MOVING ON: Transitioning to a CCRC
Virtually all of our senior friends are wrestling with the linked challenges of long-term healthcare and housing. How can we best plan for continuing affordable healthcare when American medical costs are spiraling out of control? And what housing solutions will best fit our evolving needs during our next life-chapter? Nancy and I devoted the past 18 months to identifying and evaluating available choices. We’ve now made our decision.
Blog followers have asked me to share highlights of our learning curve. This post interweaves two strands: journal notes of our transition journey; and a profile of the senior-residence type we selected – a Continuing Care Residential Community (CCRC).
Every senior individual or couple has their own set of influences framing their healthcare and housing choices: needs, values, resources, constraints and obligations. Our experience may give you food for thought.
We’re delighted to be launched on this Agile Aging adventure. How will it play out? Where will it lead us? Who will we become?
WHAT SET US IN MOTION
In February of 2018, Nancy was diagnosed with a hairline fracture of the hip. Not requiring surgery, but prompting a specialist’s caution to avoid heavy lifting, twists and bends. As bad luck would have it, within days I slipped on a sliding carpet, causing two tears in my right knee’s meniscus. The orthopedist prescribed a Velcro brace and a walker, followed by physical therapy. For the next week, I needed help with dressing and undressing, easing into and out of chairs, even toileting. And my housemate had a broken hip. Two gimps in one household were experiencing a wake-up call. Time to start thinking ahead about future professional support.
Medical concerns were not the only considerations prompting us to contemplate transitioning to a more supportive environment. In our mid-70s, we were both growing tired of household chores. Maintaining a large garden, plant-watering, shopping and cooking, laundry and housecleaning, paying bills – we longed for a simpler, labor-saving seniority.
Nancy and I had an abundance of evidence – positive and negative — from elders’ transitioning experiences within our two families. Her dad, an aunt and an uncle had all chosen to move into comfortable senior communities in their 70s and made cordial adjustments. They’d all talked about no more mowing the lawn, new buddies for bridge and backgammon, and the freedom to lock apartment doors and set off on international trips. In dramatic contrast, my older brother and one of Nancy’s aunts had both resisted moving until they’d suffered serious falls and fractures. Following surgery and rehabilitation, they’d been forced into available residential-care facilities not of their choice. They never did wholly adjust to, or accept, these placements before their deaths.
Extrapolating from these family precedents, strongly endorsed and promoted by a broad consensus of elder-care professionals, Nancy and I formed a working hypothesis. Transitioning deliberately and proactively, while still independent and reasonably fit, engenders a sense of contented empowerment. And we’d seen the alternative, up close and personal. Our chief takeaway was Don’t Leave It Too Late. Over a year and a half, we conducted on-line research and visited seven senior residential communities.
WHAT WE LOOKED INTO AND WHAT WE FOUND OUT
We quickly reaffirmed that providing medical and residential services to seniors is a rapid-growth industry, in our own California but also nationwide. (In Orange County alone, where I’d been helping my now-deceased brother, the Alzheimer’s Association’s local staff told me there were over 1,000 service providers: private- and public-sector, for-profit and non-profit, religious and secular, residential and non-residential.) Senior transitioning options spanned a wide spectrum — from staying at home and hiring at-home help, to moving to a non-medical “active-seniors” complex, to specialized facilities offering Assisted Living or Memory Care only, to comprehensive communities combining Independent Living with long-term medical care.
Aging in Place
From the outset of our search, Nancy and I were convinced we wanted to move into a residential community with on-site medical services. Retired on California’s Central Coast, we had no children, were renters, not property owners, and had developed no extended attachment to any house, neighborhood or town. But many of our senior friends loved their homes and had no intention of ever leaving. (A recent New York Times article reported that 87% of American adults over age 65 want to stay in their homes as they age.) One pal exclaimed, “I’m here until they roll me out into a hearse!” Another, in his 80s, had inherited his house from his mother. Many others had raised their kids in their homes and put down deep and wide community roots. Precisely or vaguely, these acquaintances anticipated some future regimen of on-site assistance from their on-call children or hired aides.
