Individuals and families looking for long-term senior living and care options often find it difficult to determine the right level of care for themselves or their loved one. There are a wide range of options, from independent and assisted living communities to nursing homes, memory care facilities, and even adult foster care homes. Continuing care retirement communities (CCRCs) address the changing needs of aging seniors by offering multiple levels of care at the same location.

Residents typically enter these communities when they are relatively independent and move from one level of care to another over time. Therefore, these kinds of communities can be a good option for those who anticipate their needs or preferences changing over time and/or for those who are hoping to form close and lasting friendships with other residents living in the same community.

Most people’s needs change to some degree throughout the aging process, and many seniors are faced with having to move to a new community when their current level of care no longer meets their needs.
 

What are continuing care retirement communities?

Continuing care retirement communities (CCRCs) provide a continuum of care and housing for those who require independent living, assisted living, and skilled nursing home care. Some continuing care retirement communities also have a wing dedicated to memory care, and can, therefore, accommodate seniors with dementia and other forms of cognitive impairment.

CCRCs provide a tiered approach to long-term care, and it is common for a single resident to move from one level of care to another as his or her needs change over time. Residents generally enter these types of communities when they are able to live independently and do not require specialized care. Continuing care retirement communities are designed to allow a senior to spend the rest of his or her life in the same community, transitioning from one level of care to another as needs increase. This process is often referred to as “aging in place” by those in the retirement housing industry.

Housing options vary from community to community, and living spaces in CCRCs may take the form of townhouses, duplexes, cottages, apartments, or bedrooms with shared bathrooms and kitchens. Although every community is different in terms of the particular services provided and the amenities offered, most Continuing care retirement communities also provide common areas such as dining rooms, gyms, and other recreational centers, and many also offer organized social events and activities.
 

Who needs a CCRC?

Since continuing care retirement communities offer multiple levels of care and are generally larger than communities dedicated singularly to independent living, assisted living, or nursing home care, they serve a large and diverse population of seniors with a wide range of needs and requirements.

There are currently approximately 2,000 CCRCs in the United States, which together offer a total of 600,000 living units, and the popularity of CCRCs is expected to increase in the years to come.

CCRC residents almost always enter these communities in independent living, where they typically live alone or with a spouse in a home, cottage, or apartment and require little, if any, assistance with daily needs. If and when residents require assistance with activities of daily living (ADLs) such as bathing, dressing, eating, and toileting, they generally move to the assisted living or nursing care facilities within the community.

In this way, continuing care retirement communities are not specifically designed to meet the needs of one particular group of seniors. They are instead designed to accommodate the full range of needs and allow residents to move along the continuum of care as their needs evolve over time.

These kinds of communities allow seniors to plan their retirement and long-term care services independently and ahead of time. They provide a way for older adults to choose their own community and define their own preferences and wishes before they are unable to do so independently. They also offer residents the security of knowing that if they ever require assisted living, nursing home, or memory care services, their changing needs will be taken care of.

Individuals and families may choose a CCRC as opposed to another retirement housing option for any number of reasons. Below are a few reasons you and your family may consider choosing a CCRC:

• If you are still relatively independent but anticipate your needs changing over time, CCRCs may be a good option since these communities are designed to accommodate evolving needs throughout the aging process.
• If you are looking to establish long-term connections and friendships with other residents living in the community, you may enjoy living in a CCRC, since you can remain friends with other residents even as your (and their) level of care changes over time.
• If you are looking for a long-term residence where you can stay for the rest of your life, you may find a CCRC to be the ideal option, since they are designed to allow residents to stay in the same geographical location as needs increase, although small moves may still be necessary (e.g. from an independent living cottage to an assisted living apartment).
• If you and your spouse require different levels of care or you have distinct and separate needs or preferences (or anticipate differing needs in the future), CCRCs may be a good solution. For example, if one spouse is still able to live relatively independently while the other needs help bathing and eating, both spouses will have their needs met at a CCRC. Most facilities will work with residents to allow couples to live together while receiving different levels of care.

