Residential Assisted Living Communities-A Safe Care Option During COVID-19

Residential assisted living (“RALs”) have been around for years but have received a lot of attention due to their unique benefits when dealing with breakouts of illnesses. Here are some of the top reasons RALs are safer when dealing with COVID-19 or outbreaks of illnesses such as the flu.


Less Traffic

Home to fewer residents, RALs require fewer caregivers and support staff than larger communities. Therefore, the number of people entering the building on a daily basis is greatly reduced, and it’s easier for the smaller communities to monitor its staff members.


More Individualized Care

Most RALs have 1 caregiver for every 4 residents. This enables the staff to take more frequent temperature checks and closely monitor the residents for any early signs or symptoms. Additionally, caregivers can develop much closer relationships with residents and are able to detect eating, sleeping or other changes in their behavior.


Less Area Requiring Disinfection

RALs do not have a large lobby, recreation rooms, or multiple dining halls; thereby having much less surface area in their common areas to disinfect. A typical RAL has approximately 5,000 sq. ft., while a large facility housing 80-100 residents could have more than 100,000 sq. ft. to disinfect.


Written by Evermore Senior Living 

Edited by Senior Advisors Plus

paying for assisted living

When Will Health Insurers Pay for Someone’s Stay at an Assisted Living Community?

Assisted living communities have served an important role in the US’s health care continuum—often they have been the next stop for older people who have been discharged from a hospital or a skilled nursing facility. Assisted living communities assist their residents with medication management and activities of daily living. With such an important role serving seniors, why don’t insurers pay these providers to keep their constituents safe?

Apart from long-term care insurance, it is not common for health insurers to pay assisted living communities because many insurers and providers operate on a fee-for-service basis. That means providers charge the insurers for each procedure/line item. Under this payment structure, preventative care, like what is provided in assisted living communities is over looked by the insurers–much like your insurer now probably doesn’t pay for your vitamins or exercise classes.

The Center for Medicare and Medicaid Services(“CMS”) in tandem with private insurers, are experimenting with a fee-for-value payment model. Through this model, a cohort of providers are paid a flat fee to manage the health of the insurance company’s constituents. In this model, the group of providers can earn more money by reducing the health care costs of the insured population.

As this new fee-for-value system rolls out, assisted living communities will have an opportunity to take payments from insurance companies as a way to reduce the cost of managing the health care costs of their constituents, most notably through lowering readmission rates into hospitals.

If assisted living communities become part of the formal health care continuum, many will have to change the way they do business. Now, a lot of assisted living communities operate as hospitality companies with a sliver of supplemental care. That’s because these communities must woo consumers in to their communities and we believe they do that through enhancing their hospitality features over care capabilities. The way we understand consumers is they generally require a minimum level of care and then focus on choosing a community with the nicest hospitality features that they can afford.

Under a system by which an insurance company pays an assisted living community, a community must show it knows how to manage a population of people effectively. To do this, assisted living communities may have to improve their health care capabilities. A few notable aspects that Dr. Kevin O’Neil pointed out in his interview with Senior Housing News is senior living communities must work on systems to help prevent falls and manage the medications of its residents better1. That means communities may need to have software systems in place to track metrics about their residents, to train their staff to spot people who are a fall risk, and to hire more staff to manage the communities’ residents better.

Two things need to happen for assisted living communities to take payments from insurers: (1) assisted living communities need to focus more on providing health care; and (2) insurers and providers need to organize under a fee-for-value system. When those two aspects occur in a given market, then you will see assisted living communities take payments from insurers as a result of caring for the insurers’ constituents.




Moving into a senior living community could be the second largest transaction one makes in his or her lifetime. It’s important to get it right; otherwise, a family may have to search for a new place, again, or risk depleting all their loved one’s assets. Here’s a list of three mistakes people make when searching for and choosing senior living communities.

