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Assisted Living Facilities

 Fred Moskovitz, Psy.D.

During the past ten to fifteen years Assisted Living Facilities (ALF) have developed from a concept into a full- blown growth industry. They have become one of the landmarks on the continuum of care for the elderly, falling somewhere between home health care and nursing home care or, in a manner of speaking, between independent living and long- term care institutionalization. The Assisted Living Facility is a model whose time has arrived, is evolving, and will continue its development as an integral component of health care and retirement planning. Relatively speaking, assisted living is in its infancy and will continue its maturational development for many years to come.

The demographic snapshot is one of people living substantially longer, and relatively healthier lives, with numerous manageable chronic co-morbidities requiring a level of care that is often more than can be provided for at home and not quite yet at a level that would necessitate skilled nursing. Furthermore, Nursing Homes also known as Skilled Nursing Facilities (SNF’s) have acquired a tarnished reputation over the years for not catering to the consumer in terms of quality of life issues. Parents often extract oaths from their children that regardless of what happens nursing home placement should never be considered as an option for their care. The “baby boomer” generation has been resistant to the idea of nursing home placement for themselves as well as their aging parents. They are better educated than their parents, well informed and more proactive in seeking long- term health care solutions that coincide with their concept of a “good life”. A nursing home is thought of as the “end of the line”, a facility where you go to die. Whether this is truly so or simply a bum rap or a little bit of both is irrelevant in that almost no one wants to be voluntarily admitted to a nursing home. In addition, with the very old being the fastest growing segment of the population there is a severe financial crisis in the Medicare and Medicaid systems and consequent restrictions in their reimbursement for skilled nursing facilities. Medicare pays for very limited nursing home care, and Medicaid is continually becoming more strict with its guidelines for entitlements to the point that one must be impoverished with a poor PRI (Patient Review Instrument) in order to qualify for a skilled nursing facility. In a nutshell, there is great need to supplement the health care of the elderly who are unable to thrive within the limitations of their home health care plan, and are ineligible medically, or unable financially to qualify for skilled nursing. They require an environment where they can receive assistance with their functional limitations, social support network, and an atmosphere of dignity in their pursuit of independent living. The Assisted Living Facility is capable of providing all of the above. A modest amount of both governmental regulation and financial subsidy, and a true desire on the part of the ALF industry to provide quality care for the elderly, can accommodate an aging society with a workable alternative for long-term care planning.

Assisted Living Facilities are readily available in various sizes, shapes and forms. They may be found in the form of “mom and pop” operations working out of a private home with a capacity of five to ten occupants, or a public company with facilities throughout the states with hundreds of units in each facility. Many of the large operators of ALF’s have no previous hands-on experience with health care related facilities and were formerly in real estate management or in the hotel and entertainment industry. At the same time, many ALF administrators have had adequate amounts of previous health care experience in nursing homes or other health care settings.

Assisted Living Facilities are mostly private pay and may charge anywhere from $1900.00 - $8000.00 per month. Some facilities will charge you one inclusive monthly rate for all services provided. Most ALF’s charge a base monthly rent which includes meals, housekeeping, laundry services, and a minimal amount of daily assistance with Activities of Daily Living ( ADL’s). Any additional assistance with ADL’s, medication supervision, incontinence care, dementia care, are billed at a daily or monthly rate. Medications are not provided by many of the facilities and are the responsibility of the residents. Many facilities have a Registered Nurse on duty twenty- four hours a day, but the RN to resident ratio is very low. In many facilities the ratio of aides to residents is equally disproportional. However, many facilities are responsive to the needs of their residents and are proactively working to improve the proportions of staff to residents. The majority of facilities have contracted with physicians, podiatrists, psychiatrists, etc. to visit the facility once or twice weekly, while payment for all medical services are the personal responsibility of the resident. Many facilities have a close working relationship with local hospitals and rehabilitation centers in the event of acute onset of medical emergencies. Most facilities accommodate the nutritional and dietetic needs of their clients.

