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40
D. Dobbs et al.
Table 2 Resident rights
Within the boundaries set by law, residents have the right to …
• Be shown consideration and respect
• Be treated with dignity
• Exercise autonomy
• Exercise civil and religious rights and liberties
• Be free from chemical and physical restraints
• Be free from physical, mental, duciary, sexual and verbal abuse, and neglect
• Have free reciprocal communication with and access to the LTC ombudsmen program
• Voice concerns and complaints to the ALC orally and in writing without reprisal
• Review and obtain copies of their own records that the ALC maintains
• Receive and send mail promptly and unopened
• Private unrestricted communication with other
• Privacy for phone calls and right to access a phone
• Privacy for couples and for visitors
• Privacy in treatment and caring for personal needs
• Manage their own nancial affairs
• Condentiality concerning nancial, medical, and personal affairs
• Guide the development and implementation of their service plans
• Participate in and appeal the discharge (move-out) planning process
• Involve family members in making decisions about services
• Arrange for third-party services at their own expense
a
• Accept or refuse services
• Choose their own physicians, dentists, pharmacists, and other health professionals
• Choose to execute advance directives
• Exercise choice about end-of-life care
• Participate or refuse to participate in social, spiritual, or community activities
• Arise and retire at times of their own choosing
• Form and participate in resident councils
• Furnish their own rooms and use and retain personal clothing and possessions
• Exercise choice and lifestyle as long as it does not interfere with other residents’ rights
• Unrestricted contact with visitors and others as long as that does not infringe on other
residents’ rights
• Come and go rights that one would enjoy in their own home
• In addition, residents’ family members have the right to form and participate in family
councils
a
An ALC may require that providers of third-party services ensure that they and their employees
have passed criminal background checks, are free from communicable diseases, and are qualied
to perform the duties they are hired to perform
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Table 3 ALC responsibilities
In the context of resident rights, the ALC has a responsibility to …
• Promote an environment of civility, good manners, and mutual consideration by requiring
staff, and encouraging residents, to speak to one another in a respectful manner
• Provide all services for the resident or the resident’s family that have been contracted for by
the resident and the provider as well as those services that are required by law
• Obtain accurate information from residents that is sufcient to make an informed decision
regarding admission and the services to be provided
• Maintain an environment free of illegal weapons and illegal drugs
• Obtain notication from residents of any third-party services they are receiving and establish
reasonable policies and procedures related to third-party services
• Report information regarding resident welfare to state agencies or other authorities as
required by law
• Establish reasonable house rules in coordination with the resident council
• Involve staff and other providers in the development of resident service plans
• Maintain an environment that is free from physical, mental, duciary, sexual and verbal
abuse, and neglect
41
Financing
Costs for assisted living tend to be signicantly lower than those for nursing home
care and are usually private pay. Infrequently, LTC insurance is the payment source.
Costs vary widely depending on AL type, resident care needs, and geographic
region. The median annual cost for a private room is $51,600 compared to $105,850
for a private nursing home room. Annual costs are lowest in Missouri ($36,000) and
highest in Delaware ($80,280) [14]. Costs usually include monthly rent, meals, and
basic services. Unlike skilled nursing facilities, there is no Medicare reimbursement
to ALCs, but 44 states have a Medicaid waiver program under the Centers for
Medicare & Medicaid Services (CMS) to cover personal and skilled care for quali-
ed low-income residents. In 2016 Medicaid covered some services for 17% of residents [3]. These waivers are only available when a resident meets both the state’s
criteria for being “nursing home eligible” and meet the Medicaid nancial eligibility requirement. However, residents often experience a long delay before receiving
such a waiver. ALC providers often report inadequate reimbursement under these
waiver programs. As of 2020, 25 states administer Medicaid through managed care
in order to better coordinate care and to contain costs for Medicaid recipients with
complex healthcare needs [15]. The lack of public funding for AL makes affordability a major concern for the future viability of the AL industry. Another concern
is “a la carte” pricing policies by many ALCs, with additional changes when residents need increased assistance. As many residents have limited funds, families may
be reluctant or unable to pay the increased fees, resulting in substandard care.
Despite concerns about affordability, only 6% of residents move out of an ALC due
to nancial reasons [6].
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D. Dobbs et al.