Eligibility requirements

All kinds of senior living communities ask applicants to fill out paperwork and undergo some initial screening procedures. Since residents tend to live in continuing care retirement communities indefinitely and move from one level of care to another throughout the aging process, CCRCs tend to have stricter eligibility requirements than other types of long-term care facilities.

Since potential residents are typically choosing a community to live in for the rest of their lives, the thorough screening process required by the majority of CCRCs is a good opportunity for both the community and the potential resident to determine if it is a good fit. Although the application process at each individual community is unique, there are some standard procedures and basic requirements that most CCRCs expect.
 

Health requirements and assessment

Prior to moving into the community, CCRCs will generally require you to fill out an application and provide detailed health and medical history information. Many communities also ask applicants to provide family medical history to help determine what level of care a resident may need when they enter the community and gain an understanding of what future needs may be.

Additionally, CCRC applicants undergo a physical exam performed by a medical professional to assess overall health and determine if there are any current health concerns. Many communities also perform a mental health exam during the application process. Almost all continuing care retirement communities require new residents to be in good health and able to live relatively independently when they enter the community. Many communities also require that new residents fall within certain minimum and/or maximum age limits.
 

Financial and legal requirements

Applicants must also meet certain financial requirements prior to moving into any given community, and demonstrate an ability to pay all required fees. There is generally an entry fee in addition to an adjustable monthly fee that is determined based on the level of care the resident requires. There are also often additional fees associated with the process of moving into the community. Additionally, some CCRCs require Medicare or Medicaid coverage prior to admission, although this is not always the case.

Due to the nature of continuing care retirement communities, financial eligibility requirements tend to be stricter and more comprehensive compared to those of other forms of senior living. Not only must applicants provide financial disclosure demonstrating their ability to pay for their current level of care, but they must also demonstrate an ability to pay for future services, should fees increase as they require more intensive care in the future.

Many CCRCs also ask applicants to provide copies of relevant legal documents to the community prior to being admitted. These documents are typically filed and stored at the facility, where they can be accessed by staff and used if and when a resident becomes unable to make their own medical decisions. These documents may include a living will and a power of attorney, and you may also be asked to complete an advanced directive.
 

Other considerations

Every continuing care retirement community has its own unique set of eligibility requirements, and it is important for applicants to understand the expectations of the specific community as well as to get any of their own questions answered during the screening process. In addition to the initial assessments and paperwork required during the application process, CCRCs also generally have procedures in place to regularly assess the overall health of residents on an ongoing basis and ensure all care plans are up-to-date.

Since residents generally expect to live in the same community for the rest of their lives, it is important that the community is a good cultural and social fit in addition to meeting all practical needs. It is worth noting that, if a particular CCRC is affiliated with a particular ethnic, religious, or cultural group or organization, the community may require membership in the relevant group as a prerequisite for admission.

As is the case with any form of long-term senior care, it is important to make sure the culture and values of any CCRC you are considering joining are in line with yours and that you feel comfortable and at home in the community.
 

CCRC contracts

There are three standard types of contracts that CCRCs generally offer residents who meet the eligibility requirements and have chosen to move into the community:
 

Extensive or life contracts (type A)

These contracts are the most expensive of the three types and typically have the highest entry fees. They generally include housing and residential services, use of all amenities, and unlimited access to all assisted living and healthcare services with no extra fee.
 

Modified contracts (type B)

Modified contracts generally come with lower entry fees and initial monthly fees compared to those of extensive contracts and offer many of the same services, although there are limits on the healthcare services that can be accessed by the resident with no extra fees. If the resident requires additional services not included in the contract, the monthly fee will increase.
 

Fee-for-service contracts (type C)

These kinds of contracts typically have the lowest entry fees and initial monthly fees but require residents to pay the market rate of any healthcare services on an as-needed basis.
 

