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Assisted Living

STEPHEN M. GOLANT

JOAN HYDE

INTRODUCTION

Older Americans dread the prospect of spending the last years of their lives in a nursing home with its institutional-like physical ambience and hospital-like service environment. Since the mid-1980s, older adults who have difficulties living independently in their own homes have enjoyed another option. They can receive assistance coping with their impairments or managing their health care problems in a long-term care alternative that is now widely known as assisted living (Ball, Perkins, Hollingsworth, Whittington, & King, 2009; Wilson, 2007). Most experts believe that the emergence of assisted living is, at least partly, responsible for the decline in the rate of nursing home use—even by the most physically and cognitively vulnerable population in their mid-80s and over (The Lewin Group, 2007).

Most researchers and professionals now describe assisted living as a group-oriented residential care setting not licensed as a nursing home that provides on both a scheduled and an unscheduled basis the housekeeping, meals, personal assistance, medication management, and health/nursing-related services required by older persons who have experienced physical and/or cognitive health declines. Assisted living subscribes to a social model of care in contrast to the institutional or medical model associated with nursing homes.

DEFINING ASSISTED LIVING

A COMPLEX LONG-TERM CARE OPTION

Although we initially offered a basic definition of assisted living, any such description greatly oversimplifies the complexities of this long-term care option with its many variations. Definitions of assisted living share more commonalities than differences, but even advocates of this long-term care alternative have difficulty agreeing on how to define it. This is not a homogeneous product. If you have seen one assisted living community, you have seen one assisted living community.

A major reason for this diversity is that each state regulates its assisted living properties differently. State governments have different standards and requirements for the physical design and infrastructure of their buildings, which consider the maximum severity of residents’ impairments, staffing levels and qualifications, the levels and operating standards of personal and health-related care provided, and admitting and discharge criteria (Assisted Living Workgroup Steering Committee, 2003; Brown, 2007; Mollica, Sims-Kastelein, & O’Keeffe, 2007).

Experts are more likely to agree that assisted living is distinguished because of its social model of care. This philosophy emphasizes that older people—whatever their level of vulnerability—should be accommodated in a setting that uses “residential architectural styles and scale, providing privacy and control of a resident’s personal space” (Hernandez, 2006, p. 17). Here, the residents should be treated as valued customers and made to feel “at home” (Wylde, 2008, p. 191). Even as residents receive high-acuity care, the operators of assisted living should treat them in a dignified manner and respect their personal autonomy. Like consumers of other services, they should be given the right to make choices—even bad ones—about how they live and about how and when to receive services and assistance. Foremost, proponents of a social model of care believe that these goals are achievable without excessive government regulation, which they believe has contributed to the medicalization of nursing homes. The bottom line is that they do not believe that the implementation of this philosophy of care compromises in any way the safety of the residents or the quality of their professionally delivered health-related and chronic care services. Indeed, many believe that assisted living can accommodate residents with the same severity of needs as found in nursing homes.

SOURCES OF DATA

Making accurate generalizations about this important long-term care alternative depends on good sources of information. The diversity of assisted living properties, however, makes it more difficult to obtain reliable and comprehensive data. The last statistically representative national survey of assisted living providers was conducted in 2010 by the Centers for Disease Control and Prevention’s National Center for Health Statistics, Division of Health Care Statistics. It included licensed or certified properties with at least four dwelling units or beds that provided room and board, at least two meals a day, around-the-clock on-site supervision, and help with personal care (such as bathing or dressing) or health-related services such as medication management (Caffrey et al., 2012; Park-Lee et al., 2011).

Other data about the national supply of assisted living residences come from surveys of state regulatory agencies. Two professional organizations, the National Academy for State Health Policy and the National Center for Assisted Living, currently offer summaries of how each state licenses or certifies its assisted living option (Mollica et al., 2007; Polzer, 2013). These agency data were used in a 2007 study of the locations and market area characteristics of a national cross-section of state-licensed assisted living properties (Stevenson & Grabowski, 2010). An overview of the current and future status of assisted living in the United States was also the subject of a book by the authors of this chapter (Golant & Hyde, 2008).

