Assisted living (AL) is a well-established alternative to nursing homes, promoting autonomy and choice in a residential environment. As this sector has matured, the profile of AL residents has evolved. The current article examines the opportunities that AL affords for older adults and areas for further research to optimize the fit between resident needs and the AL environment. The model of person–environment fit (Lawton, 1982) provides an organizing framework for our commentary (Figure 1). This theory posits that positive adaptation occurs when a person's competence and needs are well-matched to the opportunities and resources of the environment at the subjective level (i.e., what a person believes they need and how they interpret their environment) and objective level (i.e., assessments of health, function, cognition, and tangible resources to prevent and manage health problems).
Assisted living: person–environment fit. Adapted from Lawton (1982).
AL developed initially as a “social model,” emphasizing choice, independence, and privacy and rejecting health care associated with nursing homes (Kapp & Wilson, 1995). AL grew exponentially between 1990 and 2005, fueled by consumers' desires for less institutional alternatives for long-term services and supports, now providing services to more than 800,000 older adults (Harris-Kojetin et al., 2019). Generally, ALs provide private living quarters, congregate dining, social/recreational activities, assistance with personal care needs, and 24-hour staffing to respond to emergencies, although there is great variation in size, ownership, staffing models, and services (Carder et al., 2016). AL services were designed around resident-driven concepts, including negotiated service agreements and managed risk (Kapp & Wilson, 1995; Reinardy & Kane, 2003). Although 97% of facilities report conducting a formal functional/physical assessment and 89% report conducting a cognitive assessment pre-admission, the majority do not have a qualified health care provider on staff to perform such assessment (Acclaro Growth Partners, 2009). Although many states require some form of assessment on admission, these assessments generally focus on functional status with little or no attention to overall health status and planning for monitoring complex health conditions and identifying changes in condition.
States license and regulate AL, and some certify or license ALs to provide “memory care” for people with Alzheimer's disease and related disorders. Nationally, 23% of ALs either have a dementia care unit on site or serve only residents with dementia (Harris-Kojetin et al., 2019). Unlike nursing homes, there is no federal regulatory oversight for the AL industry. Instead, there are state-specific approaches to oversight, regulations, staffing models, or information gathering and synthesis. A review of states' dementia-specific regulations found that of five key topics, more than one half of states had provisions for administrator training, consumer disclosure, and building design features, and less than one half of states specified staffing types or levels or pre-admission assessment criteria (Carder, 2017). For example, only 16 states license or certify dementia care units within residential care/assisted living settings, and only six states specify a licensed nurse must be available to residents in dementia care units (Carder, 2017).
Approximately one half of AL facilities nationwide participate in Medicaid; yet of those, the number of residents with Medicaid is low, approximately 20% (Harris-Kojetin et al., 2019). The private pay model typically offers a la carte services, advantaging those who can afford additional supports. Facilities serving primarily Medicaid recipients offer fewer services to residents, reflecting a significant difference in support for low-income residents (Ball et al., 2004). Although widely adopted in health care settings, electronic health records are not yet widely used nor comprehensive, with greatest adoption of digital records for medication lists (often provided by pharmacy contractors) at 87.8%, followed by resident demographics (73.2%) and clinical notes (51.2%) (Holup et al., 2014).
Unlike the federal/state regulation and licensing standards for skilled nursing facilities, not all states require AL administrators to be licensed, and there is no standard requirement for a director of nursing. For the few states that require licensed administrators, minimum education requirements vary. For example, state requirements for initial orientation and training requirements for AL administrators range from 6 to 70 hours, and annual continuing education from 6 to 30 hours (Carder et al., 2016). The availability of health care professionals varies by state and is, in general, minimal. Concerns about insufficient staffing levels and training have been raised since at least 2004 (U.S. General Accounting Office, 2004). As of 2015, 38 states required ALs to have a licensed nurse (i.e., RN, licensed vocational nurse [LVN], or licensed practical nurse [LPN]) on staff or available, either through employment or as a consultant (Carder et al., 2016). Less than one half of AL facilities have any type of RN or LPN (Han et al., 2017), and in many cases, RN involvement is focused primarily on the functional role of oversight of the medication administration program (Sikma et al., 2014). A 22-state survey found that only 20% require RN oversight, 37% of ALs had a medical director, and 24% had a contract with a physician practice (Beeber et al., 2018).
