Continuing Care Retirement Communities (CCRC)

Driving through Rockwood Forest Estates, you wouldn’t think it was anything more than a slightly upscale suburb, says resident Elizabeth Hulteng. This neighborhood of roughly 150 homes, lush with landscaped gardens, pine forest, and protected wetlands, is part of Rockwood South, a Continuing Care Retirement Community (CCRC) or “life plan community” in Spokane, Washington.

Continuing care retirement communities are retirement communities with accommodations for independent living, assisted living and nursing home care, offering residents a continuum of care. A person can spend the rest of his life in a CCRC or life plan community, moving between levels of care as needed. People in the senior housing industry call this “aging in place,” although it does require leaving one’s original residence.

Hulteng and her husband chose a CCRC so their children would not have to worry about them. Since her husband had cancer in 1977, the couple also wanted his post-cancer health needs met within their community. In 1991, they moved into a Rockwood Forest Estates house. Until her husband died in 1996, all of his care took place at home, with nurses visiting and meals delivered to their doorstep. “We were able to stay in the house and felt perfectly comfortable,” says Hulteng. She says her community is an easy place to be a widow, giving her access to activities and an active social group.

There are no reliable statistics about how many seniors are living in continuing care retirement communities. “They are not licensed or certified by one entity. They are defined differently in every state; some are called CCRCs or life plan communities, others are called Active Adult Community Homes or Lifetime Communities,” says Sue Matthiesen, the managing director of Aging Services at the Commission on Accreditation of Rehabilitation Facilities (CARF), which has the nation’s only accrediting body for continuing care retirement communities (the Continuing Care Accreditation Commission, also known as CARF-CCAC). When choosing a CCRC, it is important to look at services offered by each community, the possible benefits and disadvantages, the costs, and the contractual obligations of the CCRC.

CCRC Basics

To be defined as a CCRC or life plan community, a community must offer independent living, assisted living and nursing home care all in one campus (acute care takes place at nearby hospitals.) Older adults must move into a CCRC when they are healthy. Although settings vary, most have a common dining room, activity centers, gyms, outdoor recreation and swimming pools. Social events happen on campus, and often there are outings to events, such as a night at the symphony. Depending on the community, living spaces can include houses, cottages, clusters, townhouses, duplexes and apartments.

Choosing to live in a CCRC is a costly endeavor, and individuals with low or even middle incomes and assets usually can’t afford this senior housing option. Payment plans differ at each CCRC, but a large entrance fee is usually required. This fee can be as little as $10,000 and as much as $500,000. With most continuing care retirement communities, an individual isn’t buying the place she lives in. Residents must also pay a monthly maintenance fee, which can range from roughly $200 to more than $2,000. A contract between the resident and the CCRC spells out what the monthly maintenance fee covers, as well as health care coverage and costs (see CCRC Financial Facts, below).

Benefits and Disadvantages of CCRC and Life Plan Communities

Residing in a CCRC can lessen worry for both the resident and his loved ones. Juhkentaal’s parents both lived in a Seattle-area CCRC for the last ten years of their lives. “It was a good decision. It made moving through the continuum so much easier,” he says. “They had people they knew to help them make their own decisions.”

Continuing care retirement communities can be a beneficial place for widows. According to Juhkentaal, after a spouse dies, the widow or widower often starts to self-isolate while grieving. “The other residents don’t impose themselves when someone has lost a spouse, but it’s safe to talk to someone in the dining room and the neighbors,” he says. “In essence, it is a social network that keeps people functioning and motivated.”

The health and wellness centers lead senior living activities to help all seniors lead a more active life, which can be hard to coordinate in the regular community, says Matthiesen. This engaging, community-centered lifestyle can help keep residents healthy. Juhkentaal expects to go to the 107th birthday party of a resident in September. “He gets nominal assistance in assisted living. He has subtle supports from the staff, but he can also be independent and make his own choices,” says Juhkentaal. “I don’t know if that would have happened in his own home.”

Outside of a CCRC, elderly people often need someone to mow their lawns and take them to the grocery store. Perhaps they don’t always want to prepare their meals. At a CCRC, the following services may be offered, depending on the monthly maintenance contract:

• Meals
• Transportation
• Lawn care
• Gardening
• Garbage and snow removal
• Housekeeping
• Social activities
• Laundry
• Some utilities
• Health monitoring services
• Emergency call monitoring
• Security

Hulteng spends half of each year at Rockwood South and the rest of her time at a vacation home in Idaho. “I can just walk out the door and not worry about anything,” she says.