Many Assisted Living Facilities have a requirement that residents be able to transfer out of bed on their own, or with minimal assistance. Some facilities require that the resident be able to get to the dining room on their own. The vast majority of facilities will refuse to keep a resident that requires a double transfer to get out of bed. It is crucial for the consumer to be aware that a substantial loss of functionality may lead to involuntary discharge from many facilities. Families must thoroughly investigate the policies of each individual facility and meticulously read contracts before signing them. There are many ALF’s that work in conjunction with home health care agencies or with the resident’s personal aides to maintain the resident in the facility as long as there is no clinical need for skilled nursing services.

There is a trend in many Assisted Living Facilities to provide a separate self-contained secure floor for residents with moderate to severe dementia and provide one- on- one care. However at this point in time many facilities will not accept or are unable to provide sufficient security for a resident that is in late stage AD (Alzheimer’s Disease) with a tendency for wandering or with excessive behavior problems. Once again it is the duty of the family to research the limits of care provided for a resident with dementia, and what occurs once the disease has progressed to a more severe stage.

Many Assisted Living Facilities provide their own Personal Care Attendants (PCA’s) or companions, for a fee. A resident may opt to bring his own personal attendant to most facilities. However, there are laws governing how many hours of personal care a resident may legally receive before he/she is asked to leave the facility and directed to a skilled nursing facility. Unfortunately, many ALF’s disregard these regulations and will attempt to care for the resident despite the unsafe environment and the fact that the services are insufficient. This is often the result of a profit motive, and the facility does not want to remain with a vacant bed. Families must be absolutely certain that their loved one’s health will not be jeopardized by allowing them to remain in a facility after there has been a severe deterioration in health, even if the staff is willing to retain the resident.

At present there is a vital need for the type of services provided by an Assisted Living model of care. There are currently more elderly people alive than ever before in history, and this large cohort group is expected to live much longer than ever before with more chronic co-morbidities due to a longer lifespan. In addition they will have to finance these extra years by themselves as Social Security will be inadequate and Medicare will not cover most of these expenditures. Home health care will often be insufficient to provide a level of care that is adequate, safe, and yet stimulating enough to enhance the quality of life for the elderly.

Children are living at greater distances from home than in previous generations and, often, cannot be relied upon to care for ailing parents. In most families both husband and wife work full time jobs allowing less time to devote to their elders even if they are geographically located closer to home. Parents are often unwilling or unable to admit that they are struggling with their ADL’s or are having serious memory lapses. It is very difficult for parents to confide to their adult children that they are unable to live independently and require additional assistance.

Many of our elderly are taking ten to fifteen pills everyday for various medical conditions and are double dosing or skipping doses, due to complex dosing schedules or memory impairment. The dangers of polypharmacy are well known to most health care professionals. Furthermore, many of the elderly that are in fact aging in place at home with attendants are not aging successfully. They are being cared for in the literal sense but are socially isolated, under-stimulated, depressed, and treated as if they are feebleminded as well as functionally limited by both children and/or attendants. Many of the elderly are often simply lonely more than anything else. They may require more suitable surroundings and services than they are currently receiving in the limiting confines of their homes. In addition, many homes are cluttered, unsafe and environmentally unsuitable for the elderly. The homes are not elderizedand there is great potential for falls, burns etc. Before the advent of Assisted Living the elderly had but two choices: home care in the form of family assistance, and/or personal attendants, or admission to a nursing home.

Assisted Living may furnish one of many solutions to our health care dilemma for an aging society, providing the coming generations of “baby boomers” with a viable option to age in a relative degree of independence, dignity and grace. However, at this point in time we must remember the old adage of caveat emptor, or buyer beware.

The concept of Assisted Living is rapidly growing in popularity. Thousands of facilities have appeared on the horizon over the past few years. In fact there seems to be a glut in ALF’s on the market with many facilities unable to fill their units. In my opinion, however, the problem is not one of excessive units but rather one of marketing to the consumer and equally as important is the need of lobbying the federal and state governments for assistance.