Most states permit AL facilities to employ direct care workers (DCWs) who have limited training, and are not certified or licensed, to do the bulk of personal care. In 40 states, AL facilities have flexibility to determine staffing ratios. Forty-seven states require DCWs to receive an orientation or initial training, ranging from 1 to 80 hours, and 40 states specify annual in-service training, ranging from 4 to 16 hours per year. Thirty-six states and the District of Columbia allowed DCWs to administer medications (Carder et al., 2016). Recent studies have not explored general knowledge of DCWs in AL, yet a foundational study identified a pervasive belief among DCWs that many reversible conditions among AL residents reflected normal aging (Hawes & Phillips, 2000). As licensed staff are highly reliant on reports of change in condition, this finding suggests a significant gap between what DCWs should be observing and reporting to supervising nurses and what they are likely identifying as necessary to report.
The AL model fundamentally relies on family involvement to fill gaps between negotiated, contracted care and older adults' abilities to self-manage their daily activities and care. Family roles in AL include instrumental care, routine monitoring, and management of health status, advocating for older adults' care needs and intervening as needed, and routine communication and coordination with AL staff and other providers. Families are part of “Convoys of Care,” comprising families/social networks, external aides hired to supplement care, AL staff, and the AL resident; yet, family roles vary based on a number of factors (e.g., preferences, clarity of expectations, relationships with other members of the convoy, resident needs) (Kemp et al., 2013). Three AL studies highlight the importance of staff–family caregiver communications, linking gaps in communication among members of the care convoy to medication errors (Kemp et al., 2018), family preferences for greater communication from AL providers (Port et al., 2005), and specific situations such as prior to sending an older adult to the emergency department and completing a POLST form (Sharpp & Young, 2015).
Studies describing various programmatic areas in AL include promoting physical activity (Bender et al., 2019; Bowen et al., 2018; Holmes et al., 2017), end-of-life care (Ball et al., 2014; Dobbs et al., 2012), person-centered practices (Zimmerman et al., 2015), and medication management and safety (Chun et al., 2018; Young et al., 2013). A few intervention studies aimed to enhance programmatic support, including physical activity (Chao et al., 2014), supporting residents with cognitive impairment (Ford Ii et al., 2019), and fall prevention (Mielenz et al., 2014). The role of technology in AL is emerging. With the prevalence of chronic conditions, technology in the form of sensors/monitoring devices, reminders, and for connection to family or health care providers will likely increase (Irizarry et al., 2017; Young & Nesbitt, 2017). Robotics could provide functional support and social engagement and has the potential to enhance autonomy for AL residents (Mitzner et al., 2014).
The most recent National Survey of Long-Term Care Providers revealed that the majority of ALs (residential care communities) admitted residents older than age 85 with significant health care and functional needs, including assistance with transfers, eating, dressing, and medications, and having dementia (42%), arthritis (42%), heart disease (34%), depression (31%), and diabetes (18%) (Harris-Kojetin et al., 2019). AL staff assist >80% of residents with medications, averaging 9.6 routine and 3.5 as-needed medications per day (Young et al., 2008), and approximately 40% of AL residents require assistance with three or more activities of daily living (Harris-Kojetin et al., 2019). Health disparities are clear in that Black Medicare beneficiaries are underrepresented in AL settings (at 5% vs. 9% of the general population), are more likely to be lower income (i.e., dually eligible for Medicare and Medicaid) (74% vs. 25%), are more likely to reside in facilities with fewer services, and have higher chronic disease burden than White Medicare beneficiaries in AL (Fabius & Thomas, 2019). Only 4.1% of AL residents are non-Hispanic Black compared to 14.3% of nursing home residents (Harris-Kojetin et al., 2019). Little is known about care needs and expectations of AL residents across racial/ethnic groups and the impact of health disparities in AL settings.
