The Shift From Nursing Home to Assisted Living Is It Defensible?

The author’s definition of Assisted Living:

"The provision of personal care, food and lodging in a safe and secure residential facility by a licensed care organization. Assisted living ensures coordinated health services and features individualized partnership agreements for service and risk management to maintain a high degree of tenant and family involvement and to encourage independence."

It’s a documented phenomenon which originated in the United States 15 years ago and is gaining rapid momentum in Canada: the elderly and disabled are increasingly shunning nursing homes and moving into assisted living facilities. The magnitude of this was described in an article in Health Affairs July 1999 entitled: Where are the missing elders? The decline in nursing home use 1985-1995 (Volume 18, #4).

From this report, the proportion of persons over 65 in US nursing homes fell by 8.2% in that 10 year time frame, with a corresponding decline in nursing home occupancy from 92% to 87%, representing 222,000 empty nursing home beds at year end 1995. Facing serious funding difficulties of late, as well as high liability insurance costs associated with increased litigation risks from recent court awards, the American nursing home industry is currently under siege even beyond the above-noted decline in demand.

Where were the missing elders? In an article entitled: The Bottom Line On Assisted Living in the July 1998 issue of Hospitals and Health Networks, assisted living is described as “One of health care’s highest flyers, ... set to eclipse nursing home occupancy”. By 2001, we read in January’s Consumer Report in a survey entitled: Is assisted living the right choice? “With the number of people who will need help with activities of daily living projected to increase by 51% in the next 20 years, assisted living is in growth mode. The number of licensed facilities - built by independent chains like Sunrise, hotel chains like Marriott and Hyatt, and individual entrepreneurs - has increased by 30% since 1998.” Indeed the elderly who aren’t staying put in their own homes with in-home care have been increasingly seeking the homey settings and greater autonomy offered in assisted living, thus leading to rapid growth of assisted living facilities in America.

In Canada, Alberta went first with importation of Oregon’s Assisted Living model in 1994 as a pilot project initiated by The Good Samaritan Society, a Lutheran Social Service Organization in Edmonton. Wedman House, formally Canada’s first assisted living facility, was the subject of considerable research attention ( the EPICC study), which will be discussed further in this article. It was not long before a number of assisted living facilities began dotting the landscape of Canada. Large national organizations such as Central Park Lodges, as well as several independent providers, Luther Court Society in Saskatoon and others, joined the ranks of organizations like The Good Samaritan Society, in developing these combinations of housing and care.

The Alberta government has indicated a desire to decrease its reliance upon the traditional nursing home and increase support for assisted living and other supportive housing options. In its future scenarios for care of the elderly to the year 2026, the Alberta Government’s Broda Committee estimated the need for additional nursing home beds would be in the tens of thousands if we continue to utilize them as in the past. That number came down to very few additional beds if supportive housing options (of which assisted living is but one) were more fully developed.

Alberta’s Regional Health Authorities, currently working on their Ten Year Plans for Continuing Care, have been asked to factor in this shift. At least one Regional Authority is highly enthusiastic about this shift. The Chinook Regional Health Authority’s continuing care plan currently anticipates a quadrupling of its supportive housing stock, coupled with an absolute reduction in traditional nursing home beds to half the current allotment in their Region.

A new British Columbia government, still in its early months of office, is also indicating a desire to see a similar shift to supportive housing and less reliance upon the traditional nursing home model. It is likely that other jurisdictions in Canada will adopt more and more of this shift. Even Ontario, which had of late been headlong into building the traditional nursing home model, is bound to shift, for it seems the customers are voting with their feet on this issue.

What Is The Experience With Assisted Living So Far?

From a consumer point of view, a first set of questions arise centred around “What is Assisted Living?”, “Can I expect to age in place and get the needed services when I move there?”, “Can I receive public subsidy to help me pay for some of the costs?” and “Can I continue to receive publicly funded home care services when I get there?”

A major study conducted by the Department of Health and Human Services in the US and reported in August of 2000 entitled A National Study of Assisted Living for the Frail Elderly, sampling 2,945 facilities sought to answer those questions for assisted living in America.

To the question “What is Assisted Living?” there were many answers describing facilities offering minimal service and minimal privacy, to those offering high service and high privacy. In fact, defining minimal privacy as any facility that housed three or more unrelated individuals in the same bedroom, they report 28% of facilities as falling in this category, with 31% rated as high privacy having their own bedroom and three piece bath, and the rest fell in between. The number of facilities that provide personal care and assistance was in the 80% range while that for provision of care or monitoring by a registered nurse was 52%. The latter were considered high service assisted living facilities.

The range in kinds of assisted living facilities in the US is consequently estimated as follows: high privacy and high service: 11%; high privacy and low service: 18%; low privacy and high service 12%; low privacy and low service 27%; and, minimal privacy and low service 32%. The Canadian experience is still developing and largely unknown, but when assisted living, as a concept, is broadened to include homes caring for three to ten persons, there is surely the same range operating in Canada as well. On a summary note for this point, from Consumer Report January 2001: “Assisted Living entrepreneurs emphasize that their facilities don’t look, feel or smell like nursing homes. Yet, some practically offer nursing home care, with little government oversight, while others provide so little care, that families must hire home attendants to meet their relative’s needs. (p.27)” .

