are highly sought after. 

When looking for a CCRC center, you can either go through your local Alzheimer’s and/or dementia association or search online. In either case, it is important that you do thorough research on the centers that you shortlist. Looking up reviews by residents and/or their family members for the centers can be of great help. Once you’ve narrowed down a list of CCRCs that you would like to consider, talk to the CCRC management and schedule tours for further research before making a final decision.

 

Below is a list of websites that you can use to help start your search for a CCRC:

CARF-CCAC

A private non-profit organization and part of CARF International, this organization provides accreditation for CCRCs. The CARF-CCAC accreditation process is voluntary. This accreditation comes with a high cost and a lengthy process. So centers that have received accreditation can indicate their quality and commitment to providing excellent service. The CARF-CCAC website lists all CCRCs that have been accredited. Nevertheless, a CCRC's lack of accreditation should not necessarily be taken as a bad sign.

LeadingAge

Formerly known as the American Association of Homes and Services for the Aging is the national association for the non-profit CCRCs—most CCRCs are operated by non-profit groups. The group's Web site includes tips on selecting a CCRC.

When selecting a CCRC, experts recommend choosing a "mature" facility, one that has been in business a number of years. For potential residents, this can be a huge boost in confidence in the center and their services as it can indicate experience and quality. Also, it is important to know who the CCRC's sponsor is.

You can also search for CCRCs through the following websites:

• CCRC.com
• Caring.com - CCRC
• Senior Homes - CCRC
• icarevillage.com - CCRC

When researching CCRCs, find out the different types of care that are available. Remember to make personal visits to the shortlisted centers and inspect the different types of living areas as well as the communal areas to get an impression of whether they are clean and pleasant, whether residents seem content, whether enough staffers seem to be present for the number of residents, and so on. Also, try to explore the full range of health and wellness activities and social events, both on-campus and off.

While there, be sure to ask for licensing reports, which give you an idea of how the CCRC has fared on past inspections and whether there have been any substantiated complaints. It should be noted that regulation of CCRC is not very consistent. In some states, these institutions are strictly regulated but in others, there is no overarching federal agency that oversees these facilities.

If your loved one has dementia, you should ask about what medical services are provided, what the medical care routines for the treatment of illnesses and diseases are, how emergency care works, and if there are physical therapists or rehabilitation specialists on the staff list. In addition to medical care, you should ask about housekeeping and maintenance services. Inquire about all charges and exactly what they cover. 

When visiting CCRCS, try to keep these important questions in mind:

• What happens when assisted living and nursing home facilities are full?
• Does the CCRC have a reciprocal agreement with nearby communities?
• How well is the staff trained? Do staff members go through criminal background checks?
• What is the staff-to-patient ratio in each living setting?
• Does the CCRC appear to be well-maintained, clean, and safe?
• Is there an Alzheimer's unit or memory impairment services?
• How can a resident participate in the organization's decision-making? Is there a role for residents who wish to be involved?
• Does the CCRC culture match the resident? Is it a formal environment, with dinner jackets required in the dining room, or a casual atmosphere?

Below you can find a checklist of Top 22 Questions to Have Answered by CCRC from The American Bar Association Legal Guide for Older Americans by Charles P. Sabatino, et al., Times Books, Copyright © 1998 by the American Bar Association:

Questions Regarding the Solvency and Expertise of the Provider

1. What is the provider's background and experience? The provider is the person or entity legally and financially responsible for providing the housing. Some facilities advertise that they are "sponsored" by nonprofit groups or churches that in reality have no legal control or financial responsibility. Be wary if such illusory sponsorship is trumpeted.
2. Is the provider financially sound? Ask a professional to review the facility's financial, actuarial, and operating statements. Does it have sufficient financial reserves?
3. Are all levels of care licensed or certified by the state? Check with the state office on aging and with the state licensing agency.
4. How does the facility ensure the quality of its care and services? Is it accredited by any recognized private accrediting organization?

Questions Regarding Fees and Accommodations

5. If there is an entrance fee, how much is it, and can you get a refund of all or part of it? The facility should provide a formula for a refund, based on the resident's length of stay, regardless of whether the facility or the resident initiates the termination. Some facilities offer fully refundable entrance fees.
6. What is the monthly fee? When and how much can it be increased? What happens if you cannot afford higher fees? Some facilities give residents financial help if they become unable to pay.
7. Do the fees change when the resident's living arrangements or level-of-care needs change?
8. How much say do you have in choosing where you live? How large is the living unit? Can you change or redecorate it?
9. What if your marital status changes? Will your payments change, or will you be asked to move, if you marry, divorce, become widowed or have a friend or family member move into the unit?
10. What if spouses require different levels of care?