Services provided by CCRCs

What sets continuing care retirement communities apart from other forms of long-term care options is that these kinds of communities are adaptable by nature and residents’ level of care and services are continuously reassessed and updated to meet their changing needs. Since residents typically expect to live in the community for the rest of their lives, CCRCs are designed to provide all of the services that residents may need for the duration of their lives.

In a CCRC, residents generally choose the level of care and the particular services they access based on their specific needs and preferences. Although residents in independent living are likely to require very few of the services offered by the CCRC, they have the security of knowing that, should their needs increase in the future, they will be able to stay in the same community. Continuing care retirement communities also provide emergency medical aid to residents in all levels of care.

Since each resident has his or her own particular set of needs and preferences and therefore requires a unique set of services, the services provided by CCRCs can be generally categorized based on the resident’s level of care. Although each continuing care retirement community will differ in terms of services and amenities offered, standard services offered at each level of care are listed below:
 

Independent living

• Apartments, cottages, houses, or duplexes with full kitchens
• Housekeeping, laundry, and gardening services
• Outdoor gardens, courtyards, walking paths, or parks
• Restaurant-style dining room
• Organized social activities and events
• Salon and barbershop services
• Access to recreational centers and exercise classes

Assisted living

• Private rooms or apartments (often with a kitchenette and private bathroom)
• Housekeeping and laundry services
• Outdoor gardens, courtyards, walking paths, or parks
• Emergency call-buttons
• 24/7 personal assistance with ADLs such as bathing, eating, and toileting
• Three meals provided daily and snacks between meals
• Medication management and assistance
• Transportation to and from doctors’ appointments and other outside errands and  activities
• Social and recreational activities, and scheduled trips and outings (families are often welcome to participate)
• Salon and barbershop services
• Access to recreational centers and exercise classes

Nursing home care

• Private rooms
• Short or long term care plans
• Housekeeping and laundry services
• Emergency call-buttons
• 24/7 personal assistance with ADLs such as bathing, eating, and toileting
• Skilled nursing services available 24/7
• Three meals provided daily and snacks between meals
• Licensed on-site physicians
• Rehabilitation services such as speech or physical therapy
• Medication management and assistance
• On-site laboratory and pharmacy or transportation to and from off-site appointments
• Social and recreational activities and scheduled events

Memory care

In addition to independent living, assisted living, and nursing home care, some CCRCs also have a specific wing or separate facility dedicated to those suffering from Alzheimer’s disease and dementia, and require memory care. Memory care is designed to accommodate the particular needs of residents with Alzheimer’s disease and other forms of dementia. Memory care patients are sometimes at risk for wandering and other specific behavioral symptoms, so memory care facilities have increased security and higher staff-to-resident ratios than other levels of care.

Although the above lists represent some of the common services provided at each level of care, continuing care retirement communities will generally work with each resident upon entry and on an ongoing basis to determine the unique needs of each individual resident.
 

CCRC costs

Compared to other forms of senior living, CCRCs are an expensive option. As previously discussed, the costs associated with living in a CCRC partially depend on what kind of contract a resident chooses. Typically, new residents pay an entry fee upon moving into the community in addition to an ongoing monthly fee. The amount of the monthly fee depends on the level of care required by the resident and the services the resident has access to. Monthly fees also tend to increase over time as residents require additional services over time.

The U.S. Government Accountability Office (GAO) conducted research on the average entry and monthly fees paid by residents of CCRCs and found the following, broken down by the type of contract signed:
 

Extensive or life contracts (type A)

• Entry fee: $160,000 to $600,000
• Monthly fee: $2,500 to $5,400 for all care levels

Modified contracts (type B)

• Entry fee: $80,000 to $750,000
• Monthly fee: $1,500 to $2,500 for all care levels

Fee-for-service contracts (type C)

• Entry fee: $100,000 to $500,000
• Monthly fee: $1,300 to $4,300 for independent living, $3,700 to $5,800 for assisted living, and $8,100 to $10,000 for nursing home care

It should be noted that although the cost ranges above depict the average, the amount that an individual continuing care retirement community resident spends depends on a variety of factors, including the size of the community, the type of housing or living space, and the particular services and amenities accessed by the individual resident. As is the case with all forms of long-term care services and senior living, costs vary greatly.
 

