U.S. Department of Health and Human ServicesU.S. Department of Health and Human Services
This report was prepared under contracts #HHS-100-94-0024 and #HHS-100-98-0013 between the U.S. Department of Health and Human Services (HHS) and the Research Triangle Institute. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.shtml or contact the ASPE Project Officer, Pamela Doty, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: Pamela.Doty@hhs.gov.
Additional funds were also provided from the Public Policy Institute of the Research Group of the American Association of Retired Persons. The Alzheimer's Association and the National Institute on Aging have also provided support for this project. The authors also would like to acknowledge the assistance of Vince Iannacchione, Linda Lux, Margaret Byron, and Lisa Wrage of the Research Triangle Institute. The views expressed in this report do not necessarily reflect the views of any of the sponsoring organizations.
This is the first in a series of planned reports based on data collected from surveys of a national probability sample of assisted living facilities. These data were collected as part of a study, "A National Study of Assisted Living for the Frail Elderly," funded by the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE), with additional support provided by the AARP, the Administration on Aging (AoA), the National Institute on Aging (NIA), and the Alzheimer's Association.
| This report presents the results of a telephone survey of a nationally representative sample of 2,945 places identified as assisted living facilities. |
This report presents data from a telephone survey of the administrators of assisted living facilities across the country. These facilities were selected from a national probability sample of all facilities that met the criteria for inclusion in the study. Thus, the findings are representative of the industry as a whole. As such, they represent the first empirical data on the characteristics of the assisted living industry nationwide based on a representative national sample of facilities.
The overall purpose of the study was to learn about the role assisted living facilities play in providing a residential setting and supportive long-term care services to the elderly. The specific objectives of this telephone survey were to:
Determine the size and nature of the supply of assisted living facilities
Describe the basic characteristics of the assisted living industry particularly in terms of the services, accommodations and basic price
Begin examining the extent and way in which the current supply of facilities embodies the key philosophical tenets of assisted living, and
Identify facilities for subsequent, more extensive data collection.
| Assisted living represents a promising new model of residential long-term care, one that blurs the sharp and invidious distinction between receiving long-term care in one's own home and in an "institution." |
In order to conduct the survey and obtain generalizable results, the project staff implemented a complex, multi-stage sampling design. At the first stage, project staff selected a random sample of 60 geographic areas, known as first stage sampling units (FSUs). These 60 FSUs were comprised of 1,086 counties in 34 states. In these geographic areas, project staff created a comprehensive listing of places thought to be assisted living facilities. Staff used a combination of sources to create this list, including state licensure agencies, industry trade associations, local and national retirement directories, telephone book "yellow" page advertisements, and Internet listings.
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Assisted living is still "new enough that the businesses offering it and the states that license it do not agree on a precise definition." Tamara Hodlewsky, National Center for Assisted Living, 1998 |
From this list of potential candidate facilities, project staff selected a stratified, random sample of 2,945 places. These places were then surveyed by telephone to determine their eligibility for the study and, if eligible, to secure information about the facility's size, services, price and accommodations.
Eligibility Criteria. The study's three basic eligibility criteria were that a facility had to:
1. Have more than ten beds1
2. Serve a primarily elderly population
In addition, the facility either had to:
3a. Represent itself as an assisted living facility
OR
3b. Offer at least a basic level of services, which were:
The administrators of a sample of 2,945 candidate facilities were then surveyed by telephone during 1998. If the candidate facility met the study eligibility criteria specified in a set of screening questions, then the administrator was asked to respond to questions about the facility, its size, occupancy, accommodations, services, price and basic admission and discharge criteria. A total of 1,251 facilities were contacted, found to be eligible, and interviewed.
The results of this screening activity and of the more extended telephone survey are the topic of this report. The results reported here are statistical estimates about the universe of assisted living facilities, based on responses from the nationally representative probability sample of facilities that were surveyed.
SIZE OF THE ASSISTED LIVING INDUSTRY
There were an estimated 11,459 assisted living facilities (ALFs) nationwide, with approximately 611,300 beds and 521,500 residents, as of the beginning of 1998.
GENERAL CHARACTERISTICS OF THE ASSISTED LIVING INDUSTRY
The average bed-size was 53 beds; 67 percent of the ALFs had 11-50 beds; 21 percent had 51-100 beds; and 12 percent had more than 100 beds. Facility occupancy averaged 84 percent. The average length of time the ALFs had been in business was 15 years, but slightly more than half (58%) of the ALFs had been in business for 10 years or less. About one-third (32%) had been in business no more than five years.
ACCOMMODATIONS
Unit Type. A room was the dominant type of resident unit (57%) in ALFs; 43 percent of the units were apartments.2 The most common type of room was a private room with a full bathroom (42% of all single rooms). The most common type of apartment was a one-bedroom, single occupancy apartment (41%).
Privacy. Most assisted living facilities offered consumers a range of options in terms of private or shared accommodations. Only 27 percent of the facilities had all-private accommodations. A plurality of ALFs (45%) had a mix of private and shared units. However, slightly more than one-fourth of the ALF administrators (28%) reported that the facility had at least one bedroom shared by three or more residents.
Although ALFs offered residents a range of options, 73 percent of all resident units were private. Twenty-five percent of the units were semi-private, that is, shared by two unrelated persons. Two percent of resident units were in "ward-type" rooms that housed three or more unrelated persons.
Bathrooms. While nearly three-quarters (73%) of the rooms or apartments were private, slightly less than two-thirds (62%) of the units offered a private full bathroom (i.e., toilet, sink and shower or tub). An additional six percent of the units had a private "half" bath (i.e. toilet and sink) but no bathing facilities except communal facilities shared with other residents. Thus, more than one-third (38%) of all ALF units required the resident to share a bathroom.
SERVICES AND NURSE STAFFING
General Services. Nearly all facilities provided or arranged 24-hour staff, three meals a day, and housekeeping. More than 90 percent of the ALF administrators also reported that the facility provided medication reminders and assistance with bathing and dressing; 88 percent of the ALFs provided or arranged central storage of drugs or assistance with administration of medications.
Nurse Staffing. Almost three-quarters of the ALFS (71%) had a licensed nurse, either a registered nurse (RN) or licensed vocational nurse (LVN), working on staff full- or part-time. Slightly more than half of the ALFs (55%) reported having an RN on staff either full or part- time. Forty percent of the ALFs reported having a full-time RN on staff.
Providing or Arranging Services. Administrators were also asked whether the facility provided services with their own staff or arranged with an outside agency for the provision of the service. With the exception of therapies, if an ALF offered a service, such as help with bathing, dressing, and managing medications, most provided it with their own staff. About half (52%) of the facilities provided some care or monitoring by a licensed nurse (RN or LPN) with their own staff, and one-quarter (25%) arranged for nursing care with an agency. However, one in five ALF administrators (21%) reported that the facility did not arrange or provide any care or monitoring by a licensed nurse.
ADMISSION & RETENTION POLICIES
Most ALFs reported a willingness to admit residents with moderate physical limitations, such as using a wheelchair (71%) or needing help with locomotion (62%) (i.e., walking or using a wheelchair or cart). But fewer than half the ALFs (44%) were willing to admit residents who needed assistance with transfers (i.e., in or out of bed, a chair or wheelchair). Administrators also reported that fewer than half the ALFs would admit a resident with moderate to severe cognitive impairment (47%).3
Facilities also had criteria about the retention of residents with certain types of conditions or problems, although, as with admission policies, many facilities had idiosyncratic policies (see footnote #3). Nearly one-third of the administrators (31%) reported that the ALF would not retain a resident who used a wheelchair (or that "it depends"), and 38 percent would discharge a resident who needed assistance with locomotion. Fewer than half (45%) of the ALFs would definitely retain a resident with moderate to severe cognitive impairment, and 76 percent would not retain residents with behavioral symptoms (e.g., wandering). Seventy-two percent of the ALFs would not retain a resident who needed nursing care for more than 14 days. Nearly three-quarters of the ALFs (72%) reported that one of more of their residents had been discharged within the last six months because the resident needed skilled nursing care.
RESIDENT CHARACTERISTICS
ALF administrators estimated that about 24 percent of their residents received help with three or more activities of daily living (ADLs), such as bathing, dressing, and locomotion. They estimated that about one-third of the residents (34%) had moderate to severe cognitive impairment.
DIFFERENT MODELS OF ASSISTED LIVING
The information provided by administrators identified two significant variations among the ALFs that are worth noting. One group of ALFs identified or described themselves as assisted living facilities. Another much smaller group provided the same basic services but identified themselves by some other designation, such as adult congregate living, residential care, or community residential facility. Another significant variation was between ALFs that were free-standing and ALFs located on a campus that offered multiple levels of care. Such "multi-level" campuses typically housed an ALF and a nursing home or some other type of residential care, such as congregate apartments or independent living facilities.