  1. They don’t consider that their cost of care could increase. Many communities charge rates depending on the level of care that the resident requires. It’s common for a resident’s level of care to increase as he or she ages. As a result, costs are likely to increase during a resident’s stay at a senior living community, and by how much is something people generally do not consider. When selecting a community, it is a good idea to select one well within your income limit to avoid costs overrunning assets or income.

So, by how much should one account for costs increasing over their course of his or her care needs? It depends on the client’s age, diagnoses, level of care at the start of residency, and the home, among other things. This is a question we will help families account for in our process to find them the best place for their loved ones.

  1. They don’t find communities that specialize in their love one’s care needs. While some people may consider nursing homes and senior living communities all the same, those that are familiar with the industry know that they are very different. Not only are those two settings of care different, there can also be differences in the level of care at nursing homes and senior living communities. Meaning, not all nursing homes and not all senior living communities do the same thing. When selecting a home for a loved one, to maximize value, it’s important to choose a home which offers care tailored to your loved one’s needs. Homes can differ on what they specialize in based on diagnosis, such as people with dementia, or ambulation level.

When residents are properly matched with a home based on their level of care, they have a better chance to maximize the value of the home. For instance, a resident who is ambulatory who only needs medication management would probably be overpaying if he or she moved into a home that is heavily staffed to care for people who need two Certified Nursing Assistants (“CNAs”) to help them transfer from the bed to a wheelchair. In order for the home to be able to afford to pay its CNAs, it must charge its residents a premium above its rental expense. As a result, an ambulatory person will likely be paying for care he or she does not need. That’s why it’s important for people to search and choose homes that are tailored to their loved one’s needs.

  1. They don’t negotiate with the communities. In our opinion, many people don’t negotiate because they don’t know that they have considerable buying power over the providers or are frightened at the sign of confrontation. It bears repeating, moving into a senior living community, and hence signing a contract to do so, is likely the second largest purchase one will make in their lifetime. Negotiate!

To negotiate well, one has to know his or her negotiating position. When working with clients, we combine three things to develop a negotiating position: (1) our analysis of the client’s situation; (2) number of communities to choose from; and (3) knowledge of market indicators. By following this strategy, we have been successful helping many of our clients lower their costs.

If a family is successful at avoiding these three mistakes, they have a much better chance of giving their loved one the quality of life they intend. While any family can come up with a solution on their own, we strongly suggest they seek expert advice to avoid mistakes that naturally come with trying something new. We’re happy to set up a free consultation to talk about your circumstances.

Best Wishes,


The US used to have more multi-generational households than there are today. Several generations under one roof made for a symbiotic relationship among the family members. For instance, the elders preserved the traditions of the family, shared their wisdom with the young, and provided caregiving to the infants.

Then as they grew older, the youngest child would stay home to care for their aging parents or grandparents, instead of searching for work when they became of age. When the elders passed away, the youngest would inherit most of the land and the wealth of the family. At the beginning of the 1900s in America, the average life expectancy at birth was 41 years1. Because life expectancy was short, it wasn’t long before the youngest would inherit the land and then proceed with raising a family of their own.

As real GDP per capita climbed, life expectancy increased, caregiving became more accessible, and families had fewer children, the value-proposition tilted towards children seeking independence over caring for their parents and grandparents at home. Additionally, today’s parents and grandparents have been fortunate to have access to social, retirement, and health care programs that have helped them remain independent longer. These historical trends have slowly increased the elderly’s demand to live in retirement communities.

Retirement communities in America date back to the 17th century when the English settlers brought the idea of nursing homes to America; they called them almshouses. However, almshouses were also open to orphans and the mentally ill. During the Great Depression, these houses became overwhelmed with residents, and the elderly complained2. The US responded to the complaints by passing The Social Security Act of 1935. The Act provided a small amount of federal and state assistance to what we now know as nursing homes3.

