Understanding Defining Characteristics of Assisted Living

Article Outline

• Strengths of the Assisted Living Model
• Quality and Comprehensiveness of Available Care
• Disclosure
• Staffing
• Conclusion
• References
• Biography
• Copyright

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• Ethel Mitty

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• Sandi Flores

Geriatric nurses are experiencing increasing interface with assisted living communities. Often times, nurses are unsure about what defines assisted living. “It’s not a nursing home.” All too often this is the response when the question is, “What is assisted living?” Kane and Wilson¹ in fact identified this idea in their commonly accepted definition of assisted living: “Any residential group program that is not licensed as a nursing home, that provides personal care to persons with need for assistance in daily living, and that can respond to unscheduled needs for assistance.”

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Strengths of the Assisted Living Model 

First, we must consider several strengths of assisted living:

The idea that assisted living facilities (ALFs) provide medical care in a social model is an important concept that is fundamentally the definition—and success—of assisted living. Hawes et al.² identified in a study for the U.S. Department of Health and Human Services that 79% of ALFs provide or arrange for nursing services, and “most ALFs reported a willingness to admit residents with moderate physical limitations.” The increased role of nursing in assisted living plays a large part in the ability of ALFs to manage increasingly complex resident care acuities.

Clearly ALFs are providing for the medical needs of their residents, either directly through their own staff or by arranging for outside services. What makes this important, however, is not just that nursing and other services are available but that they are provided in the homelike environment that is characteristic of assisted living. Although many nursing homes are also adapting their environments to move away from the traditional clinical setting to a more homelike setting, it is the ALF that first developed the idea of providing for medical needs within a social model.

Key to the social model in assisted living is the focus on resident autonomy, choice, and dignity.³ Providing for the necessary medical and physical needs of the resident is never done without consideration for his/her choice and autonomy. As the Assisted Living Workgroup (ALW) stated in its 2004 report the Senate Special Committee on Aging, every resident has the right to accept or refuse services.⁴ Although this is a seemingly fundamental concept, it is absolutely critical to the success of the assisted living model. ALF residents often participate in a self-directed model of care, determining care schedules, medication times, and the like. Although this can create operational challenges for the ALF provider, it is critical to maintaining the truly homelike environment that ALFs attempt to achieve.

Furthermore, because assisted living facilities are governed by state regulations, each state can establish its own definition of assisted living, both in terms of the setting and of the services provided. Whether it is private units, the availability or nurses, or the role of the unlicensed assistive personnel, each state establishes for itself what assisted living should look like, avoiding the cookie-cutter approach to federal nursing home regulations that was seen in the United States in the early and late 1980s. Thus any nurse assisting with selecting an assisted living setting for a patient, providing home health, hospice or other such services in an ALF should have a general knowledge of the state-specific regulatory requirements.

Above all, what helps assisted living establish its unique position in the long-term care continuum is resident-directed care. A resident is not “admitted” or “placed” into assisted living—those are terms that carry over from the medical model. A resident “moves into” an ALF, just as one would move into a home. Many ALF units are small apartment models complete with kitchen capability. After residents are in the assisted living facility, they are part of the process, involving themselves in everything from the creation and execution of their service plan to sitting on the menu committee to ensure their favorite meals are available in the dining room.

This means that an assisted living provider not only must answer to its state regulators, but—perhaps more important—it must answer to its customers. According to the National Center for Assisted Living, an estimated 900,000 residents reside in 36,000 ALFs in the United States, and if a resident is not satisfied with the environment or services in their ALF, they have the option simply to move out and take his or her business elsewhere.⁵ Astute ALF providers that find long-term success in this challenging marketplace understand this and take great steps to ensure residents are able to provide feedback and that their concerns are addressed. One of the most significant consumer demands is to “age in place.” Thus ALFs are responding to this demand by providing services to maintain higher acuity.

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Quality and Comprehensiveness of Available Care 

Hawes et al.⁶ found that 78% of residents who moved out of an ALF did so because they needed more care; however, 12% moved out because they were dissatisfied with the care being provided.⁶ Although some opponents of the assisted living model have argued that the extensiveness of care provided within the ALF is too high, clearly the consumer demands more from the facility, and to remain viable, ALFs must continue to find innovative ways to meet the increasingly challenging needs of their residents. Some areas of particular need include medication management, end of life and hospice care, and care for the cognitively impaired.

Addressing the many issues in ALF medication management goes beyond the scope of this article, but the need for assistance with medications by ALF residents has been clearly established in literature. At least 1 study found that ALF residents have higher average prescription drug use than do nursing home residents.⁷ Therefore an ALF must have clearly developed policies, procedures, and staff to address medication management within the facility.

Partnership with hospice—in those states that allow it—can be a highly effective mechanism by which to allow a resident to remain safely in an ALF through advancing stages of disease and through to death. Having the option of remaining in the ALF allows the resident the ability to stay in his or her home through the dying process and the availability of hospice services ensures that the resident receives the necessary medical care, as well as spiritual services for the resident and his or her loved ones.