Self-Described ALFs. Seven of ten (72%) of the administrators represented or described the facility as being an "assisted living facility or residence." Twenty-eight percent of the administrators did not describe the facility as assisted living; however, the facility still met study eligibility criteria. Despite the differences in how the administrators characterized the facilities, the two groups of facilities were remarkably similar in terms of their size, the services they offered, their nurse staffing, most admission and retention criteria, and the basic characteristics of their residents. Self-described ALFs, however, tended to have lower occupancy rates, had been in business for a shorter period of time, were more likely to offer apartments and private units, and were more likely to admit and retain residents who used a wheelchair or received help with locomotion. They also tended, on average, to have higher monthly prices.
Free-Standing ALFs Compared to ALFs Located on a Multi-Level Campus. The majority of ALFs (55%) were free-standing, while 45 percent were located on a campus housing multiple facilities or residential settings offering different levels of care. ALFs on a multi-level campus had higher occupancy rates and tended to have higher monthly prices than free-standing ALFs. They were also more likely to have private units and apartments and to provide or arrange more services for residents, most notably nursing care and therapies. ALFs on multi-level campuses also tended to have higher levels of nurse staffing than free-standing ALFs. In addition, they were more likely to admit and retain residents who needed nursing care and residents who used a wheelchair. Despite this, the administrators did not report having a "heavier care" resident case mix than the free-standing ALFs.
Categorization of ALFs By Combined Levels of Service and Privacy. Any attempt to understand assisted living and its role in providing long-term care to the frail elderly is hindered by the lack of a common definition of "assisted living." Currently, places known as ALFs differ widely in ownership, auspice, size, services, staffing, accommodations, and price. Thus, analyzing data on facilities and reaching conclusions about "assisted living" as a whole involves comparing "apples to oranges." As a result, project staff developed a classification that divided the universe of assisted living facilities into distinct categories or types of facilities, representing their mix of services and privacy. The four types the study identified represent reasonably homogeneous groups of facilities. Moreover, the data revealed significant differences among groups.
Definitions of high, low and minimal privacy. "High privacy," meant that at least 80 percent of the resident units were private. A total of 31 percent of the facilities met this definition of high privacy. Twenty-eight percent of the ALFs offered "minimal privacy" because they had one or more rooms that housed at least three residents. The remainder of the ALFs (41%) fell between these two types of facilities in a "low privacy" category.
Definitions of high, low and minimal services. "High services" was defined as having a full-time RN on staff and providing nursing care, as needed, with facility staff, as well as providing help with at least two ADLs, 24-hour staff, housekeeping, and at least 2 meals a day. Thirty-one percent of the ALFs met this criterion. Five percent of the ALFs did not offer help with even two ADLs and were thus defined as providing "minimal" services. The remaining ALFs (65%)4 were categorized as "low service," although some that did not provide nursing care with their own staff were willing to arrange a higher level of services through an outside provider, such as a home health agency.5
Combining the mix of services and privacy revealed four basic types of ALFs. The first type of ALF combined facilities in the "minimal" group of ALFs (i.e., the 32% with either minimal privacy or minimal services) and facilities offering low privacy and low service (i.e., 27% of the ALFs). The combined low/minimal privacy and services group was the most common type of assisted living facility, comprising 59 percent of all the ALFs. This type of assisted living facility cannot be easily distinguished from the traditional concept of board and care homes. A significant proportion of resident rooms were shared rather than private, and such facilities offered little beyond assistance with medications, bathing, or dressing. In two of five (41%) ALFs described by this model, there was at least one room shared by three or more people. Facilities of this type not only represented the majority of all ALFs nationwide, they also constituted 58 percent of all the facilities that described themselves as assisted living.
| DISTRIBUTION OF ALFs BY CATEGORIES | |
|---|---|
| Category | National Estimate |
| 1a. Low Privacy & Low Service | 27% |
| 1b. Minimal Privacy or Service | 32% |
| 2. High Privacy & Low Service | 18% |
| 3. High Service & Low Privacy | 12% |
| 4. High Privacy & High Service | 11% |
Another ALF type offered a high degree of privacy in accommodations but low services, a sort of "cruise ship" model of assisted living. In this type of ALF, more than 80 percent of the accommodations were private. However, these facilities would have had a difficult time helping residents age in place, since they had no RN on staff and most were unwilling or unable to provide or arrange any nursing care for residents. Only 19 percent of the ALFs in this model would provide or arrange nursing care and retain a resident who needed such care. This ALF type comprised 18 percent of all ALFs nationwide.
A third type of ALF was one described as high service/low privacy. In such facilities, two-thirds of the accommodations were in single rooms rather than apartments, and fewer than 80 percent of the rooms were private. However, all such facilities had a full-time RN on staff. About half (53%) the ALFs of this type were willing to provide or arrange nursing care, as needed, and retain residents who needed such care. This was also the type of ALF that had the most expansive admission and retention criteria and the highest resident acuity. For example, such facilities were more likely to retain residents who needed assistance with transfers and to retain residents who needed nursing care. Compared to the other ALF types, the high service/low privacy type also had a much higher proportion (35%) of residents who received assistance with three or more activities of daily living (ADLs), such as help with locomotion or using the toilet, as well as bathing and dressing. An estimated 12 percent of the ALFs across the country were in this category.
A fourth type of ALF offered high service and high privacy. Only 11 percent of all ALFs fell into this category. While resident accommodations were almost evenly split between rooms and apartments, nearly all (98%) of the accommodations were private. In addition, 41 percent of the high service/high privacy ALFs offered to arrange or provide nursing care and retain residents who needed such care. All had an RN on staff.
PRICE OF ASSISTED LIVING
There were many variations in pricing structure among the ALFs nationwide. Some ALFs had a single monthly price for what they defined as basic services and accommodations. Other ALFs had multiple rates, varying with either the type of accommodation or the service package provided to the resident.
The most common monthly basic price was between $1000 and $1999 for both facilities with a single rate (i.e., 45% were in this range) and facilities with multiple rates (i.e., the range covered the most common rate for 52% of the ALFs). Thus, the most common basic price was between $12,000 and $24,000 per year. However, it is important to note that the average price was depressed by the presence of a very large number of ALFs (59%) that offered minimal or low privacy and services and had relatively low monthly rates. The most common base price for facilities with multiple rates was just over $22,000 per year for the high service/low privacy ALFs and just over $21,000 for the high privacy/low service ALFs. The basic annual charge was slightly more than $23,000 for the high service/high privacy ALFs.
These rates are striking for two reasons. First, in many ALFs, they do not cover all services. Residents often pay extra for such services as medication administration, transportation, and any assistance with ADLs or nursing care above the minimum covered by the basic rate in a facility.
Second, the rates are largely out of reach for most low-income older persons and unaffordable for many moderate-income elderly, unless they supplement their income with additional funds generated by disposal of their assets. According to data from the U.S. Bureau of the Census,6 40 percent of persons aged 75 and older had incomes in 1997 of less than $10,000 per year. Eight-four percent of persons aged 75 and older had incomes of less than $25,000 per year in 1997. This would make the average high service ALF or the average high privacy ALF unaffordable for the vast majority of older persons, particularly since they must also pay for other basic needs (e.g., supplemental insurance, out-of pocket spending on health care and medications, clothing).7
| Even if some facilities embody the key tenets of assisted living's philosophical model, that is, policies emphasizing autonomy, dignity, and service flexibility that facilitate maximum independence and aging-in-place, the degree to which this model predominates in the industry is unknown. |
WHAT IS ASSISTED LIVING?
Any attempt to understand assisted living and its role in providing long-term care to the frail elderly is hindered by the lack of a common definition of "assisted living." Places known as ALFs differed widely in ownership, auspice, size, and philosophy. Indeed, the results of this national survey identified four different types of ALFs within the industry that had very different patterns with respect to accommodations, services, staffing, policies on admission and retention of residents, and price. Some of these types, such as those offering high privacy and the high privacy/high service ALF, appeared to be consistent with the philosophy of assisted living. Other types, such as the low-minimal privacy/low service types were much closer to the traditional concept of domiciliary care or board and care, with few services and relatively little privacy.
DOES THE ENVIRONMENT OF ALFS MATCH THE PHILOSOPHY OF ASSISTED LIVING?
The answer to this question is mixed. On the one hand, residents of assisted living facilities had considerably more privacy and choice than residents of most nursing homes and the majority of board and care homes. On the other hand, there was significant variability within the assisted living industry, and a substantial segment of the industry provided environments that did not appear consistent with the environmental aspects of the assisted living philosophy.
DO ALF SERVICES MATCH THE PHILOSOPHY OF ASSISTED LIVING?
The ability of assisted living facilities to meet health-related unscheduled needs of residents is still an open question - in part because of facility policies (e.g., staffing, retention criteria or discharge policies) and in part because of potential constraints imposed by state licensure regulations.
CAN ALF RESIDENTS AGE IN PLACE?