Questions Regarding Services and Health Care

11. What services are included in my regular fees? Ask about coverage, limitations (based on cost, time, or number of visits), and special charges for the following matters:

Supportive/Social/Recreational Services

• Meal services: Is the schedule reasonable? Is it flexible?
• Special diets/tray service: e.g. What is the policy on eating in your room?
• Utilities: Are they included in the monthly fee?
• Cable television: Is it available? Who pays?
• Furnishings: Can you bring your own?
• Unit maintenance: Who is responsible for repairs?
• Linens/personal laundry: Is there an extra charge for laundry?
• Housekeeping: Is it included in the fees? What are the options?
• Recreational/cultural activities: What is available? What is on-site?
• Transportation: To where? Is there a limit on the number of trips?
• Safety: What kind of security systems and policies are in place? Is there a fire emergency plan?

Health and Personal Care

• Assessment and plan of care: What kind of assessment is done to determine your needs and a plan for meeting those needs? What are the qualifications of the person doing the assessment? Is a detailed plan of care developed? When and how is it reviewed?
• Physician services: Can you choose your own doctor?
• Medications: Who gives medications? How is it coordinated with your physician?
• Nursing care facility services: Are they on-site? Who pays?
• Nursing services outside a nursing unit: Is assistance with medications provided?
• Private duty nursing: Is it available? Are there limits"
• Dental and eye care: Is it included in fees? Available on-site?
• Personal care services: What if you need assistance with eating, dressing, bathing, toileting, etc.?
• Homemaker/companion services: Are they available? Is there a limit?
• Drugs, medication, and medical equipment/supplies: Who pays?
• Emergency call system: Is it available? Who pays?

12. Are additional services always guaranteed? If the facility provides a nursing unit, what happens if a bed is not available when you need it?
13. Can services be changed? To what extent does the facility have the right to cut back, change, or eliminate services, or change fees?
14. What about preexisting conditions? Does the facility limit its responsibility for certain health conditions or preexisting conditions? Can the facility ask you to move if you become too sick or impaired to be cared for by the facility?
15. Who pays for health care? Can you receive Medicare and Medicaid coverage in the facility? Does the facility require residents to buy private insurance or participate in a special group insurance program for residents?
16. Who decides that you need more care, and on what grounds? What are the criteria and procedures for determining when a resident needs to be transferred from independent living to assisted living, or to a nursing care unit, or to an entirely different facility? Who is involved in these decisions?
17. What are the staffing levels? What are the professional qualifications of the staff? Nursing homes are regulated but assisted living and other supervised care may not be. Make sure that staff is professionally equipped to do their jobs. What kind of emergencies are staff expected to handle and how are they trained for them?

Questions Regarding the Rights of Residents

18. Can residents participate in facility management and decision making? What input do residents have in planning activities and meals and in-house rules? Is there a resident council? How are complaints and disputes handled?
19. What if you want an exception to a policy or to routine scheduling?
20. What are the grounds for eviction? Is there a right to appeal?
21. Are the general operating rules reasonable? What rules cover the facility's day-to-day operation? Are they reasonable? What happens if you break a rule? Can you appeal?
22. What happens if you are injured? Does the contract release the facility from liability for injury resulting from negligence? Avoid such waivers.

Residence in a CCRC requires a significant financial commitment. The fee arrangements for CCRCs vary and generally consists of two components: a monthly fee and an entrance fee (generally comparable to the average value of residential homes in the community's geographic area). Cost is based on a variety of factors including the community location, the size of the apartment or cottage chosen, and type of resident contract signed.

Most CCRCs also charge a sizeable one-time entrance fee. In some cases, the entrance fee is not refundable. In other cases, the fee may be refundable under certain circumstances. If the fee is refundable it will be held by the CCRC. It is important for you to understand that if the fee you pay to the CCRC is refundable it will be counted as an available asset if you need to apply for Medicaid, even if you cannot get access to the money yourself.

Medicare, and at times Medicaid, can be used to pay for certain services, and most CCRCs accept either Medicare or Medicaid. Although Medicare does not generally cover long-term nursing care, it often covers specific services that a CCRC resident might receive, such as physician services and hospitalization. In the case of an acute illness or injury, there are some cases where Medicare, Medigap, or veterans’ benefits will help cover some health-related costs.

Payment plans differ at each CCRC. The entrance fee can be as little as $10,000 and as much as $550,000. However, on average the fee tends to be around $115,000 for a single person. The monthly maintenance fee can range from roughly $200 to more than $4,000 depending on the additional services provided.

A contract between the resident and the CCRC spells out what the monthly maintenance fee covers, as well as health care coverage and costs. Once a person commits to CCRC living, they will have to sign a continuing care agreement. A lawyer or financial advisor should review this document first, as it is a legal contract between the resident and the CCRC. According to the AARP, the contract should cover:

• Residences
• Fee schedules
• Health care coverage
• Cancellations and refunds
• Services
• Insurance requirements
• Conditions for transfer within the community to other levels of care and a description of the CCRC's responsibility should a resident become unable to pay fees

There are typically three fee schedule options at a CCRC:

Life Care Contracts (Type A)

Life care contracts are the most expensive agreement include unlimited enriched housing/assisted living care (if offered by the community) and unlimited skilled nursing facility services, along with independent housing and residential services and amenities.