Nursing homes’ popularity accelerated later when the US enacted two health insurance programs, called Medicare and Medicaid. Modern day health insurance started in the Depression Era when Baylor University Hospital discovered a new way to charge its patients for health care. Prior to Baylor’s discovery, hospitals billed its patients directly, using a fee-for-service model. During the Great Depression, patients didn’t want to pay large, one-time medical bills when they had little-to-no income. Baylor thought that it could change consumers’ perception of health care by changing its payment structure. It began to charge patients a small amount of money each month in exchange for covering their cost of care. While that payment system is widespread today, the idea didn’t catch on quickly. In 1940, only about 9% of Americans had some form of health insurance3. However, WWII changed the health insurance marketplace.

During the War, the US had a shortage of labor, so companies tried to increase their wages to attract workers. However, the US didn’t want wages to rise. Higher wages would translate to more expensive goods, which means a more-expensive war, and increased the risk of hyper-inflation. In response, the US passed the 1942 Stabilization Act to limit rising wages. Employers responded to the Act by offering their employees health insurance–if they couldn’t entice qualified workers with higher wages, then they had to attract them with better fringe benefits.

Harry Truman saw that access to health insurance corresponded to people living longer. He tried and then failed to pass a national health care plan in 1949. Inspired by Truman, Lyndon Jonson later signed the Social Security Amendments of 1965 at the Truman library. The law established Medicare and Medicaid, which provided health insurance to many Americans, in addition to funding to nursing homes. As nursing homes’ popularity surged, assisted living communities began to sprout. Assisted living facilities were designed as a variation of nursing homes. The idea of assisted living was to reduce environmental and organizational stress while promoting residents’ autonomy: the model includes private living spaces, a full array of services, and the residents’ right to make choices regarding daily activities and health care4. The success of assisted living in promoting independence, while offering supplemental care, has led to the constructions of over 28,000 assisted living facilities in the US.


If you know someone who has had a surgery, you may know that when they first heard that they needed the procedure, they were bummed out. Chances are they got a second opinion in case another source gave them hope that there was an alternative. Similarly, anyone should get a second opinion before choosing a senior care provider.  Here’s why:

Senior care is very expensive. You should not rely on the providers to tell you what you or your loved one needs. Their opinions can be biased. That’s because providers typically generate more profit by providing higher levels of care. Before you choose a care provider, we recommend that you seek an unbiased opinion from a senior advisor, the benefits of which are more than just saving money.

While care providers typically administer an assessment, it can be incomplete. For instance, an incomplete assessment is likely to happen when someone who would qualify to live in an independent living community, applies to live in an assisted living community—a more expensive care setting. The nurse at the assisted living community will qualify the senior to live in assisted living; however, the nurse will avoid opining on whether the senior qualifies for independent living as well.

You never want to pay for more help than you need. The reason is that you will be over paying for care, and the person entering into care can prematurely lose their autonomy. If you take one thing away from this post, take this: it is extremely important to preserve a senior’s autonomy.

Karen Wilson, an original builder of assisted living communities, was inspired by her mother, because her mom wanted more independence than what she had in a nursing home. When Karen approached investors, they were skeptical of the assisted living concept, because they thought there was a tradeoff between health and freedom (i.e. more freedom meant worse health outcomes). Fortunately, she received funding and constructed an assisted living community in Portland, Oregon.

The community that Karen built supported impoverished elderly people on government support. When the community began to admit residents, she tracked their health, cognitive capabilities, physical function, and life satisfaction. Her findings revealed that the residents didn’t trade their health for freedom. In fact, their life-satisfaction increased, physical and cognitive function improved, and incidence of major depression fell. The program was a success from the cost side too: costs for those on government support were 20% lower than what they would have been at a nursing home. Karen believed that the assisted living community restored a portion of the residents’ independence, which boosted their quality of life and then drove positive health outcomes.