The answer depends on one's concept of aging in place. For example, in most ALFs, a resident could move from relative independence (e.g., needing or wanting only meal preparation, housekeeping, and staff that can respond to emergencies) to a more complex stage at which the resident needed help with bathing, dressing, and managing medications and used a wheelchair to get around. If this "span" or change in needs were the definition of "aging in place," then the admission and retention policies of ALFs suggested that they were willing to allow residents to age in place.
On the other hand, if aging in place meant that the average consumer could select an assisted living facility and reasonably expect to live there to the end of his or her life, regardless of changes in health or physical and cognitive functioning, then the answer must be "no." In most ALFs, a resident whose functional limitations necessitated help with transfers or whose cognitive impairment progressed from mild to moderate or severe or who exhibited behavioral symptoms would be discharged from the facility. The same was true for a resident who needed nursing care for more than two weeks.
Thus, there was a limitation in terms of the ability of ALF residents to age in place.
IS ASSISTED LIVING AFFORDABLE FOR LOW AND MODERATE INCOME OLDER PERSONS?
Assisted living was largely not affordable for moderate and low-income persons aged 75 or older unless they disposed of their assets and spent them down to supplement their income. Further, to the degree that some assisted living facilities were affordable for low- and moderate-income older persons, they were more likely to be ALFs categorized as low-minimal service/low-minimal privacy facilities.
A variety of demographic factors and policy initiatives have led to increased demand for residential facilities that offer supportive services for the frail elderly. These factors include:
A rapidly growing elderly population with significant levels of physical disability and mental impairment;
A strong preference of the elderly for in-home and community-based services rather than nursing homes;
Incentives at the state level to constrain the use of nursing homes.
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Board and care homes are known by different names across the states, including:
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Although families continue to be the major source of long-term care, a variety of residential settings with supportive services have emerged to supplement their efforts. These arrangements support those families whose members need more care than the family can provide and the elderly and disabled who have no family. Other than nursing homes, the most common form of residential setting with services for people with disabilities is the entity generically known as "board and care" homes. This term is used in a variety of ways across the states; however, in general "board and care" refers to non-medical community-based residential settings that house two or more unrelated adults and provide some services such as meals, medication supervision or reminders, organized activities, transportation, or help with bathing, dressing, and other activities of daily living (ADLs).
In most states, entities known as "assisted living" have been considered part of the residential care or board and care home sector. Board and care or residential care are the generic terms often used to describe various types of housing with supportive long-term care services, exclusive of licensed nursing homes. Board and care homes are regulated at the state level, and each state has different definitions and names for these facilities.8 The best estimate is that there are more than thirty names for licensed residential care facilities, and they are regulated by more than sixty different state agencies (Hawes, Wildfire and Lux, 1993; Mollica, 1998). In addition, more recently, many states have renamed or expanded the category of residential care facilities to include a specific category known as "assisted living" (Mollica, 1998).
| "In general, assisted living combines housing, personal services, and nursing and health care in an environment that promotes maximum independence, privacy and choice for people too frail to live alone but too healthy to utilize 24-hour nursing care." Tamara Hodlewsky, National Center on Assisted Living, 1998 |
Traditionally, board and care homes served a mixed population of residents. These homes fell into one of three basic types of licensed facilities (Clark et al., 1994): (1) homes serving residents with mental retardation or developmental disabilities; (2) homes serving residents with mental illness; and (3) homes serving a mixed population of physically frail elderly, cognitively impaired elderly, and persons with mental health problems (Clark et al., 1994). Most board and care homes fell into this last category, but many still cared for residents with a wide range of needs and disabilities, including sizeable numbers of persons with psychiatric conditions. Assisted living facilities, however, mainly serve only the frail elderly.
Starting in the late 1980s and early 1990s, this population of board and care homes expanded to include a growing number of facilities that identified themselves as "assisted living facilities," although most states did not have a specific licensure category with this designation. According to estimates generated from the National Health Provider Inventory based on a 1991 survey, there were an estimated 34,000 licensed board and care homes in the United States, including facilities known as assisted living, with more than 613,000 beds (Clark et al., 1994). A 1991/92 survey of state licensing agencies found a higher number, with an estimated 34,000 homes serving only older persons (Hawes, Wildfire and Lux, 1993). Added to this were an unknown number of unlicensed homes, some of which were assisted living facilities. A ten-state study that enumerated unlicensed homes estimated that, on average, the supply of unlicensed homes in 1993 was about 12 percent of the licensed supply serving a mainly elderly population (or elderly/mixed) (Hawes et al., 1995a). Applying this estimate to the nation would mean that, as of 1993, there were probably 38,000 licensed and unlicensed residential care homes with something between 800,000 and 900,000 beds serving an elderly/mixed population. Adding an estimated 7,000 places serving only persons with persistent mental illness or developmental disabilities brought the estimated total of all residential care beds to nearly one million (Clark et al., 1994; Hawes et al., 1995; Hawes, Wildfire and Lux, 1993; U.S. House, 1989). As a point of comparison, there were an estimated 17,000 licensed nursing homes with approximately 1.68 million beds serving more than 1.5 million nursing home residents (DuNah et al., 1993).
This supply of residential care facilities significantly expanded with the recent growth of assisted living facilities. By the mid-1990s, the most rapidly expanding type of residential care was among facilities known as "assisted living." Assisted living originally developed as a Scandinavian model of residential long-term care, emphasizing the importance of the social aspects of care and departing from what is generally termed a "medical" model or organization of the care setting (Coleman, 1995). Essentially, the goal of a social model of care is to create a normal, homelike living environment that is organized around promoting independence rather than the provision of health care services or performance of personal care assistance tasks.
Assisted living means different things to different people, but there is general agreement on the key aspects of what constitutes assisted living. For example, one commonly accepted definition has been offered by Kane and Wilson (1993):
Any residential group program that is not licensed as a nursing home, that provides personal care to persons with need for assistance in daily living, and that can respond to unscheduled needs for assistance.
The key philosophical principles or
tenets that distinguish assisted living are:
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A similar but more expansive definition was specified by the Assisted Living Quality Coalition. This coalition is a group representing consumer groups (the Alzheimer's Association and AARP) and provider associations (the American Association of Homes and Services for the Aging [AAHSA], the Assisted Living Federation of America [ALFA], the American Seniors Housing Association [ASHA], and the American Health Care Association's [AHCA]/ National Center for Assisted Living [NCAL]). According to the Coalition, an assisted living setting is:
A congregate residential setting that provides or coordinates personal services, 24-hour supervision and assistance (scheduled and unscheduled), activities, and health related services; designed to minimize the need to move; designed to accommodate individual residents' changing needs and preferences; designed to maximize residents' dignity, autonomy, privacy, independence, and safety; and designed to encourage family and community involvement.
As would be expected, the provider associations that belong to the Coalition espouse definitions that are very much in line with the Coalition's. For example, ALFA defined an "assisted living" residence as:
A special combination of housing, supportive services, personalized assistance and healthcare designed to respond to the individual needs of those who need help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Supportive services are available, 24 hours a day, to meet scheduled and unscheduled needs, in a way that promotes maximum dignity and independence for each resident and involves the resident's family, neighbors and friends (ALFA, 1996).
AAHSA also emphasized the central tenets of choice, privacy and dignity and noted that in assisted living, services may be provided or arranged:
Assisted living is a program that provides and/or arranges for the provision of daily meals, personal and other supportive services, health care and 24-hour oversight to persons residing in a group residential facility who need assistance with activities of daily living and instrumental activities of daily living. It is characterized by a philosophy of service provision that is consumer driven, flexible and individualized and maximizes consumer independence, choice, privacy and dignity (Gulyas, 1997).
| "The Coalition believes that, more than any other type of long-term care service, assisted living must be driven by a philosophy that emphasizes personal dignity, autonomy, independence, and privacy in the least restrictive environment. Further, it should enhance a person's ability to 'age in place'..." Assisted Living Quality Coalition, 1998 |
Similarly, an investment banking firm defined assisted living as:
A combination of housing and services provided in facilities that are designed as multi-unit properties containing communal dining and recreation areas. The facilities offer a broad spectrum of continuous or as-needed services to elderly senior citizens in an effort to promote their independence and personal dignity while replicating a safe and home-like environment for them to age in place (Conway et al., 1997).
Finally, the National Center for Assisted Living noted an important distinction regarding the place of assisted living in the continuum of long-term care services:
Assisted living represents an option of care that is generally less than that provided by and required of skilled nursing facilities but more than is offered by independent living apartment complexes (Hodlewsky, 1998).
In summary, there is substantial agreement among provider and consumer groups about the key elements of the assisted living philosophy. Moreover, some, like the Assisted Living Quality Coalition, argue that some of these elements or principles distinguish it from other types of long-term care. There is less agreement on the degree to which the current industry embodies those principles.
