Assisted living facilities pressed to address growing needs of older, sicker residents

Reviewed by Emily Henderson, B.Sc.Dec 5 2022

Assisted living communities too often fail to meet the needs of older adults and should focus more on residents' medical and mental health concerns, according to a recent report by a diverse panel of experts.

It's a clarion call for change inspired by the altered profile of the population that assisted living now serves.

Residents are older, sicker, and more compromised by impairments than in the past: 55% are 85 and older, 77% require help with bathing, 69% with walking, and 49% with toileting, according to data from the National Center for Health Statistics.

Also, more than half of residents have high blood pressure, and a third or more have heart disease or arthritis. Nearly one-third have been diagnosed with depression and at least 11% have a serious mental illness. As many as 42% have dementia or moderate-to-severe cognitive impairment.

"The nature of the clientele in assisted living has changed dramatically," yet there are no widely accepted standards for addressing their physical and mental health needs, said Sheryl Zimmerman, who led the panel. She's co-director of the Program on Aging, Disability, and Long-Term Care at the University of North Carolina-Chapel Hill.

The report addresses this gap with 43 recommendations from experts including patient advocates, assisted living providers, and specialists in medical, psychiatric, and dementia care that Zimmerman said she hopes will become "a new standard of care."

One set of recommendations addresses staffing. The panel proposes that ratios of health aides to residents be established and that either a registered nurse or a licensed practical nurse be available on-site. (Before establishing specific requirements for various types of communities, the panel suggested further research on staffing requirements was necessary.)

Like nursing homes and home health agencies, assisted living operators have found it hard to retain or hire staff during the covid-19 pandemic. In a September 2021 survey, 82% reported "moderate" or "high" level of staffing shortages.

Dr. Kenneth Covinsky, a geriatrician and professor of medicine at the University of California-San Francisco, witnessed staffing-related problems when his mother moved to assisted living at age 79. At one point, she fell and had to wait about 25 minutes for someone to help her get up. On another occasion, she waited for 30 minutes on the toilet as overworked staffers responded to pagers buzzing nonstop.

"The nighttime scene was crazy: There would be one person for 30 to 40 residents," said Covinsky, the author of an editorial accompanying the consensus recommendations. Eventually, he ended up moving his mother to another facility.

The panel also recommended staffers get training on managing dementia and mental illness, on medication side effects, on end-of-life care, on tailoring care to individual residents' needs, and on infection control — a weakness highlighted during the height of the pandemic, when an estimated 17% more people died in assisted living in 2020 compared with previous years.

"If I were placing my parent in assisted living, I certainly would be looking not just at staffing ratios but the actual training of staff," said Robyn Stone, senior vice president of research at LeadingAge and co-director of its long-term services and supports center at the University of Massachusetts-Boston. LeadingAge is an industry organization representing nonprofit long-term care providers. Stone said the organization generally supports the panel's work.

The better trained staff are, the more likely they are to provide high-quality care to residents and the less likely they are to feel frustrated and burned out, said Dr. Helen Kales, chair of the Department of Psychiatry and Behavioral Sciences at UC Davis Health.

This is especially important for memory care delivered in stand-alone assisted living facilities or a wing of a larger community. "We have seen places where a memory care unit charges upwards of $10,000 a month for 'dementia care' yet is little more than a locked door to prevent residents from leaving the unit and not the sensitive and personalized care advertised," wrote Covinsky and his University of California-San Francisco colleague Dr. Kenneth Lam in their editorial.

Because dementia is such a pervasive concern in assisted living, the panel recommended that residents get formal cognitive assessments and that policies be established to address aggression or other worrisome behaviors.

One such policy might be trying non-pharmaceutical strategies (examples include aromatherapy or music therapy) to calm people with dementia before resorting to prescribed medications, Kales said. Another might be calling for a medical or psychiatric evaluation if a resident's behavior changes dramatically and suddenly.

Further recommendations from the panel emphasize the importance of regularly assessing residents' needs, developing care plans, and including residents in this process. "The resident should really be directing what their goals are and how they want care provided, but this doesn't always happen," said Lori Smetanka, a panel member and executive director of the National Consumer Voice for Quality Long-Term Care, an advocacy organization.

"We agree with many of these recommendations" and many assisted living communities are already following these practices, said LaShuan Bethea, executive director of the National Center for Assisted Living, an industry organization.

Nonetheless, she said her organization has concerns, especially about the practicality and cost of the recommendations. "We need to understand what the feasibility would be," she said, and suggested that a broad study look at those issues. In the meantime, states should examine how they regulate assisted living, taking into account the increased needs of the residents, Bethea said.

Because the nation's roughly 28,900 assisted living communities are regulated by states and there are no federal standards, practices vary widely and generally there are fewer protections for residents than are found in nursing homes. Some assisted living facilities are small homes housing as few as four to six seniors; some are large housing complexes with nearly 600 older adults. Nearly 919,000 individuals live in these communities.

"There are many different flavors of assisted living, and I think we need to be more purposeful about naming what they are and who they're best suited to care for," said Kali Thomas, a panel member and an associate professor of health services, policy, and practice at Brown University.

Originally, assisted living was meant to be a "social" model: a home-like setting where older adults could interact with other residents while receiving help from staff with daily tasks such as bathing and dressing. But given the realities of today's assisted living population, "the social model of care is outmoded," said Tony Chicotel, a panel member and staff attorney with California Advocates for Nursing Home Reform.

Still, he and other panelists don't want assisted living to become a "medical" model, like nursing homes.

"What's interesting is you see nursing homes pushing to get to a more homelike environment and assisted living needing to more adequately manage the medical needs of residents," Chicotel told me, referring to the current pandemic-inspired reexamination of long-term care. "That said, I don't want assisted living facilities to look more like nursing homes. How this all will play out isn't at all clear yet."

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