Paying for a continuing care community

The high cost of CCRCs is a major concern for many individuals and families considering this option. Not only are residents of CCRCs paying for the services and amenities they currently require, but they are also paying for the security of knowing that their future needs will be taken care of and that their spouses, children, or other loved ones will not have to make sudden, unexpected decisions about their healthcare and other needs as they age.

Although monthly fees at continuing care retirement communities tend to be higher than those at other types of long-term care facilities, most people’s primary concern is the substantial entry fee associated with moving into a continuing care community. It is very common for new residents to cover the cost of the entry fee with proceeds from selling their home.

It is important to compare the types of contracts offered by a particular CCRC and compare the monthly fees with current housing, utility, food, healthcare, and activity expenses. It is important to remember that food, utilities, and recreational and social activities are typically included in monthly fees. You may choose to attend a one-time consultation with a financial advisor to go over the options and weigh the pros and cons of your long-term care options.
 

Savings, assets, and long-term care insurance

As discussed above, residents frequently use home equity to pay for long-term care with the proceeds earned from the sale of their home. Proceeds from the sale of other assets such as stocks, bonds, and jewels and any retirement savings can also help cover long-term care costs at a CCRC.

Long-term care insurance policies can also help pay the costs associated with living in a CCRC if the resident requires assistance with activities of daily living (ADLs). It is worth noting that many of these policies place limits and restrictions on how much money they will provide policyholders and for how long they will pay.
 

Medicaid and Medicare

It is common for seniors who meet the eligibility requirements to use Medicaid to cover the costs of long-term care. However, Medicaid is designed to help low-income individuals, and most states require that Medicaid beneficiaries meet both financial eligibility requirements (which, depending on the state, may include limits on both income and assets) and functional eligibility requirements.

Due to the high costs associated with continuing care retirement communities, and the fact that the majority of residents enter these communities when they are still able to live independently, many CCRC residents do not meet the financial and functional eligibility requirements of Medicaid in their states. Residents who do not meet these requirements are likely to pay out of pocket until they have exhausted their assets.

Although Medicare does not cover the cost of living in a long-term care community, it does often cover the cost of medical care such as skilled nursing care and hospitalization. Learn about the eligibility requirements for Medicare coverage here.
 

Veterans assistance

CCRC residents who have served in the armed forces may be eligible to receive Veterans Administration (VA) benefits that may cover a portion of the costs of long-term care. Wartime veterans who meet the financial eligibility requirements and are over the age of 64 or are disabled qualify for the tax-free Veterans Pension benefit.

Aid and Attendance (A&A) is another VA benefit that can sometimes be added to eligible veterans’ pension payments to help cover the costs of long-term care. New residents of CCRCs who are entering the community in independent living are unlikely to qualify for A&A, but veterans may qualify as needs increase over time.
 

Choosing a facility

Choosing a place to live is always a very individual process, and each potential resident brings his or her own particular set of expectations, preferences, and needs to the search for a retirement living community. Since residents of continuing care and retirement communities are planning for the future and generally expect to live in the same community for the rest of their lives, it is especially important to consider every aspect of a particular community. Below are a few important considerations:
 

Individual circumstances, needs, and preferences

When looking for a CCRC, it is important to consider any specific needs and preferences you have, as well as your wishes for future care. For example, single or widowed seniors may be looking for different housing options and social opportunities than couples, and those with ongoing medical conditions may want to make sure that certain specialized medical services are available.

In addition, some residents prefer larger, apartment-like facilities, while others prefer smaller neighborhoods with cottage-style living spaces. It is important to carefully consider your unique needs and preferences before making a decision.

