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Correspondence: Address correspondence to Catherine Hawes, PhD, School of Rural Public Health, 3000 Briarcrest, Suite 416, Bryan, TX 77802. E-mail: hawes{at}srph.tamushsc.edu
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Abstract |
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75 unless they use assets as well as income to pay. Implications: ALFs differed widely in ownership, size, policies, and the degree to which they manifested the philosophy of assisted living. This diversity represents a challenge for consumers in terms of selecting an appropriate facility and for policy makers in terms of deciding what role they want assisted living to play in long-term care.
Key Words: Assisted living • Residential care facilities • Long-term care
A congregate residential setting that provides or coordinates personal services, 24-hour supervision and assistance (scheduled and unscheduled), activities, and health related services; designed to minimize the need to move; designed to accommodate individual residents' changing needs and preferences; designed to maximize residents' dignity, autonomy, privacy, independence, and safety; and designed to encourage family and community involvement. (p. 4)
As suggested by this definition, the key philosophical elements of assisted living include the following: (a) services and oversight available 24 hr a day; (b) services to meet scheduled and unscheduled needs and facilitate aging in place; (c) care and services provided or arranged so as to promote independence; (d) an emphasis on consumer dignity, autonomy, and choice; and (e) an emphasis on privacy and a homelike environment.
Although there has been general agreement, at least at the national level and among provider groups, on the key principles or elements of assisted living, there has been less agreement on the degree to which the current industry embodies these principles. This article is an attempt to address that issue and presents data from a telephone survey of the administrators of assisted living facilities (ALFs) across the country (Hawes, Rose, & Phillips, 2000). These facilities were selected from a national probability sample of all facilities that met the criteria for inclusion in the study. Thus, the findings are representative of the industry as a whole. As such, they represent the first empirical data on the characteristics of the assisted living industry nationwide, based on a representative national sample of facilities. The specific objectives of this telephone survey were to determine the size and nature of the supply of ALFs and to describe the basic characteristics of the assisted living industry, particularly in terms of the services, accommodations, and basic price.
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Methods |
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From this list of potential candidate facilities, project staff selected a stratified, random sample of 2,945 places. The administrators of these places were then surveyed by telephone to determine the facility's eligibility for the study and, if eligible, to secure information about the facility's size, services, price, and accommodations.
The study's basic eligibility criteria were that a facility had to serve a primarily elderly population and have more than 10 beds. A previous study funded by the Department of Health and Human Services and Office of the Assistant Secretary for Planning and Evaluation (DHHS–ASPE) focused on licensed and unlicensed board and care homes. Two thirds of those facilities had 10 or fewer beds, and the study found that none of the small homes called themselves assisted living. Few provided assistance with more than two activities of daily living (ADLs; Hawes et al., 1995). Thus, we concluded that the vast majority of these small facilities would not provide the services generally considered a fundamental part of assisted living. Further, the small homes tended to serve a younger population of residents and a population that was more likely to have mental retardation, developmental disabilities, or persistent mental illness. In addition, no states that licensed a specific category known as "assisted living" reported any facilities with fewer than 11 beds. For these reasons, ASPE and the project staff decided to exclude small homes from this study of assisted living for frail elderly persons.
In addition, the facility either had to represent itself as an assisted living facility or offer at least a basic level of services, which included 24-hr staff oversight, housekeeping, at least two meals a day, and personal assistance, defined as help with at least two of the following: medications, bathing, or dressing.
The administrators of a sample of 2,945 candidate facilities were then surveyed by telephone during 1998. If the candidate facility met the study eligibility criteria specified in a set of screening questions, then the administrator was asked to respond to questions about the facility, its size, occupancy, accommodations, services, price, and policies on admission and discharge. A total of 1,547 of these facilities were eligible for inclusion in the study. Among those eligible for the survey, administrators in a total of 1,251 facilities were interviewed. This provided an overall response rate of 81%. An adjustment for nonresponse was included in the facility weights (Iannacchione et al., 2000). Because of the complex nature of the sample, analyses were performed by using SUDAAN in order to provide appropriate variance estimates (Shah, Barnwell, & Bieler, 1996).
