In Texas, an assisted living facility (ALF) is a residence that provides living accommodations, meals, assistance with activities of daily living (ADLs), such as personal hygiene, dressing/undressing, eating, and/or giving medications/overseeing intake of medications. Recreational activities, as well as limited skilled nursing services may also be provided. The residences must accommodate a minimum of 4 residents, none of which may be a relative of the owner of the facility. Worth mentioning, in the state of Texas, any residence that is not licensed by the Texas Health and Human Services Commission (HHSC) cannot use the term “assisted living”.
Texas has two types of assisted living facilities (ALFs): Type A and Type B. The main differentiation between these two types is the residents’ ability to safely exit the facility if there is an emergency need to exit. In order to be a Type A facility, residents must be competent to remove themselves from the facility without assistance. In addition, residents must be able to understand and act according when given direction, must show that they can comply with evacuation practices, and must not require regular assistance during the night. For Type B facilities, none of the above rules apply, as residents can require assistance with exiting the residence if there is an emergency and they can require regular assistance overnight. That said, a resident must not be confined to his/her bed. In addition to being a Type A or Type B facility, all facilities are categorized as small or large. To be small, the residence must accommodate fewer than 16 residents, and to be large, there must be accommodation for a minimum of 16 residents.
All ALFs that accommodate persons with Alzheimer’s disease and related dementias are Type B assisted living residences and are formally referred to as Alzheimer’s certified facilities or Alzheimer’s certified units. That said, these names are considered to be mostly legal terminology. In more common language, these residences are called Memory Care Homes.
These types of homes in Texas differ from traditional assisted living in several ways. These include increased security and supervision, additional staff training, a greater number of employees, recreational activities specific for persons with dementia, and of course, cost. A point of distinction should be made that memory care homes are not nursing homes. In most cases, these residences are less expensive and offer a better quality of life to their residents.
Due to the added level of security and supervision of Alzheimer’s certified facilities in Texas, memory care generally costs several hundred dollars more per month than does traditional assisted living. Statewide, as of 2019, the average cost of memory care is $4,478 / month, but based on the geographic location in which one resides, the monthly cost varies greatly. For instance, memory care can be found as low as $1,600 / month and as high as $11,000 / month. Some of the more affordable locations within the state are closer to the bordering states of New Mexico, Oklahoma, Arkansas, and Louisiana. These include the following cities with the following average cost: El Paso ($2,655 / month), Texarkana ($2,672 / month), and Longview ($3,658 / month). On the other hand, the most expensive cities are Austin ($6,124 / month), Odessa ($5,433 / month), and Dallas ($5,133 / month). However, even within one specific area, such as Austin, the price of memory care ranges greatly with a low average of $3,835 / month and a high average of $9,103 / month.
In Texas, Alzheimer’s certified facilities and units are physically constructed for the safety and wellbeing of those with such neurological disorders. Examples of what this might entail are secure facilities / units that are locked 24 /7 and an enclosed outdoor area to prevent wandering. All ALFs must have a manager that oversees it. In order to fill this role, one must take a 24-hour management-training course, which must be completed within one year of being employed. (Those hired prior to August of 2000 are not required to complete this training.) In addition, managers are required to continue their education by taking continuing education courses (12 hours annually). The covered topics range from management to resources in the community to interacting with residents and more.
In order to be employed at an ALF, one must be a minimum of 18 years old OR a graduate of high school. Training of staff varies depending on one’s position and responsibilities. That said, all employees must go through an orientation, which is 4 hours. After the orientation and prior to working independently, those who provide direct care to the residents are required to do on-the-job training (16 hours). In addition, direct care employees require an additional 6 hours of training each year.
For employees working with persons with Alzheimer’s disease and related dementias in Alzheimer’s certified facilities and units, the training is similar, but is more dementia-specific. For instance, this is the focus of the 4-hour orientation. Like with traditional assisted living, staff in memory care homes who directly work with residents must complete 16 hours of on the job training, which is to be completed immediately following orientation.
