U.S. Department of Health and Human Services

The Size and Characteristics of the Residential Care Population: Evidence from Three National Surveys

Executive Summary

Brenda C. Spillman and Kirsten J. Black

The Urban Institute , Health Policy Center

January 4, 2006

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This report was prepared under contract #HHS-100-97-0010 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Urban Institute. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, John Drabet, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. His e-mail address is: John.Drabek@hhs.gov.

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National data collections have only recently begun to respond to the need for data on growth in residential care alternatives to both traditional nursing homes and care at home for older persons with disability. This information is critical to understanding the evolving long-term care delivery system and to the ability to monitor care arrangements and quality for public policy and for consumer information.

This report is the second of two prepared as part of a project to better understand the size and characteristics of the long-term care population in all settings. The first report reviewed existing estimates of the older population in residential care, generally divided into nursing homes and alternative residential care settings. Substantial variation was found across different types of data and even across studies using the same data, and differences in estimates generally were larger for residential alternatives than for nursing homes (Spillman and Black 2005). As part of that report, we identified a set of key methodological issues contributing to observed differences in existing estimates that could be investigated using available national surveys.

They are:

• age of the population examined,
• sample representation and weighting,
• methods for assigning individuals to the “facility” or “institutional” population (and conversely, the “community” or “noninstitutional” population),
• methods of identifying nursing homes,
• methods of identifying alternative residential care settings.

We also identified three recent federally supported surveys--the 2002 Health and Retirement Survey (HRS), the 2002 Medicare Current Beneficiary Survey (MCBS) Cost and Use file, and the National Long Term Care Survey (NLTCS)--as being best suited for the purpose because of their focus on the older population and data elements that allow identification of residential care alternatives by name, services, or both. In this study, we report on our analysis of these surveys and discuss the implications of our findings for improving collection of data on residential settings.

Methods and Data

Our analytic strategy was first to identify relevant residential care samples as consistently as possible across the three surveys analyzed and then to compare the characteristics of the populations identified. We defined the following residential categories that could be measured across surveys, excluding persons living in facilities for the mentally ill or mentally retarded, rehabilitation facilities, and other facilities not identified as nursing homes or alternative residential long-term care:

• Traditional private residences.
• Nontraditional residences, including retirement or senior housing or other such community settings not meeting criteria for residential care.
• Residential care settings:
  • Nursing homes;
  • Alternative community residential care;
  • Alternative facility residential care.

We drew on existing sources of guidance, including definitions developed by the Assisted Living Workgroup (ALW) formed by the U.S. Senate Special Committee on Aging in 2001, and a survey of state licensing practices (Han, Sirrocco, and Remsburg 2003) to develop feasible criteria for defining residential care settings using data elements on the three surveys. Alternative residential care settings encompass a variety of places and care arrangements that provide both housing and services outside of a nursing facility for those who are unable or unwilling to live independently. They include such diverse settings as small foster care homes, board and care or personal care homes, congregate housing, or assisted living facilities. Hallmark services generally include assistance with instrumental activities of daily living, such as meals and housekeeping, and activities of daily living (ADLs), such as bathing and dressing.

Our aim was to identify all residential care settings, rather than a subset qualifying as assisted living, per se. Therefore we followed a general strategy similar to one used by Hawes et al. (1998) in an earlier project to develop a survey of assisted living, which relied on either facility self-identification or services. To identify all settings, however, we used a broader array of place types and a less restrictive set of services, constrained by the type of data available on each survey. (Detailed specifications of our constructions for each survey are in Appendix A.)

Key Findings on the Size and Characteristics of the Residential Care Population

Estimates from the three major national surveys of the older population examined are in substantial agreement that about 6.5 percent of persons age 65 or older--about 2.2 million persons--live in some type of residential care other than settings for special populations such as the mentally ill or mentally retarded. The estimates indicate that most--about 1.45 million--live in nursing homes, but more than 750,000 live in alternative residential care settings.