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Results |
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The most common type of room was a private room with a full bathroom (42% of all single rooms). The most common type of apartment was a one-bedroom, single occupancy apartment (41%). Most ALFs offered consumers a range of options in terms of private or shared accommodations. Only 27% of the facilities had all-private accommodations. A plurality of ALFs (45%) had a mix of private and shared units. However, slightly more than one fourth of the ALF administrators (28%) reported that the facility had at least one bedroom shared by three or more unrelated residents. Although ALFs offered residents a range of options, 73% of all resident units were private, and 25% of the units were semiprivate, that is, shared by two unrelated persons. Two percent of resident units were in "ward-type" rooms that housed three or more unrelated persons.
Although nearly three quarters (73%) of the rooms or apartments were private, slightly less than two thirds (62%) of the units offered a private full bathroom (i.e., toilet, sink, and shower or tub). An additional 6% of the units had a private "half" bath (i.e., toilet and sink). However, more than one third (38%) of all ALF units required the resident to share a bathroom.
Facilities were classified into five groups based on their levels of services or privacy. These classification categories are described in Table 2. Other dimensions or cut-points might have been used, but these classes were considered the most appropriate for our analytic purposes. However, for other purposes or in other samples, other schemes may be equally useful. As Table 2 indicates, almost one third of the sample offered either minimal services or minimal privacy, whereas another 27% offered low services and low privacy. The greatest variation among facilities came in the degree of privacy, rather than service. Although the bulk of the ALFs did not offer high services involving a full-time registered nurse on staff and provision of nursing care with their own staff (69%), very few (4.3%) offered minimal services, that is neither nursing care or oversight nor assistance with ADLs. The ADLs we asked about included bathing, dressing, locomotion, toilet use, transfers, and eating. Most ALFs (65%) reported that they offered residents assistance with at least two ADLs or one ADL and medications. These results indicate that only approximately 11% of facilities offered both high privacy and high service.
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ALF administrators estimated that approximately 24% of their residents received help with three or more ADLs, such as bathing, dressing, and locomotion. They estimated that approximately one third of the residents (34%) had moderate to severe cognitive impairment, that is, problems with short-term memory or with making decisions about daily life tasks and activities.
As Table 4 indicates, nearly all facilities provided or arranged 24-hr staff, three meals a day, and housekeeping. More than 90% of the ALF administrators also reported that the facility provided medication reminders and assistance with bathing and dressing; 88% of the ALFs provided or arranged central storage of drugs or assistance with administration of medications. Almost three quarters of the ALFS (71%) had a licensed nurse, either a registered nurse (RN) or licensed vocational nurse (LVN), working on staff full or part time. Slightly more than half of the ALFs (55%) reported having an RN on staff either full or part time. Forty percent of the ALFs reported having a full-time RN on staff.
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One of the major distinctions in the assisted living sector is between those ALFs that are operated as free-standing or single-level facilities and those operated as part of a multilevel campus that includes other levels of service, most often a nursing home. In 1998, multilevel facilities comprised 46% of the industry and housed an estimated 56% of ALF residents. Tables 5 through 8 illustrate the substantial differences between these two types of facilities. ALFs on multilevel campuses, in comparison to free-standing ALFs, were significantly larger, more expensive, more likely to offer private accommodations, more likely to offer higher levels of service, more likely to admit and retain individuals who were in wheelchairs or needed nursing services, and more likely to offer therapies or monitoring or care by licensed nursing staff.
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Discussion |
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Do ALF Environments Match the Philosophy of Assisted Living?
The answer to this question is mixed. On the one hand, residents of ALFs had considerably more privacy and choice in accommodations than did residents of most nursing homes and the majority of board and care homes. On the other hand, there was significant variability within the assisted living industry, and a substantial segment of the industry provided accommodations that did not appear consistent with the environmental aspects of the assisted living philosophy, particularly the segment of the industry that offered only shared accommodations.
Do ALFs Meet Health-Related Unscheduled Needs of Residents?
