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Continuing care retirement communities (CCRCs), or multi-level care facilities, assure their residents independent living as long as possible, and provide for assisted living and nursing assistance if or when it is needed.

This type of living arrangement can be particularly useful to financially sound couples who are in need of different levels of care and who wish to maintain a strong relationship. The typical CCRC resident is a physically and financially independent, 80-year old, highly educated, single female.

Although CCRCs gained a somewhat negative reputation in the 1980s because some closed due to financial difficulty, the number of CCRCs in the United States has reached about 1,200 and continues to grow. (Maryland has 37 CCRCs)

Approximately 350,000 residents live in these for-profit and not-for-profit facilities, and this number will continue to increase as more individuals are able to meet the eligibility requirements for CCRCs. Entrance restrictions normally specify a minimum age, as well as a certain level of health and finances.

Waiting lists can be months or years long for such facilities, so it’s best to start looking into continuing care facilities well before you are planning to move.

Levels of care

Most CCRCs provide three separate levels of care: independent living units, assisted living, and skilled nursing care. In some cases, individuals move progressively through these levels of care: they need little care in the beginning and progressively require a greater amount of care. In other cases, residents require additional care for a limited period of time and then return to independent or assisted living.

During the first of these levels, the resident lives in his or her own residential unit. Double occupancy units exist for married individuals, but the majority are single units in the form of studio apartments, one-bedroom, two-bedroom, or larger units.

During this period, residential services might include housekeeping, laundry services and meals. Acute medical treatment in the form of skilled nursing, physical therapy, or assistance with personal needs is also available.

While independent, residents are most likely to take advantage of the residential facilities — which can include craft rooms, gardening areas, golf courses, recreational facilities, tennis courts, swimming pools and walking trails.

Assisted living is an intermediate level of care that some residents experience between independent living and skilled nursing care. During this phase, residents with chronic care needs are assisted both medically and with personal care tasks (bathing, dressing, eating, etc.).

Finally, skilled nursing care is also offered by the majority of CCRCs in the form of short- and long-term nursing care and rehabilitative services. These services are often offered on-site, although some facilities contract with nearby nursing homes.

Services offered to all residents typically include educational programs, exercise classes, meals, on-site healthcare, organized social activities and transportation.

Under almost all circumstances, an individual must be healthy and reasonably independent to be admitted to a CCRC. The level of care needed by the resident is initially assessed, and this process should be clearly explained in the residential contract. Normally, care is assessed by a group that includes family members, medical advisors, and the manager of the CCRC.

Fees and payments

The availability of these services and activities can make CCRCs quite expensive. All fees should be clearly detailed in the initial membership contract.

Before you sign a contract, you should have a financial advisor look over your finances to make sure you will be able to meet the terms of the contract for the years to come. Additionally, the financial advisor should look over the finances of the CCRC to make sure that it is a sound financial investment for the future.

Three types of payment plans exist for CRCCs, including a plan with an entry and monthly fee, a plan with a rental fee, and a plan based on equity.

•   Entry and monthly fee plans are the most widely used. Under this type of plan, the resident pays a sizable up-front entry fee, which may be nonrefundable, refundable on a declining basis over time, partially refundable, or even fully refundable. The policies concerning the initial entrance fee vary between CCRCs, so check the contract of the specific facility to learn more about its policy. On average, entrance fees range from $100,000 to $750,000, and monthly fees of $3,000 to $5,000 are charged to cover expenses associated with the living unit, required medical care and services.

•   Rental plans charge a rental or monthly fee to cover housing and services. Many times healthcare isn’t included in these services, so check carefully when looking at these plans.

•   Equity-based plans allow individuals to purchase their own living area. In doing so, individuals also may gain value from the appreciation of the living area, but are allowed to resell the unit only to qualified individuals. In these situations, an owner’s association governs the residential services and healthcare, which residents can purchase in addition to the living area.

Regardless of the payment plan, costs vary due to age, gender, marital status, and location of the facility. You should expect to pay higher rates if you:

 • are young and financially secure, such that monthly rates will be paid for a period of years,

 • are female, because of the longer life-expectancy, and/or

 • are married, because there is a greater likelihood that one spouse will become ill and the other will eventually move to a smaller living unit, increasing turnover in the unit.

Three kinds of contracts

It is also important to have an attorney review the CCRC contract before you sign it. Remember that this document is legally binding and intended to cover housing and healthcare for the remainder of your life.

Payment contracts for CCRCs are set up in one of three ways: extensive, modified, and fee-for-service.

•   Extensive contracts are the most comprehensive, covering amenities, residential services, housing, and long-term nursing care without an increase in monthly payments (except for normal inflation adjustments). The structure of extensive contracts spreads health risk among all residents so that no resident will experience financial ruin. Most CCRCs offer this type of contract.

•   A modified contact covers amenities, residential services, housing, and only a specified amount of nursing care. After the duration of the specified nursing care has been used, a resident would pay for required services on a daily or monthly basis.

•   A fee-for-service contract covers amenities, residential services, and housing, but only emergency or short-term nursing care. Residents must pay for long-term nursing care at daily rates.

Finding the right facility

Since there are no federal regulations governing CCRCs, find out what state or local guidelines exist. Additionally, check to see if the facility is accredited by CARF — an independent, nonprofit accrediting body. Accreditation by CARF means that the facility has met certain standards in the areas of residential life, health and wellness, financial resources and disclosure, and governance and administration. This accreditation requires CCRCs to submit annual financial statements and must be renewed every five years.

Courtesy of the National Caregivers Library. For additional articles on caregiving, housing and healthcare, see www.caregiverslibrary.org.