When Hulteng is in-residence, her CCRC checks daily on her well-being. If a Rockwood South resident doesn’t check-in by 10:30 am (by pressing a button in her home), the staff attempts to reach her by phone. If no one answers, the nursing staff physically checks on the resident.

This community awareness of a person also helps with health care needs. Juhkentaal says a housekeeper may be the first person to note a change in a resident. Perhaps a resident always kept her apartment as neat as a pin, but now it is noticeably messier. “The early evidence gets treatment,” he says. The staff also helps ease transition into other levels of care. Knowing most care (except hospitalization) is provided within the campus can be reassuring for residents.

However, continuing care retirement communities aren’t right for every individual. “Not every consumer wants to leave [his] home,” says Matthiesen. Besides leaving cherished space and familiar territory, a person is moving into a community almost entirely composed of senior citizens. Often someone likes his neighborhood because there is an intergenerational mix, with toddlers, young couples and retirees, says Juhkentaal.

A person also needs to be comfortable with both the healthcare continuum and the monetary responsibility of living in a CCRC. Deciding healthcare options for the rest of ones life and committing to lifelong financial obligations is a big decision.

CCRC Financial Facts

When a person commits to CCRC or life plan community living, he signs a continuing care agreement. A lawyer or financial advisor should review this document first, as it is a legal contract between the resident and the CCRC. According to the AARP, the contract should cover:

• Residences
• Fee schedules
• Health care coverage
• Cancellations and refunds
• Services
• Insurance requirements
• Conditions for transfer within the community to other levels of care, and a description of the CCRC’s responsibility should a resident become unable to pay fees.

Every contract should have a clause about refundability. If a person leaves a CCRC, she often loses part or all of her entrance fee, depending on how long she has lived at the CCRC. According to Juhkentaal, most continuing care retirement communities offer multiple agreement choices and people can choose based on degree of refundability.

There are typically three fee schedule options at a CCRC:

1. Extensive Contracts: The most expensive agreement, give residents unlimited access to healthcare with little or no increase in the monthly maintenance fee.
2. Modified Contracts: This contract offers residents unlimited access to healthcare, but residents pay for healthcare as needed, with monthly maintenance fee increases to cover healthcare needs. Often the healthcare costs are offered at discounted rates.
3. Fee-for-Service Contracts: Residents pay for all health care costs separately. Although this can initially be the least expensive contract, it can be quite costly if a resident eventually has extensive health care needs.

Continuing care retirement communities may also offer residents a certain number of skilled care days each month without raising the monthly maintenance fee. (Sometimes this is a part of the modified contract schedule option.) For example, Rockwood South residents receive 10 free days a month of skilled care.

Juhkentaal notes that potential residents need to have a thorough understanding of how a CCRC applies its rates. “Residents who are looking at CCRCs are making lots of decisions, [such as] selling a house and disposing of stuff,” he says. “Ask deliberate questions about the extent of charges for the levels of care, as well as the guidelines for determining where a resident lives.”

Researching Aging in Place

Beyond the continuing care agreement, potential residents need to fully explore the details of each CCRC they are considering. Traditionally, continuing care retirement communities were not-for-profit organizations; today some CCRCs have for-profit business structures. If the CCRC is for-profit, the business might be sold someday. If there is a possibility of sale, how would that affect a resident’s contract?

Some continuing care retirement communities are accredited by CARF-CCAC, a lengthy process that must be renewed every five years. If a CCRC is approved, there is an annual and ongoing reporting process during the five-year term. “[If a CCRC has accreditation, it means] the organization is constantly self-examining what’s working and meeting a third party set of standards,” says Matthiesen. “The organization is very, very focused on the highest levels of performance, financial solvency, and good business practices.” Rockwood South is an accredited CCRC. “For us, it is a consumer value,” says Juhkentaal.

When visiting continuing care retirement communities, try to keep these important questions in mind:

• What happens when assisted living and nursing home facilities are full?
• Does the CCRC have a reciprocal agreement with nearby communities?
• How well is the staff trained? Do staff members go through criminal background checks?
• What is the staff-to-patient ratio in each living setting?
• Does the CCRC appear to be well-maintained, clean, and safe?
• Is there an Alzheimer’s unit or memory impairment services?
• How can a resident participate in the organization’s decision making? Is there a role for residents who wish to be involved?
• Does the CCRC culture match the resident? Is it a formal environment, with dinner jackets required in the dining room, or a casual atmosphere?

Try to explore the full range of health and wellness activities and social events, both on-campus and off. And don’t just look at the independent living quarters. Also visit the assisted living and nursing home facilities. “You don’t want to move into a CCRC without having really looked at all the services, being very upfront and honest with yourself during the process,” says Matthiesen.