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The Decision No One Wants to Make: Senior Care at Home or in an Institution?

If you're like most families, you have (or will someday soon) come to a crossroads where you'll have to accept the fact that your elderly parents can no longer live independently and will need professional help - perhaps not skilled nursing care - but some kind of assistance with basic living that can't be provided by family members.

Chances are you or your parents have been independent most of your adult lives and you feel uncomfortable in the new roles you find yourselves in. Once you've recognized that the need exists (and that's a big step for most families), the next question is where should the care be provided: at home, in a skilled nursing or assisted living facility? Of course, there's no single right answer for everyone, but there are some key questions you can ask that will lead you to the right one for you and your family. Let's discuss a few of those questions and some of the solutions for each one.

What level of care will they need?

Sometimes a doctor or geriatric nurse case manager determines exactly what kind of care a patient needs if there's been surgery, then rehabilitative care, and so on. Or just as often our parents get too old or weak, perhaps from arthritis, to care for themselves, and we have to rely on our own judgment that they need help. Some telltale signs: poor housekeeping, poor nutrition, poor hygiene. If they need skilled medical care, including injections, wound care, tube feeding, etc., they probably need to be in a skilled nursing facility or have skilled nursing care at home. But if they need help with meals, dressing and bathing, etc., they can either be in an assisted living facility or have in-home assistance from a professional agency.

What can you afford to pay?

For many this may be the deciding factor. If your parents need care around-the-clock, institutions are almost always less expensive than in-home care. But if hourly or daily assistance is sufficient, in-home care is usually less expensive than a nursing or assisted living facility. And yet, surprisingly, Medicare, Medicaid and most long term care insurance policies tend to provide coverage primarily for institutional care, although that's beginning to change with private insurance. Still, many people believe that Medicare picks at least half of the cost of long term care, when in fact, it pays very little (only after acute care, like surgery). That's why it's a good idea to look into long term care insurance and to be sure it covers both institutional and home-based care.

What are your parent's wishes?

One can't ignore the emotional impact decisions like these have on the entire family, which is why it's a good idea to discuss these issues before the need arises, when cooler heads can prevail. (Parents: this means you should make your wishes known to your children.) Clearly, the vast majority of us prefer to stay at home. But there are seniors who may feel lonely and would prefer being in an assisted living facility, to the surprise of their children, in some cases.

In an assisted living facility, seniors have access to round-the-clock care, if they need it, the companionship of people their own age, meals prepared for them or the option, sometimes, to prepare their own, all without the burdens of owning property. At the same time, if they have a period when they do need private duty nursing and the facility can't provide it, you or they can always engage the services of an outside adult care service company. At home, of course, they have familiar surroundings, generally more contact with friends and family and often more independence. An in-home caregiver can provide personal, one-on-one attention and build a close personal relationship that's hard to find in an institution.

Whatever decision you make, the most important thing you can do is to bring everyone who will be affected by it into the room. Then lay out all the options, list the pros and cons of each and arrive at a decision as a family. You and your parents will be much happier if you come to a decision they feel they had a major role in making and are assured they won't be placing a burden on anyone.