Three major insurance companies have conducted market surveys that report on what it costs elderly consumers to occupy assisted living properties, but they do not provide information about their sampling procedures (Genworth Financial, 2013; Metlife Mature Market Institute, 2012; Prudential Insurance Company of America, 2010). Five major trade associations (LeadingAge, American Seniors Housing Association, Assisted Living Federation of America, National Center for Assisted Living, and the National Investment Center for the Seniors Housing & Care Industry) regularly poll their assisted living/senior housing memberships of providers and managers, but their participation in these surveys is voluntary (American Association of Homes and Services for the Aging, 2009; American Seniors Housing Association, 2010). These surveys also differ in several ways: the size and statistical representativeness of their samples, the extent that they include licensed as opposed to unlicensed properties, the scope of their questions, and the extent that they include smaller sized assisted living properties.

A BRIEF HISTORY OF ASSISTED LIVING

Assisted living as we know it today is a relatively new concept. During the 19th and the early decades of the 20th century, only small percentages of people lived to an advanced old age and rarely survived for long periods with extensive care needs. Consequently, older people usually lived on their own or relied on assistance from their extended families. “Homes for the aged”—sometimes called almshouses or poor farms—were operated by municipal or county governments, churches, or community-based charities and primarily served elders who were destitute or had no family supports. Elders who had dementia were often housed in state mental hospitals (Doty, 2008; see Chapter 2).

After the Great Depression of the 1930s, changing demographics, the advent of the Medicare and Medicaid programs, and the institution of regulation led to the creation of the nursing home industry (see Chapters 2 and 13). The less medically intensive old-age homes—variously called “board and care,” “rest homes,” or other comparable names continued to operate. These were sometimes family homes that took in older adults as boarders, or buildings operated by nonprofit or religious organizations. Also available since the 1900s were continuing-care retirement communities (CCRCs), originally known as life care communities. These age-restricted properties accommodate older persons with all levels of assistance and care needs in independent living, assisted living, and skilled nursing facilities found on a campus-like setting.

The mid-1980s first witnessed the availability of stand-alone assisted living communities. Initially, they were located in Virginia and Oregon, primarily due to the efforts of visionary people—Paul and Terri Klassen in Virginia and Keren Brown Wilson in Oregon. These founders were idealists who knew there had to be a better way to serve people who needed some care, but who neither needed nor wanted to live out their lives in the highly regulated atmosphere of the nursing home. The growth of assisted living in Oregon was further aided by its being the first state, under the leadership of Richard Ladd, to provide funding under the Medicaid community-based waiver model (Wilson, 2007).

This residential option soon expanded to other states. Sixty percent of the current supply of units opened their doors between 1990 and 2001 (Wilson, 2007). The for-profit sector—disproportionately privately owned as opposed to publicly held companies—mostly developed these properties, usually without the help of government financing. Only about a dozen states imposed any controls on how many units could be built (such as certificate-of-need requirements) (Stevenson & Grabowski, 2010).

By 2010, there were over 51,000 assisted living properties with over 1.2 million beds/dwelling units in the United States (Mollica, Houser, & Ujvari, 2012). However, the size of this industry depends on how one defines this alternative. These numbers include small board and care/foster care properties (with as few as two beds/dwelling units). If we restrict the universe to larger properties (four or more units/beds), there were over 31,000 properties with about 970,000 units/beds (Park-Lee et al., 2011).

The 11 states with the highest older population penetration rates (assisted living units divided by number of people age 65 and over) included Minnesota, Virginia, Oregon, Nebraska, Washington, Pennsylvania, North Carolina, California, Illinois, Maine, and Iowa (Stevenson & Grabowski, 2010). These states are more likely to be occupied by older populations with higher incomes, educational status, and housing wealth. They are also in locations where providers, regulators, and consumers appear to value community-based long-term care alternatives over institution-like nursing home options (Stevenson & Grabowski, 2010).

