Inside Assisted Living: The Search for Home

10 The Reality and the Promise of Assisted Living

195` TEN The Reality and the Promise of Assisted Living Assisted living communities are an important element of the longterm care continuum, with more than a million residents and 38,000 to 68,000 facilities as of 2006 (NCAL 2007). Lost in these numbers is any insight into the lived reality and promise of life inside these settings. The findings from this in-depth ethnographic study allow a sustained view of the assisted living experience, providing an opportunity for better understanding by consumers, their families, providers, policymakers , researchers, students, and others interested in this type of housing and care. In addition, looking inside the walls gives a view of challenges and opportunities that make up the future of assisted living. The first half of this chapter describes eight core realities of assisted living that emerged across the group of settings we studied. The second section considers the promise and future of assisted living as informed by this research. That future is shaped and constrained by both internal and external factors, such as the “success” of having residents age in place, the policy and regulatory environment, potentially shifting consumer care preferences, funding and financing limits, and workforce challenges clearly already at the doorstep of this relatively new option in long-term care. The Core Realities of Assisted Living Heterogeneity A common refrain among those familiar with assisted living is that “once you’ve seen one assisted living setting, you’ve seen one assisted living set- 196 INSIDE ASSISTED LIVING ting.” Some commentators complain about the lack of uniformity (Bruce 2006; Carlson 2005), primarily because, unlike the standardization of the highly regulated nursing home sector, it allows for variations in both quality and range of services. They argue that this variability makes it more difficult to monitor whether dependent older adults are receiving the care they need and the services they desire. Focusing on consumers, proponents of universal standards for assisted living argue that the heterogeneity creates unfair challenges for residents and their families: locating a facility in one’s own community, much less in another state, is too complicated . Given that the move into assisted living often occurs during a health or social crisis, comparison shopping might not be possible, yet the heterogeneity of assisted living residences demands spending time to find the right place. Further, medical professionals and others who work on behalf of older persons might not understand that one assisted living residence , for example, accepts persons with dementia, while another does not. Other experts, however, see the range of environments, prices, service packages, and amenities as a natural response to diverse consumer demand and as exactly what the concept of assisted living was intended to provide. If assisted living operators are to provide a setting that is “homelike,” then it would follow that the wide range of what constitutes “home” in the broader community would be true as well in long-term care. Thus, for some, Valley Glen Home meets the standard of home, while for others the choice would be either the Chesapeake or Laurel Ridge. As demonstrated in earlier chapters, the diverse settings in the single state we studied vary in their structural and organizational characteristics and in the lived culture of that home for all who participate in its days and nights. We selected our six settings to reflect key structural and organizational elements identified in other research and policy reports. These elements include the size of the facility; its for-profit or nonprofit status; its urban, suburban, or rural location; the services and amenities it offers; and the socioeconomic and sociodemographic characteristics of the residents served. For example, all of the residences studied here are categorized as “for-profit,” yet this designation masks the significant differences between the small “mom-and-pop” operations (with six or eight residents ) and the larger corporately owned and operated chains. In these THE REALITY AND THE PROMISE OF ASSISTED LIVING 197 larger assisted living residences, the structural and organizational characteristics are more bureaucratic and hierarchical, with formal differentiation of staff roles (e.g., direct care providers, housekeepers, food services) and “shift work.” As organizations, the larger residences share more traits with nursing homes, from which the assisted living sector tries hard to distance itself. To some people the for-profit designation of the various settings we studied implies benefits to the assisted living owner at the expense of the resident consumer; such a perspective belies the...