A Model Home

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Sitting on a screened-in porch at the Barclay Friends assisted-living facility, enjoying a late-summer afternoon, 81-year-old Ellen Lyon can relax. She doesn't have to worry about cooking dinner — someone will remind her when it's time to eat. If she needs her oxygen, someone's nearby to help. When it's time for her medicine, it's all sorted and ready to swallow. And if she wants to take a walk, well, she can take a walk.

This scenario is a far cry from her life just two years ago. Lyon was struggling with heart problems, living alone in Sloatsburg, N.Y. She was in and out of the hospital, and each time she was discharged, she faced the prospect of heading back to a big, empty house. Her second husband had passed away, and three of her four children were scattered along the East Coast. Increasingly, she was having a hard time keeping the house in decent shape. But mostly, she was lonely. "Most of my friends had moved or passed away, and I hadn't even noticed that, until my husband passed away," Lyon says. "I missed not being able to talk to anybody."

So Lyon asked her son Bert to come by so they could talk. It was time, she told him, to sell the house.

Initially, Lyon wanted to move to Kendal Crosslands, a continuing-care community where her two sisters live. But faced with a waiting list of several years, Lyon decided to look into Barclay Friends, in West Chester, Pa., which offers both assisted living and a separate skilled-nursing facility (which provides round-the-clock care) on the same grounds. (Barclay has been around for 100 years, but in 1994 it became an affiliate of Kendal Corp., a nonprofit, Quaker-run chain of communities in the Northeast.)

While Barclay, like most assisted-living facilities, does not require an entry fee, residents do pay a monthly maintenance charge that is near the upper end of the industry average. But a year after moving in, Lyon has no doubt her new home is worth the cost. "It's wonderful to have the privacy of your own apartment and still to be able to just go down the hall and know there's always somebody around," she says.

Apart from its welcoming atmosphere, Barclay stands out for its details, both residents and local geriatric-care workers say. Its policy is to clean the apartments at least once a week, and the staff actually does it. "They'll clean under the bed, turn over the mattress and even help me get packages out of the closet," Lyon says. The times when she has needed help late at night, it's taken only a few minutes for someone to answer her emergency call bell.

Finding the Right Facility
As Lyon and her family have discovered, assisted living can work. But finding a place where it actually does isn't easy. When starting your research, ask to read a facility's licensing and inspection report. A good facility should make it available. Another source to check is your state's long-term-care ombudsman, who may be able to tell you if there's a record of complaints against a specific facility. (Call the government-sponsored Eldercare Locator at 800-677-1116 to reach your local ombudsman program.)

To get the inside scoop on a facility, hire a local geriatric-care manager. Hourly fees can range from $40 to $150, depending on where you live, though you'll generally have to pay an initial assessment fee (up to $400) as well. Your first question to the care manager, however, should be this: Do you get paid by facilities for placing people? If the answer is yes, find somebody else. For more help, head to the Web site of the National Association of Professional Geriatric Care Managers.

The first, and possibly most important, step for finding the right facility is accurately assessing the care your family member needs. Don't hold anything back just so they can get in. Ultimately, it will come out and create a problem. If your parent is incontinent, for example, say so. "People are always trying to hide it," says Barclay's resident-services coordinator, Diane Williams. "At least 30% of the people here are incontinent, and for at least 25% of them, we didn't know that until they walked in the door."

While you can never predict when someone's health will deteriorate, you do need to try to think ahead. Does the person have Parkinson's, diabetes or other known conditions that will require increasing care, which some facilities may be unable to handle? Then there's your own lifestyle to consider. If the home doesn't provide laundry services, are you sure that you'll be able to drive an hour every weekend to pick up Mom's dirty clothes? And transportation: How will your family member get to and from doctor's appointments? Some facilities offer a van service.