Granted, sometimes nursing homes are necessary. While nursing homes are for people who need a high level of care, the best ones creatively find ways to give seniors purpose. When Bill Thomas became the medical director at Chase Memorial Nursing Home, he enhanced the purpose of the residents when he purchased one hundred birds, four dogs, two cats, a flock of hens, a colony of rabbits, and hundreds of plants. Some of the residents got birds, some got plants, and some got both. Bill said that people who had been completely withdrawn and non-ambulatory started walking the dogs, and others, who he thought couldn’t speak, started to talk again.

Researchers studied the effects of Bill’s program over two years, comparing a variety of measures of Chase’s residents with those of residents at a nearby nursing home. Prescriptions-required-per-resident fell to half that of the nearby nursing home, total drug costs fell to just 30 percent of the comparison facility, and deaths fell by 15 percent. The study couldn’t say why, but to Bill it was obvious that the difference in death rates could be traced to the fundamental, human need for a reason to live. In this case it was caring for a plant or an animal.

The key take away from Karen’s story is that independence can actually improve health outcomes and quality of life. Bill’s story demonstrates that when given responsibility, seniors’ will-to-live increased. When someone is overqualified for a level of care, but he or she is given that level of care anyway, his or her autonomy can be prematurely stripped—the assistant performs more of the senior’s daily tasks than needed, which can have undermining effects on the senior. This may result in an expedited decline of the senior’s health, because the caregiver has just taken away something fundamental to that person, a sense of purpose.

Rather than asking a care provider if a person qualifies for a level of care, ask a senior advisor. A senior advisor will give you unbiased advice that could preserve a person’s quality of life and lower the bill.

This post was inspired by “Being Mortal” by Atul Gawande. His book is a must read if you find this topic interesting. The stories herein are from his book. 


Caregivers are expected to be in short supply, but will the state-led minimum wage increases attract new talent or lessen families’ access to caregivers? Read about my opinion in the post below:

Maryland and D.C. have voted to approve an increase in the minimum wage while Virginia has not. D.C. led the pack in 2016 when Mayor Muriel Bowser signed an Act that would increase D.C.’s minimum wage a little each year until July 1, 2020. Afterwards, the minimum wage will remain at $15 per hour. The minimum wage requirement applies to any employee who works at least 50 percent of the time in D.C., regardless of where the worker resides. The date of this post marks the second to last minimum wage increase in D.C. As a result, D.C.’s minimum wage will be $14 per hour until July 1, 20201.

Currently, Maryland’s minimum wage is $10.10 per hour. At the end of March 2019, Maryland’s General Assembly overrode Governor Larry Hogan to pass an Act that will increase Maryland’s minimum wage over the course of seven years. Below is a summary of the state’s planned increases2:

For companies with at least 15 employees, this is the schedule of increases:

  • $11.00 on Jan. 1, 2020
  • $11.75 on Jan. 1, 2021
  • $12.50 on Jan. 1, 2022
  • $13.25 on Jan. 1, 2023
  • $14.00 on Jan. 1, 2024
  • $15.00 on Jan. 1, 2025

For companies with fewer than 15 employees, this is the schedule of increases:

  • $11.00 on Jan. 1, 2020
  • $11.60 on Jan. 1, 2021
  • $12.20 on Jan. 1, 2022
  • $12.80 on Jan. 1, 2023
  • $13.40 on Jan. 1, 2024
  • $14.00 on Jan. 1, 2025
  • $14.60 on Jan. 1, 2026
  • $15.00 on July 1, 2026

Personal care aides typically make more than the current minimum wage, but home care agencies and senior living communities will likely need to pay their aides more, especially as the minimum wage approaches $15 per hour. An RTI International report in 2017 found that nationwide 87% of healthcare support-related occupations in assisted living (AL) and continuing care retirement communities (CCRCs), namely personal care aides, will require wage increases if the minimum wage increases to $15 per hour3. Experts believe that even if caregivers are currently making more than $15 per hour, employers of personal care aides will have to increase their wages due to the “spillover” effect. That’s because the caregivers may find more valuable work elsewhere, say for a firm that does increase its wages. As a result of the minimum wage increases, it is likely that caregivers who work in the home and in the community will receive a pay bump regardless if they make minimum wage or not.