In addition to current needs and circumstances, it is a good idea to also carefully contemplate how your long-term wishes match up with the policies and procedures of the CCRC. As previously discussed, many CCRCs ask new residents to provide copies of legal documents such as living wills and advanced directives. It is also important to understand a community’s end-of-life policies prior to signing a contract.
 

Cost and levels of care

Cost is an important concern for almost all individuals and families. Since there are almost always substantial entry fees associated with moving into a continuing care and retirement community, and seniors generally live in one community for long periods of time, it is important to carefully consider the costs and payment options of a community. Since monthly fees tend to be adjustable based on the level of care required and the services and amenities accessed, it is important to understand how costs are calculated, even for services that you may not currently require.

Although you are likely to enter a CCRC in independent living, it is important to consider what services you may require in the future and understand what services are provided at which levels of care. For example, residents with a family history of Alzheimer’s disease may want to limit their search to CCRCs with a dedicated memory care and Alzheimer’s care wing, and those with ongoing medical conditions may want to look for communities with on-site physicians, laboratories, and pharmacies.
 

Location and proximity to family, friends, and loved ones

For many seniors, living in close proximity to family and other loved ones is a top priority when looking for retirement housing and long-term care. In fact, a survey by the National Council on Aging (NCOA) recently found that “relationships with friends and family outweigh financial concerns among older Americans seeking fulfillment in their senior years.”

In addition to finding a community that meets all of your practical requirements, it is important to consider a continuing care and retirement community’s proximity to your family and friends. Although most CCRCs offer an array of social opportunities and activities, and residents are likely to make strong and long-lasting connections with other residents, it is also important to many seniors to be close to family and existing loved ones.
 

Amenities and services offered

Although there are some standard services and amenities offered by most continuing care and retirement communities, each community is unique, and amenities vary greatly from community to community. Most CCRCs provide different services and amenities at different levels of care. In addition, many CCRCs include some amenities in the cost of monthly fees and offer others as add-ons. Most communities provide lists of available amenities on their websites. Common amenities at continuing care and retirement communities include:

• Communal seating and gathering areas
• Recreation center or gym
• Exercise classes
• Restaurant-style dining rooms
• Organized social events and activities
• Beauty salon and barber shop services
• Library
• TV room
• Courtyard, gardens, walking path, or parks

Each community offers unique amenities and services, and each individual is likely to have particular preferences and expectations when it comes to such things. Most continuing care and retirement communities offer guided tours, so potential residents can see the housing options and get a sense of the services and amenities offered at each level of care.
 

Questions to ask on a tour

Although each individual will bring different needs, preferences, and concerns about the process of deciding on a CCRC, below is a list of general questions to consider asking on a scheduled tour:
 

The community

• What are the housing options for each level of care (houses, cottages, apartments, rooms, etc.)? What are the price differences?
• In assisted living and nursing home care, are rooms private or shared? Do they have private bathrooms?
• Are there call buttons in every room? Bathrooms?
• What is the size and layout of the community? How many residents are in each level of care?
• What communal rooms are there at each level of care (dining rooms, TV rooms, seating areas, etc.)?
• What is the menu like in the dining rooms? Do food options change on a daily or weekly basis?
• What outdoor areas are there?
• What activities, classes, and amenities are offered at each level of care?
• Are there special events for holidays and birthdays? Are families welcome to participate?
• How do residents receive mail?
• What are the fire and emergency policies and evacuation plans? How are families notified in case of an emergency?

Staff and medical care

• How are staff members trained? Are there separate staff members for each level of care?
• What is the staff turnover? How long has the average staff member been in the community?
• Whatmedical care isoffered at each level of care?
• Is there a memory care unit?
• In assisted living and nursing home care, what medical professionals are on staff 24/7?
• Is there a laboratory and/or pharmacy on-site? If not, is there transportation to and from off-site appointments?
• What is the staff-to-resident ratio at each level of care? Is it different at night?
• In assisted living and nursing home care, are medications and prescriptions managed? What is this process like?
• What steps are taken to monitor changing medical needs? How are residents’ needs assessed, and how and when is it determined that a resident needs a more intensive level of care?
• What are the procedures in case of a medical emergency?
• How is end-of-life/hospice care provided? What are the policies for following a will and/or power of attorney?

