Transitions are special times. Dawn and dusk, when the world changes between night and day. The change of seasons, when the world changes between green and brown. The day your advanced-in-years cared-for moves out of the house, and everything changes.

Conventional wisdom is that people should stay in their homes for as long as possible, but there may come a point when, all things considered, that’s no longer the best option. When that happens, a transition is necessary.

I wrote in Caregiver Thoughts #9 about selecting a new home. Once that’s done, it comes down to execution.

Like any move, it starts with what to take and what to leave behind. Moving from a house to an assisted-living home (somehow the term “facility” just doesn’t work for me) will likely involve leaving a lot behind. If there’s not a lot of distance involved, this is a lot easier, as you can always swap things back and forth as necessary.

While the move might be accomplished in a day, the transition will take much longer. It’s a project. While you will have sorted out the major items (room, medications, schedules, etc…) pretty quickly, there will be a million little things that will only show up after the move. It’s just impossible to identify every little thing that needs to be taken along or left behind or changed. The important thing is to expect this.

Probably the biggest thing will be adapting to new routines. The cared-for will need to learn how things work at their new home: when are the meals, meds, what activities go on, how to get assistance, what’s this thing I’m supposed to eat? etc… The caregiver will need to take over things that the cared-for might have been taking care of around the house, adjust to making visits to the new home, work out how to stay in touch, provide those things that the new home doesn’t.

The caregiver’s role will change, but not really diminish. While I’m not as concerned now about being there every day to dispense meds, or having to jump out of bed in the night or rush off from work to handle some urgent issue (there are professionals there now 24×7 who can handle those immediate things), I am taking a larger role on the financial and paperwork side. Of course, I’m still my cared-for’s patient advocate, attend all medical appointments, keep up with what meds are for what, etc…

As patient advocate, it’s also important to coordinate with the home’s medical staff. Any notes I take from a doctor’s appointment need to be forwarded on along with any specific doctor’s orders. Everybody needs to have the appointment schedule, especially if the home will be providing any transportation.

I think it’s important to set expectations at the outset. It’s probably not going to be practical to visit in person for hours every day, so take a shot at what’s doable and work towards that. Having electronic communications can help to fill in any gaps there. While staying fully in “the loop”, I think it’s in everyone’s best interests to push as many routine things onto the home’s staff as practical. The staff is there 24×7, and if they can provide a favorite food, that’s one less thing that’s subject to disruption if I get diverted.

A lot of “givens” will need to be tossed overboard. Just because something was done a certain way, or in a certain sequence, when cared-for and caregiver were living together doesn’t mean that’s now the best way to handle those things. This can leave both feeing a bit lost as that structure evaporates, and before a new pattern begins to settle in. You just have to keep going, get done what needs to be done, and see how things play out. Keeping a to-do list (at least for the caregiver) can be handy, as it gathers in one place all those things that needs to be sequenced.

Right now we’re in the middle of the northern hemisphere winter, but I know we’ll be transitioning to spring soon. The only thing that doesn’t change is change.

At some point, particularly if your cared-for is of advanced age, changes will be required. Your cared-for may need increasing assistance that you just can’t provide and still hold on to a full-time job, or maybe you just can’t be there enough. Watch for these changes and get ahead of them. Too often people need to move to a higher degree of care/assistance when some crisis occurs, and that can lead to hasty decision making.

So, give some thought to these things now, and investigate options in your spare time (yeah, right, spare what?).

I’ve recently been evaluating assisted living facilities. Ultimately, so long as your cared-for is competent, it’s their decision and it will come down to what’s affordable and where they feel most comfortable. The latter is necessarily subjective, but is also the most important.

As caregiver, I think the most important thing you can do is to watch for red flags that might veto a particular facility. Here’s a list of things to consider or ask about:

• Security: are doors kept locked? Are visitors identified and escorted? How do friends and family gain access? Can anyone walk in off the street?
• Is there a disaster plan? Are arrangements in place to house residents elsewhere if there’s a power outage, HVAC failure, or fire? Does the facility have a generator and how often is it tested?
• If you keep in touch with your cared-for via electronic means, is Internet access available? Phone lines? How’s the cell phone coverage?
• What sort of medication management is available? Is there flexibility if your cared-for handles some or all of their own medications?
• Is transportation to doctor’s appointments available? If so, what are the limitations (distance, days, etc…)? Is there a charge for this?
• Are pets allowed? This could work both ways, depending on whether your cared-for has a pet they want to bring, or would rather not have small furry/scaly/feathery critters around.
• How many residents are there, and how many is the facility licensed for?
• How many staff are on site when? Pop quiz question: how many staffers are on site right now?
• Can the facility provide all the care your cared-for requires? Meals are probably a given, but what about assistance with bathing and dressing?
• What sort of activities are there to fill the resident’s days? Are there exercise facilities?
• Look around: are there exit signs? Smoke detectors? Is the facility clean, neat, and organized? Do the residents appear to be comfortable and well cared for?
• What’s the reputation of the facility? Is it well-regarded in the community?
• Who owns the facility? Many may appear to be local, independent facilities, but most are owned by larger companies that own and operate a number of facilities. This, also, can work both ways: a local, independent facility will likely be more flexible, maybe even cheaper, but may not have the resources of a larger organization. OTOH, a facility part of a larger chain will likely have more “disaster” options (nearby “sister” facilities) and more financial backing, but may be more subject to the machinations of Corporate America, like management changes and rules that might not be as flexible as one might hope.
• If you can, get a look at recent health department reports. My own state does not make this information available (I tried), but if you can get access, do so. Just keep in mind that one report doesn’t mean much. Look at reports over at least a year, looking for recurrent problems. I know from experience that the day the auditor shows up and wants to see a file restored from a backup, that’s the one time the tape will throw an error. If there’s something in a report, look to see that it was resolved.
• What mechanisms are there for a resident to call for assistance? Are pull stations located conveniently, and is a pendant that can be worn available?
• Is there a waiting list? If so, would space be available when you think you’ll need it?
• If your cared-for has to leave the facility temporarily (for a hospital stay, or vacation), will their space be held for them, and what adjustments to fees are made?
• How are emergency situations handled? What happens when someone falls?
• Is there a process to address concerns?
• What range of care is available? If your cared-for needs increasing levels of assistance, or nursing care, is that available at the facility in question, or would they need to move?

Again, your cared-for is the best one to decide where they’re going to be happy. You’re just looking to vet out the choices.

All the facilities I looked at provided respite care, where your cared-for could stay there for a week or so. This can be a good way to try out a facility, and may be an option if you, as care-giver, need to go on a business trip or something, or just need a break.

Finally, and maybe most importantly, don’t let your cared-for think that you’re just going to drop them off and disappear. Y’all have been working together for perhaps a very long time, and that needs to continue. If nothing else, you need to keep a sharp eye on things to make sure they’re getting the level of care they need (and you’re paying for). You’ll need to change your routines to accommodate regular visits and general staying-in-touch. Your cared-for will continue to need a “patient advocate”. There will likely be incidental things, like reading material, music, or a favorite food that’s not readily available, that you’ll need to provide. Take them out to dinner occasionally. Celebrate their special days. And, just be there for them.