If the communities assume all of the financial impact from the increased labor costs, they may be able to preserve demand for their rooms. However, that is an unlikely scenario as investors will want to mitigate the financial impact of wage increases. A more likely scenario is that communities will pass on labor cost increases to the consumer in the form of higher monthly rates. Higher monthly rates will translate to less affordable housing options to consumers.

I believe the same dynamic will persist for home care agencies and registries: minimum wage increases will cause these firms to pay their caregivers more and then to pass on part of the cost increases to the consumer by charging more.

Fortunately, there is a winner in all of this: the hard-working people we know as caregivers. The US health care system needs more of them and needs them to remain with their clients longer. Higher wages will hopefully help resolve both of those issues. It’s not fair to the families and seniors who are constantly having a new face walk in their house because the former caregiver had to leave her job to find a better opportunity—that’s unhealthy for both the caregiver and the senior. So while wage increases may make access to care more difficult for some, it has the potential to better many more lives. If you are concerned about the rising cost of care, talk to a senior advisor. He or she may be able to guide you to an affordable option.




Power of Attorney
-This person can pay your bills, make investment decisions, market and sell your house
-Depending on how you want it written, it can become active immediately or based on certain criteria

Private Personal Information Profile
-Power of attorney will thank you if you have one of these

Physician Orders for Life-Sustaining Treatment – Good if you have a life-limiting condition, such as dementia and heart disease. Typically has four sections:
-CPR this is the same as the Do Not Resuscitate (“DNR”) form.
-Medical Interventions – life-sustaining treatments
-Artificial nutrition – feeding tubes

Advanced Healthcare Directive – Referenced when a patient cannot make his/her own decisions and is on life-sustaining treatment. Typically composed of two parts:
1. Living will – important for describing what you want your end of life treatment to be. You want to consider what level of mental awareness and physical functioning is acceptable for doctors to continue to provide prolonging treatments. Give a copy to friends, family, your physician, hospital, and lawyer. Carry something in your wallet that says you have an advanced directive and who to call to access it.
2. Medical power of attorney – you appoint a person to fill in the gaps that your living will doesn’t address. A doctor may reference both your living will and your medical power of attorney to create the POLST form, if you haven’t done so already.

HIPAA release – For someone that you trust to get access to your medical records.
-“The HIPAA Privacy Rule allows HIPAA-covered entities (healthcare providers, health plans, healthcare clearinghouses and business associates of covered entities) to use and disclose individually identifiable protected health information without an individual’s consent for treatment, payment and healthcare operations. In all cases, when individually identifiable protected health information needs to be disclosed, it must be limited to the ‘minimum necessary information’ to achieve the purpose for which the information is disclosed.”
-May come in handy so that your medical power of attorney or agent can have access to information that gives him or her the information to make decisions about you if you’re incapacitated, to dispute a bill, or to discuss medical conditions with your doctor if you’re still lucid.
-People also may give their lawyers permission, since their lawyer may have a copy of their living will.

Will or Living Trust
-Will – Gives directions on how to distribute assets after one dies, their estate will enter the probate process, by which a judge will give legal permission for assets to be distributed to heirs.
-Living Trust – may reduce legal fees in the long run, may have certain estate tax advantages, and mitigates the estate from going through probate.

End of Life Wishes –
-Talk with a funeral director to learn about your options and let you know the costs of each.
-Write down instructions and share them with family members and include them in your will or trust.
-Make sure you either pre-pay or have funds allocated to pay for your arrangements in your will or trust.


Two weeks ago we gave our opinion on how to clear the contents of a house quickly. This week we want to give you our opinion on how to clear the contents of a house so that you maximize the value that you get from its contents.