Staff Training
Both a sufcient number and sufciently trained staff and 24-h stafng should
be available at the ALC. Staff should be familiar with the changes that occur
with normal aging and be trained in the basics of medication management and
the recognition and assessment of medical and social problems that commonly
occur in older adults. When staff lack education and training in basic geriatric
principles, nor recognize a resident change in condition, emerging conditions
may go undetected and result in increased morbidity and unnecessary
hospitalization.
Ideally, staff should be able to determine when to contact a family member and/
or the resident’s assigned practitioner when a signicant change of condition
occurs. State regulations now require more rigorous staff and administrative training. Most states require dementia care training for direct care staff [10]. As a
majority of ALCs admit and retain residents near the end of life, palliative and
end-of-life care education are increasingly important for nursing and direct care
staff [16]. End-of- life training for staff has been associated with a greater utilization of hospice and more engagement with family and residents in advance care
planning [17].
Studies have shown that the most common resident/family complaints and survey
deciencies cited are related to medication administration (48%), stafng and staff
qualications (41%), and services insufcient to meet resident needs (36%) [18]. A
report in 2020 found similar results with the two most common cited deciencies
among Florida ALCs related to stafng requirements and lack of staff in- service
training [19].
Disaster Preparedness andCOVID-19
Disaster preparedness and response, including that to the recent COVID-19
pandemic, require an all-hazards approach, whereby disaster planning
incorporates common principles that can be readily adapted to a specic event,
such as a hurricane, wildre, earthquake, or pandemic [20]. Although most states
require ALCs to have a disaster plan, these plans are not as prescriptive as those
for nursing facilities [21]. As a case in point, less than 10% of ALCs in Florida
reported having a pandemic emergency plan separate from an infection control
plan [20].
Despite accounting for less than 1% of the US population, LTC settings have
disproportionately contributed to 5% of COVID-19 cases [22]. As of March 2021,
the “Atlantic COVID-19 Tracker” project reported that 1 out of every 12 COVID
deaths in the USA occurred in residents of LTC facilities (including nursing homes
and ALCs) [23]. Most of the federal guidance recommendations for COVID-19 are
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related nursing facilities and do not take into consideration the unique situation of
ALCs (such as the designation of as “essential,” workers who care for residents with
dementia). Common strategies that facilitate family visitation during COVID-19
included use of technology such as face-time via Skype and Google Hangouts, window visits, and outdoor socially distanced visits. COVID-19 testing in ALCs has
also been a challenge. In order to meet this need, some communities have contracted a physician to serve as their “Director of Laboratory” in order to meet CLIA
requirements.
Decisions made by ALC administrators before, during, and after hazard events
are varied. Among 143 ALCs that were affected by hurricanes in 2004 and 2005,
three-quarters sheltered residents in place, while 23% evacuated during at least one
hurricane [24]. For Hurricane Irma (2017), administrators who had worked for at
least 10years in ALCs felt more prepared and had increased condence in the decision to either evacuate or shelter in place [21]. Also vital is collaboration with
local emergency operation centers and state agencies. During both Hurricane
Irma and the COVID-19 pandemic, administrators in ALCs with more than 25 beds
and part of a corporate chain were more satised with the level of collaboration
with state agencies compared to others who were not [20]. The availability of corporate resources of larger ALCs can have an essential role in the coordination of
the needs of the ALC.The establishment of state healthcare coalitions can bring
together private and public organizations to share emergency response responsibilities [20].
Medical Care
The clinician’s role in AL has been largely undened, due in part to the industry’s
history of distinguishing between the “medical” vs. “social” models of care, and the
concern that involvement of medical providers may result in “medicalization” and
higher costs [25, 26]. AMDA—The Society for Post-Acute and LTC Medicine has
stressed the importance of medical care in AL, and convened a consensus conference to address the needs and issues related to ALCs. Four concerns were identied:
medication management, the clinician’s role, communication and care coordination, and clinical direction [27].
Medication Management
Medication management is a major concern. As in other settings, it entails evidencebased prescribing, e-prescribing, and administration. Healthcare providers should
be knowledgeable about the basic tenets of geriatric prescribing (see the chapter
“Medication Management in Long-Term Care” for a more detailed review). These
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D. Dobbs et al.
tenets include the ve “Rs”—the Right medication, at the Right time, the Right
dose, and the Right route of administration for the Right patient. The Beers Criteria
of potentially inappropriate medications for older adults is a useful guide [28].