The three surveys also provide a consistent picture of the characteristics of the residential care population. Relative to older persons remaining in traditional private housing, the residential care population was far more likely to receive help with ADLs and to suffer from Alzheimer’s disease or other dementias. Estimates from the two surveys that include the facility or institutional population, indicate that the prevalence of disability and dementias is dramatically higher in facility residential care than in community care settings, and higher yet in nursing homes.

Persons living in residential care facilities are more likely to be over age 85, more likely to be female, and more likely to be widowed, than are persons residing in traditional housing. Residential care facilities serve a broad income range. Persons living in those facilities are more likely to have incomes below $10,000, roughly approximating the federal poverty level for older couples. In both the MCBS and the NLTCS the proportion who are nonWhite was lower than in either traditional private housing or nursing homes.

Discussion and Conclusions

The consistency of estimates across three major national surveys, after reducing methodological differences to the extent possible, provides confidence in the existing data on the size and characteristics of the residential care population. Two different methods are used to obtain data on the characteristics of the person’s residence. Individuals are asked to describe their type of residence. The responses yield a set of place types (e.g., retirement community, assisted living, etc.). The other method is to ask individuals whether or not the place they live offers specific services, usually by asking about each service on the interviewer’s list of potential services. However, accurately identifying a residential care facility as the place of residence through the use of survey questions is difficult. Neither named place type, as in the NLTCS, nor services alone, as in the HRS, appears to be sufficient to draw firm conclusions about the nature of the setting.

For example, the NLTCS, allows identification only by named setting type, and makes special effort to identify “assisted living.” The NLTCS reports a larger proportion of community residents in generic types of “senior” or “retirement” housing than do the other two surveys. However, no information is gathered on services available, regardless of whether the respondent uses them. Consequently, it is difficult to determine whether these generic settings meet the criteria for alternative residential care, such as those proposed by the ALW or used in state licensing.

Among the MCBS community residential care population, which we identified using a combination of named place type and services offered, only about 30 percent identified their residence by name as assisted living or any other place type clearly associated with residential care. About 8 percent of the group reporting that their residence was assisted living reported that none of the services included in the survey were available, and only about three-quarters reported the availability of medication supervision, considered to be a hallmark service for higher quality residential care settings.

Finally, although the estimates of the characteristics of the residential care population from the three surveys show reasonable consistency, comparisons were complicated both by differences in measurement and availability of data across community and facility settings and by small sample sizes.

If, as widely believed, the older population in alternative residential care is growing rapidly, either as a substitute for or a precursor to traditional nursing homes, it is important to have reliable national data to document both the growth and the implications for the welfare of older persons with disability. The three major surveys of the older population we examined have made a first step in that direction. In fact, such data offer the only opportunity for an integrated understanding of the entire long-term care delivery system and those who use it, rather than piecemeal examination of sometimes artificially defined segments.

Nevertheless, improvements are needed if national surveys are to support studies that improve understanding of the residential care “missing link.” This analysis indicated several key areas for improvement:

• A hybrid approach to identifying settings would seem to be ideal, in which a broad screen for nontraditional settings is applied, as in the HRS, and then information on both services available and named place type is gathered. Ideally information similar to that in the HRS and MCBS on whether services are included in housing costs or cost extra and whether services are actually used also would be collected.
• More consistency is needed across all community and facility settings in the information collected on characteristics of settings and services offered, as well as the characteristics of residents, so that analyses can identify factors associated with choice of setting, transitions between settings, and outcomes.
• Existing sources of guidance, such as those cited here, can provide a foundation for survey organizations to identify the minimal array of key setting characteristics and services needed to identify and discriminate between residential care settings.
• Although growth over time eventually will increase sample sizes, a sound methodology for oversampling the population in alternative residential care is needed if national population-based surveys are to provide the data to support reliable estimates.

The Full Report is also available from the DALTCP website (http://aspe.hhs.gov/_/office_specific/daltcp.cfm) or directly at http://aspe.hhs.gov/daltcp/reports/3natlsur.htm.