​First, contact your realtor to make sure both of you are on the same page about selling furniture. You may want to have a buyer pick up a piece of furniture after your realtor takes pictures of the house to market it.

Second, define your goal for clearing the house by determining if you want to:

  1. Clear the contents of the house quickly?
  2. Maximize your earnings?

Herein we are going to discuss how to maximize your earnings. To know that this post applies to you, you’ll want evidence that some contents in the house are actually valuable. Find an appraiser; we recommend doing so through the American Society of Appraisers. An appraiser will give you a rough idea of how much your belongings are worth. If you have a lot of valuables, we recommend that you explore selling them through several different channels.

We believe that if you don’t have a lot of expensive items, then you should start your sale process by hosting an estate sale. However, if you have some valuables that you want to maximize your earnings from, then sell them through other channels. Rare art, guns, valuable collectables, cars, antiques, designer rugs, expensive jewelry, and farm equipment are examples of items where you should explore the best marketplace. There isn’t a hard and fast rule as to the value of an item that you should explore which marketplace to sell it, but here are a few things to consider:

  • Difference in commission amounts – could you earn more money by choosing a marketplace that charges a lower commission?
  • Transportation costs – how much money will you spend to transport the item?
  • Your time – what’s your time worth?
  • Quality of the marketplace – some marketplaces may be able to generate better demand for your item (e.g. very expensive items require a unique marketplace).

When in question about which marketplace to use, we advise our clients to start their research by calling online auctions, auction houses, online consignment sites, and consignment stores to question them about selling a piece that they want to get rid of. People who buy expensive items through these channels typically trust them because they have secure payment mechanisms. In other words, the likelihood of the buyers and the sellers getting scammed is very low. That’s why we suggest approaching these four channels over Ebay and Craigslist to sell valuable items.

Online auction

  • There are two main players, Soetheby’s and Christie’s. At the time of writing this article, Soetheby’s prices were lower than Christie’s. Sotheby’s charges 20% on the first $100,000 in sale value and 12% on the sale value that exceeds $100,000. You’ll want to double-check the terms that an auction house sets for your items.


  • You’ll have to locate your local auction house. The fees are generally between 20%-50% of the sale price but check with you local house for actual pricing.

Online consignment

  • The main player in the online consignment industry is TheRealReal. It charges between 15% and 60% of the item’s sale price. It’s a big range, but the charge depends on the item and its value.


  • You’ll have to locate a local consignment store. Consignment stores generally charge between 10% and 60% of the item’s sales price.

Because prices vary through all of these channels, you’ll want to call around to get quotes on what you want to sell. You’ll also want to inquire about how often these channels sell merchandise similar to the one that you’re proposing to sell—you want to choose a seller that is familiar with selling the item that you have.

Don’t be afraid to explore other channels as well. You want to find a marketplace that best suits your listing. For instance, if you have a motorcycle to sell, consider selling it on a website that specializes in selling used bikes, such as Cycle Trader. Do you have a used car? Try selling it through Autotrader.

These fees are absurd. If that’s what you’re thinking after you’ve called the auction houses and the consignment shops, then consider using Ebay and Craigslist to sell your merchandise, especially if they are everyday items. You may pay a lower price to sell them through either of these sites, and possibly nothing at all. However, we would not advise that you use these sites for substantial transactions for a couple of reasons: (1) buyers may be reluctant to bid on your item because they may not trust you; and (2) you could be scammed. Ebay and Craigslist are a great way to sell run-of-the-mill merchandise because the money at risk is very low.

Once you’ve sold all the items you’d like through auction sites or consignment shops, consider hosting an estate sale. For an overview of what to do from here, reference our last post Clearing the Contents of a House Quickly.

If you’re hesitant to pay the fees of an estate seller, you may want to host an estate sale or yard sale on your own. Afterwards, call a junk removal service or take whatever’s left to a thrift store first, then to a recycle center, and lastly to a dump. If you do all that yourself, you’ll deserve a pat on the back.