First and foremost the assisted living industry must establish a criteria of what actually constitutes an ALF. There is no uniformity or homogeneity among many facilities that call themselves Assisted Living Facilities. Some are licensed Adult Homes while many are Retirement Homes, or any mixture of the two. Even amongst the ALF’s themselves there is no uniformity of services and policies. Every facility is free to create its own rules and regulations. One ALF may have a totally different admissions and discharge criteria than the next. One may be a social model while the next will be a medical model. One dispenses medication while the next requires the resident to be responsible for his own medication administration. The consumer is totally befuddled and feels that he is being taken advantage of. He has no inkling of what he should be looking for or what to keep away from, as there are no specific guidelines of what is considered good better or best. He has no method for comparing the ALF that looks like a country club versus a facility that looks like a skilled nursing facility. The consumer often confuses nice lobbies for good care. The consumer needs a set of standards and guidelines that encompass all ALF’s. The Assisted Living industry will have to monitor its members and establish a user- friendly set of criteria and guidelines that span all facilities wishing to belong to the umbrella organization.

The government should, and will eventually have to regulate the Assisted Living industry. Excessive regulations are usually counterproductive and may force Assisted Living Facilities to operate more like nursing homes with rules for almost every service and program preventing innovation and stifling an independent style of living. Too much regulatory power will discourage the consumer who is looking for relative freedom in homelike surroundings. Some consumers may simply want an Assisted Living Facility as their new retirement residence without any of the responsibilities of living in an apartment or private house. In fact, some residents are functional enough to maintain their own cars and go to work in part time jobs. Many residents are searching for a new lifestyle where they can cultivate new friendships and perhaps even pursue a romantic relationship. These consumers need the least amount of regulatory oversight. On the other hand there is a need to protect the welfare of the resident who is frail and requires additional help with ADL’s and should be able to expect a level of care that is uniform in quality and quantity. These services should be similar in all Assisted Living Facilities so that the consumer understands clearly what is being offered to him in terms of services and what he can realistically expect when he will be a resident of an “Assisted Living Facility.” There remains a need for limited State and Federal oversight to protect the consumer. A happy medium must be reached where there is some governmental oversight and yet it remains at a level that offers legal protection for the consumer while still maintaining an autonomous atmosphere of living at home, unfettered. Many potential consumers would become actual residents if they were less “anxious” about the “fine print” in the contracts of most Assisted Living Facilities as a result of full and uniformly regulated disclosure.

The State and/or Federal government should, and will eventually be forced to provide financial assistance, and offer some form of subsidies to elderly consumers and/or Assisted Living Facilities. Many individuals cannot afford to make private payments and at the same time do not qualify for SSI or Medicaid. ALF’s are not cheap and most elderly people are unable to afford them. Social Security payments are not sufficient to cover the cost of an ALF. Some ALF’s will accept SSI or Medicaid after their resident “spends down” whereas most facilities will require a resident to leave when financial resources have been depleted. It is much more economical for the government to subsidize assisted living than it is to pay for a patient in a nursing home, or for 24 hour live-in home care. In fact it would be cost Medicaid approximately the same amount of money to provide for 8 hours of daily care on a weekly basis, at home, as it does to pay for Assisted Living Facilities for an entire month. Many more people would be in ALF’s were it not for the cost.

As we enter the new millennium, there is an impending crisis in long- term care for the elderly. How do we bridge the gap between home health care and skilled nursing care in an economical, safe, and esthetically pleasant manner? How do we protect the frail while advocating for the needs of the healthy retiree? How do we accommodate the working class as well as those that are better off? How do we protect the rights of the consumer while maximizing an independent style of life? How will we provide for the continuity between new retirees and the very frail requiring skilled nursing? How will the future accommodate the “baby boomers” desire for affordable health care, catered in a hotel like atmosphere with autonomy and self-esteem? Assisted Living Facilities!