Unlike skilled nursing facilities, there is no federal requirement for a consultant
pharmacist to perform a monthly medication review. However, consultant pharmacists do provide medication review and monitoring at 84% of ALCs [10]. The overprescribing of medication [29] is an issue that consultant pharmacists can address,
particularly for those who have advanced qualications in geriatric pharmacy
patient care.
Administration of medication can result in errors if unskilled non-licensed staff
have had inadequate training and/or supervision. However, sufciently trained medication aides in ALCs do not commit more errors than LPNs [30]. Requirements for
the extent of staff training and oversight of medication administration do vary
among states, as does allowing nurse delegation [31]. In addition, staff may lack
assessment skills, and result in medication-related adverse side effects being unrecognized. Furthermore, unlike in nursing homes, medical providers may not be notied when a resident has refused to take his/her medication. Also challenging is
allowing residents to self-administer medication, which over time may become
unsafe. Adding to the complexity is the use of over-the-counter medication and
alternative and herbal therapies, and those brought to the resident by family
members.
Other medication issues include diverse record keeping and untimely medication
delivery and storage. Order changes, inadequate medication monitoring, and multiple provider prescribing, all challenge safe medication management. Although
medical practitioners may have no inuence on a particular ALC’s structure, staff
competency, ongoing quality improvement processes, or accountability in regard to
medication administration and management, they can offer expertise in medica-
tion management.
When applying the basic principles of medication management in older adults,
careful consideration must be given to the fact that any medication can cause side
effects. Because staff may have limited training, common geriatric syndromes
potentially caused by medication (e.g., falls, incontinence, change in appetite, new
or worsened mental status) may be unrecognized. Without well-established notication channels, the attending clinician may be unaware when new medications are
prescribed or doses changed by another practitioner. In addition, as in nursing
homes, medications are often prescribed without a face-to-face visit by the
practitioner.
Because the federal government categorizes an AL resident the same as a
community- dwelling person in regard to Medicare Part D (the benet for medication coverage), residents and their families may be presented with higher pharmacy
costs when reaching the “donut hole,” at which time the increased costs, combined
with other AL fees, can result in signicant nancial hardship for the resident
and family.
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Clinician’s Role andModels ofCare
Residents often require an initial assessment by a practitioner prior to move-in, with
the assessment varying by state and facility. Toward that end, one of the recommendations of the AMDA consensus conference was to develop standard assessment
tools and clinical protocols to help improve clinical care [27]. Unlike a formal mandatory plan of care in a nursing home, the ALC may develop a “service plan,”
which is similar in nature. Some service plans, however, may not incorporate a
healthcare plan.
Unlike nursing homes where there are mandatory medical visits every 60days,
ALC residents are required to be seen at least annually. Follow-up care can be provided by private community-based clinicians. As previously noted, ALCs can use
contract services from home health and hospice agencies. It is important to recognize that residents typically receive care by clinicians who are neither geriatricians
nor specialty trained in geriatrics or long-term care medicine. These clinicians may
have an age bias and not recognize the special challenges and needs of the aging
ALC resident, and not be cognizant of the risks inherent to hospitalization (e.g.,
delirium, pressure injuries, inappropriate prescribing, and nosocomial infections).
Many residents continue to receive routine medical care in a medical ofce/
clinic outside the ALC, by the providers who had treated them prior to their move
into the facility. However, there is an increasing use of models of care where physicians either alone or in combination with nurse practitioners and/or physician assistants, visit residents at the ALC on a regular basis. One study has shown that 50%
of physicians visited an AL setting once a year or less, while only 20% visited
weekly or more [32]. Another study using CMS 2017 claims data found that fewer
than 0.001% of clinicians who care for ALC residents had more than 80% of their
billing attributed to care to residents in ALCs. Though this number is minute, it is
56% increase from 2014 [33]. Many ALCs have recognized the benet of medical
care being provided on-site (see Table4).
Table 4 Benets of medical care providers performing on-site care at an ALC
• Learns about ALC capabilities
• Sees resident in their own environment
• Improved communication with AL staff
• Increased reimbursement from Center for Medicaid and Medicare for domiciliary codes
• No need for community transportation/escort costs
• No need for family transport time/costs
• More efcient use of clinician and staff time
• Increased resident/family/community satisfaction
• Potential for more patients for the clinician
• Potential for improved resident care
• Potential for reduced medical errors
• Better marketing/public relations for community
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D. Dobbs et al.
