For six years, Barbara Williamson helped her elderly father shower and dress each morning, prepared his meals and changed his diapers. Alzheimer’s disease had stripped Jerry Fox of the ability to care for himself, so he’d been living with Williamson and her husband in Potomac since 2004.
But in 2010, Fox suffered a bout of pneumonia. To support his recovery, he spent two months at ManorCare Health Services, a rehab facility in Potomac. That’s when Williamson realized that her father needed more care than she could provide. She had promised never to put him in a nursing home. So instead, Williamson found him a spot in an upscale assisted living group home run by Bethesda-based Eden Homes Group.
“It wasn’t until my dad moved into Eden Homes that I realized how stressful [caring for him] was,” says Williamson, who is 59. “It didn’t seem stressful at the time.”
Now 97, Fox receives personalized attention from several nursing assistants trained in dementia. Known as Greyswood, the eight-bedroom house where he lives sits on a quiet street in Bethesda between the Beltway and Democracy Boulevard. With its wraparound porch and homemade bread baked fresh daily, Greyswood conjures up the word “home” rather than “facility.”
Williamson is among scores of adult children across Maryland who are choosing more intimate, less institutional settings for aging parents in need of 24-hour supervision. The deciding factor for Williamson was the low caregiver-to-resident ratio at Greyswood—1-to-2.5, compared with larger facilities where it can be as high as 1-to-14.
Although several group homes opened in Montgomery County in the 1990s, it’s only in the past few years that this segment of the assisted living market has taken off. Among the roughly 200 assisted living providers in the county, 150 have 10 beds or fewer, according to state records. Last year alone, 10 new homes applied for licenses.
The choices can feel overwhelming to families, since group homes vary widely in terms of costs and amenities. Monthly fees—which are not covered by Medicare or Medicaid and must be paid by long-term care insurance or out of pocket—range from $1,700 for a basic room with a shared bath to $14,000 for a luxurious double room with a private bath.
Fees typically cover room and board, laundry, medication management and limited transportation.
“Each group home has its own model and its personality, just as every client has their own personality,” says Vicky Hulcher, a geriatric care manager and owner of Brookville-based Compassionate Care for Seniors, which helps families find the right facility.
That said, group homes aren’t for everyone, says Jonathan Edenbaum, co-owner of Eden Homes. “The larger [assisted living] facilities are great for people who are healthier and fairly independent,” he says.
Typically owned by corporations, large facilities tend to be more expensive and have “more layers of people to pay before [making] a profit,” says Alisa Scheiner, founder and president of Loving Decisions, a senior housing referral service in Bethesda.
Edenbaum, who has spent three decades in the senior care industry, says the “more medically needy and frail” used to be handled exclusively by nursing homes, but that population has now become the niche of assisted living group homes and specialized units within large facilities.
At Eden and other group homes, residents receive on-site medical care, including doctors’ visits, lab work and even short-term skilled nursing services such as physical therapy or intravenous medications. Several group homes bring in hospice care workers, as well, toward the end of residents’ lives.
Edenbaum and business partners Lori Larson and Lisa Max run six homes in Montgomery County—four in Bethesda, one each in Potomac and Silver Spring—with three caregivers for every eight residents during the day. They say most of their residents suffer from mild to severe dementia, a spectrum of diseases that impairs memory and impacts personality, behavior and mood. Nearly all need help with at least three “activities of daily living,” Larson says, like bathing and grooming, eating and taking medications.
Tanie Guirand, a registered nurse who owns The Angels Garden group homes in Rockville and Silver Spring with her husband, Pierre, has also seen a higher incidence of dementia among her residents. In recent cases, other diagnoses have complicated matters. “It’s dementia with heart failure, or dementia with MS [multiple sclerosis],” she says, or dementia with depression or anxiety.
“They do better in a smaller environment,” says Guirand, who has trained at the Copper Ridge Institute, a dementia research center in Sykesville affiliated with the Johns Hopkins University School of Medicine. “There’s more structure. …They’re seeing the same staff, the same families. When you’re already confused, it’s hard to be in a place for 400 people.”
Some conditions, though, are considered too severe even for group homes. The state prohibits group homes from admitting anyone with an airborne communicable disease like tuberculosis or people in need of a ventilator or consistent skilled nursing or with advanced-stage bed sores.
An assessment tool developed by the state is used to screen group home applicants’ ability to function. They’re scored from mild (Level 1) to moderate (Level 2) to severe (Level 3) impairment. Most homes in the county are licensed up to Level 3, since owners expect residents to decline as they age. Families often make the mistake of waiting until their loved one is a Level 3 patient before placing him or her in a home, Williamson says, making the transition more difficult.
All group homes are required by state law to develop plans for managing a resident’s medical conditions, diet and daily living needs. These plans are supposed to be reviewed every six months.
Applicants can be turned down if an owner determines they’re not a good fit with other residents. In fact, owners exercise total discretion on admissions and can discharge residents with 30 days’ notice. Pam Heir, owner of Asheir Manor, a new five-bed home in Germantown whose monthly rate for a Level 1 resident ranges from $5,550 for a room with a shared bath to $8,820 for a double room with a private bath, says one disruptive or aggressive resident can upset the balance of the entire household.
“If you’ve got two or three people who are very healthy and who can do a lot for themselves, especially mentally, and you have two that are not mentally…there, then your mix isn’t quite right,” she says.
Heir is not the only provider in search of more upscale and independent clients. Susan Rodgers, a registered nurse and president of Capital City Nurses, a private-duty nursing company, recently opened the Cottage at Curry Manor near Bradley Boulevard in Bethesda. She says she hopes the 8,000-plus-square-foot, gated mini-mansion, which is licensed for eight beds, will become the county’s “Relais & Chateaux of assisted living,” referring to the luxury hotel-restaurant compendium.
“We’re a fussy bunch of people in this county,” she says. “We know nice things, we like nice things and we want them to continue.”
At Cottage, where all rooms include private baths, singles range from $8,500 to $12,000 per month while monthly fees for doubles start at $14,000, says Shaun Toomey, Capital City’s director of business development. Those fees cover the perks of what Rodgers calls “refined residential living.” Among them: gourmet meals, trips to museums and the Kennedy Center, and ample opportunities to pursue hobbies such as gardening, music or painting. “We’re looking for someone social who can enjoy the amenities,” Rodgers says.
Eden Homes, too, offers more hands-on services thanks to fees that range from $8,000 to $9,800 a month at its Bethesda locations. In addition to contracting with an interior designer to create its photo-ready interiors, the company employs a full-time nurse who keeps close tabs on residents’ well-being. Its activities staff consists of a full-time art therapist and a full-time music therapist since mental stimulation can slow dementia, according to Larson. The therapists spend time with each resident to develop an engagement plan based on “who they used to be before they came here,” says Irene Joy, Eden Homes’ vice president.
But just because someone is paying more to get all those perks doesn’t mean he or she is getting better care. “I would not say cost reflects care,” Hulcher says.
As with real estate, the group home market reflects the county’s income levels, with more affordable options in Silver Spring and Rockville. For many families, an Eden Homes facility in Bethesda will always be out of reach due to cost, Scheiner says.
Certain providers accept residents who pay a subsidized monthly rate in order to keep their beds occupied. Aberdeen House in Rockville accepts subsidized placements as long as they “don’t require much work,” says owner Kenneth Cherian. “We provide very good basic care,” he says, but “the activities are really minimal” and subsidized residents will likely share a bedroom and bath.