Assisted living (AL) is a congregate residential setting for 6 or more adults that provides or coordinates personal services, 24-hour supervision and assistance (scheduled and unscheduled), activities, and health-related services (Stevenson, 2010). Known by several names—residential care, home for the aged, housing with services, board and care, personal care, enriched housing—the distinctions lie in state regulations, certification, or licensing; type of housing unit (e.g., shared room or apartment); and the needs that can be met. Today all types of group residential care are commonly referred to as assisted living (Assisted Living, 2011). In contrast, state-licensed adult foster or family care is for four to six people residing in the provider's home. In 2012, the federal government continued releasing data from the first nationally representative survey of assisted-living/residential care facilities. The study found that in 2010 there were 31,100 facilities with 971,900 licensed beds serving 733,400 residents. Thirty-seven percent of residents were receiving assistance with three or more activities of daily living (ADLs) and 42% had Alzheimer's disease or other dementias.
Although some federal laws apply, AL is regulated and monitored by the state. The number, nature, and scope of AL regulations continue to increase particularly as AL residents are frailer, sicker, and older than when AL first appeared as a residential-care option.
AL is generally defined as an environment that offers and/or provides assistance with ADLs and instrumental activities of daily living (IADLs) such as meals and assistance with medications. A vexing problem for states as well as providers is the balance between resident autonomy (and risk taking) and safety needs. In about one third of states, residents (or their family or surrogate) can sign a “negotiated risk” contract that allows them to remain in the assisted-living residences (ALR) despite functional and/or cognitive decline. Also known as “managed risk” or “shared responsibility,” potential consequences of the resident's actions must be described as well as options to limit risk and honor the resident's wishes, such as requiring the resident or family to hire extra help if needed. The agreement process and areas of disagreement must be documented. Some states (e.g., Oregon) do not permit a risk agreement if the resident is unable to comprehend the consequences associated with actions.
The consumer-centered philosophy of AL, as defined by the National Center for Assisted Living (Assisted Living, 2013), promotes wellness and maximizes quality of life, independence, privacy, choice, safety, decision making, and “aging in place” in a homelike environment. Private living units, including private bath (85% of ALRs), are a critical feature of AL; residents may lock their doors. At least 30 states allow two people to share a unit (i.e., apartment) or bedroom but, in some states, only if the two parties choose to do so (e.g., Washington). Depending on the licensing category, some states allow as many as four people to share a unit. Regulations in 21 states contain a statement of AL philosophy, in greater or lesser detail (e.g., aging in place), as well as describe services that may or may not be offered. Given the likelihood of increasing needs and frailty, and the ALRs’ obligation to provide appropriate care, many ALRs feel they will evolve into a kind of “nursing home lite” environment—something they did not intend philosophically, operationally, or fiscally. Although state regulations set boundaries for the scope of services, providers (i.e., operators) nevertheless have considerable latitude in deciding what will be offered and which residents (i.e., tenants) will be admitted, retained, or discharged.
An occupancy, service, “contract,” or “residency” agreement, executed before or immediately on admission to an ALR, is based on an assessment of the person's need for services and how they can best be met. Virtually all states require that ALRs disclose the services that will be provided to meet reasonable care needs. More than half of the states require disclosure of costs and services beyond the basic rate, discharge criteria, grievance processes, resident rights, and retention and relocation criteria in case the ALR is unable to meet the resident's health and safety needs. In some states, ALRs must disclose their staffing pattern and staff training. Forty-four states have special regulations for ALRs that claim they provide dementia care including specific disclosure regarding services provided, programming, staff training, the environment, and security provisions.
States can have a single level of AL or a two- or three-level model stipulating the services that can be provided or needs that can be met. It is illegal for an ALR to refuse to admit an individual whose health care needs can be met in the ALR as stipulated in the state's regulation and as protected by the Americans with Disabilities Act (ADA). The most compelling reason for discharge, permitted by 39 states, is when the ALR cannot provide the services needed or care needs exceed what the ALR license permits. Hence, the nature, frequency, duration, and intensity of health-related and nursing care permitted by regulation will determine the feasibility of aging in place. A resident can be at risk of discharge for reasons unrelated to licensure but rather for financial reasons, that is, inability to privately purchase the additional care and services needed from a home health agency. The worst-case scenario is a resident who remains too long in an ALR where the staff is not trained for complex health care management and provisions are not made to secure the health and safety of the resident.
