U.S. Department of Health and Human Services

Residents Leaving Assisted Living: Descriptive and Analytic Results From a National Survey

Executive Summary

Charles D. Phillips, Ph.D., M.P.H., and Catherine Hawes, Ph.D.
Texas A&M University System Health Science Center

Kathleen Spry, Ph.D., and Miriam Rose, M.Ed.
Myers Research Institute

June 2000

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), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Research Triangle Institute. Additional funding was provided by American Association of Retired Persons, the Administration on Aging, the National Institute on Aging, and the Alzheimer's Association. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Gavin Kennedy, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. His e-mail address is: Gavin.Kennedy@hhs.gov

This report was prepared under contracts HHS-100-94-0024 and HHS-100-98-0013 from the Office of Disability, Aging and Long-Term Care Policy, Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services. AARP, The Alzheimer's Association and the National Institute on Aging have also provided support for this project. AARP provided special support for this analysis. The views expressed in this report do not necessarily reflect the views of any of the sponsoring organizations other than DHHS/ASPE.

Assisted living is the fastest growing sector of “housing with supportive services.” While aging in place is an important tenet of the assisted living philosophy, departures or discharges from assisted living are a fact of life; but there is little information available about the reality of movement out of assisted living facilities (ALFs).

This report provides information on departures from assisted living, the reasons for departure, and those resident and facility characteristics that affected the likelihood of various resident outcomes associated with departure. The report focuses on a nationally-representative sample of ALFs in 1998 that offered either a relatively high level of services or a relatively high level of privacy or both high services and high privacy. This special group of ALFs represents about 40 percent of places calling themselves assisted living facilities.

Our best estimates from this national sample indicate that in 1998 approximately 24 percent of residents left an ALF over the course of 12 months. The results indicate that roughly one-third of the residents who left a study ALF between baseline and follow-up (roughly 8 percent of all residents on a yearly basis) either died in the ALF or elsewhere prior to follow-up contact. The bulk of the remainder who left went to a nursing home or some other residential care setting or ALF. On an annualized basis, 8 percent of all residents went to a nursing home and 4 percent of all residents moved to some other residential care setting. The need for more care was the most common reason cited by respondents for leaving an ALF. Very few respondents indicated that they or their family member left the original ALF because they could no longer afford to remain in the facility.

This research also provided some heretofore unavailable information on the characteristics of residents and facilities that affect individuals’ movement out of assisted living. In the multivariate analyses that controlled for both individual and facility characteristics, age and marital status affected a resident’s likelihood of death prior to follow-up. Although only a small percentage of ALF residents were married, they were twice as likely as unmarried residents to die prior to the follow-up interview. The only individual-level variable that affected an individual’s likelihood of entering a nursing home was cognitive status.

In the multivariate models, facility characteristics also had an impact. No facility characteristics had a significant impact on a resident’s likelihood of death. However, residence in a for-profit ALF was highly associated with movement into another residential care setting other than a nursing home. Also, residing in an ALF with a full-time RN who provided care to residents reduced a resident’s likelihood of going to a nursing home or to some other setting roughly by half.

These results have a number of relatively interesting policy implications. For policy-makers interested in developing an assisted living industry that can delay nursing home use, creating incentives for facilities to provide a higher level of service could be productive. However, such a policy stance would mean encouraging the development of higher cost ALFs, yet how to develop ALFs that are affordable for individuals with low or moderate income is now becoming a major issue. In addition, if higher cost ALFs are encouraged, then the specific amount of delay in nursing home use (i.e., the number of person-months) that results from these increased costs becomes a critical parameter for policy discussions. In addition, one must consider any additional home health, ambulatory care, medications, or acute care that are required during the delay and might have been avoided by placement in a nursing home.

For consumers intent on avoiding or delaying nursing home placement, seeking out ALFs that have full-time RNs and provide nursing care with their in-house staff may represent a good choice in an ALF. For consumers interested in aging in place, choosing a facility with a full-time RN active in direct care is one way to reduce the likelihood that they will have to move to a nursing home, or another ALF or residential care setting.¹

Most people entering an ALF are not as disabled as those entering a nursing home. This means that the choice to enter an ALF with a full-time RN active in direct care may only be important to more impaired residents or to residents over the course of time as they age in place. Thus, many consumers might end up paying “at the front-end” for services that will only be important to them later, if they stay in the same facility.

One must also remember that this analysis focused on facilities that chose at a specific point in the evolution of the industry to have a full-time RN and provide direct care with in-house nursing staff. These services seem to have had a direct impact on resident outcomes. However, the results of these services in facilities that add such services as a marketing tool, as the result of some reimbursement incentive, or because of a regulatory mandate may differ.

The finding that cognitive impairment has such an important impact on nursing home placement may also have substantial policy implications. To the degree that the industry is encouraged to care for more severely cognitively impaired residents, then savings in nursing home costs may accrue. However, the industry’s ability to provide appropriate care to this population is unproven.

As the discussion above indicates, the policy issues here are complex, and our knowledge base is limited. This is, after all, a single study. Even though it is based on a nationally-representative sample of higher service or higher privacy facilities, an appropriate measure of caution should be used when considering these results in the policy-making process.

NOTES

1. Some “unmeasured” facility characteristic that is very highly correlated with our service measure (i.e., a full-time RN who does direct care) may be driving this relationship, either wholly or partially. However, this relationship does not appear when one uses other service measures, so any unobserved variable must be correlated with this specific measure and not with overall RN staffing, aide staff, the willingness to arrange for RN care, or simply having an RN on staff. Such a characteristic is relatively hard to conceive of, so the authors’ best judgment, until other evidence is provided, is that the observed relationship is driven by the measured characteristic--the presence of a full-time RN providing direct care.