In the view of many observers in the United States, assisted living facilities represent a promising new model of long-term care, one that blurs the sharp and invidious distinction between nursing homes and community-based long-term care and reduces the chasm between receiving long-term care in one's own home and in an "institution." In addition, assisted living facilities are thought to provide (or be capable of providing) a range of long-term care services that makes them a viable but less institutional alternative to nursing homes (Kane & Wilson, 1993; Mollica and Snow, 1996; Wilson, 1993).
| "Assisted living is known by dozens of different terms throughout the country. ...The multitude of names for assisted living reflects the diversity of services offered in the cloudy nexus between retirement housing and skilled nursing care." Tamara Hodlewsky, National Center for Assisted Living, 1998 |
Other observers hold a more jaundiced view of the performance of the industry. First, some evidence suggests that assisted living predominantly serves a private-pay market of well-to-do elderly. If true, this would make its reality more limited than its promise. In addition, there is ample evidence of considerable variability in the ownership, auspice, operation, size, service package, physical plant, and client orientation in the industry (Manard et al., 1992). Indeed, even among industry trade associations there is no uniformity among the various facilities known as assisted living. For example, members of ALFA include both "purpose-built" assisted living facilities with private apartments and providers from the National Association of Residential Care Facilities (NARCF), which merged with ALFA. NARCF represented older, more traditional board and care homes in which the predominant accommodation is in a semi-private bedroom. Thus, even within ALFA, there is considerable variation. As the National Center on Assisted Living observes:
Assisted living...is known by dozens of different terms throughout the country...The multitude of names for assisted living reflects the diversity of services offered in the cloudy nexus between retirement housing and skilled nursing care (Hodlewsky, 1998).
Many places that call themselves assisted living are licensed as board and care homes and look like board and care homes. Others are "purpose-built" assisted living facilities whose physical plant and other environmental characteristics are quite distinct from most board and care homes. However, even in purpose-built facilities, studies find tremendous variability in their basic policies, the services they provide, their approach to care, and the resident population they serve. Indeed, many assisted living facilities look very similar to what have traditionally been known as board and care homes (Hawes et al., 1995b; Kane and Wilson, 1993; Lux, 1995).
| Even if some facilities embody the key tenets of assisted living's philosophical model, that is policies emphasizing autonomy, dignity, and service flexibility that facilitate maximum independence and aging-in-place, the degree to which this model predominates in the industry is unknown. |
Given these factors, there is likely to be considerable variation in how assisted living facilities define their role and how they operationalize key concepts of consumer autonomy and choice. Evidence from a prior survey of ALF administrators found that there was substantial variation in policies and practices on several issues thought to be related to consumer autonomy and choice. For example, almost half the facilities surveyed by Kane and Wilson (1993) reported they had assigned seating of residents at meals; 60 percent reported they did not require staff to knock on residents' doors before entering their rooms or apartments. Only half allowed overnight guests in the tenant's room/apartment. Only 14 percent said that it was the tenant's choice to refuse services, and one-third said such refusal was grounds for discharge.
In short, there are significant variations in the environment, services, and policies about resident autonomy among facilities known as "assisted living." Thus, even if some assisted living facilities embody the key tenets of assisted living's philosophical model, that is, the autonomy, dignity, and service flexibility that facilitates maximum independence and aging-in-place, the degree to which this model predominates or is even widespread in the industry is unknown.
There are several reasons for this variability. First, assisted living has not developed in an orderly, planned manner. It began largely as a market phenomenon, one thought to be responsive to consumer preferences and local conditions, rather than a planned outgrowth of public policy (i.e., regulatory and reimbursement policy) (Kane and Wilson, 1993; Manard et al., 1992; Mollica and Snow, 1996). Second, there are no federal regulations, oversight , or federal minimum standards for assisted living. Instead, regulation, where it exists, is a state responsibility. As a result, there has been enormous variation across the country in (a) the degree to which assisted living facilities are regulated and (b) the way they are regulated (Mollica and Snow, 1996; Mollica, 1998). Third, to some degree, the term "assisted living" may be more significant as a marketing tool than as a useful descriptor of a facility that distinguishes it from other residential care settings. For example, as previously noted, many of the members of ALFA were formerly members of the National Association of Residential Care Facilities (NARCF), but assisted living has been viewed as the more appealing "name." Thus, many members simply began calling themselves assisted living rather than residential care facilities.
In the sections that follow, we describe the expansion of assisted living and the emerging role of public policy in fueling and shaping that growth.
From its start in the United States in the late 1980s, mainly in Oregon, assisted living has become the most rapidly growing source of residential care for the elderly (American Seniors Housing Association [ASHA], 1998; Citro and Hermanson, 1999; Mollica, 1998). For example, construction of housing for seniors grew by 11 percent between 1997 and 1998,9 with assisted living residences dominating the new construction. Indeed, assisted living represented three-quarters of all new senior housing construction (ASHA, 1998). This pattern of rapid growth has been particularly striking among larger assisted living facilities (>25 beds) and among high-profile, publicly-traded multi-facility systems. For these firms, such as Sunrise, Assisted Living Concepts, Marriott, and American Retirement Villas, more than half their total supply of facilities were developed or acquired in a five-year period between 1991 and 1996.
Several factors have fueled the growth of
assisted living, including:
|
This growth has been, in no small measure, the product of investor interest in fabled returns being earned by some firms. For example, The SeniorCare Investor ranked one of the major assisted living corporations as having the most outstanding stock market performance in 1998. This firm had a return to shareholders of 159 percent, a rate that far outstripped the rates achieved by firms concentrated in nursing homes, subacute care, and traditional residential care facilities (SeniorCare, 1998). In fact, in 1997-98, seven of the top ten stock market performers in the area of senior care were assisted living companies, with an average return for the group of 47 percent (SeniorCare, 1998).
Predictably, stock analysts were bullish about assisted living. Fortune magazine identified assisted living as one of the top three potential growth industries for 1997 (GAO, 1997). Similarly, the investment banking firm of Salomon Brothers reported in 1997, "we are enthusiastic about the sector and the underlying factors driving its explosive growth" (Conway, MacPherson and Sfiroudis, 1997). As a result, both the stock market and lenders provided considerable support to companies wishing to expand (Conway, MacPherson and Sfiroudis, 1997; Leaman, 1998; Meyer, 1998; Manard and Cameron, 1997).10
Despite this growth and soaring interest among lenders and developers in the mid-1990s, assisted living is still "new enough that the businesses offering it and the states that license it do not agree on a precise definition," as observed by the National Center for Assisted Living (Hodlewsky, 1998).
The last decade has seen a tremendous expansion in state activity regulating and paying for assisted living; however, this has led to greater variability rather than a common definition of what assisted living is or should be.
| No consensus has emerged among state policy-makers on the appropriate regulatory model for assisted living. |
While assisted living initially developed as a market phenomenon in the absence of much regulation or public financing (except for Oregon), states have moved fairly rapidly to develop and implement assisted living regulations. The first licensure regulation specifically directed at assisted living was in Oregon in 1989. By 1992, fewer than 10 states had such regulations in place. By 1994, 14 states had developed regulations or enacted legislative statutes. By the summer of 1996, that had grown to 22 states, with an additional 10 states having study commissions addressing how to regulate and pay for assisted living. Further, the number of states providing some type of Medicaid funding for Medicaid eligible elderly in assisted living facilities (mainly through Medicaid waiver programs) grew from 10 to 21 between 1994 and 1996. Indeed, by 1996, when combining all State activities -- legislation, current regulation, study commissions, and Medicaid funding -- only 14 states had no activity related to assisted living (Mollica and Snow, 1996).
By 1998, 30 states had passed legislation or issued regulations, and 22 states had licensing regulations using the term "assisted living," up from 15 in 1996. Other states were considering draft regulations or revising their regulations, and 35 states reimburse or plan to reimburse services in assisted living or board and care facilities as a Medicaid-covered service (Mollica, 1998).
Although there has been increasing state policy activity, to date, no consensus has emerged on the appropriate regulatory model for assisted living. As Mollica and Snow noted (1996), the models varied. In some states, policies sought to create assisted living as a unique long-term care arrangement, with distinctive environmental features (e.g., requiring that assisted living facilities provide apartments with kitchens). Other states, however, basically allowed the same types of accommodations and services as board and care homes (Mollica, 1998). In addition, states differed on whether the features that ought to be subject to regulation should include the housing component or should be limited to only the service component, in effect treating assisted living as a kind of "home health" service (Mollica, 1998; Mollica and Snow, 1996). Thus, regulation was a contributor to the emergence of different models of assisted living around the country, leading to a lack of uniformity on environment, services, and other policies. As Mollica and Snow (1996) observed:
A common definition or understanding of assisted living grows increasingly unlikely as state policy makers, legislators, consumers and providers develop models that address local circumstances.
Despite this variation, states have clearly been interested in expanding the use of assisted living and other residential settings that offer supportive long-term care services. In part, states have been interested because some research suggested that housing with supportive services could be a cost-effective alternative to nursing homes (Leon, Cheng, and Neumann, 1998; Mor, Sherwood and Gutkin, 1986). It also appears that some states substituted residential care beds for nursing home beds in their long-term care system (Hawes et al., 1993; Hawes et al., 1995c).
