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The Top Ten Questions to Ask When Choosing an Independent, Assisted-Living, or Memory Care Community

When you tour an assisted-living and/or memory care community, you will most likely be told about the highlights and features of the property, the food, the activities, and other amenities. Let’s face it, all the expensive communities do these reasonably well and with very little variation. The real differences lie in how they cater to the individual preferences and care needs of the people they are being paid handsomely to serve. How well they communicate to one another and to you about what is and isn’t working and what is being done to make continuous improvements along the way is absolutely essential to achieve the highest quality of living possible.

The following questions will help you get to the heart and soul of the community you are considering. You will quickly learn which ones truly care about and respect elders beyond the stereotypical marketing messages. The sales person leading the tour may very well not know all the answers to the care questions and may even seem annoyed that you are asking. You can let them know that they can get back to you after speaking with those in charge of managing the care (they have different titles at different places) or that you would like to address your questions directly to them.

If you are speaking to a marketing person who is able to answer these questions with confidence and without hesitancy, you may have found your community. Am I expecting a lot from these organizations? Absolutely! It’s important to remember that on-line information and reviews are not always comprehensive, up-to-date or un-biased. There are often high quality, lower-cost communities that are under-represented on the internet. Turn to your local sources who work closely with qualified organizations to serve seniors.

1. What is your caregiver-to-resident ratio?

In memory care or higher acuity sections of an assisted-living, I like to see 1 to 5 or maybe 1 to 6 during the day shifts, slightly less during the overnight shift being acceptable. In low acuity assisted-living, no less that 1 to 8. Some communities that have a weak ratio will tell you that it’s better than it sounds because there is a med-tech and a manager. Med-techs do not count in this ratio in my book because their job is to focus on distributing the medications and they often are not available to assist when a care need arises (such as assistance with going to the toilet, changing soiled clothing, assisting with dining, and other physical and emotional needs). I don’t count managers in the ratio because we all know where managers spend their time…meetings, doing schedules and other paperwork, responding to e-mails and phone calls, etc. and they most often leave in the early evening. The other day I was told a 1 to 9 ratio in memory care works fine because they don’t take people who need lots of care and if a resident begins to need more assistance, they are asked to leave!

2. How do you ensure that there is adequate staff in the event of employee call-offs or during staff meetings?

A community may strive for a certain staffing ratio, but still fall short of providing the coverage needed if they do not have an adequate plan for handling staff call-offs. Certain times of the year, such as the cold and flu season and holidays, it is not uncommon for several staff members to call off on the same shift. What I want to hear when I ask this question is that there is a deep list of on-call staff members who are summoned immediately to cover the shifts or that private agencies provide staff in a crunch. There is technology available that puts out a call to multiple on-call staff members until all spots are covered. It is also important to me that during shift change and other all-staff meetings, there is a plan to provide assistance to those who need it.

3. What is your average call response time when a resident pushes their call button?

I want to hear that it is consistently around 3 to 5 minutes, absolutely no more than 10. No community can achieve 100% on this, especially during meal times or shift changes, but I want to hear that they meet this goal most of the time. Most places have systems that track the call and response time. I recommend being adamant about receiving a solid answer to this question as it is a critical safety concern.

4. What are your procedures if my loved one falls or has another medical crisis?

State stature requires staff to call 911 if a resident is known or suspected to have hit their head or if there are obvious critical issues. However, some communities are now instructing their staff not to assist a person to stand up after a fall, even if there are no apparent issues. These policies may lead to unnecessary, stressful, and expensive trips to the emergency room. In addition, most communities do not send a staff member along when a resident is sent to the emergency room even until a family member can get there. The whole experience of an emergency room visit is traumatic for most people going through it, especially those who are more frail. Some older folks have extreme reactions to such a chaotic environment on top of what sent them there in the first place. For many, it takes days or even weeks to return to their pre-emergency baseline.

5. What is the average length of employment of your management and staff?

Frequent changes in leadership and staff positions are disorienting and unsettling for those living in supported living communities and their families and is often a signal of greater organizational problems. Some communities have a majority of employees who have spent many years with the company and others have constant turnover. There are many who have a new Executive Director every year. I look for those who have consistency in all levels of the organizational structure.

6. What are your procedures for handling an observed change in behavior and/or condition?

I’ve been shocked in the past by emergencies that arose because noted behavior changes did not lead to care plan adjustments that could have prevented the crisis. Any change of behavior should trigger a care plan meeting involving key personnel, family members, and the resident if appropriate.

7. What do you do to help my loved one with the adjustment to their new home?

The first several days after a move-in are critical to a healthy adjustment to a new living situation. Communities vary greatly (even the most expensive) in how well a new resident is supported in the initial days. I like to see that they have a plan for helping them meet peers with whom they may best connect, how they learn about community offerings and policies, how they communicate across all levels and shifts so that all employees know about the new resident, and more.

8. Who would be my primary point of contact and what can I expect in terms of responsiveness to my inquiries?

Probably the most frequent complaint I receive from residents and family members about their care community is in regards to poor communication and confusion about who to speak with about which concerns. Some type of organizational chart should be made available that lets you know who to go to with different needs such as billing inquiries, questions about events, matters of company policy, and questions about care. There should always be a primary point of contact who can answer all questions about important care needs. Minor issues can often be handled by other members of the team as long as communication is strong throughout, but mistakes happen when there is not a single individual who is accountable for important care issues. You have the right to expect a speedy response regarding any need. I would say no more than 48 hours on non-urgent questions, no more than 12 on more urgent issues, and no more than 2 on highly urgent questions. If a person is on vacation, they should have a clear coverage plan that adheres to roughly this time-frame.

9. Would you provide a copy of the care plan?

An adequate care plan should detail every aspect of what the community will provide to meet the resident’s care needs, medication needs, social/emotional needs, and dietary needs.

10. How do your Resident Council and Family Council influence your policy and procedures?

Assisted-Living and Memory Care communities are required under Title 22 of the California Code of Regulations to have a Resident Council and many also have a Family Council to ensure that residents and family members have a collective voice in expressing concerns and making needed improvements. This is only effective if the administration welcomes and incorporates the input into its decision-making processes. When I ask about this, I look for an answer that is specific about how this is done, such as: “Each department manager reviews the notes from the meeting and reports to the Executive Director about how they will address the needs and suggestions that pertain to their department.” How they answer this question speaks volumes about how community-focused they are. Ultimately, it’s really only a “community” if it takes into account the individual and shared needs of all who live there. When you ask some or all of these questions, it will become apparent which communities have strong organizational structures as well as a deep commitment to serve the needs of their residents and their families. Working with a qualified placement specialist will ensure that you get the answers and support you need before, during, and after your community is chosen.