Optimal fit reflects the ability of the AL environment to meet the competence and needs of residents, including autonomy, choice, health status, function, cognition, and social considerations. There is little research on resident and family perspectives of the person–AL environment fit, the related benefits, and limitations. However, there is evidence that some residents' needs are not met in this setting. One such group are older adults with serious mental illness, including major depression, schizophrenia, and bipolar disorder. For the most part, AL lacks adequate provisions for their assessment and care and appropriate staff training to support their mental health needs (Morgan et al., 2016). The 2011 National Health and Aging Trends Study data examined consequences of difficulty or lack of help for mobility, self-care, and household activities and found that the risk of having unmet needs among Medicare beneficiaries was highest in AL (42%) versus any other setting (37% in senior housing and 31% in community housing) (Freedman & Spillman, 2014). Other insights come from use of other health care resources by AL residents, including avoidable hospitalization due to limited ability of staff to monitor and detect changes in condition (Sharpp et al., 2012). Some AL settings are responding to the higher acuity in part by increasing the use of licensed home health care (Nazareno et al., 2020) and hospice (Dougherty et al., 2015).
Preferences to age-in-place are at the philosophical core of AL, yet admission/discharge policies vary and the agein-place option is not guaranteed. State level regulations trigger facilities to discharge individuals whose health-related needs they cannot meet (Carder et al., 2016). Consequently, the average annual turnover is 42%, with an average length of stay of 28.3 months; approximately one half of AL residents move out for health reasons, either to a nursing home or to live with a relative.
Lack of minimum standards makes assessment of quality and transparency of outcomes difficult, even within a state. Only 12 states require quality assurance and performance improvement in AL (Carder et al., 2016). The American Health Care Association/National Center for Assisted Living (2012) launched a voluntary quality improvement program in 2012 focused on increasing resident satisfaction, reducing rehospitalization, reducing antipsychotic medication use, and improving staff stability. Research has focused on three major areas of AL quality—regulatory deficiencies, medication safety, and elder abuse.
A study of deficiencies in Florida revealed quality variability, with 90% of deficiencies classified as having potential risk of harm and the most common deficiencies around staffing standards and training (June et al., 2020). The medication safety studies (Young et al., 2008; Young et al., 2013; Zimmerman et al., 2011) document the complexity of medication regimens that reflect the underlying chronic disease burden of AL residents. In most states and many settings, these medications are managed by DCWs with minimal training beyond the task of administration, lacking the knowledge to detect adverse events or evaluate the benefits of treatment and with minimal access to nursing, pharmacy, and medical oversight for the overall medication program (Sikma et al., 2014). The little information available suggests that elder abuse is an issue in AL, but the extent and sequelae are not well known. A study in Texas reviewed long-term care ombudsman complaints and found that verbal/psychological abuse was most commonly reported with disproportionate rates of financial exploitation (Magruder et al., 2019). Another perspective comes from a survey of AL DCWs in one state: 59% reported observing another staff member verbally abusing residents, 52% suspected others of physical abuse, 38% reported deliberate withholding of food, 26% reported destruction of resident belongings, and 11% reported sexually inappropriate behavior (Castle & Beach, 2013).
The issues of person–environment fit are magnified in a crisis. The COVID-19 pandemic disproportionately affected older adults in long-term care, including AL, with estimates that 45% of COVID-19–related deaths have occurred in long-term care (Kaiser Family Foundation, 2020). The extent to which the lack of AL–specific regulations for infection control affected staff preparation and capacity to respond to an outbreak is unknown (Young & Fick, 2020). Regarding infection control, 31 states require training for AL staff, yet only 13 have robust infection control policies and procedures (Bucy et al., 2020). Only 50% of the 50 states require reporting of disease outbreaks to the health department (Kossover et al., 2014), so the full impact of COVID-19 in AL remains unclear. Front-line staff face daunting challenges to provide care for AL residents, risking their own personal safety and often being blamed for negative outcomes. With visitor restrictions put in place overnight, some residents were left with unmet needs that—pre-COVID-19—were routinely addressed by family. The pandemic highlights the importance of strengthening AL through evidence-based practice.
Discussion and Implications for Future Research
Now in its fourth decade of existence, AL has evolved over time and is a substantial provider of long-term services and supports. There is considerable variation across settings in the model of care, staffing, health care professional involvement, and limited data about quality outcomes. Although families are engaged in care, it is not uncommon to have misalignment around understanding and facilitation of the role of family members. There is little information about resident and family perspectives on quality of life and the fit of their needs with the setting, including cultural appropriateness.