The number and type of staff vary with the number of residents, their needs, and the services provided. Personal-care staff can be employed by the facility or contracted from an outside agency (e.g., licensed home care agency). Twenty-six states require the ALR to employ or contract with a licensed nurse (i.e., RN or LPN). Only one state, Alabama, requires a physician medical director. Every ALR must have an administrator (i.e., manager, director, or operator) who has overall responsibility for staff performance and resident well-being. Administrators must be specially trained in 72% and specially licensed in 46% of states. At least 70% of ALRs have a registered nurse or licensed practical/vocational nurse on-site a few hours per week or a few hours per day. Some ALRs employ an advanced practice nurse (i.e., geriatric or adult nurse practitioner) to conduct admission assessment, develop a plan of care, and provide health maintenance oversight and medication management.
Forty-two states have specific staffing standards based on resident needs; 18 have minimum staffing ratios. In all ALRs, there must be at least one person available during the night hours. Most states (98%) require that direct-care staff are trained at the time of or prior to employment, but the curriculum varies: resident rights (required in 80% of states); emergency procedures (including CPR), first aid, and fire/safety/disaster preparedness (60%); infection control and abuse/neglect prevention (42%); dementia and behavior management (35%); special needs of resident/elderly (36%); and the aging process (18%). Few states develop the curriculum; the ALR or a staff-development enterprise can create the content with scant state review for quality. Few states require an examination or trainer standards; training can vary from just a few hours to 25 hours or more; and 84% of states require continuing education.
All ALRs monitor residents’ well-being and provide daily supervision and assistance with IADLs and ADLs; three meals a day, including therapeutic diets; housekeeping and laundry services; medication management; transportation for recreational and shopping trips; and an emergency call system. Twenty-one states permit nonlicensed staff to administer medications. Residents who are temporarily incapacitated or recuperating from surgery, injury, or illness, or those who are dying, can remain in the AL facility if it can provide the necessary services and care. Each resident's health care is supervised by a physician of his or her own choosing.
Admission and retention criteria vary widely among states. In the 10 states with broad criteria and flexible rules (e.g., Maine, Oregon, and Minnesota), ALRs are most likely to support aging in place. However, the ALR is not required to retain the resident. Some states simply require that a prospective resident be in stable health and not need 24-hour nursing care; other states’ criteria screen out those who are bedbound, incontinent, have deep pressure ulcers, need artificial feeding or hydration, or are ventilator-dependent. States might have criteria relating to independent ambulation, ability to use the toilet unassisted, and stage of dementia. New Jersey ALRs may admit and retain residents who are continuously dependent in four ADLs, have impaired decisional capacity, are bedbound more than 14 days, are medically unstable, a danger to self or others, and require treatment for severe pressure sores. Almost all states require discharge if the resident is no longer independently mobile, a requirement linked to fire safety and ability to evacuate the premises.
Exceptions to a state's discharge criteria, approved by the state, include temporary conditions (associated with remaining in bed for as many as 10 days); the resident's ability to independently perform or direct another in performing a medical procedure (e.g., oxygen administration, tube feeding, sterile dressing, insulin injection); consent by the resident, facility, and physician; state approval on a case-by-case basis; and family assistance with care. Thirty-one states allow home health care or third-party provider assistance for “skilled nursing care” if it is short term, temporary, or for an acute illness. Home health is permitted in more than two thirds of states as a component of AL, unrelated to admission or retention. Residents can contract directly with the agency or third-party provider for desired services.
Home care can be provided in ALRs for Medicare beneficiaries who meet eligibility criteria. A registered nurse from a certified home-care agency supervises and monitors the care. Hospice care as a home care service can also be provided in ALRs. This decision is made by the facility and the resident or family, is not contingent on state regulations, and constitutes an exception from the discharge requirement.
More than 70% of AL residents are female. More than 50% are 85 and older, with 10% under the age of 65. Approximately 75% of residents receive some type of assistance with ADLs. Thirty-seven percent have three or more ADL limitations, and 42% have Alzheimer's or some type of dementia. Although most residents come to AL facilities from their own homes, slightly fewer than 20% come from nursing homes. Studies indicate that AL residents are taking more medication, in general, than nursing-home residents and receive more psychotropic medications than their nursing home and community-residing peers. In addition, many of their medications are inappropriate for their age, unrelated to a diagnosis or condition, and poorly monitored. After an average stay of 26 months, approximately 45% of residents are discharged to nursing homes and 26% have died. Approximately 5% of residents leave AL facilities for financial reasons.