Senior health-care professionals repeatedly cautioned us against such plans. Most middle-aged children are too busy with their own careers and personal obligations to come running whenever aging parents request. Equally important, very few of those children have the medical or weight-lifting skills to provide safe and reliable in-home care.
Contracted home-service providers are, of course, an option. But apart from high costs ($20,000/month for three shifts in Southern California,) my brothers and I discovered that, after our elderly father became emotionally attached to an attractive nurse’s aide, she and her boyfriend backed up a pickup into my father’s driveway and began carting off his valuables, allegedly with his tacit consent.
NARROWING OUR FOCUS TO CCRCs
Nancy and I soon honed our search criteria for a senior residence. We wanted (1) a comfortable living environment, (2) with easy access to quality medical services, (3) at predictable long-term cost. Unintentionally, our criteria had just defined a Continuing Care Residential Community. We learned that CCRCs are few and far between. In California, for example, just over 100 such facilities serve the State’s 5 million senior citizens.
Of historical interest, many CCRCs were established by religious institutions in the 1960s, initially as safe retirement homes for congregation widows who were outliving their spouses. Most remain not-for-profit, and many church-affiliated, to the present time.
CCRCs are exceptionally comfortable residential communities. Although some occupy high-rise towers in major cities, more common are single-story complexes on expansive suburban or rural campuses. If they’ve been around for 50 or more years, trees and plantings are often mature, maintained by professional landscaping crews. Resident accommodations range from studio apartments, through one- and two-bedrooms, to large duplexes and detached cottages. Shared facilities include dining rooms, meeting spaces, libraries, auditoriums, seminar rooms, gyms with trainers and swimming pools.
CCRC benefits and services normally include residents’ apartment rent, utilities and basic cable, building renovations and maintenance, linen service and housekeeping, dining-room and carry-out meals, 24-hour security, parking, and complimentary transport to local destinations. Active programs of on-campus activities range from live concerts and movies to guest lectures and seminars, to wellness coaching, to arts and crafts studios. Excursions are regularly organized to nearby cultural exhibitions and performances. Some CCRC residents’ groups even sponsor international travel. The target ambience is a stimulating environment for active seniors.
The “Continuing Care” in CCRCs’ title is what most distinguishes these facilities from other senior residences. Although a large majority of CCRC residents occupy Independent Living accommodations, these campuses also include on-site components offering long-term medical care: Assisted-Living, Skilled-Nursing and Memory-Care. In addition, some CCRCs offer affiliations with, and hospital services at, nearby medical centers. CCRC residents are guaranteed lifetime care, as needed, in these medical facilities.
Paying the Bills
CCRCs are expensive for both host institutions and residents. Communities’ operating budgets cover residential amenities and medical services by charging a combination of Entrance Fees and Monthly Fees. While Entrance Fees vary widely by local property values and accommodation size (from studios to cottages,) in Central and Northern California they currently tend to range between $300,000 and $1.5 million for double-occupancy. Corresponding Monthly Fees might run from $7,000 to $10,000.
To help us gauge affordability, Nancy and I applied financial managers’ common rule-of-thumb. To be personally affordable, a CCRC Entrance Fee should cost no more than one-half the value of the applying individual’s or couple’s total assets. And a Monthly Fee should cost no more than one-half to two-thirds the value of their monthly income (from Social Security, annuities and pensions but not from a drawdown of assets).
Most CCRCs offer their residents three alternative contract types:
- Under the main Life-Care contract, the host institution guarantees to provide the resident’s life-time medical services, if and when needed, at the on-site medical units and the affiliated hospital, paying the resident’s Medicare co-pays and deductibles. No Monthly-Fee increases will be charged beyond a modest annual-inflation adjustment.
- The Continuing-Care contract variation is for residents preferring to retain their private Long-Term-Care insurance and/or supplemental health insurance policies, paying their own co-pays and deductibles. This variation reduces the Entrance Fee.
- Continuing-Care-with-Partial-Reimbursement allows residents to recover future rebates for passing on to their estates. The trade-off is higher Entrance Fees.
To sustain the viability of their business model, CCRCs require applicants to submit extensive supporting medical and financial data and documentation. In essence, they are seeking to attract solvent, reasonably healthy seniors.
