Assisted Living: Needs, Practices, and Policies in Residential Care for the Elderly

Introduction

Introduction Catherine Hawes, Ph.D. The past decade has seen the emergence and growth of a new industry known as assisted living. Consumer demand, concerns about nursing home quality, and pressure from providers have combined with state interest in containing long-term-care costs to produce dramatic growth in this industry. Initially, its development was largely a market response to both demographic trends and consumer preferences. More recently, however , state involvement in setting standards and developing Medicaid payment policies has expanded exponentially. The “graying” of the U.S. population represents a major public policy challenge, particularly given estimates that the number of elderly persons needing long-term care will double to 14 million over the next two decades (US GAO, 1999). As a result there have been a number of private- and public-sector responses to meeting this growing need for long-term care. The initial response among state policymakers was to expand the role of residential care facilities. Other than nursing homes, the most common form of residential setting with long-term-care services is the entity generically known as board-and-care or residential-care homes. Such facilities are known by more than thirty different names across the country, including personal care homes, adult-care homes, adult congregate living facilities, and homes for the aged. As of the early 1990s, there were an estimated 40,000 such facilities, licensed and unlicensed, with an estimated 750,000 beds nationwide (Clark et al., 1994; Hawes et al., 1995; Hawes, Wildfire & Lux, 1993). Recently the field of residential care has expanded with the development and rapid growth of a new and overlapping form of care, termed assisted living (ASHA, 1998; ALFA, 1998; Citro & Hermanson, 1999; Gulyas, 1997; Mollica, 1998). One-third of facilities that call themselves assisted living have been in business for five or fewer years, and 60 percent have been in operation for ten or fewer years (Hawes, Rose & Phillips, 1999). Part of this growth can be attributed to increased state involvement . During the past decade, many states expanded their definition of residential care to include a specific licensure category known as “assisted living”; other states simply incorporated these facilities into their traditional concept of residential care (Hawes, Wildfire & Lux, 1993; Mollica, 1998). Further, more than half the states provided some type of Medicaid funding for services in assisted living facilities by 1998 (Mollica, 1998). However, the real impetus for growth has been from private investment , including both lenders and the stock market (ASHA, 1998; Conway, MacPherson & Sfiroudis, 1997; PVG, 1997; SeniorCare, 1998). In the view of many observers, assisted living represents a promising new model of long-term care that blurs the sharp and invidious distinction between nursing homes and community-based 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 services that makes them a viable but less institutional alternative to nursing homes (Kane & Wilson, 1993; Leon, Cheng & Neumann, 1998; Wilson, 1993). Despite such optimism, there is a general lack of knowledge about the assisted living industry. First, there is disagreement about the size of the industry. Second, there is tremendous variation among those facilities that call themselves assisted living. Third, there are questions about the performance of the industry and the quality of care. Finally, there is confusion about the role that assisted living plays in meeting the long-term-care needs of the elderly population and the interaction of assisted living with other segments of the health and long-term-care systems. This dearth of information is a serious matter, given the rapid growth of the industry, its increasingly prominent role in providing long-term care for frail elderly persons, and the largely uncritical enthusiasm that has dominated its emergence and growth. The key philosophical tenets of assisted living are based on the goals of meeting customers’ needs, promoting independence and dignity, and allowing residents to age in place in a homelike environment. As defined by the Assisted Living Quality Coalition,1 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 2 C. Hawes preferences; designed to maximize residents...