For the question of cost and subsidization, the answers are also variable but for the most part the National Study reports that “Assisted Living was largely unaffordable for moderate and low income older people...two out of three older persons could not afford even the most common monthly price of assisted living (i.e. almost $19,000 a year),..or the most common monthly rate in even the low privacy/low service facilities (i.e. $16,500).”

Prices in Canada for assisted living tend for the most part to share the unaffordability of their American cousins. While a few states like Oregon include payments for assisted living in their Medicaid budgets, these numbers are small and on the decline. The vast numbers of near-poor and moderate-income elderly could neither afford most assisted living facilities nor qualify for public payments. The sale of assets and the assistance of relatives are the two chief ways this population has for meeting the costs on their incomes. As summarized in statement from The Bottom Line on Assisted Living, “... only private-paying seniors need apply…when you run out of money they throw you out.”

A small number of units in assisted living facilities in Canada are subsidized as in Designated Assisted Living projects in Alberta and B.C., but the majority are not.

The question of “aging in place” in assisted living depends almost entirely on three factors: how much disability is associated with the aging of an individual; the range of services the facility offers; and the financial resources available to the individual to pay for the needed services as they might increase over time. In the US, as reported in the National Study, 54% of Assisted Living facilities said they would not retain an individual who needed assistance with transfers, nor would they retain an individual who needed nursing care for more than 14 days (72%).

Consequently, and as reflected in their high discharge rates, aging in place is not at all guaranteed in US assisted living facilities. For this reason, assisted living facilities are not considered serious alternatives to nursing homes. Only 24% of residents of assisted living receive help with three or more activities of daily living as compared to 83% of those residing in nursing homes.

This data can lead to a certain degree of suspicion and skepticism about the merits of increasing our reliance upon assisted living as opposed to traditional nursing home care in Canada. It is clear that some assisted living facilities can and do substitute for nursing homes, though the greater majority do not. We may have good reason, however, to believe some “made in Canada” opportunities for assisted living programs could make them more consistently successful in their ability to provide an alternative to nursing homes.

Prior to going into these possibilities, however, there is one additional important area to address, and that is the critical area of outcomes. Let’s examine what the evidence is thus far, concerning the quality of the assisted living experience for residents in living in these settings.

One of the first quality issues raised is that the shift from assisted living away from a medical model that could result in deteriorated health conditions and increased morbidity and mortality of residents. Any such possibility that assisted living is a “dumbed down” nursing home, an inferior and temporary solution only, must not be left unexamined. Though the amount of research regarding this aspect is still relatively small, to date there is little evidence to support this negative view. Our own experience at The Good Samaritan Society points rather to the contrary and some very good outcomes.

Comparing assisted living residents with continuing care residents, Good Samaritan clients were matched by age grouping, mental status and care needs classification grouping by a university research group. Assisted living clients: were older by 5 years, exhibited more independence, had less difficulty coping, had lower potential for self injury, and maintained or bettered their functional status over time. (EPICC study)

Another study, reported in The Gerontologist, 2000, Vol 40, No.4, pp. 422 428 - The Effect of Long-Term Care Environments on Health Outcomes also compared assisted living and nursing home residents and found that type of facility did not influence patterns of mortality, or relocation due to declining health, or trends in cognitive ability, functional ability, depression or subjective health”.

Quality of life in assisted living homes: A Multidimensional Analysis, Journal of Gerontology: Psychological Sciences, 2000, Vol 55B, No. 2, pp. 117 127, reports a sample of 55 assisted living facilities in California wherein 201 resident participants stated that overall satisfaction with quality of life was very good.

In a survey of 13 facilities involving 375 residents in Maryland reported in The Gerontologist: 1999, Vol.39. No.4, pp. 450 456 – “Organizational determinants of resident satisfaction with assisted living”; Sikorska, E. cited the following: that choice in mealtime, visiting hours and pets were choices that matter most; that a cohesive social climate, mutually supportive and free from conflict, was the strongest predictor of quality of life in Assisted Living. The second strongest predictor of quality of life was family contact and participation in social activities. Higher levels of resident satisfaction were associated with smaller facility size, a moderate level of physical amenities, and greater availability of personal space.

Another study reported in International Journal of Geriatric Psychiatry; 2000, No.15, pp. 586 593 –“Characteristics and Outcomes of Dementia Residents in an Assisted Living Facility” found that assisted living facilities had a lower death rate than nursing homes by two years. Age, dementia, medical co-morbidity, presence of extra pyramidal symptoms and gender were not predictors of time-to-discharge. Frequency of falls and wandering though were good predictors of discharge to higher facility.

Finally, a White Paper published by the National Academy of Elder Law Attorneys entitled Assisted Living: A Good Innovation in Need of Fixing, outlines their assessment of assisted living in the US this year. Not unexpectedly, their recommended fixes are concentrated in the area of regulatory vacuum surrounding assisted living and with its primary dependence upon contracts. It is clear that a regulatory mixed bag does surround this program in America (as does it in Canada), but this group’s underlying belief, however, is stated in this fashion: “Although the positives (of Assisted Living) outweigh the negatives, the negatives do need to be addressed.” Even the lawyers think assisted living worthwhile!