Last Updated: April 22, 2015
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) 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, 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
There are no reliable statistics about how many senior citizens
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, 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.
To be defined as a CCRC, 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 & Possible Disadvantages of Continuing
Care Retirement 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
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
- Lawn care
- Garbage and snow removal
- Social activities
- Some utilities
- Health monitoring services
- Emergency call monitoring
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
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 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:
- Fee schedules
- Health care coverage
- Cancellations and refunds
- 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
There are typically three fee schedule options at a CCRC:
- Extensive Contracts: The most expensive
agreement, give residents unlimited access to healthcare with
little or no increase in the monthly maintenance fee.
- 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
- 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
- Does the CCRC have a reciprocal agreement with nearby
- 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
- Is there an Alzheimer's unit or memory impairment
- 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
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