Once you've hit upon a facility that sounds promising, it's time to start asking questions in person. Several groups provide checklists to help with this process; the best by far comes from the Consumer Consortium on Assisted Living, a group funded by private and public money — not by the assisted-living industry. The list offers useful tips and nearly 100 detailed questions on areas such as costs (What initial payments are required? Are they refundable?), services (How often are activities scheduled?) and — perhaps most crucial — rules for discharging residents.

But it's one thing to know what questions to ask and another to know what the answers should be. And getting a handle on the quality and qualifications of a staff can be tricky. Don't be swayed by impressive staff-to-resident ratios. (In some states that ratio may even be set by law.) It's a thinly disguised secret in the industry that in order to meet those guidelines, homes will count cooks, janitors and administrators as staff. What you need to know is what kind of staff is on hand at various points in the day to actually assist the residents. How many people are on duty at 3 in the morning? Is there someone to run weekend activities? And do the math: A facility may say it will provide an hour of care each day for each resident, but does it have enough people to actually do it? Look into employee turnover — which is notoriously high in the elder-care business — but don't ask just the facility. Instead, ask the residents and their family members how much the staff changes.

As for credentials, most facilities don't have much more than one registered nurse on staff — in some cases, none at all (although more are hiring them to boost marketing efforts). Unless you feel the prospective resident will need greater medical care within the year, this does not have to be a negative.

Nevertheless, it's essential to understand a facility's policies for handling medical emergencies and the way it distributes and tracks medication. Often, elderly residents forget (or simply refuse) to take it. "A lot of families end up finding pills jammed under cushions or in the cracks of the floor," says Karen Knutson, a geriatric-care manager in Charlotte, N.C. At Barclay, for example, residents have the option of self-medicating, in which case the staff will regularly count the pills to make sure the drugs are being taken. If there's a discrepancy, the family is contacted and the staff begins distributing medication to the resident. "And if a resident has a doctor's appointment, we don't let them walk out the door without a slip of paper showing all their medications," Williams says.

Above all: Visit, visit and revisit the facility. Arrange to spend at least one night before making your final decision. Make sure at least one of your visits — preferably the first — is unannounced. Just walk in and act like you know what you're doing — don't look lost. Then sit down and chat with residents. Keep an eye out for how the staff interacts with someone who may be a bit hard to handle. Look around. Are the wastebaskets in the rooms overflowing with trash? If you walk in at 9:30 in the morning, do all the residents appear to be up and dressed? Does the staff know the residents' names?

Mealtime is especially good for evaluating a facility. Taste the food. Is the color boiled out of even the beets? And is the staff making sure that residents show up for meals? A common problem among the elderly is simply not eating.

The Fine Print
So, you're satisfied you've found the right home, and it's time to sign on the dotted line, right? Stop. Show the contract to a lawyer, preferably one who has experience in elder law. If you don't know one, the National Academy of Elder Law Attorneys' Web site has its own question-and-answer section on finding a good attorney.

As too many assisted-living residents are finding out, a close read of the contract is critical. "You should have a clear list of what services you're getting and what services they will provide for an extra cost," says Jan Meyers, Colorado's long-term-care ombudsman. "If it's something like they say they'll bathe the resident, they should say how often."

Finally, understanding the precise circumstances under which a resident will be discharged from the facility — and finding out what your recourse is for fighting such a move — is of critical importance. Barclay's policy, for example, is to discharge residents who are incontinent to the point that they need round-the-clock assistance, as well as those who pose a threat to other residents. However, those who are discharged get first priority for admission in Barclay's 99-bed skilled-nursing center next door.

Given the possibility that your loved one will be forced out of a facility, you should have a backup plan in place from day one. It often makes sense, for instance, to find an assisted-living community that's attached to a skilled-nursing home. At a good facility, however, a resident's brief illness should not be grounds to send them packing. Recently, Ellen Lyon came down with a case of pneumonia. The staff at Barclay Friends brought the bedridden woman her meals on a tray, first checking to see what she wanted to eat. Says a now-recovered Lyon: "They've been great!" And that's the way it ought to be.