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Assisted living too often fails older, sicker residents, report says

A caregiver helps a resident of an assisted-living facility to exercise her legs. (iStock)

Assisted-living communities too often fail to meet the needs of older people 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 percent are 85 and older, 77 percent require help with bathing, 69 percent with walking and 49 percent 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. 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 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 at 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.”

Look at staffing levels in assisted-living facilities

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.

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

Kenneth Covinsky, a geriatrician and professor of medicine at the University of California at 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 staff members responded to pagers buzzing nonstop.

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

The panel also recommended staff members 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 percent more people died in assisted living in 2020 compared with previous years.

Training for long-term care providers makes a difference

“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 at 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 Helen Kales, chair of the Department of Psychiatry and Behavioral Sciences at UC Davis Health in California.

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 Kenneth Lam, his UCSF colleague, 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.

Care plans should focus on individual residents’ needs

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 recommendations’ practicality and cost. “We need to understand what the feasibility would be,” she said. Meanwhile, states should examine how they regulate assisted living, taking into account residents’ increased needs, Bethea added.

Because the nation’s roughly 28,900 assisted-living communities are regulated by states and there are no federal standards, practices vary widely. Generally, there are fewer protections for residents than are found in nursing homes.

Originally, assisted living was meant to be a “social” model: a home setting where older people 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.”

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