Although the assisted living industry has experienced much growth since its beginnings, it has witnessed several periods of rapid expansion alternating with spells of sparse development. Similar to other economic activities, it has been susceptible to the vagaries of consumer demand, overbuilding leading to excessive supply, and the vicissitudes of the U.S. economy. During the Great Recession and housing meltdown in the United States (2007–2009), for example, assisted living building and occupancy rates dropped sharply because of tight construction-lending standards, because prospective older consumers could not sell their homes and the accompanying stock market decline resulted in serious losses to their wealth—thereby reducing their spending. As the economy subsequently recovered, occupancy rates again moved higher.

TYPOLOGY OF ASSISTED LIVING MODELS

There have been several attempts to classify the different types of assisted living residences. One useful typology used a statistical procedure known as cluster analysis to distinguish assisted living properties based on their ownership, size, years in business, resident characteristics—level of frailty, dementia, and socioeconomic status—and the level of services and privacy of accommodations offered to residents (Park, Zimmerman, Sloane, Gruber-Baldini, & Eckert, 2006; Zimmerman & Sloane, 2007). The study labeled one of the largest groups of facilities as new-model assisted living. These were typically corporate-owned facilities, occupied by a relatively large number of residents, and found in modern buildings that offered greater resident privacy. They accommodated persons with a wide range of impairments, but, because of costs, were less likely to accept residents dependent on Medicaid. This group contrasted with two other facility clusters that tended to be smaller, older, often “mom and pop” establishments that served lower income elders who were more likely to share their units.

Even among the new-model assisted living category there is much diversity. The average new-model assisted living building contains about 50 units, although some of the largest properties have over 120 units (Assisted Living Federation of America, 2009). Their buildings variously encompass Victorian mansions, boxy multiunit apartment-style structures, luxurious Trump Towers-like high-rise apartment structures, and resort-like two- or three-story buildings. Interior architectural designs sometime resemble the décor of luxurious hotels, but (sadly) in some cases are more similar to the medical-like interiors of nursing homes. Most have predominantly one-bedroom and studio apartments, but some assisted living properties have a wider mixture of one-, two- and even three-bedroom apartments. Some features are more widespread among new-model assisted living properties. Most living units have their own self-contained kitchens, full bathroom facilities, doors that lock, and individual temperature controls. Residents can fill them with their own furnishings. Most occupants (90%) do not share their apartments or rooms (Figure 10.1).

FIGURE 10.1 Examples of assisted living properties.

With thanks to James A. Antonucci, Executive Director of The Village, Gainesville, Florida.

About 37% of new-model assisted living properties consist of freestanding buildings. Another 19% are in buildings that also have separate floors or sections (or are on a campus setting) with independent living units (see in the following sections). Fewer than 10% of assisted living properties are part of CCRCs. Finally, about 7% consist of buildings that also include a nursing home (Assisted Living Federation of America, 2009).

To accommodate the growing share of older occupants who have some form of dementia, particularly Alzheimer’s disease, an additional 28% of assisted living properties have a physically separated area dedicated to serving persons with dementia. These dedicated floors, sections, or wings are usually referred to as special care units (SCUs; Hyde, Perez, & Forester, 2007), or more recently, memory support neighborhoods. The residential units tend to be smaller in these specialized dementia wings and may consist of only studio or bedroom units as opposed to an apartment. Shared occupancy is more common. Entry and exit doors of these living areas are often secured by locks, alarms, or passcode systems to prevent residents from wandering. Some, although not all SCUs, also have “safe and interesting walkways, and appropriate levels of auditory and visual stimulation, to yield improved outcomes, such as reduced agitation and enhanced quality of life” (Hyde et al., 2007, p. 56).

In contrast, old-model assisted living properties, now also usually subsumed under the general “assisted living” label—but often referred to as board and care/adult foster care—are more likely to be in smaller buildings. Their accommodations are more likely to consist of bedroom-like units. Multiple residents may have to share toilet facilities and/or bathing areas found in another part of the building. The oldest assisted living properties, some of which were converted from nursing home wings, are more likely to offer these more institutional-like accommodations (Hernandez, 2006). This category of assisted living is occupied by higher percentages of residents with dementia and/or psychiatric diagnoses, but unlike the new-model assisted living properties, these residents are often mixed in with the other residents.