In addition to creating new licensure categories and expanding Medicaid waiver programs, many states began making more aggressive use of Medicaid personal care service payments for residents in board and care homes (Harrington and DuNah, 1994; Mollica, 1998). Further, they have started allowing higher levels of care to be provided outside nursing homes. For example, the majority of state licensing agencies allow board and care homes to house residents who are chair-fast because of health problems or who use wheelchairs to get around inside the facility. Indeed, even in the early 1990s, one-third of the licensing agencies allowed board and care homes to retain residents who were bedfast (Hawes, Wildfire and Lux, 1993). Some states also embarked on more aggressive strategies for expanding the potential role of board and care homes and assisted living facilities by permitting the provision of daily or intermittent nursing care (including skilled care) and hospice care (Hawes, Wildfire and Lux, 1993; Kane and Wilson, 1993; Manard et al., 1992; Mollica, 1998; Mollica and Snow, 1996; Newcomer, Wilson and Lee, 1997).
Given the promise of the philosophy of assisted living and its rapid growth, as well as the forces that have contributed to tremendous variability across the country, there is natural interest in the role assisted living can play in meeting the long-term care needs of the elderly. In addition, there are natural concerns about the quality of care and consumer protection issues (Cody, 1996; Hawes et al., 1995a; Hawes et al., 1997; US-GAO, 1997; 1999). Thus, a number of public and private agencies have recently initiated studies of assisted living.11
| This report presents the results of a telephone survey of a nationally representative sample of 2,945 places identified as assisted living facilities. |
This is the first in a series of planned reports based on data collected from a survey of a national probability sample of 2,945 places thought to be assisted living facilities. These data were collected as part of a study, "A National Study of Assisted Living for the Frail Elderly." This study was initiated and funded by the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE). Additional support for the project has been provided by AARP, the Administration on Aging (AoA), the National Institute on Aging (NIA), and the Alzheimer's Association.
Both ASPE and AARP have a long-standing interest in the potential of housing with supportive services, including board and care homes and assisted living facilities, to meet the needs of aged and disabled persons for residential long-term care services. ASPE commissioned a study in the early 1980s by Denver Research Institute (DRI) that described board and care homes and residents in five States and investigated the effect of regulation on quality of care (Dittmar and Smith, 1983). Other studies during the 1980s also attempted to describe homes and residents, the regulation of these homes by States, and the role these facilities play in providing long-term care (i.e., Mor, Sherwood and Gutkin, 1986; Sherwood, Mor, and Gutkin, 1981; Reichstein and Bergofsky, 1980).
In the early 1990s, both ASPE and AARP initiated a new examination of board and care homes and their role in the long-term care system. Specifically, they supported studies that examined the supply (Manard et al., 1990); described regulatory systems (Hawes, Wildfire and Lux, 1993); and described the facilities, residents, and staff (Hawes et al., 1995b). Finally, ASPE sponsored a study of the effects of regulation on quality in licensed and unlicensed homes, including a sizeable number of assisted living facilities (Hawes et al., 1995a).
ASPE and AARP placed a high priority on examining board and care homes, quality, and regulatory effectiveness for several reasons. These included increased state and federal expenditures on home and community-based care, growing disability among residents, concerns about inadequate quality, and questions about the effectiveness of state regulatory efforts.
While those were the major reasons for examining board and care homes, ASPE and AARP's interest in assisted living has been rooted more in its promise for meeting the needs of frail elders while enhancing the quality of their lives. In particular, they are interested in determining the role ALFs play in meeting the needs of the frail elderly and where assisted living fits in the long-term care "continuum," an issue displayed in Exhibit 1.
Associated with this over-arching issue are a host of questions about the role of assisted living, some addressed by this study and some by other ongoing studies of assisted living. These questions include:
What are trends in demand and supply and what factors affect them
What is the meaning of "quality" in assisted living; how do residents and families define quality
What features of assisted living are most valued by residents and families
How do consumers select assisted living and what are key consumer protection issues
Are residents able to age in place in ALFs
Do ALFs serve low and moderate income elderly To what extent do ALFs serve as a viable substitute for nursing homes
What is the relationship between traditional board and care homes and their newer incarnation, assisted living facilities
To what degree does the current industry embody the philosophy of assisted living
How are personal and health care services organized and provided
What is the effect of various arrangements (services and privacy) on such factors as consumer satisfaction, length of stay, cost, case mix
What is the total cost of assisted living, including ancillary services
What is the impact of the use of assisted living on Medicare and Medicaid
In addition, the phenomenal growth in the supply of facilities that advertise themselves as "assisted living" has augmented ASPE and AARP's interest in issues related to demand, supply and quality in assisted living. The result has been a number of projects and reports sponsored by ASPE and AARP. These ongoing interests also led to the funding of the current project.
The remainder of the report focuses on the current study.
Section 2 describes the overall study goals and the specific objectives of the telephone screening and survey. It also presents a brief overview of the study methods.
Section 3 presents general descriptive data on the industry, based on the results of this telephone survey.
Section 4 discusses the accommodations provided by the assisted living industry.
Section 5 presents data on the services and staffing.
Section 6 describes the admission and discharge policies of assisted living facilities and presents data on resident case mix.
Section 7 discusses different models of assisted living and the consequences of the model differences on variations in accommodations, services, staffing, and admission and discharge policies.
Section 8 presents data on the price of assisted living.
Section 9 discusses the implications of the study findings, particularly in terms of the degree to which the characteristics of the industry conform to the basic philosophical principles of assisted living.
The Myers Research Institute at Menorah Park Center for Senior Living and Research Triangle Institute (RTI) collaborated on this effort to examine the role of assisted living for the frail elderly.12
The National Study of Assisted Living for the Frail Elderly was designed to achieve the following objectives:
To identify trends in demand for and supply of assisted living facilities;
To identify barriers to the development of assisted living and factors that contribute to those trends in demand and supply;
To determine the extent to which the current supply matches the central philosophical and environmental tenets embodied in the concept of "assisted living" and to describe the key characteristics of the universe of assisted living facilities; and
To examine the effect of key features that embody the philosophical tenets on selected outcomes, including resident satisfaction, autonomy, affordability, and potential to provide nursing home level of care.
To achieve these objectives, the project team implemented a number of activities and issued several reports that are available from ASPE.13 In addition, the project team will issue subsequent reports on the characteristics of the assisted living industry and its staff, as well as the residents. These are based on data collected during site visits to 300 facilities and interviews with administrators, staff caregivers, residents, and family members. Project staff will also interview and report on the experiences of a sample of discharged residents or their next-of-kin.14 However, the current report addresses only the results of a telephone survey of administrators in 2,945 places thought to be assisted living facilities.
The specific objectives of this telephone survey were to:
Screen a listing of places thought to be assisted living facilities and determine their eligibility for the study
Determine the size and nature of the supply of assisted living facilities
Describe the basic characteristics of the industry particularly in terms of the services, accommodations and price
Begin examining the extent to which the current industry embodies the key philosophical tenets of assisted living
Identify facilities for subsequent, more extensive data collection.
To accomplish the objectives of the initial telephone survey, project staff (1) implemented a complex sample design; (2) created a comprehensive list of potentially eligible facilities; (3) determined whether a sample of facilities on the list met study eligibility criteria; (4) conducted a telephone survey of eligible facilities; and (5) analyzed the data. This section of the report provides a brief overview of these activities. Other reports will provide greater detail about study methods.15
In order to conduct the survey and to obtain results that could be generalized to the nation as a whole, project staff implemented a stratified, multi-stage national probability sample. At the first stage, a random sample of geographic areas, known as first stage sampling units (FSUs), were selected. At the second stage of sampling, staff selected a sample of facilities.16
The sample design called for selection of a set of geographic areas prior to selecting the facility sample for several reasons. First, in order to conduct the survey, staff had to construct a listing of assisted living facilities. There is no national list that is comprehensive and exhaustive. Moreover, as noted earlier, definitions of assisted living vary across the states. In some states, there are no limits on the type of facility that may call itself "assisted living" or advertise that it provides assisted living, regardless of the kind of services and accommodations it provides. Further, some states did not have a licensure category known as "assisted living."17 As a result, the study could not rely on state licensure lists to provide a comprehensive and exhaustive listing of assisted living facilities. Some places meeting study criteria would be missed, while other facilities licensed under the category of "assisted living" might not meet more commonly understood definitions of assisted living.
Lists from established trade associations were also insufficient as a sampling frame. First, while there are multiple trade associations, their combined membership accounts for an unknown proportion of the total number of assisted living facilities (ALFs) in operation. Second, ALFA merged with the association that represented board and care homes (i.e., the National Association of Residential Care Facilities). As a result, the membership of ALFA was expected to include both assisted living facilities and places that are more traditionally thought of as board and care homes, some of which would meet study criteria and some which might not.