This issue is still an open question. Variations in staffing patterns and admission and retention policies suggest that not all ALFs are prepared to meet the scheduled and unscheduled needs of residents. For example, 29% of the ALFs had no licensed nurse on staff, raising questions about their ability to recognize changes in a resident's health or functional status that signal a need for evaluation or treatment. Further, a significant proportion of facilities were unwilling to admit or retain residents with significant health-related needs, such as help with locomotion, assistance with transfers, or care or monitoring from a nurse. What is less clear is the source of these variations. Certainly, in some states, licensing regulations limit the services, such as nursing care, that ALFs may provide; however, most states are changing their regulations to allow assisted living and other residential care facilities to provide more extensive health care services to a fairly impaired resident population (Mollica, 1998). Most facilities appear to have considerable flexibility in determining what services to provide and what policies to implement regarding admission and discharge.
Can ALF Residents Age in Place?
The answer depends on one's concept of aging in place. For example, facility retention policies suggest that, in most ALFs, a resident could move from relative independence (e.g., needing or wanting only meal preparation, housekeeping, and staff that can respond to emergencies) to a stage at which the resident needed help with bathing, dressing, and managing medications and used a wheelchair to get around. If this "span" or change in needs were the definition of "aging in place," then ALF admission and retention policies indicate that they were willing to allow residents to age in place. In contrast, if aging in place meant that the average consumer could select an ALF and reasonably expect to live there to the end of his or her life, regardless of changes in health or limitations in physical and cognitive functioning, then the answer must be "no." In most ALFs, a resident would be discharged once he or she needed help with transfers, had cognitive functioning that had progressed from a mild loss to a moderate or severe limitation, or exhibited behavioral symptoms, such as wandering or resisting ADL assistance. The same was true for a resident who needed nursing care or monitoring for more than 2 weeks. Thus, there were facility policies and practices that limited the ability of ALF residents to age in place. The degree to which these were a reflection of facility choices versus a reaction to state licensing regulations is not known. However, as already noted, states are increasingly offering greater flexibility to assisted living and residential care facilities in terms of the services they may provide and the types of residents they may admit and retain. Thus, the ability of residents to age in place seems more likely to be a product of facility choices about the resident mix they wish to serve and the market "niche" they wish to occupy. Additional evidence supporting this contention was found in analysis of facility factors associated with discharge of residents, including interviews with a probability sample of discharged residents or their next of kin (Phillips, Hawes, Spry, & Rose, 2000).
Is Assisted Living Affordable?
Assisted living was largely not affordable for moderate- and low-income persons aged 75 or older, unless they disposed of their assets and spent them down to supplement their income. Few elderly persons had incomes sufficient to cover even the basic monthly charge in the average ALF. According to data from the U.S. Bureau of the Census (1998, Table 8, "Income Distribution of Older Persons"), 84% of persons aged 75 and older had incomes of less than $25,000 per year in 1997. With annual charges for basic services of more than $20,000, the average high-service ALF and the average high-privacy ALF would be unaffordable for the vast majority of older persons, particularly because they must also pay for other basic needs (e.g., supplemental insurance, out-of pocket spending on health care and medications, clothing, and so on) as well as any charges by the ALF for supplemental services such as additional ADL assistance or transportation.
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There are four basic limitations to our study findings. First, although we provide generalizable findings, the study is limited to the study's definition of assisted living and exclusion of small facilities from the study sample. It is worth noting that none of the states that specifically licensed ALFs in 1996 and 1997 reported having any ALFs with fewer than 11 beds. Second, the data reported here represent responses from administrators. Some of these data were necessarily estimates made by the administrators, such as the proportion of residents with moderate to severe cognitive impairment. Such estimates should be regarded as such, rather than the more precise data that would result from cognitive testing. Third, the study reports data on facility policies and practices but is unable to attribute these definitively to either state regulations governing the facilities or to individual choices by the facilities. Finally, these findings represent a snapshot of a dynamic and largely young industry at a particular point in time. At the same time, responses from this national probability sample of ALFs provide the most comprehensive picture of the assisted living industry to date.
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Footnotes |
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1 Department of Health Policy and Management, Texas A&M University System Health Science Center, College Station, TX.
2 Myers Research Institute, Menorah Park Center for Senior Living, Beachwood, OH.
3 Department of Statistics, Texas A&M University, College Station, TX.
Decision Editor: Laurence G. Branch, PhD
Received for publication June 5, 2002. Accepted for publication October 8, 2002.
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