Given these substantial fees and contractual complexities, Nancy and I knew we had to conduct careful advance CCRC research. We reached out to our financial advisors, tax accountant, estate lawyer and health-insurance agent for professional advice. Our homework also included digesting two practical, consumer guides published by California Advocates for Nursing Home Reform (canhr.org): “CCRCs: Is One Right for You?” and “Points to Consider for CCRC Consumers.” We also contacted the responsible State certification and licensing authority, the California Department of Social Services, Continuing-Care Contracts Branch (cdss.ca.gov).
Together, these experts and materials cautioned us to pay careful attention to crucial details not emphasized by CCRCs’ websites, four-color brochures or marketing presentations. There was an ample paper trail for us to examine, including licensed CCRCs’ mandated Disclosure Statements with audited financial figures. How long had a facility been in business? Who were its owners? What were their financial assets and reserves? What State inspections had been conducted and with what results? Was there a public record of complaints or standards violations? Were residents’ fees all-inclusive or only partial? Fixed or open-ended? If annual-inflation increases were built into the formula, at what rates had they been assessed for the past several years? (Consumer-protection advisors recommended 3.5% as a reasonable guideline.) What financial penalties were imposed if residents changed their minds and wished to withdraw? Were model-apartment sizes, fixtures and finishes truly representative?
Occupancy rates were another tell. The CCRCs with the best track records have rates above 90%. Much lower rates should be a clear danger signal, since they could indicate resident dissatisfaction as well as management’s inadequate revenues for improvements and upkeep. Waiting lists could be discouraging and slow to clear. But they also could constitute a positive sign: that demand for admission was outpacing supply.
To see – and hear – for ourselves, we were advised to visit our preferred CCRC campuses repeatedly, stay overnight, eat in the dining rooms, and talk privately with residents as well as with professional staffs.
WHERE WE CAME OUT
For Nancy and me, two selection criteria in particular helped us choose between “competing” CCRCs. One was proximity to, and affiliation with, a respected hospital system for possible future major medical treatment. The other was the prevailing atmosphere – separating “country clubs” from more low-key resident communities.
We gradually limited our CCRC candidates to two outstanding facilities. The one we ultimately selected appealed to us greatly due to its institutional relationship with Stanford University Health Services, where both of us already receive our specialized major medical treatment. (A Stanford primary-care satellite clinic is located just three miles from this community.) The cordial, unpretentious vibe of this residents’ community was also of core importance. Convenient access to San Jose and San Francisco for enjoying cultural and entertainment programs was a promising bonus.
The available apartment on offer at this preferred facility was attractive to us in size (2BR, 1.5BA, with a peninsula kitchen) and placement (on the community perimeter, facing a forested hillside.) We also welcomed the flexibility to sign up for only one meal a day in this community’s dining room. Other CCRCs had required our paying for three, whether we ate them or not.
We had hoped to make this transition at a relaxed pace, leaving Pacific Grove near the end of 2020. Instead, we were strongly encouraged by our chosen CCRC’s management team to accelerate our transition. If we were willing and able to move in by the end of 2019, they could offer us generous financial incentives. In addition, the attractive apartment that was currently available was undergoing thorough renovation, down to studs and concrete slab. We could have input into not only finishes like flooring and paint colors, but also the layout of interior walls and closets. These representatives also diplomatically alerted us that, if we postponed our application another year, full Life-Care benefits might no longer be on offer, our preferred apartment-type might not be available, and any intervening injury restricting our mobility might disqualify us for admission.
Weighing these carrots and sticks, we agreed to take occupancy on December 27, 2019. This speeded-up transition process has been hectic and demanding. But a flurry of gracious au revoir invitations from Central Coast friends and neighbors have lifted our spirits above logistics.
SOME TRANSITIONAL ISSUES: CHALLENGES AND OPPORTUNITIES
Before returning to the United States, Nancy and I lived for 15 years in a renovated Italian country house, with 3,300 square feet of interior space plus adjacent outbuildings. Retiring in California, we rented a succession of two 1,250-square-foot houses, both with 400-square-foot garages utilized as giant closets – a 50% reduction in living space. Surplus possessions were kept in commercial storage. Now suddenly we’ll be squeezing into an 860-square-foot apartment with negligible additional storage. Yet another 50% reduction.