Further, the study could not rely solely on retirement directories or local advertisements, since they appeared to have differing definitions (or no criteria) for what should be classified as assisted living. Similarly, in many localities, there were no restrictions on the kinds of places that could call themselves "assisted living."
As a result, a crucial aspect of the sampling design was the development of an enumeration strategy that would enable selection of a nationally representative sample of ALFs. However, because of the extensive level of effort involved, creating a comprehensive list at the national level (i.e., in each of the >3,000 counties) would have been prohibitively expensive for this project. Thus, project staff decided to select a random sample of geographic areas across the country in which to enumerate an exhaustive list of facilities.18 This involved a two-stage enumeration and screening process to provide comprehensive coverage of the target population of assisted living facilities.
2.2.1.1 Creating a List of ALFs
In order to create a list or sampling frame of assisted living facilities, project staff first had to define the relevant study population. These are the criteria used to determine whether a place was eligible for inclusion in the study. As noted, the definition of assisted living was variable across the country. Thus, to define "assisted living" for this study, project staff specified selected features about which there was general agreement among industry and consumer groups that the feature was characteristic of "assisted living."
2.2.1.1.1 Eligibility Criteria
The project's first criterion was that to be eligible for this study, a facility had to serve a mainly elderly population. Second, it had to have more than 10 beds.
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ELIGIBILITY CRITERIA To be eligible for the study, a facility had to:
AND Either
OR
|
There were several reasons for this size restriction. First, we had several reasons for expecting that small facilities would not meet study criteria. A 1993 survey funded by DHHS/ASPE examined board and care homes in ten states (Hawes et al., 1995b). Two-thirds of the board and care homes had 10 or fewer beds. Few of those facilities identified themselves as assisted living or provided personal assistance with two or more activities of daily living (ADLs). In addition, during the period of sampling, none of the states that had specific licensure categories known as assisted living had licensed facilities with fewer than 11 beds. Thus, project staff expected that few small facilities would meet the service-related criteria. Second, small homes tended to have significant numbers of non-elderly residents and were more likely to have residents with mental retardation, developmental disabilities, and persistent and serious mental illness. These findings were consistent with those of other studies (e.g., Dittmar and Smith, 1983; Hawes et al., 1995c; Sherwood and Seltzer, 1981; Sherwood, Mor and Gutkin, 1981). Finally, the small homes were well-described in the prior study. As a result of all these factors, ASPE and project staff concluded that including these facilities on the sample frame would be a costly endeavor that would produce little if any "pay-off" in terms of identifying eligible ALFs.
In addition to the eligibility criteria based on population served (i.e., elderly) and size (i.e., >10 beds), the facility had to describe or represent itself as being an assisted living facility or it had to be a place that offered at least a basic level of services. Those services were:
The next project task was to select a sample of FSUs. As noted earlier, this involved a two-stage enumeration and screening process. First, staff developed a nationwide, county-level sampling frame that estimated the relative distribution of study-eligible facilities across the 3,141 counties and county equivalents that are listed in the 1990 Census. Staff did this in order to focus the sample of FSUs in counties with the highest concentrations of ALFs so that the project would be able to obtain a sufficient sample for all phases of the data collection.
Project staff initially considered the use of county size measures based on the population aged 65 or older in selecting FSUs. This was based on the assumption that the number of ALFs serving the frail elderly in a geographic area would be proportional to the number of older persons. However, the available evidence about development and construction indicated that the industry was expanding at different rates in different states (e.g., ALFA, 1996; Mollica and Snow, 1996). If the distribution of ALFs did not match the distribution of older persons, project staff could expect that this method of selecting FSUs would concentrate the sample in states with high numbers of elderly but few ALFs.
Selection of the FSUs. In order to increase the efficiency of the sample, project staff created an initial national listing of places thought to be eligible for the study in all 3,141 counties (or county equivalents) across the country. The sources were the unduplicated listing of a national retirement directory (DRF, 1995) that reported having listings from licensing agencies in all 50 states and three national associations that had members who identified themselves as assisted living facilities. (It is important to note that the primary purpose of this activity was to focus the sample in counties with concentrations of ALFs not to enumerate the entire population of ALFs.) Based on this 1995 listing of more than 17,000 places in all counties, project staff selected 60 FSUs, giving a somewhat higher probability of selection to those counties with higher concentrations of candidate facilities.
As expected, the FSUs identified by the process differed from those that would have been selected based only on the proportion of the population aged 65 and older. For example, without this initial enumeration process at the national level, the sample of FSUs would have been more heavily concentrated in states like Texas, Ohio and Illinois, which had few ALFs compared to relatively high numbers of older persons. Instead, FSUs in states like Pennsylvania, California or Oregon, which had a large number of ALFs relative to their older population, had higher selection probabilities.
The 60 FSUs were randomly selected, with higher selection probabilities for those FSUs containing large numbers of "expected" assisted living facilities. These FSUs contained 1,086 counties in 34 states. They also contained 40 percent of the U.S. population aged 65 and older and 43 percent of the initial sample frame of "expected" assisted living facilities.
2.2.1.1.2 Source of Listings of Candidate ALFs
The next task, which was completed in September, 1997, was to create a comprehensive list of candidate ALFs in each of the 60 FSUs. This involved the collection of multiple lists of places that described themselves as assisted living facilities and other places that appeared to meet the study's eligibility criteria. For each FSU, project staff obtained data from the following:
ALFA's 1997 list of members
The AHCA 1997 list of assisted living members
AAHSA's 1997 list of assisted living members
The 1997 HCIA Directory of Retirement Facilities (DRF, 1997)
State licensure agency lists for 1997 for all types of residential care facilities that have 11 or more beds
Listings and advertisements from telephone book "yellow" pages
State directories of local ALFA members, in those states in which the state affiliate of ALFA had one, and
Local retirement directories and Internet listings of facilities.19
After collecting these multiple lists, project staff spent considerable effort making sure they were in one of the 60 FSUs20 and creating an unduplicated list. Creating an unduplicated list was particularly complex because of the large number of multi-facility systems and the large number of facilities at the same address on campuses that housed several different levels of care. In addition, staff found high prevalence of multi-level settings that housed two or more places that met the eligibility criteria.21
Eliminating Known Ineligibles From the Sampling Frame. Prior to creating a sample frame, project staff excluded some places from the unduplicated listing generated from the sources mentioned above. For example, based on the definition provided by the HCIA Directory of Retirement Facilities (DRF), project staff included places listed under the category "assisted living/residential care" and places listed as "congregate living". On the other hand, places listed by the DRF only as "independent living" were excluded from the sampling frame of candidates because the DRF definition made it clear that they did not: (1) describe themselves as assisted living nor (2) provide the basic level of staffing and services required. However, if another source (e.g., licensure list or association membership list) listed an "independent living" facility as a potential candidate for the study, it was included on the sampling frame. As a result, there were still a large number of facilities on the second-stage sampling frame that identified themselves as "independent living." As expected, the subsequent telephone survey revealed that few met the study's eligibility criteria (e.g., did not provide 24-hour staff and help with at least two of the following: medications, bathing, or dressing).
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Among the 18,298 places on the combined list of candidates:
Among the remaining 10,720 candidates:
Utility of sources:
Size of facilities on master list: of candidate ALFs:
|
From all these sources, for the 60 FSUs, a total of 18,298 candidate facilities were listed. Project staff then eliminated known ineligibles based on size. Information on size was missing from many lists (e.g., ALFA and other membership lists); however, size of each facility was present for almost all of the candidates (i.e., 97%) on the state licensure lists. Thus, at the start, size was unknown for 4,204 facilities (23%) on the list. For facilities for which size was known, small homes (i.e., 2-10 beds) were deemed ineligible and removed from the master list. Project staff found that among the 18,298 candidates 7,578 places (41%) were ineligible because they had 10 or fewer beds. The degree to which such small facilities might otherwise have met study criteria (e.g., be a self-described assisted living facility or provide the required services) is unknown. However, as noted earlier, prior studies found that small facilities tend to have a younger resident population and to provide supervision but less hands-on assistance with ADLs than larger facilities (Dittmar and Smith, 1983; Hawes et al., 1995; Wildfire et al., 1995; Sherwood, Mor and Gutkin, 1981; Sherwood and Seltzer, 1981).
Selecting The Sample For The Telephone Screening and Survey. The next task was to select a sample of facilities from the remaining 10,720 candidates on the combined listing (e.g., after eliminating the 7,578 places with 10 or fewer beds).
In selecting the sample to be screened by telephone, project staff oversampled the larger facilities (>51 beds) in order to increase the likelihood of encountering ALFs offering a high level of services. This was based on an earlier study of residential care which found that larger facilities were more likely to have nurse staffing and to offer more services (Hawes et al., 1995a,1995b). Thus, project staff's assumption at this stage was that larger facilities would have greater capacity to offer more services. Further, this approach would improve the sampling efficiency at later stages (i.e., when the resident sample was selected, since most residents lived in large ALFs). This oversampling did not affect final estimates about the prevalence of various types of ALFs (including various sizes), since data were weighted to account for the oversampling.22
From this list of 10,720 potential candidate facilities, project staff selected a stratified (by size), random sample of 2,945 facilities for the telephone survey.