ASSISTED LIVING: DIFFERENT FROM OTHER HOUSING CARE OPTIONS

Many advocates and consumers describe assisted living by emphasizing its differences from other supportive housing and care arrangements. In physical appearance, assisted living residences resemble what the senior housing industry now refers to as independent living communities, once labeled as congregate housing. Like assisted living communities, these residential-like settings provide hotel-like hospitality services such as meals, housekeeping, laundry, transportation, and recreational activities (Case Study 10.1).

Independent living communities are less likely than assisted living residences to accommodate physically or cognitively impaired residents (Hyde, Perez, & Reed, 2008). When older occupants receive personal assistance and health-related services to cope with their functional limitations, they rely on family members or professionals who are often employed with licensed home care agencies.

In contrast, assisted living residences are usually licensed by state governments to offer in-house services. Twenty-four-hour on-duty staff provides scheduled and unscheduled personal assistance and protective oversight. They sometimes offer residents health- or nursing-related services, such as medication and incontinence management. Staff may also monitor the chronic health problems of older residents and coordinate their care after they have a hospital stay. Increasingly, staff members are available to responsively and reassuringly assist older persons who suffer from dementia-related cognitive declines or behavioral problems, and they operate social/recreational activity programs tailored specifically to these occupants.

OFTEN COMPARED WITH NURSING HOMES

Assisted living communities differ in important ways from nursing homes. The more institutional-like setting of the nursing home is more focused “on the delivery of appropriate health care services,” (Polivka & Salmon, 2008, p. 400) with the result that nursing homes have a much stronger medical or hospital ambience about them and tend to have a more rigid set of rules and regulations governing every aspect of their physical design and operations. In contrast, assisted living properties are far more likely to offer supportive- and health-related services relying on a person-centered or social model of care.

Proponents of nursing homes argue that they are different from assisted living because they serve a sicker and more impaired older population who require 24-hour nursing services (Golant, 2004). This is generally true, but some states allow assisted living properties to accept residents meeting their nursing homes’ minimum level of care occupancy criteria. Thus, they can serve older persons who require discreet skilled nursing services, but “no states allow persons who need a skilled level of nursing home care to be served in [assisted living] (e.g., individuals who require 24-hour-a-day skilled nursing oversight or daily skilled nursing services)” (Mollica et al., 2007, p. 19). Even this generalization must be qualified because states do not have uniform nursing home admitting criteria. Thus, assisted living properties in some states will admit older occupants when they need more assistance than will others. Many states also permit assisted living providers to offer hospice care for terminally ill residents (Cartwright, Miller, & Volpin, 2009).

OCCUPANCY COSTS

Older persons typically rent new-model assisted living units on a monthly basis. The number of services offered by these facilities partly drives their pricing plans. These can include care management and monitoring, personal assistance with everyday activities, housekeeping and laundry, medication management, recreational facilities, security, transportation, and two or more meals a day (Metlife Mature Market Institute, 2010). In 2013, the median annual cost of new-model assisted living properties (one-bedroom single occupancy) was $41,400. Even these averages may understate occupancy costs. Older persons will pay more to occupy architecturally luxurious assisted living properties and when they receive services that require more hands-on care by staff. As a rule of thumb, the more demanding the physical or cognitive impairments of the resident, the higher the occupancy costs. As an example, in 2012, the national average monthly base rate for dementia care was $4,807 (or $57,684 annually; Metlife Mature Market Institute, 2012). Assisted living properties will also charge more for private than semiprivate units. Location also matters. As examples showing the range, in 2013, the median annual cost for assisted living in Missouri was $27,450, whereas in Delaware it was $66,396. To put all these prices in perspective, it still costs less to occupy assisted living residences than nursing homes. Older persons paid on average $95,265 ($261 daily) a year for a private room in an Alzheimer’s disease wing of a nursing home (Metlife Mature Market Institute, 2012).

