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Thu, Sept. 19

THE GOOD PATIENT: What if you need to move from assisted living to nursing/skilled nursing?

This is the 10th in a series of articles intended to demystify the experience of living in a retirement community.

What if you're in assisted living in a retirement community and you need more care?

One option is to move to a building in your retirement community where they offer the care you need. For example, Good Samaritan and Las Fuentes both offer nursing/skilled nursing facilities in addition to assisted living units.

If your community doesn't offer that level of care - Granite Gate and Alta Vista don't offer nursing/skilled nursing facilities, for example - then a second option is to move to a different retirement community's unit that offers that level of care, or to leave retirement communities entirely and move to a free-standing long-term care facility (nursing home).

Moving to Las Fuentes or Good Samaritan in Prescott from Alta Vista isn't geographically a big move. All three communities are within shouting distance of each other. Although it would require a little bit of effort on the part of your family or friends left behind, it should not be too difficult for them to come see you. Granite Gate is further away.

But suppose that you very much like your assisted living apartment and don't want to move. Or suppose that you are half of a couple, and only one of you needs skilled nursing. You might find it very expensive to pay for two separate homes, one an apartment in assis-ted living and one a room in a skilled nursing unit. Even if you have the money to pay for two homes, perhaps the two of you don't want to live apart.

Then you might consider a third option, which is to stay in assisted living and bring supplemental skilled nursing services in from outside the retirement community to your apartment.

The law prohibits a facility that is licensed to provide assisted living from providing skilled nursing services to you that it isn't licensed to provide. However, the law does not prohibit you (or your representatives) from independently making arrangements with an organization such as a nursing agency to come in and provide additional services to you.

The law does put half a dozen hoops in your way, but they do not seem very hard to jump through. For example, you may have to get a note signed by your doctor saying that she agrees that you can safely stay in the assisted living unit.

You or your representative may have to sign a document saying that you understand the limits of the assisted living services provided and explicitly saying that you want to stay in assisted living anyway. And so forth.

It is less clear that this strategy is workable at Alta Vista, which is licensed to provide the first and second levels of assisted living care, but not the third level. Assisted living units licensed to provide "personal care" (the second level) are forbidden by law from having people living in them who require "directed care" (the third level). Nursing home care is typically a level beyond the third level of assisted living care.

Alta Vista points out that residents could revert to independent living status, and arrange to get all services from outside agencies, in order to stay there. That approach is possible, although it sounds to me as if it might be cumbersome. If you are interested in Alta Vista, talk to its management about this topic, because individual circumstances and solutions can vary, and the law is complex.

If you've moved into a skilled nursing facility, does that mean that you're done moving? Not necessarily. If you develop dementia and become hostile or threatening to other residents, or you start to wander away and don't know how to find your way back or even how to ask for help, you might have to move again, to a memory care unit specifically set up to handle such situations.

What's the key point? Before you decide to move to a retirement community, it's important to understand clearly what care you can - and cannot - expect to get there, and what other arrangements you might eventually need to make to get some types of care.

Elizabeth L. Bewley is president and CEO of Pario Health Institute and the author of "Killer Cure: Why Health Care Is the Second-Leading Cause of Death in America and How to Ensure that It's Not Yours." To tell Elizabeth your story or to ask her a question, write to thegoodpatient@pariohealth.net.

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