Residents being cared for are older and sicker than they used to be


Assisted living communities too often do not meet the needs of older people and should focus more on the medical and psychological concerns of residents, according to a recent report by a diverse expert panel.

It is a clarion call for change, inspired by the changing profile of the population that assisted living serves today.

Residents are older, sicker and more disabled than in the past: 55 percent are ages 85 and older, 77 percent need help with bathing, 69 percent with walking, and 49 percent with using the toilet, according to data from the National Center for Health Statistics .

In addition, more than half of the residents suffer from high blood pressure and a third or more from heart disease or arthritis. Thirty-one percent have been diagnosed with depression, at least 11 percent have a serious mental illness, and 42 percent have dementia or moderate to severe cognitive impairment.

“The nature of the assisted living clientele has changed dramatically,” but there are no universally accepted standards for addressing their physical and mental health needs, said Sheryl Zimmerman, who led the panel. She is co-director of the Aging, Disability and Long-Term Care Program at the University of North Carolina at Chapel Hill.

The report addresses that gap with 43 recommendations from experts, including patient advocates, assisted living providers and specialists in medical, mental health and dementia care, that Zimmerman hopes will become “a new standard of care.”

View staffing levels in assisted living facilities

A number of recommendations deal with staffing. The panel proposes establishing the ratio of health workers to residents and providing either a registered nurse or a licensed practical nurse on site.

Like nursing homes and ambulatory health services, assisted living operators are finding it difficult to retain and hire staff during the pandemic. In a September 2021 survey, 82 percent reported a “moderate” or “severe” shortage of staff.

Kenneth Covinsky, a geriatrician and medical professor at the University of California, San Francisco, witnessed staffing difficulties when his mother, aged 79, moved into assisted living. Once she fell and had to wait about 25 minutes for someone to help her get up. On another occasion, she waited 30 minutes in the restroom while overworked employees responded to non-stop buzzing pagers.

Eventually, Covinsky, co-author of an editorial accompanying the consensus recommendations, transferred his mother to another facility.

The panel also recommended training for staff on how to manage dementia and mental illness, drug side effects, end-of-life care, tailoring care to the needs of individual residents and infection control — a weakness highlighted at the height of the pandemic , when an estimated 17 percent more people died in assisted living in 2020 than in previous years.

Training for long-term caregivers makes a difference

“If I were to place my parent in an assisted living facility, I would certainly look not only at the staffing levels but also at the actual training of the 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 at Boston. LeadingAge is an industry organization representing non-profit providers of long-term care. Stone said the organization is generally supportive of the panel’s work.

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

This is particularly important for memory maintenance carried out in a stand-alone assisted living facility or a wing of a larger community.

“We’ve seen places where a memory care ward charges more than $10,000 a month for ‘dementia care,’ but is little more than a locked door to prevent residents from leaving the ward, rather than the empathetic one advertised and personalized care,” wrote Covinsky and Kenneth Lam, his UCSF colleague, in their editorial.

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

Care plans should be based on the needs of each resident

Other recommendations from the panel emphasize the importance of regularly assessing residents’ needs, developing care plans, and involving residents in the process.

“The resident should really determine what their goals are and how they want to provide care, but that doesn’t always happen,” Lori Smetanka, panel member and executive director of the National Consumer Voice for Quality Long-Term Care, told Advocacy.

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

Still, she said her organization has concerns, particularly about the practicality and cost of the recommendations. “We need to understand what the feasibility would be like,” she said. In the meantime, states should review how they regulate assisted living while considering the increased needs of residents, Bethea added.

Because the country’s roughly 28,900 assisted living communities are state-regulated and there are no federal standards, practices vary widely. In general, there is less protection for residents than in nursing homes.

Originally, assisted living was intended to be a ‘social’ model: a home environment where the elderly could interact with other residents while being assisted by staff with daily tasks such as bathing and dressing. Given the realities of today’s assisted living population, “the social model of nursing is outdated,” said Tony Chicotel, a panel member and advocate for 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 that you’re seeing nursing homes pushing to create a more livable environment, and assisted living needs to more appropriately manage residents’ medical needs,” Chicotel told me, referring to the current pandemic-inspired review of long-term care. “However, I don’t want assisted living facilities to look more like nursing homes. How all this will play out is not yet clear.”

This item was produced by Kaiser Health News, a program of the Kaiser Family Foundation, a donated nonprofit organization that provides information to the nation on health issues.


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