WHO OCCUPIES ASSISTED LIVING RESIDENCES?

PAST RESIDENTIAL HISTORIES AND DEMOGRAPHICS

About 70% of older adults who live in new-model assisted living properties moved from their own homes or apartments, whereas 7% came from their family’s dwelling. About 9% had earlier resided in an independent living community and 5% in another assisted living property, whereas 9% moved from a nursing home. Most had previously lived within a 10-mile (62%) or at least a 25-mile (80%) radius of their current assisted living property (American Association of Homes and Services for the Aging, 2009). Between 20% and 25% of assisted living occupants decided mainly on their own to occupy these places. These proactive older persons tended to have higher income and education levels (Ball et al., 2009). In contrast, family members or professionals had a major say in the decisions of the others.

On average, assisted living residents occupy their accommodations just over 2 years, but many have shorter and longer stays. About a third of the residents in assisted living die at the end of their occupancy. Median annual resident turnover (move-outs divided by average occupancy during the year) is high and ranges from 40% to 50% (American Seniors Housing Association, 2010). Among residents who relocate to other housing and care settings, well over 70% move to a nursing home or hospital setting because they require a higher level of care. The remainder move for financial or other personal reasons and variously relocate to their former residences, the homes of a family member, or to another senior housing option such as another assisted living residence or an independent living community (Assisted Living Federation of America, 2009).

The typical person who occupies new-model assisted living is White, widowed, female, and in her mid-80s (Hernandez & Newcomer, 2007). To be more specific, the average age of assisted living residents is 87; three quarters are female, just over three quarters are widowed, just over 12% are still married, and the remainder are divorced or separated. When older persons first move into assisted living properties, they are on average a somewhat younger 84.6 years.

Non-White older persons, particularly African Americans, are under-represented in new-model assisted living (Ball et al., 2009). Rather, these and other racial and ethnic minorities are more likely to occupy “the smaller, older, and lower priced [board-and-care] homes that have fewer residential and safety enhancing architectural design features” (Hernandez & Newcomer, 2007, p. 113).

Many older occupants of the new-model corporate owned or operated assisted living residences have high incomes, but about half have modest incomes that would appear to make their accommodations unaffordable. These seniors made up their income gap either by drawing on the cash proceeds from the sale of their homes or other assets or by receiving financial help from their families. A recent survey estimated that about 11% of older adults identified family as their primary payment source and another 24% as their secondary payment source (Assisted Living Federation of America, 2009).

A second group of low-income older persons is able to occupy assisted living residences because they have income and asset levels low enough to qualify for means-tested government support programs. As of 2010, Medicaid covered at least some of the costs for 19% of assisted living occupants (Caffrey et al., 2012).

Conspicuously absent from assisted living are another group of older persons with low incomes. Not only are they unable to afford the costs of assisted living, but also they do not have low-enough incomes to qualify for assistance from most government programs. Academics and professionals have referred to this group as the Tweeners (Knickman, Hunt, Snell, Alecxih, & Kennell, 2003) or the Gap Income Group (Moore, 2009). Experts estimate the incomes of this group range from $12,000 to $30,000 and that they represent about 35% of all U.S. households over the age of 75.

IMPAIRMENT AND HEALTH PROFILES

After they turn 65, about seven out of 10 persons will need long-term care (either from family or paid workers) at some point before they die. On average, they will be in their homes for two thirds of their years of need, and in nursing or assisted living properties for the remainder (Kemper, Komisar, & Alecxih, 2005). When they need such care, it generally means that they will require hands-on or standby assistance from another person to perform their activities of daily living (ADLs) or instrumental ADLs (IADLs; Kemper et al., 2005). ADLs include bathing, dressing, eating, using the toilet, and getting into and out of a bed or chair (transferring). IADLs include preparing meals, managing money, shopping for necessities, getting around outside the home, light housework, and using the telephone.