The administrators (or their designees) in 2,945 facilities were interviewed by telephone to determine facility eligibility for the study. The telephone survey was conducted by Research Triangle Institute (RTI) during the period of January March, 1998. RTI used computer-assisted telephone interviews (CATI) for this task. The respondent was the administrator (or in his/her absence, the assistant administrator or resident care director). (A copy of the questionnaire appears in Appendix A.)
First, the interviewer had to determine whether the sample facility was on a multi-level campus that contained several distinct levels of care or residential settings (e.g., assisted living, congregate care, nursing home). If it was on a multi-level campus, then the questionnaire was automatically routed by the CATI program to a set of questions aimed at determining what those levels were and whether any of the multiple units or divisions were eligible for the study. This process was also intended to ensure that the responses (e.g., bed size, accommodation type, services offered) were specific to each single unit or residential setting.
Next, in the questionnaires for both the settings on multi-level campuses and for free-standing facilities, there was a set of questions intended to determine whether the sample facility was eligible for the study. If the facility was determined to be eligible, then the respondent was asked a series of additional questions that took about 10 minutes. The topics covered included:
Exhibit 2 displays the results of the telephone screening for eligibility, the reasons for ineligibility of the listed candidates, and the response rates. As shown, the most striking finding was the rate of ineligibility.23 The listings on the sample frame, as noted earlier, were from multiple sources that most observers presumed were reliable sources or identifiers of assisted living facilities. It is also worth noting that the source of the largest number of valid listings, the DRF, was also the source of the largest number of ineligibles. This demonstrates the difficulty involved in determining how many assisted living facilities are currently in operation and in identifying those facilities, given varying definitions and criteria across our sources of listings, across states, and across facilities themselves. It may also help explain why some estimates of the total supply of assisted living facilities are quite high, as discussed in the next section.
| EXHIBIT 2. Final Disposition of the Facility Screening Sample | ||
|---|---|---|
| Disposition | Total Percent | |
| RESPONDING LOCATIONS | ||
| Eligible Facilities | 42.5% | |
| Responding but Ineligible Facilities | 41.0% | |
| Subtotal | ||
|
(9.8%) | |
|
(12.2%) | |
|
(13.2%) | |
|
(5.8%) | |
| NON-RESPONDING LOCATIONS | 16.2% | |
| Subtotal | ||
| Contacted | ||
|
(7.6%) | |
|
(2.4%) | |
| Non-Reponding Ineligibles--Unable to Contact (no telephone number, out-of-order, or no answer after at least 10 calls)* | (6.2%) | |
| TOTAL | 100% | |
| *The places listed as "unable to contact" were also assumed to be ineligible. First, project staff used multiple sources, including "white" and "yellow-page" telephone listings, retirement directory listings, local information, and so on, to secure telephone numbers. We assumed that an eligible ALF would have a listed number if it were still in business. Second, project staff made at least 10 telephone calls during business hours to each place. We assumed that if the place was an eligible ALF, there would have been staff on duty 24 hours per day and someone would have answered at least one of >10 telephone calls at various times of the day. Thus the total number of ineligibles was estimated as 46% (i.3., 41 + 6.2). | ||
The reasons for ineligibility are also interesting. At the first level of "cleaning" the list of candidate facilities, staff eliminated a large number of small facilities (i.e., more than 40% of the originally compiled list). This effort was apparently fairly successfully, since only 10 percent of the remaining sample were ruled out because of size. However, a total of 25 percent of the facilities on the sample frame (i.e., the "independent living" facilities and other ineligibles) were ruled out because they offered few services and little, if any, personal assistance (e.g., help with medications, bathing, dressing).24 Most observers would agree that such facilities should not be regarded as "assisted living." Finally, staff concluded that an additional 12 percent of the listings were ineligible. These miscellaneous reasons for ineligibility were because the facility was closed or was something other than an eligible facility (e.g., was a convent or a licensed nursing home) (5.8%) or the facility fell into the category "unable to contact" (6.2%) (See footnote 23).
For most of the analysis, this report presents descriptive statistics for individual variables, such as the mean for interval indicators and percentages for categorical measures. Project staff utilized t statistics for comparisons between two groups (e.g., self-described ALFs and other facilities). For comparisons among more than two categories (e.g., the combination of different levels of service and privacy), regression equations were estimated that allowed the research team to compare the overall sample mean for all facilities with the mean for facilities in each category and to test the statistical significance of any difference.
All of the analyses were carried out on data weighted to represent the assisted living industry in the nation as a whole. SUDAAN, a statistical software package that provides appropriate variance estimates for clustered data derived from multi-stage samples, was used for all analyses.
Despite the enormous interest and enthusiasm generated by the philosophy of assisted living and its rapid growth in this country, there is little definitive data available on the number and characteristics of facilities and residents. While there have been a number of studies, particularly surveys sponsored by national trade associations, they have been limited by two factors.
First, many prior studies of assisted living facilities have focused on the industry in only a few states (personal communications from Kane; Newcomer; Zimmerman and Sloane). Second, most of the national surveys have been conducted by industry trade associations and have not selected the facilities from a nationally representative sample (e.g., ALFA, 1998; Gulyas, 1997; Hodlewsky, 1998). The lack of a national listing of facilities, the limitations of state licensure lists, given the variability in licensure policy and definitions, and the potential bias introduced from surveying only trade association members have hindered attempts to describe the assisted living industry and to understand its role in meeting the needs of frail elders. Third, the existing national surveys of facilities have been limited by somewhat low response rates among the facilities surveyed.25 As a result, the available data cannot be regarded as representative. Thus, there are no definitive data generalizable to the nation as a whole that describe the assisted living industry.
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In early 1998, there were an estimated 11,459 assisted living facilities in the U.S. that:
And
Or
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The ASPE study fills that void with empirical data drawn from a survey of a nationally representative sample of assisted living facilities and a response rate of better than 84 percent. The sections that follow provide data on the size and characteristics of the assisted living industry in the United States.
As noted earlier, there is general agreement that assisted living is the most rapidly growing type of senior housing in the United States. There is less agreement, however, on the size of the current supply of assisted living facilities. In 1998, for example, estimates of the number of facilities ranged from a total of about 27,000 facilities to more than 40,000 ALFs (Mollica, 1998; ALFA, 1998; Hodlewsky, 1998). Estimates of the number of beds ranged from about 350,000 to more than one million (Citro and Hermanson, 1999; Mullen, 1997; ALFA, 1998; Hodlewsky, 1998). Thus, one of the key objectives of the ASPE study was to determine the size of the current supply of assisted living.
| The data presented in this report are national estimates based on the survey of the nationally representative sample of assisted living facilities. |
As shown in Exhibit 3, estimates based on the telephone survey of administrators indicated that in early 1998, there were 11,459 facilities and 611,300 beds that met the definition of assisted living that was embodied in the study's eligibility criteria.26
| EXHIBIT 3. Assisted Living Industry Size | |
|---|---|
| Industry Characteristics | National Estimate |
| Estimated Total Number of Facilities | 11,459 |
| Estimated Total Number of Beds | 611,300 |
| Estimated Total Number of Residents | 521,500 |
In comparison to other estimates about the assisted living industry, the ASPE study estimate is considerably lower than those of provider organizations, such as ALFA. However, there are several reasons for believing the ASPE study represents an accurate estimate of the number of ALFs that met study eligibility as of early 1998.
First, this study's estimates are the product of an extensive attempt to secure a comprehensive list of all possible eligible facilities. Second, they are based on a national probability sample of facilities, unlike other studies. Third, it involved a systematic effort to determine whether the places believed to be assisted living or "called" assisted living met a commonly accepted definition of "assisted living." In particular, the ASPE study made a concerted effort to exclude facilities on the list of candidate ALFs that in reality provided few services or did not offer meaningful personal assistance to residents.27 Fourth, as noted, the ASPE study excluded small facilities (i.e., 2-10 beds). Exhibit 4 displays the distribution of the candidate facilities that were provided to project staff on various lists and represented as being ALFs. As shown, the majority of facilities on those lists did not meet study eligibility criteria. Finally, the survey results and estimates are based on very high participation rates among the sampled facilities. These features of the ASPE study have helped overcome limitations in other studies that estimated the supply of assisted living facilities as being much larger.
