What are the Alternatives to Nursing Homes for Persons with Alzheimer’s / Dementia?

Last Updated: July 15, 2020


Just because someone with dementia requires nursing-home-level care does not mean they must move into a nursing home, and the alternatives can be a huge relief for people with dementia and their families. This article will explain the options a person with dementia has besides moving into a nursing home, the costs associated with each type of care, and possible sources of public assistance.


At Home

Losing independence obviously means someone cannot live alone. This can be distressing for adults who consider themselves self-sustainable, but there are ways to make staying in the house easier for people as they advance through multiple stages of dementia. Routine and continuity are vital for managing symptoms of dementia, so staying at home may be the best choice.


Caregiving by a Loved One

Caregiving by a loved one is appropriate in the earliest stages, but usually becomes too hard after about two years. This is especially true when the caregivers are elderly themselves. Caregiver stress and even burnout is a major problem with dementia. Caregivers must help a person dress, bathe, and possibly even eat. Aggression and even hallucinations can become a problem. Respite care is available to provide temporary relief of caregiving duties. However, typical respite care programs, while free or affordable, might only offer a 4-hr window of care, once weekly. Adult day care, described below, has more consistency and is a good option to relieve the workload of a caregiver.

There are a variety of programs that will pay family members to care for their loved one at home. However, not every family will be eligible for these programs and caregivers should expect to jump through a significant number of hoops to participate. Further, caregivers should expect only to be compensated for a limited number of hours and to be paid about minimum wage.

 Did You Know? Studies have shown caregiving causes chronic stress that affects health. It also, however, strengthens family relationships.


Live-in Care

Live-in caregivers are a great option for someone who wants to stay at home, obviously, but issues include cost (usually at least $200 per day) and space (you need a separate room for the caregiver). Live-in care is slightly less expensive than 24-hour home care because some of the cost is offset by the room and board benefits received by the caregiver. Since it is not uncommon for elderly individuals to reside in a home with more bedrooms than residents, having an extra room is not always a problem.

There are rules that must be followed when hiring a live-in caregiver. You actually need two caregivers, because four or five days per week is all that’s legally allowed. For the other two or three days, you must fill in or hire someone else with the same skills or qualifications. Caregivers must have four hours of a break every 24 hours, and an eight-hour allotment every night to sleep. Proper insurances are important. To hire live-in caregivers you’ll need to provide, at least, liability insurance and worker’s compensation insurance in case of injury or negligence.

Possible sources of financial assistance include Medicaid and VA Benefits. There is very little non-Medicaid, public assistance available for live-in care and Medicare offers no assistance.


24-Hour Home Care

This option typically sees three caregivers hired to split the duties. They might take 12-hour shifts or split the time up by exchanging eight-hour shifts to stay sharp throughout the days and nights. The differences between this and traditional live-in care above is that this option is more expensive. You will need to pay hourly, instead of daily, rates. Depending on the area of the country in which the individual resides, the hourly rate for home care is between $15 and $30. A downside of this approach is that it means less consistency for the person with dementia. An upside is that it is easier to find caregivers through home care agencies vs. finding a live-in caregiver. Working through a home care agency also eliminates the logistics associated with hiring an employee directly (such as insurance and payroll).

Medicaid, VA benefits and to a lesser extent Medicare through a PACE / Life program or through a specially designed Medicare Advantage program will provide financial help for home care.


Combining Home and Adult Day Care

Adult day care, also called “Alzheimer’s Day Treatment”, makes days more interesting and productive for your loved one with dementia, while allowing caregivers to still go to work or take a much-needed break. For hours every day (usually during normal business hours, but ask about this), adult day care provides seniors a home away from home with nutritious meals, activities including social games and exercise, health and personal care, and even behavior management and therapies. Adult day care costs roughly $75 per day (or $1,575 per month based on 21 workdays per month on average) but the cost is less expensive than home health care, and many day cares accept Medicaid and VA benefits. Options sometimes include transportation to and from their location, and staff can often take your loved one to doctor appointments.