On average, residents in assisted living communities need help with over four IADLs. In particular, over 80% need assistance with light housework, personal laundry, preparing meals, using transportation, and managing their medications. They also need assistance with an average of 1.6 to 2.6 ADLs (American Association of Homes and Services for the Aging, 2009; Cohen, Shi, & Miller, 2009). In particular, over 60% require assistance with bathing, 40% with dressing, 26% with toileting, and almost 20% need assistance with transferring. Although about 23% could walk unaided, 54% depend on some assistive device (e.g., cane, walker), over 22% use a wheelchair at least part of the time, and 10% are bedfast (American Association of Homes and Services for the Aging, 2009).

Studies offer a wide range of estimates of the share of assisted living residents diagnosed as having some form of dementia, including Alzheimer’s disease. Numbers range from as low as 40% to as high as 67% (American Association of Homes and Services for the Aging, 2009; Cohen et al., 2009; Hyde et al., 2007). These residents experience severe memory loss and manifest disoriented behaviors. Consequently, they require cueing assistance to perform their everyday activities, need a physically secure building to prevent them from wandering, and need staff with the ability to deal with disruptive or aggressive behaviors. Tragically, these cognitive declines often afflict older persons who are still in relatively good physical health.

Even as older persons enter assisted living properties mainly to address their long-term care needs, they often must rely on these settings to help them coordinate care for their acute and chronic health care problems. A 2009 study found that a large percentage of the occupants of assisted living in the United States suffered from one or more chronic health problems, usually high blood pressure, arthritis, coronary heart disease, osteoporosis, and/or depression. Consistent with the presence of these health problems, about 42% of residents were treated in a hospital emergency room in the past year, and about 35% were treated in a hospital overnight or longer (Assisted Living Federation of America, 2009).

CHANGING DEMOGRAPHICS OF ASSISTED LIVING RESIDENCES

Assisted living providers must continually adjust their operations to conform to the changing demographics of older consumers. Providers are finding that they must accommodate older persons who are more impaired and require higher acuity services and care than in the past. Today’s older adults only enter these residences after extensive periods of aging in place in their own homes and at ever higher chronological ages. These trends explain why a growing share of assisted living properties has SCUs for their older residents with Alzheimer’s disease or a related disorder (Hyde et al., 2007). The competitive environment is also a factor. Older persons can now remain longer in independent living communities because they receive personal assistance and health services from the flourishing home care industry.

Assisted living providers must continually change their business models to keep up with the continually changing preferences of prospective residents. One expert noted that assisted living residences are increasingly tailoring their properties to accommodate very different niche subgroups: Asian Americans; gay, lesbian, and transgender populations; nudists in Florida; and intellectually striving university-based retirees (Carle, 2010).

THE REGULATORY ENVIRONMENT OF ASSISTED LIVING

MUCH STATE DIVERSITY

Regulatory agencies in more than two thirds of the states use the term assisted living. Other state governments refer to long-term care facilities as residential care, boarding homes, board-and-care facilities, basic care facilities, homes for the aged, personal care homes, adult care homes, and adult foster care (Mollica, 2008; Polzer, 2013). Adding to the confusion is that many state regulatory agencies have multiple licensing standards and recognize three or four different assisted living categories, each with distinctive physical infrastructure and service requirements. This helps explain the proliferation of 200-plus page manuals outlining how each state’s assisted living program differs from the others (Mollica et al., 2007; Polzer, 2013).

Even within any given state, assisted living properties may not look or operate the same. Most state regulatory agencies give assisted living providers the discretion of admitting a less impaired population than allowed by their requirements, and they may involuntarily discharge residents when they cannot meet their needs (Carlson, 2005; Hernandez, 2006). On the other hand, some assisted living properties accommodate older persons who are as physically or cognitively impaired as their state regulations allow.

Regulations governing assisting living are in continual flux. Between 2012 and 2013, the National Center for Assisted Living—an advocacy group for the American Health Care Association (AHCA)—reported that 18 states had made statutory, regulatory, or policy changes that influenced the appearance or operation of their assisted living properties (Polzer, 2013).