As shown in Exhibit 5, the majority of facilities (72%) that met study eligibility criteria described themselves as assisted living facilities or advertised that they provided assisted living services. However, more than one-quarter (28%) of the facilities that met study eligibility criteria did not hold themselves out as being "assisted living," even though they provided the same type of care and services as places calling themselves "assisted living."28 In part, this may be a product of state licensure regulations. For example, in Wisconsin, assisted living facilities are termed residential care apartment complexes or community-based residential care facilities (Mollica, 1998).
| EXHIBIT 5. General Industry Characteristics | |
|---|---|
| Characteristic | National Estimate |
| Self-Described Assisted Living | 72% |
| Free-Standing ALFs | 55% |
| ALFs on Multi-Level Campus | 45% |
| Average Length of Time in Business | 15 years |
| Average Occupancy | 84% |
| Average Number of Beds | 53 |
| Average Number of Residents | 46 |
ALFs ranged in size from 11 beds to more than 1500. The average facility had 53 beds (in rooms or apartments) with a median of 48 beds. Most ALFs (67%) had between 11 and 50 beds, as displayed in Exhibit 6. Twenty-one percent of the ALFs had 51-100 beds, while 12 percent had more than 100 beds.
While most facilities were in the range of 11 to 50 beds, two-thirds (67%) of the residents -- were in the larger facilities (i.e., >50 beds). This was consistent with ASPE's earlier study of board and care homes that found most residents lived in larger facilities, even though two-thirds of the homes were very small (i.e., 2-10 beds) (Hawes et al., 1995).
The average occupancy was an estimated 84 percent nationwide.
Another feature of facilities was their affiliation. The administrators reported that the majority of facilities were free-standing (55%); however, a sizeable proportion of ALFs (45%) were located on multi-level campuses that housed other types of residential settings or multiple levels of care. An estimated 5,220 facilities were located on such multi-level campuses at the start of 1998.
Exhibit 7 displays the main types of residential care settings found on multi-level campuses. Some multi-level campuses housed several different types of residential settings (e.g., nursing home, assisted living, congregate or independent living).29 Other multi-level campuses housed only an assisted living facility and a nursing home. In fact, a campus with a nursing home and an eligible "assisted living" facility was the most common configuration on multi-level campuses. In addition, the administrators of ALFs located on a multi-level campus were asked whether there was any kind of SCU on campus.30 As shown in Exhibit 7, five percent of the administrators reported that the ALF was located on a campus with an SCU that was part of a licensed nursing home. Six percent reported that an SCU providing residential care or assisted living was located on the campus.
The assisted living industry also displayed considerable variation in terms of the length of time the facilities had been in business as of early 1998. The average was 15 years, but there was a wide range around that. As shown in Exhibit 8, almost one-third (32%) of the facilities had been in business for five or fewer years as of early 1998. More than half (58%) of the facilities eligible for the study had been in business for a decade or less. Thus, while many facilities (19%) had been providing residential care with supportive services for more than 20 years, the majority ALFs started in business during the preceding decade.
For many advocates of assisted living, environmental characteristics are considered one of the most important features that distinguish assisted living from nursing homes and other types of residential care facilities. As noted earlier, privacy and consumer choice are key elements of the philosophy of assisted living in the view of both consumer and provider groups (Assisted Living Quality Coalition, 1998). Moreover, individual and focus group interviews with consumers found that they overwhelmingly preferred to reside in private rooms or apartments (Jenkens, 1997; Kane et al., 1998). Thus, the nature of the environment, that is the accommodations, is a key component of assisted living.
| 82% of all respondents in one survey indicated their preference for a private room or apartment in assisted living. |
Despite widespread consensus among residents about their preferences, there is disagreement within the industry about the environmental features that are essential for a place to be defined as an "assisted living facility," particularly about whether private rooms or apartments and kitchens were essential features. In addition, there is disagreement among policymakers about whether privacy and apartments are key features of a place that can be licensed or reimbursed under Medicaid waivers as "assisted living" (Mollica, 1998).
Privacy31 and consumer control of the environment encompass a variety of concepts and features of the environment, facility policies, and staff behavior. Typically, these are defined in terms of such policies or features as the ability of residents to lock their doors; control the temperature in their units; or have pets. Autonomy, however, can also include other features, such as whether the resident can control arrangement of furniture, whether staff knock on doors before entering, and so on. These multi-facted aspects of environmental autonomy and control will be addressed in a forthcoming report.32 The initial telephone survey concentrated only on whether units were shared or private.
| Privacy is typically defined as a unit (room or apartment) that is not shared except with a related individual. |
As noted above, there is ample evidence that consumers prefer private living units. In one study, 82 percent of the elderly respondents indicated their preference for a private room or apartment in assisted living. Only four percent indicated a preference for sharing their accommodations with an unrelated person (Jenkens, 1997). In another study, 94 percent of the residents of assisted living facilities who were interviewed indicated that a private room and bath were important features and that they considered such private accommodations essential to maintaining their independence and dignity (Kane et al., 1998).
Despite the widespread agreement among consumers about the importance of privacy, the supply of places calling themselves assisted living did not uniformly meet this preference. As shown in Exhibit 9, the majority of facilities (73%) had some shared bedrooms (in a room or apartment unit).33 Only 27 percent of the assisted living facilities nationwide had all-private units. While this arrangement may not meet the general preferences of consumers, it did allow consumers choice about accommodations and may have made assisted living affordable for moderate- and low-income seniors.
Because state policy had not reached a consensus about the environmental features that are an essential component of assisted living, one goal of the study was to examine the effect of different levels of privacy and services. In order to describe the assisted living industry more systematically and to facilitate comparisons among ALFs, facilities were classified according to the level of privacy they offered.
High Privacy. Initially, project staff defined high privacy facilities as only those in which all units (rooms or apartments)34 were private. However, members of industry trade associations argued that many facilities offered a few shared units to meet the needs and preferences of some residents. Thus, a high privacy facility was defined as one in which 80 to 100 percent of the units were private. As shown in Exhibit 9, all units were private in only 27 percent of the ALFs. Allowing up to 20 percent of the units to be shared raised the proportion of ALFs in the "high privacy" category to 31 percent, as displayed in Exhibit 10.
| EXHIBIT 10. Privacy Levels | |
|---|---|
| Level of Privacy | National Estimate |
| High Privacy | 31% |
| Low Privacy | 40% |
| Minimal Privacy | 28% |
Low Privacy. Any ALF that had no bedrooms shared by three or more unrelated persons but in which fewer than 80 percent of the bedrooms were private was defined as low privacy. As shown in Exhibit 10, 40 percent of all the assisted living facilities were categorized as offering a "low privacy" setting.
Minimal Privacy. Any facility that housed three or more unrelated individuals in the same bedroom (whether in a room or apartment) was defined as providing minimal privacy. Such a room, referred to as a "ward-type bedroom," was considered incompatible with the concept of assisted living. Thus, any facility with such rooms was defined as providing "minimal privacy" regardless of the characteristics of their other units. As shown in Exhibit 10, more than a quarter of all facilities had at least one bedroom that housed three or more residents.
The proportion of facilities that offered low or minimal privacy seemed large for an industry in which one of the chief philosophical tenets is "privacy." To examine this issue more carefully, comparisons were made between two groups of facilities that met study eligibility criteria. The two groups were: (1) those that defined or identified themselves as an "assisted living facility" (a "self-described" ALF) and (2) those that did not call themselves "assisted living" but met specified criteria related to availability of services (the "other " ALFs).
As shown in Exhibit 11, facilities offering "minimal privacy" were less common among self-described ALFs (26%) than among the "other" ALFs (34%). Similarly, high privacy facilities were more common among self-described ALFs (34%) than among the "other" ALFs (23%). Despite the fact that self-described ALFs were more likely to offer high privacy than "other" ALFs, the proportion of self-identified ALFs with low privacy (40%) or minimal privacy (26%) was still substantial. At the same time, the fact that more than two-thirds of self-identified ALFs (70%) offered consumers both private and semi-private accommodations can be viewed as offering consumers a greater range of choices.
Facility-level distributions indicated significant variability among the industry. However, an examination of the actual distribution of units provides a more accurate picture of privacy from the resident's perspective. While most facilities offered shared units (either rooms or apartments), as shown in Exhibit 12, an estimated three-quarters of the units (73%) across all ALFs were private. Only an estimated one-quarter (25%) were semi-private rooms or apartments. Only two percent of the units were "ward-type" rooms shared by three or more unrelated individuals. The reports by administrators demonstrated that while the majority of ALFs offered some semi-private units, the industry as a whole recognized consumers' preferences for privacy.35
There was somewhat less privacy for residents with respect to bathrooms. Administrators reported that only 62 percent of all resident units had private full bathrooms (i.e., toilet, sink and bathtub or shower), as shown in Exhibit 13. An additional five percent of all units had a private "half" bath (i.e., toilet and sink); however, residents had to share bathing facilities. Further, a third (33%) of all units in ALFs required the resident to share a full bathroom, including the toilet, sink and bathing facilities (i.e., tub or shower). Thus, a total of 38 percent of the resident units involved sharing all or part of bathroom facilities.
The survey also asked administrators about the types of rooms or apartments offered and the bathrooms available to residents.
As noted earlier, no model of regulation at the state level has emerged to define the essential characteristics of assisted living. The earliest legislative model, which was in Oregon, however, defined a model of assisted living that required resident accommodations or units to be apartments and generally mandated privacy for both bedrooms and bathrooms.