Communication andCare Coordination
Effective communication and care coordination is essential to healthcare in all
settings. There is a need to develop professional and respectful relationships between
the ALCs staff and the residents’ medical providers that can facilitate clear and timely
communication, especially as it relates to medication management and ongoing documentation of resident health status [26]. However, poor communication can occur at
multiple levels. Staff may have no formalized “sign out” between shifts, insufcient
assessment skills, nor when and how to contact providers. Practitioners may not
receive accurate information from staff (especially after hours), nor be aware of the
ALC’s capabilities. Many clinicians who practice only in the hospital and/or the community are unaware of the differences in the provision of care and services available
between ALCs and nursing homes. This lack of awareness is problematic when a
resident returns from the emergency department or hospital to the ALC that lacks the
ability to provide needed monitoring and treatment, or when a resident, who remains
at the ALC is no longer able to receive the level of care needed. For this reason, some
suggest the development of a medical provider education packet that describes the
health and medical services that the ALC is capable to provide to residents [26].
Care Coordination andCare Transitions
Lapses in care and commination commonly occur when older adults are either
newly admitted to an ALC or readmitted from the hospital. The “National Transitions
of Care Coalition” website includes information and tools for consumers, facilities,
and healthcare professionals to facilitate transitions of residents between healthcare
facilities. It is important for practitioners to assure that residents are transferred
back to the ALC when safe to do so. Additional services provided by a home care
agency may be necessary. To ensure a safe, appropriate, and timely transition of
care, staff should be encouraged to evaluate the resident prior to their return from
the hospital or skilled nursing facility.
Care Coordination andTechnology
While most ALCs lag behind hospitals and nursing homes in the use of technology,
advances have been made. As of 2016, 26% of ALCs used some form of electronic
health records [34]. High-tech sensor devices and other innovations are already in
use in ALCs to better monitor residents, as are various tool, such as medication
reminders, fall detection systems, and technologies to help residents to stay engaged
and connected with friends and family [35]. Smart home technology is being increasingly used, such as the TabSafe In-Home Medication Dispensing System that can
assist older adults with medication management and allows providers both to make
medication adjustments and to monitor as-needed (PRN) medication use. Smart
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toilets and bladder scanners are already available to monitor residents in some ALCs.
In addition, assistive robots can help older adults overcome physical limitations and
to safely engage in daily activities. Cost savings may be possible if robot “companions” enable ALC corporations to virtually visit communities while telemedicine can
enable clinicians to promptly assess residents in remote regions. With the COVID-19
pandemic, more frequent use of telemedicine will continue for non-pandemic care.
Care Coordination andAccountable Care Organizations
As part of the Affordable Care Act, Accountable Care Organizations (ACOs) were
enacted in 2012 to serve as provider networks to share nancial responsibility and
risk for providing care to a dened Medicare fee-for-service population. Under the
law, an ACO must be responsible for at least 5000 Medicare beneciaries for at least
3years [36]. If the ACO is able to provide better care as dened by certain quality
metrics, and the care results in cost savings to Medicare via fewer days spent in the
hospital, then providers who are part of the ACO will share in the Medicare savings.
Nursing homes have played a key role in post-acute care as providers in ACOs. If
nursing homes can provide quality care and avoid readmission to hospitals, this can
result in considerable cost savings to the ACO.Four tenets (see below) are needed
for AL providers to participate in a ACO provider network [37]. Due to a lack of
necessary resources ALCs with less than 25 beds and those not part of a large
corporate- owned chain have less leverage for contracting with an ACO.
• ALCs should assess both their ability and intent to keep residents out of the
hospital; if the AL does not see itself as a network partner who is able to reduce
hospital admissions, then being part of the ACO is not a good idea because of the
nancial penalties associated with frequent resident hospitalizations.
• ALCs should have strong care coordination programs. Lack of care coordination
between care settings can lead to costly mistakes and not only frequent hospital-
izations, but also medication errors [38].
• ALCs need to build coalitions with quality post-acute and LTC providers.
• ALCs need to measure and maintain partnerships, and to electronically track
hospital admission rates and resident transitions: key data points that align with
other ACO providers.
Clinical Direction (i.e., Medical Director or Not!)