Population studies reveal that complexity and intensity of need are increasing among AL residents. Although AL settings are responding by increasing use of home health care and hospice, there is less information about how the organizations are approaching DCW training and involvement of health care professionals. Although nursing home studies confirm a positive relationship between resident outcomes and nurse staffing levels, interpretation of findings is complicated by unaccounted differences in leadership style and quality, failure to distinguish among levels of nurse credentials, and high nurse turnover rates (Kane et al., 2007). The complexity of relationships between nurse staffing and relevant outcomes in AL is even greater, as resident characteristics, staffing, and state regulations are much less consistent than is found in nursing homes. RN expertise can enhance community health and prevent negative outcomes (Young & Haight, 1993); however, the full potential of the RN role remains unexplored. There are several important programmatic areas for future attention, such as the optimal provision of health care and RN involvement in AL, including prevention of avoidable adverse events, managing transitions, end-of-life care, care for persons with cognitive impairment, and best practices for family engagement.
The overarching model of AL has prioritized choice in the environment, affording larger and more private living spaces, with associated higher operating costs. The business model did not anticipate the costs of health care delivery, raising issues of affordability with enhanced services and potential disparities as low-income residents may not have resources to augment services with private help. The model inherently values autonomy over risk reduction (Sikma & Young, 2001), a calculus that may have shifted with increasing morbidity among residents. Transparency and communication are vital to assure person-centered solutions. Research could advance this important dialogue regarding fit.
Research to date is largely descriptive, cross-sectional, and has used convenience sampling. Because AL predominately serves private pay and White residents, less is known about how AL could improve quality of life for individuals from diverse communities and low-income populations. There are several methodological challenges to AL research, including the high variability between AL settings and across states, lack of common data elements, and difficulty accessing representative samples. Studies have highlighted several areas for further inquiry, at the person level, within the environment and for promoting optimal outcomes in care and health. Table 1 includes potential research questions to advance knowledge to improve person–environment fit in AL. More sophisticated research designs, including longitudinal studies, exploration of multiple perspectives on the same phenomenon, and comparative effectiveness trials, could advance the evidence for program improvement and resident outcomes. Finally, with the popularity of AL as an option, it will be important to continue to examine how this environment can evolve to meet the changing needs of the resident population, while balancing the elements of autonomy and affordability.
Potential Research Questions to Optimize Person–Environment Fit in Assisted Living (AL)
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Potential Research Questions to Optimize Person–Environment Fit in Assisted Living (AL)
| How do consumers of AL make decisions (e.g., at move in, after move in) and what information would promote realistic expectations and prioritizing their preferences?|
| What are the needs and relevant outcomes for sub-populations of AL residents (e.g., dual-eligible, racial/ethnic minorities, people with Alzheimer's disease and related disorders, mental health issues)?|
| What is the experience of residents and families with AL? How does the culture fit with expectations? What are perspectives on the balance of risks with autonomy?|
| How could environments (staffing, training, processes) best support AL residents?|
| How could leaders and staff of AL promote effective collaboration with families?|
| What programs support quality of life for residents/families (e.g., physical activity, cognitive care, transitions)?|
| What state policies and regulatory structures promote optimal outcomes? How do we improve care without over-regulation? What is the relative impact of facility vs. state policy?|
| How could accessible and transparent quality information improve programs?|
| What is and could be the role of the nurse in AL?|
| How could technology enable care delivery and reduce social isolation in AL?|
| What is the impact of external health professional and referring agency understanding of AL capacity?|
| How adequate are case finding, infection control, and public health supports for AL?|
| How can the concept of balancing autonomy and risk inform programmatic decisions and policy in AL?|
| What are the most important quality indicators and how is AL doing with quality?|
| How does engagement of health care professionals within AL and the community promote optimal outcomes?|
| How could leadership in AL promote optimal person–environment fit?|
| How can AL promote health equity and cultural inclusion across racial/ethnic, LGBTQ, and economic groups?|
| How does AL respond to residents' changing needs over the course of stay through end of life?|
| How could the role of the RN evolve with changes in the resident population to include community health and leadership elements?|