Families who are searching for the optimal place for their loved ones with dementia now have an almost overwhelming set of choices.

Assisted living facilities are generally described as congregate residential settings that provide 24-hour supervision, at least 2 meals daily, and an array of personal and health-related services.

Assisted living facilities are licensed by individual states, meaning that there are NO CONSISTENT REQUIREMENTS FOR THE QUANTITY AND QUALITY OF CAREGIVING PERSONNEL.

• Assisted living facilities are rapidly replacing nursing homes as the preferred setting for residential long-term care for persons with dementia.

Nationally, 1 million older adults reside in one of the 30,200 assisted living facilities, according to the  National Study of Long-Term Care Providers – 89% of these residents are living with dementia.

• Nursing homes are generally settings that provide much closer supervision and tend to be more aligned with a hospital or medical model (although that is rapidly changing as nursing homes become more “home” and less “medical”).

All meals and medications are provided. 24/7 licensed nurse supervision is available. And, nursing homes are regulated by Medicare and have “certified” Medicare beds.

• Nursing homes are inspected every year by surveyors who check to see if the facilities are following the rules—including rules about prescribing drugs often used to reduce or stop behaviors in persons with dementia.

They are “under the microscope” and are expected to handle behaviors, like yelling or wandering, using non-drug approaches.

• Assisted living facilities, on the other hand, are inspected by the health department, and inspections may vary. Often, the assisted living facility is inspected when it first opens and only afterwards if there are complaints.

Nursing homes are held to specific rules and standards, which may limit how “homelike” a room may be or prevent the kitchen from serving soft-boiled eggs. However, a nursing home rarely “kicks out” a person with dementia who shows difficult or challenging behaviors.

What does this mean for the caregiver? 

Which one is the best option for my loved one? One very important driver is cost. In some states, assisted living facilities accept Medicaid. This is great for seniors with very limited financial resources. The assisted living option would be more financially feasible than a nursing home option.

However, if your loved one is in the hospital for 3 or more CONTINUOUS nights and meets strict Medicare requirements (such as needing physical, occupational, speech therapy), you will need to find a rehabilitation facility, often a nursing home with a “short stay” unit. This is because Medicare pays for 100 days of skilled nursing and therapeutic care (physical therapy, occupational therapy, speech therapy) for CERTIFIED FACILITIES ONLY.

Medicare Part A covers all costs for the first 20 days of rehab stay, then charges the beneficiary $165 co-insurance each day until day 100 (assuming that the person is still receiving the services and making progress).

There are Medigap policies that cover the co-insurance. I would recommend speaking with the hospital social worker and the facility social worker and getting this information in writing.

• Assisted living facilities are not certified by Medicare, even if they offer identical services. Medicare will not pay for post-hospital care in an assisted living facility, and most major health insurance companies follow Medicare’s lead.

In some states, like Alabama, any assisted living facility who admits persons with dementia must be licensed as a “specialty care assisted living facility” or SCALF.

• SCALF’s are locked (secured) facilities and staff having direct resident contact are mandated by the Dementia Education and Training Act (DETA) to receive very specific dementia training.

Unfortunately, the training materials were developed in 1997 and last updated in 2008. Some of the content is frankly wrong (e.g., “Psychiatric symptoms usually respond to medication”) and insulting (“Fifty to sixty percent of all nursing home residents are demented”).  While Alabama is held up as a good example and model for SCALFs because “mandatorydementia training” looks great on paper, the reality is much different.

See 5 Critical Questions to Ask When Selecting a Memory Care Facility .

Bottom Line: You can obtain information about nursing homes using the “Nursing Home Compare” website that contains important Medicare information and results inspections.

The information is a couple of years behind, but you can see trends with items like staffing, infections, and bedsores.

There are no sites like this for assisted living facilities.

I would recommend going to your state’s health department web site and seeing if there is information posted there.

Talk to health care providers, especially nurses, who usually know a lot of “behind the scenes” information.