Clinician condence in staff has been shown to increase in smaller ALCs, when
there is an increased presence of nursing staff and if the facility has established the
position of a physician Medical Director [29]. Though there is no federal mandate
that requires an ALC to have a Medical Director or Physician Advisor, some facilities have established this position. The AL Workgroup did not reach a majority
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D. Dobbs et al.
consensus to support a recommendation that ALCs have a Medical Director, but did
agree that an “external professional consultant” should be contracted. Not unsurprisingly, the need for increased “on site” medical oversight and coordination of
care in AL become necessary during the COVID-19 pandemic [39].
Clinical Direction andHospice
In 2016, hospice services were available in 81% of nursing homes and 68% of
ALCs [3]. The addition of hospice care may allow residents to stay in the ALC during their nal days of life. The Medicare hospice benet provides an all-inclusive
daily payment for hospice services based upon four levels of care: (1) routine home
care, (2) general inpatient care, (3) inpatient respite care, and (4) continuous home
care. Residents who receive hospice can receive routine home care (least expensive)
or continuous home care (most expensive). Sixty percent of Medicare beneciaries
who received hospice in ALCs had an ill-dened condition, dementia, or Alzheimer’s
disease as their terminal diagnosis. Ill-dened conditions included, adult failure to
thrive, senility without psychosis, and unspecied debility [40]. However, Medicare
no longer accepts these nonspecic diagnoses.
The federal government has been scrutinizing hospice payments in ALCs. The
US Department of Health and Human Services Ofce of Inspector General (OIG)
released a report in 2015 entitled “Medicare Hospices Have Financial Incentives to
Provide Care in Assisted Living Communities” as part of a mandate to reform the
hospice payment system as directed by the Patient Protection and Affordable Care
Act. The median length of stay on hospice per beneciary is 98days in ALCs, compared to 50days in nursing homes, 30days in skilled nursing, and 45days in the
home. The OIG concluded that hospices are incentivized to target ALCs because
they offer the greatest nancial gain to the hospice agency. Targeted reviews, adoption of claims-based measures of care, and making hospice data available to beneciaries are subsequent recommendations. The entire report is available at www.oig.
hhs.gov. In general, in all settings, the federal government is more closely scrutiniz-
ing the level of care at which a hospice is billing [40].
Practitioner Billing E/M Codes
The appropriate and correct use of billing codes is essential for practitioners. Note
as of January 1, 2023 assisted living visits should use the home visit E/M codes
99341, 99342, 99344, and 99345 for new patient visits and 99347, 99348, 99349,
and 99350 for established patient visits.
AL uses Place of Service Code 13. Reimbursement for AL medical services is
generally higher than equivalent codes for other sites of service, such as the ofce
and nursing home. This can serve as an incentive for clinicians to include AL resident visits in their practice.
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The Future ofAssisted Living
The increased number of AL beds, rising resident acuity, and concerns about the
quality of care have resulted in increased scrutiny of the AL industry. Over time,
state regulations have increased and more attention has been given to affordability.
In 2014, CEAL convened a roundtable entitled “The Future of Assisted Living:
Consumer Preferences and the Era of Healthcare Reform.” At that time, the three
main factors driving change in AL were increased resident medical acuity, the provision of healthcare transitions from traditional settings to non-institutional community settings through ACOs, and the increased expectations of baby boomers due
to a higher level of education, more work experience and use of technology. The
CEAL identied 14 major themes (Table5), with key areas of focus being personnel, data, state regulations, and affordability.
In 2021, a diverse group of stakeholders came together through AMDA-The
Society for Post-Acute and Long-Term Care to foresee the future of AL.They identied current issues related to models of AL (e.g., noting that the combination of
services and housing limited consumer choice), regulations (e.g., while intended to
improve quality, they often are outdated or ineffective), nancing (e.g., AL costs
are too expensive and so inaccessible to most consumers), residents (e.g., rising
acuity necessitates a need for procient healthcare), and the nurse and direct care
workforce (e.g., insufcient numbers, training, and opportunities that limit the
quality of care) [41]. Implications on future practice and policy and research were
delineated.
The AL industry will likely follow nursing home trends toward quality
improvement. The American Health Care Association and National Center for
Assisted Living (AHCA/NCAL) have established The Quality Initiative for AL,
which focuses on four core areas with measurable goals.
Table 5 Important themes in AL (asterisk indicates key themes)
• Aging in place
• Diverse models
• Future market
• Assisted living without walls
• Value proposition
• State regulations
*
• Data
• Technology in AL
• Personnel
• Keeping the “home” in AL
• Risks and choice
• Affordability
• Consumer education
• Flexibility
*
*
*
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