Opinions vary as to whether this diverse and changing regulatory environment is a bane or blessing. Critics charge that “the state regulatory scheme is chaotic, disorderly, and largely ineffective” (Bruce, 2006, p. 82) “and that the current assisted living regulatory scheme, implemented state-by-state, is ineffective due to the piecemeal and varied state regulation” (Bruce, 2006, pp. 62–63). They argue for the increased role of federal regulation as a way to achieve more uniformity. Some providers, especially those who own and operate properties in multiple states, argue that this diversity hampers their ability to communicate a standardized marketing message. A diverse product line can also confuse older consumers, who are often unclear about a property’s admitting policies, services, and costs.

Other experts are quick to counter these criticisms. They argue that this regulatory diversity and provider flexibility are strong plusses. A uniform assisted living product would fail to recognize the failings of a one-size-fits-all shelter-and-care environment (Mollica et al., 2007). Older consumers want to have more long-term care choices, providers want to implement different business models and serve distinctive niche markets, and state governments want their assisted living residences to serve older persons with different vulnerability profiles and satisfy different requirements and regulations—some more stringent than others (Golant, 2008b).

STATE REGULATORY ENVIRONMENTS

State regulation of assisted living residences contains two main categories of requirements. The first establishes standards for physical infrastructure, appearance, and design attributes. State regulatory agencies usually require that assisted living properties meet minimum building and unit designs. Some require that assisted living properties have apartment-like units with self-contained kitchens and bathrooms, although they will require different minimum area sizes for these spaces. Some states allow only one person to occupy these physical accommodations. Other states, following what is labeled as an “institutional model” (Mollica et al., 2007), allow multiple-occupancy bedrooms, shared by up to four people, without attached baths, and with shared toilets and bathing areas. These regulatory differences are often very detailed. For example, Connecticut requires that each resident’s unit includes a full bath and equipment for the preparation and storage of food, and residents are not required to share a unit. In contrast, New York allows shared units, and includes units that do not have their own toilets, and depending on the facility category, only requires one toilet for every three or six residents, and one tub/shower for three to 10 residents (Polzer, 2013).

The second category of regulatory requirements identifies the allowable supportive- and nursing-related services, staffing responsibilities, and admitting and discharge criteria that take into account the residents’ chronic health problems, physical and cognitive functioning, and behavioral problems.

Most states view assisted living as a “housing and services model,” whereby they license or certify both the appearance of new-model apartment-like properties and their long-term care assistance. Fewer states regulate assisted living as a “service model.” They do not regulate the building or shelter arrangement itself, but “allow existing building codes and requirements—rather than new licensing standards—to address the housing structure” (Mollica et al., 2007, p. 1–8). However, they license either the assisted living provider or outside community-based service providers (e.g., home health agency or an adult day care center) to control the types and levels of offered care.

ALLOWABLE IMPAIRMENTS OF RESIDENTS AND LEVEL OF SERVICES

States differ substantially regarding the types and level of allowable supportive and health-related services (Mollica et al., 2007). Some allow properties to only offer light care and minimal medical or nursing services with the result that they accommodate less physically or cognitively limited older persons. Other states mandate that assisted living properties accommodate some minimum percentage of residents who are very frail. These are typically persons having difficulties performing four or more ADLs and requiring the services of a nurse or equivalent health care professional several times a week.

Regulations also specify minimum levels of staffing and their qualifications and training requirements. These regulations may restrict who can administer nursing-related services such as catheterization, ostomy care, care of skin wounds, and oxygen therapy. They may specify whether licensed health personnel, such as registered nurses, can delegate certain nursing procedures, such as administering medications, to unlicensed staff, such as nurses’ aides or certified nurse assistants. They also will specify under what circumstances assisted living providers can contract or outsource services from other agencies or organizations (for example, certified home health agencies), thereby enabling their residents to receive higher acuity care than provided by in-house staff.

New Jersey is an example of a state that allows assisted living properties to serve more severely impaired older persons. Although they cannot serve residents “who require a respirator or mechanical ventilator or people with severe behavior management problems” (Mollica et al., 2007, p. 21), they can accommodate residents if they have the following impairments or care needs (Mollica et al., 2007, p. 21):

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