Options like transportation might cost extra; you’ll want to be very clear on all charges, including optional fees, before placing your loved one in adult day care. Also be sure to specifically ask whether staff is trained to handle dementia symptoms, and for the staff-to-resident ratio (a good ratio is around 1-to-5). Because routine is so important for a person with dementia, the transition to day care might be difficult. Seniors often resist at first, but after a while become very happy with their time in adult day care. A good idea to get used to it is taking your loved one once or twice per week, for about three or four hours at a time, until they’re comfortable.


Outside the Home

When living at home becomes too difficult or unsafe, especially as dementia advances out of earlier stages, moving out of the house and into a specialized community will become necessary. The planning for this should begin as soon as there’s a diagnosis, before moving becomes necessary, so that your loved one can provide input on which residential care option is best.


Adult Foster Care

Adult foster care is a level of care for people with illnesses including dementia that lies somewhere between staying at home and moving into a nursing home. Adult foster care homes typically serve two or three seniors, so it feels more familiar and personalized. Meals, activities, and help with activities of daily living are provided in adult foster care, but usually not medical care. For this reason, adult foster care is not appropriate for people in the late stages of dementia. Adult foster care does not need a staffer awake at all times, unlike assisted living. The industry is regulated by states, so rules vary. The cost of adult foster care is typically between $2,000 and $4,000 per month. Medicaid and VA benefits might provide financial help.


Board and Care Homes

Board and care homes, like adult foster care, are a good choice for people who need caregiving but want to live in a smaller, cozier residence. Also called “group homes” or “residential care homes,” these are houses with senior- and dementia-friendly upgrades for safety and mobility, as well as staff trained to provide health and personal care. There are usually less than 10 residents in a single board and care home. The cost is often between $3,000 and $5,000 per month, and Medicaid and VA benefits programs may be able to help.

Board and care homes are best for people in the early and middle stages of dementia, who don’t necessarily need 24-hour supervision. Meals, snacks, and housekeeping will be taken care of, but there will probably be less structured activities and socialization in a board and care home. Of course, investigate the home thoroughly to ensure a good match with your loved one before committing. Free assistance is available to help families locate board and care homes that meet their loved one’s needs and budget. Start here.


Assisted Living

Regular assisted living is usually a studio or apartment-style living with basic assistance including help with activities of daily living. These communities are usually not specifically designed for people with dementia, but in the early stages it might be appropriate. Residents in assisted living need to have some independence, but the community will provide meals in a cafeteria or common eating area, structured activities, and help with medical issues including transportation to and from doctor’s appointments. Supervision is provided 24 hours per day, with someone awake at all times.


Memory Care

Memory care is assisted living specifically for people with dementia. (Other terms for memory care include Alzheimer’s Units and Dementia Units.) Memory care may be a wing of an existing assisted living community, or an entire residence. The most important aspect of memory care for people with dementia is that staff is specifically trained to communicate with and assist people who have dementia. For this reason, memory care is the best option for someone with Alzheimer’s disease, or related illness, who cannot remain at home. For more on the differences between memory care and nursing homes – including a comparison table with costs, staff training, and eviction policies – click here.

 Did You Know? The families of persons with dementia can get assistance finding, touring and negotiating with Memory Care residences. Start here.


The Green House Project

The Green House Project is an alternative to traditional assisted living, memory care, and nursing homes. Available in more than 30 states, these residences are similar to board and care homes (see above), with less than 10 residents for a more intimate setting. Seniors who move into Green House Project homes share common areas but have their own room and bathroom. There are not structured activities. That level of independence means the home might not fit someone in the later stages of dementia, but these homes have small staff-to-resident ratios, and staff are trained to deal with the health and personal care needs of people with Alzheimer’s disease or related dementia. The homes are designed to be state-of-the-art in terms of energy efficiency and smart technology like adaptive care devices and senior-friendly computers. Costs are similar to a nursing home, making this an expensive option for your loved one. To find a home, visit the company’s website here.