Policies, care plans, and pricing

• How are residents assessed upon move-in? How are needs re-assessed over time?
• What is the entry fee and what are the monthly fee and contract options? Are there additional move-in fees?
• Can staff help with the initial move? With subsequent moves to new levels of care?
• Can residents bring their own furniture? Can they hang things on the wall? Are these rules different at different levels of care?
• How customizable are care plans?
• At each level of care, what services and amenities are included in base monthly fees? How do add-ons affect cost? Are utilities, laundry services, and housekeeping included in monthly fees at all levels of care?
• Is long-term care insurance accepted? Are Medicare and Medicaid accepted? What about other assistance programs and benefits?
• How are families updated? Are there regular meetings with residents or their families with community staff or administrators?
• How are residents moved from independent living to assisted living to memory care or nursing home care when needed?
• What are the rules for visitors and visiting hours at each level of care?
• Are family members welcome in the dining room and during scheduled activities?
• Can spouses who require different levels of care live together? How does this work and how does this affect costs?
• Are pets allowed at any or all levels of care?

In addition to questions for the administrators and staff, you may want to ask yourself some questions about your overall impression of the community, the staff, and the residents during a scheduled tour. For example, do residents seem happy? Do staff members seem competent, caring, and understanding of the needs of residents? What are the noticeable differences between each level of care?

It is a good idea to keep a list of observations and additional questions throughout the process of choosing a facility.
 

Continuing care FAQs

1. How is a CCRC different from other long-term care options?

The primary difference between continuing care retirement communities and other forms of long-term care is that continuing care retirement communities provide multiple levels of care, often referred to as a “continuum of care.” Residents typically enter CCRCs when they are able to live with very little, if any, assistance with daily activities, and move to more intensive levels of care over time as their needs change.

In this way, CCRCs allow seniors to plan their long-term care in advance and on their own terms. These communities tend to be more expensive than other forms of long-term care, and they typically include substantial entry fees in addition to monthly costs.

2. How big do CCRCs tend to be?

According to the American Seniors Housing Association (ASHA), the average CCRC is made up of fewer than 300 units, while about 30% have more than that. Only 8% of all continuing care and retirement communities have greater than 500 units. Most communities have all levels of care and living options located on a single campus, although buildings may be separate. Communities that offer cottages and houses to independent living residents tend to have larger campuses, as do those with lots of outdoor and recreational amenities.

3. How old is the average resident?

The average age of new residents in CCRCs is 81, and recent survey data indicates that most CCRC residents are women. The majority of continuing care and retirement communities have minimum and/or maximum age requirements for new applicants. It is common for communities to require new residents to be over the age of 64 when they move in.

4. How can I find more information about each level of care in a particular community?

The best place to find information about a particular community is through the CCRC’s website. Most communities provide lists of the services offered at each level of care as well as general information about amenities and policies on their websites. CCRCs also typically offer potential residents the opportunity to schedule a guided tour, which will give you the chance to visit the community and ask any questions you may have.

Expert Reviewed

Leona J. Werezak RN, BSN, MN is a registered nurse and adjunct nursing professor. She has 24 years experience working in a variety of healthcare settings including such remote locations as the Arctic Circle. Her research in early stage dementia was published in the Canadian Journal of Nursing Research and re-published in their 40th anniversary issue which showcased exceptional research published since the journal began. Her work in dementia care has also been published in the Journal of Gerontological Nursing. She currently teaches surgical nursing care on a thoracic/vascular unit to baccalaureate nursing students. Her clinical work with nursing students involves extensive work with older adults who have multiple chronic health conditions.

Edited By
Wes Fuller, CEO