The resident's monthly fee cannot change due to a change in the level of covered health care required by the resident (except for normal operating costs and inflation adjustment). This means that the resident pays the same monthly fee in the skilled nursing facility as he or she paid in independent housing.

Modified Contracts (Type B)

Modified contracts include independent housing and residential services, but include only a limited number of skilled nursing facility days. The number of skilled nursing facility days covered in a modified contract may vary, but the contract must include at least 60 days of skilled nursing facility coverage, exclusive of Medicare days. As in the life care contract, the resident's monthly fee cannot change due to a change in the level of covered health care required during the skilled nursing facility benefit period included under the contract.

Modified contracts may also include an enriched housing/assisted living benefit (if this service is offered by the community). If included in the contract, the resident's monthly fee cannot change due to a need for enriched housing/assisted living services during this covered benefit period. When the contracted health care facility days have been exhausted, the resident must then pay a market or per diem rate if additional skilled nursing care days (or enriched housing/assisted living days) are needed.

Fee for Service Contracts

Fee-for-service contracts include independent housing, residential amenities such as scheduled transportation and social activities, and access to a continuum of long-term care services. The long-term care services, enriched housing/assisted living and skilled nursing facility care are available on a fee for service or per diem basis. There is no long-term care benefit included in the contract; the resident pays for long-term care as and when needed.

Residents pay for all health care costs separately. Although this can initially be the least expensive contract, it can be quite costly if a resident eventually has extensive health care needs.

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Every contract should have a clause about refundability. If a person leaves a CCRC, she often loses part or all of her entrance fee, depending on how long he has lived at the CCRC. Most continuing care retirement communities offer a variety of entrance fee refund options.

The CCRC decides what contract options to offer prospective residents. At a minimum, all resident contracts must provide a refund of some portion of the entrance fee during the first four years of residency. This option is called the traditional declining contract. Under the traditional declining contract, the resident's entrance fee refund is reduced by 2% per month with a one-time 4% processing fee. After 48 months of residency, the entrance fee refund is reduced to zero.

Many CCRCs offer contracts which refund a specific percentage of the entrance fee regardless of the length of residency (for example, 90% or 50% refundable contracts are currently offered in several communities). The refund is paid to the resident or the resident's estate if the contract is terminated or upon resident’s death.

Deciding on a CCRC is a long-term commitment and a significant financial investment. It is a decision that should be made carefully. Reading and understanding the contract is important when helping an older adult choose any continuing care (contracts can be long, detailed, and complex). You should make sure you understand the contract before signing, and you would be well advised to seek legal or financial counsel before entering into any agreement.

Firstly, it is important to underline that a CCRC may be a viable option for a person’s future, given all the services provided, the quality of life and the possibility to “age in one place”. However, depending on the type of CCRC and the age range, there may be a vast majority of people that depend on medication and the correct administration of that medication.

Therefore, it is very important to be ensure that the CCRC team is organized, responsible and capable of correctly managing and administrating medication to each resident and mainly to your loved one.

In the case that some incident occurs, an incident report should be filled. However, keep in mind that having many incident reports does not necessarily mean less quality in the services. Sometimes it could mean that the institution is willing to bet on more problematic residents, leading to an increased number of incidents.

Nevertheless, in the case of an incident, you have to be sure to understand what the facility is liable for. It is very important to understand where their responsibilities end and yours or your loved one’s begin. It should be noted that there are some protocols the facility should follow in case of an incident. Below is a basic outline of what the medical staff should do in in case of an emergency:

• Provide medical care at once
• Call an emergency team if needed
• Call the family and explain what happened
• Start an investigation in order to understand how it happened
• Call the resident’s insurance company and report the incident 

Sometimes, depending on the situation, there may be the need to fill a complaint to the CCRC management in order to try and solve the situation without legal action. However, in some cases, the management may ignore those complaints, thereby obligating the families to hire an attorney and take legal action.

There are also some situations that are more serious and a “simple” complaint to the management is not enough. In these cases, one should know there are several channels that they can take up. Depending on the type of issues, there may be one or more regulatory agency to which they can file a complaint to. The specific entity to which the complaint should be filed will also depend on the nature of the issue and the level of care at which the problem occurs. 

One of the ways to correctly file a complaint and to deliver it to the right regulatory agency is to rely on the local Long Term Care Ombudsman Program. They can be reached via this site or through the Crisis Line Number 1-800-231-4024 after hours or on the weekends.