Not complaining, after these and prior international moves we’ve learned to appreciate residential relocations as opportunities. Now in our mid-70s, we’re approaching this latest downsizing challenge as a liberating simplification. Not only of possessions but of lifestyle.
We’ve basically divided our worldly goods into five piles: Keep and Take, Estate Sale, Garage Sale, Donations, and Toss. Our “Take” inventory started with furniture. What pieces would we need, balancing familiar favorites with a new spare look? How many and which ones would fit into the smaller spaces? Nancy gauged floor space and furniture dimensions with a tape-measure and plotted arrangements on graph paper. A sofa and two rockers. Beds and desks. Chairs, tables and lamps. Our dining table for six was too large and would have to go to the Estate Sale. As a replacement, we’d have to be on the lookout for a drop-leaf table for two.
For decorations, we each soberly asked ourselves “Which items do I really care about? What do I want to carry with me into the rest of my life?” Family heirlooms? Cherished paintings, carpets or objets collected in exotic foreign lands? “Do I need to hang on to that to retain its memory?” Which favorite pieces would work together, room by room? Ditto with the scaled-back kitchen and no separate dining room. Did it make sense to transport eight dinner plates? The giant pasta kettle or huge skillet? Good china and silver?
We passed our clothes through a comparable selection filter. “Have I worn it in the last year? Am I likely to wear it with my new lifestyle?” For books, “Which ones am I likely to read in the coming year, especially if I haven’t already?” “Which few are treasures that changed my life?”
For our new apartment’s patio garden, we’re taking a few healthy plants in attractive pots, ceramic figures acquired in Southeast Asia, France and Italy, and a new flowering vine to decorate a planned trellis.
Altogether, our “Take” strategy is to help create a new environment to support our new life-chapter. Smaller, simpler, bright, cozy and nurturing.
We started our Leave-Behind culling with good-quality Estate-Sale selections, either inherited from parents or collected on our international travels. They’ll be appraised, publicized and displayed by the professional managers for sale at a multiple-estates consortium early in the new year.
For our Downsizing (Garage) Sale of lesser-value items, we deliberately priced everything low, not seeking to get rich but to have buyers pay us to haul our goods away. Individual items were priced with labels to avoid confusion or haggling. The array spanned potted plants, dishes, pots, pans, linens, tools and plants. Another couple brought some of their own items to sell, swelling the volume. Nancy advertised in advance, on Craig’s List and local websites, broadening the appeal with accompanying photos. On the day of the event, we stapled posters to telephone poles at well-traveled intersections. The result was a near-total success. Thirty pots of plants sold within as many minutes. By the end of the two-day event, we had disposed of 95% of everything on offer.
Donations featured much of our collection of African memorabilia and crafts, acquired when we both had lived and worked in East Africa 50 years ago. A friend will use them to help boost cultural-heritage awareness among African-American teens. Unsold books went to a local library sale. Clothing and remaining household goods are en route to a charity for their resale shop.
Balancing Solitude with Fellowship
In Italy, our five-acre farm was sited at the end of a long country road. Our present rental house sits on 3.5 sloping, ocean-view acres. In our CCRC apartment, we’ll share common walls on both sides, in a community of 300 residents occupying 200 apartments. Already, we’re being invited to get involved in any of 30+ on-campus activities. A Welcoming Committee is reaching out before we’ve picked up our door keys.
As introverts and writers, Nancy and I are accustomed to spending most of our time alone. We do a modest amount of socializing and are members of some local clubs. But the vast majority of our waking hours are solitary. Making interesting new friends and neighbors will be a treat. We appreciate the freedom to get involved with fellow residents and campus activities at our own pace.
HERE WE COME
Reflecting on these logistical tradeoffs, Nancy and I envision ourselves embarking upon no mere change of place but a change of lifestyle. This relocation constitutes a final – or perhaps penultimate – milestone on long and scintillating life journeys. We both relish change and are eager to begin this latest Agile-Aging adventure. A fresh beginning in a new year. A new nest, new community, new environment and excursions, new rhythms and routines, new vistas and horizons.
Stay tuned for additional progress reports early in 2020. In the interim, my warmest wishes for your happy and hopeful holiday season.