The AL market is predominantly private pay; there is no ALR entry fee. On April 15, 2011, the Centers for Medicare and Medicaid Services (CMS) issued proposed regulations that would better define community settings where Medicaid recipients could receive services that are covered by §1915 (c) HCBS waiver programs. The proposed regulation would require that AL services (24-hour on-site supervision, safety, and social and recreational programming) be provided in settings that are home and community-based, integrated into the community, and provide access to the community (Assisted Living, 2011).
Forty-three states pay for some components of AL for Medicaid-eligible ALR residents (estimated at 121,000) under the Medicaid state plan, the Home and Community-based Service (HCBS) waiver (Section1915c), (www.cms.hhs.gov/Medicaid StWaivProgDemoPGI/05 HCBSWaivers-Section1915(c).asp), or some combination. Under the waiver (36 states), states can provide home and community services to nursing home–eligible Medicaid beneficiaries, such as personal care and homemaker services, medication management, home-delivered meals, and staffing for supervision and services. Inasmuch as room and board cannot be covered by the waiver, some states assist Medicaid AL residents by fixing the room and board cost that the ALR can charge the resident, supplementing the resident's Supplemental Security Income (SSI) payment to use for this cost, or offering housing subsidies. State Medicaid policy determines the type of unit (i.e., single or shared) for Medicaid beneficiaries in ALRs (Washington permits shared units only by choice). Long-term-care insurance is infrequently used or available among AL residents.
Average monthly fees are about $2,000; this is higher than the typical board and care fee but lower than nursing-home costs. The actual fee paid by the resident depends on the type of housing (i.e., shared vs. private room) and the kind and number of services included in the contract. Medicaid reimbursement can be an all-inclusive, flat-rate monthly price; tiered pricing based on the package of services needed (or desired) by the resident; tiered rates based on the resident's acuity level; fee-for-service pricing based on the resident's “a la carte” selection of services; or some combination of these models.
Several states are developing innovative financing mechanisms to assist developers in constructing affordable AL housing. A growing number of nonprofit and for-profit nursing homes are converting beds and wings to AL. Many continuing care retirement communities offer AL either in the tenant's current domicile or by relocation to an AL facility on the premises. Medicare capitated, managed-care organizations view AL as being well suited for managing rehabilitation and providing a supportive environment for frail managed-care enrollees.
Virtually every state is studying or promulgating regulations and licensure requirements that distinguish AL from other long-term-care and residential models. States have the authority to set provider standards; many have done so with respect to food preparation and fire safety. There is wide variability across facilities in services offered and across states in the degree of government involvement as a regulator of these services (Stevenson, 2010).
Medication management, staffing, qualifications and quality, adequacy of care, and plans of care are the major sources of complaints and deficiencies. Twenty-four states use different surveyors for AL and nursing-home quality-of-care inspections. Federal quality-of-care standards probably will not be promulgated in the near future because it is unlikely that the federal government will become a major AL payer. The state role in monitoring and licensure will continue to grow, especially as Medicaid assumes greater responsibility for the costs of care and services.
A growing body of scholarly research, much of it multidisciplinary, is engaging the AL industry as well as state legislative bodies, advocacy groups, professional associations, and academia (Grabowski, 2012). In-depth information is needed about AL users: their expectations and preferences, finances, functionality, conditions and illness trajectories, relocation, and outcomes. Research is needed regarding dementia care services and outcomes. Comparisons with other kinds of long-term health and social services and settings might help sharpen the focus and future of AL. An examination of the lack of uniformity among states in quality standards and regularity expectations is needed to meet the needs of our aging population.
See also Continuing Care Retirement Communities; Nursing Homes.
- Assisted living and residential care in the states in 2010. (2011). Association for the Advancement of Retired Persons Washington DC. Retrieved from www.aarp.org.
- Assisted living state regulatory review. (2013). National Center for Assisted Living Washington, DC. Retrieved from www.ahcancal.org.
- Assisted living expansion and the market for nursing home care. Health Services Research, 47(6), 2296-2315. ; ; (2012).
- Sizing up the market for assisted living. Health Affairs, 29(1), 35-43. ; (2010).
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