For memory care residences that house 17 residents (or more), it is required that an activity director is hired to work a minimum of 20 hours per week. Residences that have less than 17 residents do not have to hire an activity director, but must appoint a staff member to organize and carry out cognitive and recreational activities.
When it comes to staffing ratios in Texas, there isn’t a specified staff to resident ratio. That said, all ALFs, including memory care homes, must have enough employees to meet the residents’ needs. In addition, it is required that residences report and post the number of staff (and their positions) each month. For night shift staffing, small and large traditional assisted living facilities must have employees on duty that are available to meet the needs of the residents right away. Unlike with large traditional assisted living residences, the nighttime staff of small traditional residences may sleep on duty. With memory care, the overnight staff must be awake at all times, regardless of the size of the residence. For large Alzheimer’s certified facilities or units, there must be two night shift employees on duty and available.
In Texas, in order to be admitted to an assisted living residence, including Alzheimer’s certified facilities, one must be at least 18 years of age and have a functional need based on a functional assessment score. Individuals cannot be admitted to a residence if they have needs that are greater than can be met at the residence or have needs that are unable to be met through third party services. This should go without saying, but residents of Alzheimer’s certified facilities and units must have Alzheimer’s disease or some form of dementia.
Residents must have a physical exam within a defined period of time, to be completed by a doctor. This timeframe is between 30 days prior to admission to 14 days after admittance. An exception is made for residents transferring from another ALF or a hospital and a physical exam has already been done and is in one’s medical file.
Within 2 weeks of admittance to an ALF, a resident assessment must be completed and a care plan created. The assessment may vary based on the assisted living residence, but most likely will cover competency of performing daily living activities, cognitive deficiencies, problematic behaviors/symptoms, medical needs, etc.
In most cases, it will take several weeks for a family to research and choose an assisted living residence that will best suit the needs of for their loved one. Then, a few more weeks are usually spent relocating their loved one and getting him/her settled in. An important note: Many assisted living residences have waiting lists, which means admission is not always immediate.
While the cost of memory care can be quite expensive, financial assistance is available for low-income persons who need it.
Medicaid is a jointly funded federal and state health care program, and in Texas (like all states), it pays for nursing home care for financially needy persons. In addition to the state plan, Texas also offers home and community based services (HCBS) via a HCBS Medicaid waiver. Intended to delay the need for institutionalization, the Star+PLUS Medicaid waiver is for persons 65 years of age and older (or disabled) who require a level of care consistent to that which is provided in a nursing home. Under this wavier, several supportive services/ supports are available, including personal care assistance for persons residing at home or in assisted living facilities (and Alzheimer’s certified facilities). To be clear, this program will not cover the cost of room and board. It only covers care assistance. Please note: Unlike with the state Medicaid plan, the Medicaid waiver has participant enrollment limits, which means a waiting list may exist.
The Texas Community Care for the Aged / Disabled Program, abbreviated as CCAD, provides adult day care, meal delivery, emergency response services, and assistance with daily living activities for persons over the age of 18 who have a functional need. Available services may include help with bathing, grooming, dressing/undressing, eating, mobility, transitioning, cooking, and shopping for essentials. Personal care assistance is available in one’s home, an adult foster care home, or in an assisted living facility.
While not limited to Texas, the VA offers an Aid & Attendance (A&A) pension (monthly cash assistance) for veteran’s and surviving spouses who are eligible for one of two pensions: Basic VA pension or the basic survivor’s VA pension. Applicants must be a minimum of 65 years of age (or disabled) and require assistance with completing daily living activities. Examples include assistance with mobility, transferring, toileting, eating, and bathing. The cash assistance received from VA pensions can be used as the recipient sees fit, which means it can go towards the cost of memory care. In addition, the cost of residential care can be deducted from one’s income, effectively reducing one’s countable income when determining one’s pension benefit amount. As of 2019, veterans can receive as much as $26,765 per year, and surviving spouses can receive as much as $14,529 per year. For additional information, click here.
Another option is state Veterans homes, which are residential care facilities that provide long-term care for Veterans. In addition to nursing home care, assisted living and memory care may be provided. Payment is made directly from the VA to the facility.