Addressing cognitive decline is perhaps the most significant challenge assisted living faces in terms of comprehensiveness of care. According to Hawes et al.,⁶ “In most ALFs, a resident whose functional limitations necessitated help with transfers or whose cognitive impairment progressed from mild to moderate or severe or who exhibited behavioral symptoms would be discharged from the facility.”

Although there has been an increase in the prevalence of specialized ALFs to care for residents with cognitive impairments and dementia,³ many residents will go through a transitional period in which they begin to display signs of cognitive impairment but do not yet require the additional safety or security measures afforded in a specialized dementia care unit. For this and other reasons, ALFs should provide for the following to address the needs of residents with cognitive impairments⁵:

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Disclosure 

Although it is not a realistic expectation to think every ALF will be able to meet the needs of any and all potential residents, it is a minimum expectation that they have disclosure procedures in place to ensure that prospective residents fully understand, before move in, the environment and scope of services available in a particular ALF.

Although many residents have clear expectations regarding the environment and services they seek when looking for an ALF, more than 35% of residents who move out of an ALF say their priorities and expectations changed over time.⁶ It should be the goal of the assisted living provider to educate consumers as much as possible before they make the decision to move in, and many states in fact now require clear, written disclosure. Unfortunately, however, consumers choosing among their assisted living options often lack the information they need to make a fully informed decision. A 1999 U.S. General Accounting Office (GAO) report found that written materials provided to consumers by ALFs are often vague, incomplete, or misleading.⁸

According to the GAO report, “facilities’ written materials often did not contain key information, such as a description of services not covered or available at the facility, the staff’s qualifications and training, circumstances under which costs might change, assistance residents would receive with medication administration, facility practices in assessing needs, or criteria for discharging residents if their health changes.”⁸

The following items from the Oregon Uniform Disclosure Statement are examples of baseline information often included in an assisted living disclosure document. The nurse involved in discharge planning may request this information to assist with appropriate placement.⁹

Increased nurse involvement in the disclosure process can help to ensure that prospective residents and their families have a clear picture of the services offered. The nurse’s ability to understand the complexity of the resident’s clinical issues and potential future needs allows him or her to identify the ability of the ALF to meet the resident’s needs now, and in the future.

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Staffing 

The availability of sufficient and competent staff is the proverbial “white elephant in the room” during discussions on challenges facing the assisted living industry. Needless to say, the improvements to the quality and breadth of care provided in assisted living cannot be achieved without the appropriate staff. It is not, however, enough to simply put staff in place in great numbers and expect this to solve any and all issues. Staff must receive the appropriate orientation and ongoing training to ensure they can competently provide the services needed by the resident population within a given ALF.

Whether to employ a licensed nurse is another important staffing consideration for the ALF provider. Although having a nurse on staff is not currently a requirement in most states, research has shown that the likelihood of an ALF resident having to move to a nursing home or other setting is reduced by half when the ALF employs a full-time RN.⁶

The following areas must be considered when addressing staffing concerns within the ALF:

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Conclusion 

Although assisted living has made great progress in redefining our concept of long-term care for the elderly, it is not without challenges. Close attention by nurses working in the industry to the critical issues of quality and comprehensiveness of care, disclosure, and staffing will ensure the continued success of assisted living and the further refinement of it as a model in the long term care continuum.

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References 

1. Kane RA, Wilson KB. Assisted living in the United States: a new paradigm for residential care for frail older persons?. Washington, DC: American Association of Retired Persons; 1993;
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2. Hawes C, Phillips C, Rose M. A national study of assisted living for the frail elderly: final summary report. Washington, DC: U.S. Department of Health and Human Services; 2000;
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3. Wright B. In brief: an overview of assisted living. Washington, DC: American Association of Retired Persons, Public Policy Institute; 2004;
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4. Assisted Living Workgroup. Assisted Living Workgroup report to the U.S. Senate Special Committee on Aging. Washington, DC: Assisted Living Workgroup; 2003;
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5. The State Long-Term Health Care Sector Data Resource Book: 2006 Update. The information comes originally from, Robert Mollica (2005) State Residential Care and Assisted Living Policy: 2004. Portland, ME: National Academy for State Health Policy. November. http://aspe.hhs.gov/daltcp/reports/04alcom.htm.
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6. Hawes C, Phillips C, Spry K. Residents leaving assisted living: descriptive and analytic results from a national survey. Washington, DC: U.S. Department of Health and Human Services; 2000;
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7. Briesacher B, Stuart B, Doshi J. Medication use by Medicare beneficiaries living in nursing homes and assisted living facilities. Washington, DC: U.S. Department of Health and Human Services; 2002;
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8. U.S. General Accounting Office. Assisted living: quality-of-care and consumer protection issues in four states (GAO/HEHS-99-27; andGAO/HEHS-97-93). 1999;Washington, DC: April 26
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9. Oregon Department of Human Services. Consumer guide for assisted living and residential care facilities. 2005;Oregon
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